International Journal for Equity in Health - Latest Comments

Table 2 is a modified version

Hee-Sun Lee — 2012-03-13T10:59:33Z

Table 2 is a modified version which has previously been used (Han et al., 2012).
"A Multilevel Analysis of the Compositional and Contextual Association of Social Capital and Subjective Well-Being in Seoul, South Korea", Sehee Han, Heaseung Kim, and Hee-Sun Lee, Social Indicators Research, DOI 10.1007/s11205-011-9990-7.

Equity and the problem of legitimacy

Christine Loignon — 2011-06-10T09:45:39Z

I really appreciated reading the Starfield's editorial entitled "The hidden inequity in health care". As a sociologist, my scientific research in primary care leads me to consider the importance of the user point of view regarding the problem of legitimacy. Underserved patients I've met who experience both multiple chronic conditions and poverty encountered the problem of legitimacy toward the health care system. The problem of legitimacy could be defined as the perception of not having a legitimated place in the health care system. It comes with the humiliation that goes with poverty experience and with being perceived as ¿bad patient¿ through social experience of the health care system. Negative past experience of care, stigma, economics and social barriers of access to care and discouragement all play a central role in the occurrence of the problem of legitimacy. Relational accessibility through positive, inclusive and repetitive contacts with the primary health care system (both at the GP level and care organization level) is a core component of the effective social legitimacy. The capability of the primary health care system to take into account the roots of the social inequities and the problem of legitimacy experienced by patients is in my sense one avenue of solution for enhancing equity!

Author's corrections

Jon Ivar Elstad — 2011-03-28T09:14:44Z

Two minor print errors were unfortunately not discovered before publishing. (1) In table 1, bottom line, Gini for household-adjusted post-tax income: The range should be 0.188-0.363 (not 0.118-0.363). In the text, p.6, this range is correctly stated. (2) Table 3, bottom line, Model 4: Upper 95%CI limit should be 0.04893 (not 0.0483).

Correction

Ali Montazeri — 2011-03-28T09:14:04Z

I would like to indicate that in the Abstract, the Results section, the number should read as (65 died at hospital and 99 died at home).

Where are young carers in the findings of this research?

Joseph Mavindu Mutunga — 2009-02-14T15:50:24Z

The researchers seem to have left out something crucial in their methodology, which led to young cares of persons living with Aids being invisibilised, save for one boy.

It is unlikely that young carers do not play a major role in caring for PLWHA. Sometimes they do more than women! Given that a large section of care recepients are people whose spouses are dead or dying because of Aids, young carers must be doing more than this paper has recognised.

It is a great research paper noetheless.

Thank you.

Mavindu Mutunga

On Dis-aggregating sex and gender

Udaya S Mishra — 2005-09-05T10:42:06Z

We have no doubt come a long way in defining and measuring gender, however, differentiating between sex and gender still remains hazy for many. As most of the gender analysis bases on sex dis-aggregated information, we need to manifest gender as a derivative of sex differential. If all the sex differential is not due to biological difference (sex) then the residual has to be ascribed to gender. Pampel (2001) provides a sensible illustration of this kind in the context of gender differential in road traffic accident victims. In this venture, two issues are equally important; one refers to the measurement of the differential in the first place and the second is the substantive difference in gender roles to substantiate the residual difference beyond biological self. As regard the measurement, the differential needs to be sensitive to changing levels of the phenomenon (Mishra and Subramaniam, 2005) to be pronounced at better levels compared with worse levels. Also the differential characteristic advantage/disadvantage in risk of a phenomenon between sex should be read as gendered characteristics.

Mishra U.S. and S. Subramanian (2005) ` On Measuring Group Differentials displayed by Socio-economic Indicators’ Applied Economic Letters (forthcoming)

Pampel F.C. (2001) Gender Equality and the Sex Differential in Mortality from Accidents in High Income Nations, Population Research and Policy Review, Vol.20, pp.397-421.

Infection and cardiovascular disease

Syed Wamique Yusuf — 2005-01-27T16:16:42Z

Dear Sir /Madam

In the recent paper (1), the authors have elegantly covered the issue of cardiovascular disease in the developing countries. They have have mentioned how cardiovascular disease (CVD) is now an emerging epidemic in developing countries and by year 2010, CVD will be the leading cause of death in the developing countries. They have cited life style changes brought about by industrialization and urbanization in developing countries as a factor and have targeted traditional risk factors like tobacco, alcohol, hypertension and physical inactivity for prevention purposes. Interestingly no mention was made of the association between infection and heart disease. They have failed to mention that prevention of infection, immunization and vaccination against common infections may also be a very important part of preventive cardiology in developing countries.

Even in developed countries, the prevalence of Chlamydia pneumonia is somewhat higher in Asian population compared to Caucasians (2) and childhood infections are relatively more frequent in South Asians resulting in higher risk of chronic infections, like Hepatitis (3). Infection has been lined with Ischaemic heart disease (IHD) and atherosclerosis (4, 5), and there is a strong association between development of new atherosclerotic lesion and chronic infection (5). In particular the pathogen burden contributes to atherogenesis (4) with Hepatitis A virus being independently predictive of IHD (4). In patients with angiographically normal coronary arteries, infection with multiple pathogens is also an independent determinant of endothelial dysfunction (4). IHD is increasingly being recognized as an inflammatory disease, and both C-reactive protein (CRP) and fibrinogen are significantly elevated in chronic infections (5). There is also a correlation between pathogen burden and CRP levels, with a higher CRP level in patients with a greater pathogen burden (4). Even young otherwise healthy patients with only periodontal disease show evidence of endothelial dysfunction and systemic inflammation (6). Although studies have not shown a conclusive causal link between infection and IHD, it is known that an increase in inflammatory markers are prognostically important, both in healthy population and in patients with IHD (7, 8).

There is increasing evidence that influenza can trigger coronary and vascular events (9). Influenza vaccination has been associated with about 50% reduction in all-cause mortality in healthy senior citizens, leading the authors to recommend vaccination of all persons over 50 years of age and in all patients with cardiovascular disease (9). Assuming a 50% reduction in cardiovascular death, influenza vaccination could save 91 000 lives per year (9), and influenza vaccination may be one of the most cost-effective interventions for cardiovascular patients (9).

A lot of these infectious processes could begin in early childhood and by inducing low grade inflammation could manifest or precipitate atherosclerosis at older age. Alternatively an acute infection can generate intense inflammatory response and

precipitate an acute coronary event. For prevention of growing epidemic of IHD in the developing countries, the authors mention aggressive risk factors management. Perhaps vaccination and preventing infection may be helpful in prevention of atherosclerosis and cardiovascular disease and this aspect of preventive cardiology should be integrated into primary health care.

REFRERENCES:

1. Boutayeb A, Boutayeb S. The burden on Non Communicable Diseases in developing countries. Int J Equity Health; 2005:4(1):2

2. Cook PJ, Davies P, Honeybourne D. Chlamydia pneumoniae infection and ethnic origin. Ethn Health 1998; 4:237-46

3. Aspinall PJ, Jacobson B. Ethnic disparities in health and health care. A focused review of the evidence and selected examples of good practice.

http://www.lho.org.uk/Publications/Attachments/PDF_Files/Ethnic_Disparities_Report.pdf (Accessed on 3rdJan 2005)

4. Prasad A, Zhu J, Halcox JPJ, Waclawiw MA et al. Predisposition to Atherosclerosis by Infections. Role of Endothelial Dysfunction. Circulation. 2002; 106:184-190

5.Kiechl S, Egger G, Mayr M, Weidermann CJ et al. Chronic infections and risk of carotid atheroscelrosis. Prospective results from a large population study. Circulation 2001; 103:1064-70.

6.Amar S, Gokce N, Morgan S, Luokideli M et al. Periodontal disease is associated with brachial artery endothelial dysfunction and systemic inflammation. Arterioscler Thromb Vasc Biol 2003; 23:1245-49.

7.Toss H, Lindahl B, Siebahn A, Wallentin L. For the FRISC Study Group. Prognostic influence of increase fibrinogen and C-reactive protein in unstable coronary artery disease. Circulation 1997; 96:4204-10,

8. Ridker PM, Cushman M, Stampfer MJ, Tracy RP, Hennekens CH. Inflammation, aspirin and risk of cardiovascular disease in apparently healthy men. N Engl J Med 1997; 336:973-9

9. Madjid M, Naghavi M, Litovsky S, Ward Casscells S. Influenza and cardiovascular disease: a new opportunity for prevention and the need for further studies. Circulation. 2003; 108:2730-6.

S.W.Yusuf, M.D M.R.C.P.I

University of Texas MD Anderson Cancer Center

Houston, Texas 77030, U.S.A