Many HIV-infected women are not realizing the benefits of highly active antiretroviral therapy (HAART) despite significant advancements in treatment. Women in Vancouver's Downtown Eastside (DTES) are highly marginalized and struggle with multiple morbidities, unstable housing, addiction, survival sex, and elevated risk of sexual and drug-related harms, including HIV infection. Although recent studies have identified the heightened risk of HIV infection among women engaged in sex work and injection drug use, the uptake of HIV care among this population has received little attention. The objectives of this study are to evaluate the needs of women engaged in survival sex work and to assess utilization and acceptance of HAART. During November 2003, a baseline needs assessment was conducted among 159 women through a low-threshold drop-in centre servicing street-level sex workers in Vancouver. Cross-sectional data were used to describe the sociodemographic characteristics, drug use patterns, HIV/hepatitis C virus (HCV) testing and status, and attitudes towards HAART. High rates of cocaine injection, heroin injection, and smokeable crack cocaine use reflect the vulnerable and chaotic nature of this population. Although preliminary findings suggest an overall high uptake of health and social services, there was limited attention to HIV care with only 9% of the women on HAART. Self-reported barriers to accessing treatment were largely attributed to misinformation and misconceptions about treatment. Given the acceptability of accessing HAART through community interventions and women specific services, this study highlights the potential to reach this highly marginalized group and provides valuable baseline information on a population that has remained largely outside consistent HIV care.
Cites: J Gen Intern Med. 2002 May;17(5):341-812047730
Cites: CMAJ. 2002 Apr 2;166(7):894-911949985
Cites: AIDS Patient Care STDS. 2000 Jan;14(1):47-5812240882
In British Columbia, Canada, the City of Vancouver's notorious Downtown Eastside (DES) represents the poorest urban population in Canada. A prevalence rate of 30% for HIV and 90% for hepatitis C makes this a priority area for public-health interventions aimed at reducing the use of injected drugs. This study examined the utility of acupuncture treatment in reducing substance use in the marginalized, transient population. Acupuncture was offered on a voluntary, drop-in basis 5 days per week at two community agencies. During a 3-month period, the program generated 2,755 client visits. A reduction in overall use of substances (P=.01) was reported by subjects in addition to a decrease in intensity of withdrawal symptoms including "shakes," stomach cramps, hallucinations, "muddle-headedness," insomnia, muscle aches, nausea, sweating, heart palpitations, and feeling suicidal, P
Mental health problems among adolescents have become a major public health issue, and it is therefore important to increase knowledge on the contextual determinants of adolescent mental health. One such determinant is the socioeconomic structure of the neighbourhood. The present study has two central objectives, (i) to examine if neighbourhood socioeconomic deprivation is associated to individual variations in utilisation of psychiatric care in a Swedish context, and (ii) to investigate if neighbourhood boundaries are a valid construct for identifying contexts that influence individual variations in psychiatric care utilization. Data were obtained from the Longitudinal Multilevel Analysis in Scania (LOMAS) database. The study population consists of all boys and girls aged 13-18 years (N=18,417), who were living in the city of Malmö, Sweden, in 2005. Multilevel logistic regression analysis was applied to estimate the probability of psychiatric care utilisation. The results from the study indicate that the neighbourhood of residence had little influence on psychiatric care utilisation. Although we initially found a variation between neighbourhoods, this general contextual effect was very small (i.e. 1.6%). The initial conclusive association between the neighbourhood level of disadvantage and psychiatric care utilisation (specific contextual effect) disappeared following adjustment for individual and family level variables. Our results suggest the neighbourhoods in Malmö (at least measured in terms of SAMS-areas), do not provide accurate information for discriminating adolescents utilisation of psychiatric care. The SAMS-areas appears to be an inappropriate construct of the social environment that influences adolescent utilisation of psychiatric care. Therefore, public health interventions should be directed to the whole city rather than to specific neighbourhoods. However, since geographical, social or cultural contexts may be important for our understanding of adolescent mental health further research is needed to identify such contexts.
Cites: J Epidemiol Community Health. 2009 Dec;63(12):1043-819666637
Using questionnaires, we analyzed associations between different pain variables (e.g., pain intensity) and age (20-65+ years) among 949 primary pain patients. Older patients (a) were more often divorced, were blue-collar workers, were less educated, and had greater difficulties with living expenses; (b) had pain of longer duration, more frequently and of more complexity, and felt more disabled; (c) consumed more painkillers, analgesics, sedatives, and other medications, and had received more pain treatments; and (d) had more health problems. Younger patients had more severe pain, were financially strained, and were more often unemployed. A multivariate regression analysis showed that high disability was more determined by older than young age. However, other factors (e.g., pain complexity) were also important. Thus, older and younger patients experienced their pain differently
The nexus between substance use and aggressive crime involves a complex interrelationship among mediating individual and community-level variables. Using multilevel logistic regression models, we investigate how community-level concentration of poverty variables mediate the predictive relationships among individual level social attachment variables and substance use on aggressive crime in a large national sample of male arrestees (N = 20,602) drawn from 24 U.S. urban areas. The findings support our hypothesis that individual social attachments to marriage and the labor force (education and employment) are the principal individual-level pathway mediating the substance abuse/aggression nexus. In the random intercept model, 3.17% of the variation not explained by the individual-level predictor variables is attributable to community-level variation in urban area female-headed households and households receiving welfare. This confirms our hypothesis that social structural conditions of an urban environment differentially expose persons to conditions that predict being arrested for an aggressive crime. Our findings tend to counter the cultural theorists who argue for an indigenous culture of violence in inner-city ghettos and barrios.
Area-based socio-economic status (SES) measures are frequently used in epidemiology. Such an approach assumes socio-economic homogeneity within an area. To quantify the agreement between area-based SES measures and SES assessed at the individual level, we conducted a cross-sectional study of 943 children who resided in 155 small enumeration areas and 117 census tracts from 18 schools in Montreal, Quebec. We used street address information together with 1986 census data and parental occupation to establish area-based and individual level SES indicators, respectively. As compared with the SES score determined at the level of the individual, 13 different area-based SES indices classified the children within the same quintile 28.7% (+/- 2.8%) of the time. The discrepancy was within one quintile in 35.3% (+/- 2.3%) of cases, two quintiles in 20.6% (+/- 3.6%), three quintiles in 11.3% (+/- 4.2%) and four quintiles in 4.1% (+/- 0.2%). In conclusion, we observed a substantial discrepancy between area- based SES measures and SES assessed at the individual level. Caution should therefore be used in designing or interpreting the results of studies in which area-based SES measures are used to test hypotheses or control for confounding.
Researchers and public health officials in Canada, the United States and Australia have for some time noted broader geographic accessibility to gambling establishments, above all in socioeconomically underprivileged communities. This increase in availability could lead to more and more gambling problems. This article focuses, in an ecological perspective, in particular on a spatial analysis of the geographic accessibility of sites possessing a VLT permit in the Montréal area, i.e. Montréal Island, the South Shore and Laval, from the standpoint of the development of an indicator of the vulnerability (socioeconomic components and demographic components) to gambling of populations at the level of certain neighbourhood units (dissemination areas). With the recent development of geographic information systems (GIS), it is now possible to ascertain accessibility to services much more accurately, for example by taking into account the configuration of the road network.
The findings of our analysis reveal widespread geographic accessibility to sites possessing a VLT permit in the downtown area and in pericentral districts. In some neighbourhood units, a site possessing a VLT permit may be within a three-minute walk. In the region studied overall, average walking time to a VLT site is nine minutes. Access to this type of service on foot is usually limited in the outskirts. However, a number of groups of sites possessing VLT permits are found along certain axial highways. According to local spatial self-correlation analyses, the findings suggest a significant link between walking accessibility to sites possessing VLT permits and the vulnerability of the communities. In a number of neighbourhood units with ready access to VLT's the populations display high vulnerability.
These findings reveal that accessibility to sites possessing a VLT permit is often linked to the vulnerability (socioeconomic and demographic components) of communities. Reliance in our analyses on neighbourhood units with fairly small areas enabled us to emphasize the rectilinear dimension of the spatial distribution of sites possessing VLT permits. This is a significant link that public health officials must consider when elaborating programs to combat pathological gambling.
Cites: J Epidemiol Community Health. 2001 Feb;55(2):111-2211154250
This study of cancer survival compared adults in Toronto, Ontario and three US metropolitan areas: Seattle, Washington; San Francisco, California; and Hartford, Connecticut. It examined whether socioeconomic status has a differential effect on cancer survival in Canada and the United States.
The Ontario Cancer Registry and the National Cancer Institute's Surveillance, Epidemiology and End
(SEER) programme provided a total of 23,437 and 37,329 population-based primary malignant cancer cases for the Toronto and US samples, respectively (1986-1988, followed until 1994). Census-based measures of socioeconomic status were used to ecologically control absolute income status.
Among residents of low-income areas, persons in Toronto experienced a 5 year survival advantage for 13 of 15 cancer sites [minimally one gender significant at 95 per cent confidence interval (CI)]. An aggregate 35 per cent survival advantage among the Canadian cohort was demonstrated (survival rate ratio (SRR) = 1.35, 95 per cent CI= 1.30-1.40), and this effect was even larger among younger patients not yet eligible for Medicare coverage in the United States (SRR = 1.46, 95 per cent CI = 1.40-1.52).
Systematically replicating a previous Toronto-Detroit comparison, this study's observed consistent pattern of Canadian survival advantage across various cancer sites suggests that their more equitable access to preventive and therapeutic health care services may be responsible for the difference.
Greater area-level relative deprivation has been related to poorer health behaviours, but studies specifically on alcohol use and abuse have been equivocal. The main purpose of the present study was to investigate how area-level relative deprivation in Denmark relates to alcohol use and misuse in the country.
As individual-level data, we used the national alcohol and drug survey of 2011 ( n= 5133). Data were procured from Statistics Denmark to construct an index of relative deprivation at the parish level ( n=2119). The deprivation index has two components, which were divided into quintiles. Multilevel linear and logistic regressions analysed the influence of area deprivation on mean alcohol use and hazardous drinking, as measured by the Alcohol Use Disorder Identification Test.
Men who lived in parishes designated as 'very deprived' on the socioeconomic component were more likely to consume less alcohol; women who lived in parishes designated as 'deprived' on the housing component were less likely to drink hazardously. But at the individual level, education was positively related to mean alcohol consumption, and higher individual income was positively related to mean consumption for women. Higher-educated men were more likely to drink hazardously.
Area-level measures of relative deprivation were not strongly related to alcohol use, yet in the same models individual-level socioeconomic variables had a more noticeable influence. This suggests that in a stronger welfare state, the impact of area-level relative deprivation may not be as great. Further work is needed to develop more sensitive measures of relative deprivation.