Impact of an oral care subsidization reform on intersectional inequities in self-rated oral health in Sweden.

BACKGROUND: Oral health in Sweden is good at the population level, but seemingly with persisting or increasing inequities over the last decades. In 2008, a major Swedish reform introduced universal partial subsidies to promote preventive care and reduce the treatment cost for patients with extensive care needs. This study aimed to apply an intersectional approach to assess the impact of the 2008 subsidization reform on inequities in self-rated oral health among adults in Sweden over the period 2004-2018. METHODS: Data from 14 national surveys conducted over 2004-2018 were divided into three study periods: pre-reform (2004-2007), early post-reform (2008-2012) and late post-reform (2013-2018). The final study population was 118,650 individuals aged 24-84 years. Inequities in self-rated oral health were examined by intersectional analysis of individual heterogeneity and discriminatory accuracy across 48 intersectional strata defined by gender, age, educational level, income, and immigrant status. RESULTS: Overall, the prevalence of poor self-rated oral health decreased gradually after the reform. Gender-, education- and income-related inequities increased after the reform, but no discernible change was seen for age- or immigration-related inequities. The majority of intersectional strata experienced patterns of persistently or delayed increased inequities following the reform. CONCLUSIONS: Increased inequities in self-rated oral health were found in most intersectional strata following the reform, despite the seemingly positive oral health trends at the population level. Applying an intersectional approach might be particularly relevant for welfare states with overall good oral health outcomes but unsuccessful efforts to reduce inequities.

Exploring the Possible Impact of Oral Nutritional Supplements on Children's Oral Health: An In Vitro Investigation.

Eight pediatric oral nutritional supplements (ONSs) and 0.5% fat bovine milk were examined in vitro regarding their effect on the adhesion of three caries-related bacteria, Streptococcus mutans (strain CCUG 11877T), Lactobacillus gasseri (strain CCUG 31451), and Scardovia wiggsiae (strain CCUG 58090), to saliva-coated hydroxyapatite, as well as their pH and capacity to withstand pH changes. Bacteria were cultivated and radiolabeled. The adhesion assays used synthetic hydroxyapatite coated with whole or parotid saliva. Measurements of pH and titration of the products with HCl and NaOH were conducted in triplicate. Three ONSs promoted the S. mutans adhesion to saliva-coated hydroxyapatite (increase from 35% to >200%), supporting caries risk enhancement. S. wigssiae and L. gasseri adhered only to one and no ONS, respectively. Most supplements had limited buffering capacity to counteract acidification changes, suggesting their low capacity to neutralize acids, and one ONS showed a significant capacity to counteract basic changes, suggesting a high erosive potential. S. mutans adhesion was influenced by the ONS pH and volume NaOH added to reach pH 10. L. gasseri and S. wiggsiae adhesion was influenced by the ONSs' carbohydrate and fat content. Interdisciplinary efforts are needed to increase awareness and prevent the possible negative impact of ONSs on children's oral health.

Assessing inequities in unmet oral care needs among adults in Sweden: An intersectional approach.

OBJECTIVES: The goal of the Swedish oral healthcare system is to achieve good oral health and equitable access to care for the entire population. However, considerable inequities in oral health and care are evident and occur across a range of social dimensions. This study uses an intersectional approach to examine complex inequities in unmet oral care needs among adults in Sweden over the period 2004-2021. METHODS: Data were obtained from 14 Health on Equal Terms surveys conducted during 2004-2021. The final sample was 129 473 individuals aged 26-84 years. Applying intersectional analysis of individual heterogeneity and discriminatory accuracy, inequities in unmet oral care needs were estimated across 48 intersectional strata defined by gender, age, educational level, individual disposable income and immigrant status. RESULTS: A high risk of unmet oral care needs was found among strata consisting of immigrants and those with low income. However, being an immigrant and/or having a low income did not universally entail a high risk but varied by the social position along other axes, particularly age and education. The discriminatory accuracy was moderate. CONCLUSION: Groups with certain social disadvantages are highly heterogeneous themselves. An intersectionality approach is important to prevent the risk of stigmatizing large heterogenous groups while failing to identify the most vulnerable strata. The discriminatory accuracy analysis suggested that further policy and/or interventions may be the most effective if approaching the whole population, combined with selected targeted interventions directed at the most disadvantaged social strata.

Post-infectious fatigue following Puumala virus infection.

Background: Puumala virus infection or nephropathia epidemica (NE) is common in northern Sweden. NE causes haemorrhagic fever with renal syndrome. Most patients make a full recovery, but a convalescent phase with fatigue has been reported. Although post-infectious fatigue has been demonstrated for other viral infections, it is not well studied in relation to NE. This study assessed recovery time and levels of fatigue in former NE patients, as compared to the general population. Methods: NE patients diagnosed in northern Sweden between 2007 and 2011, together with a comparison sample from the general population, answered a questionnaire on demographic and health-related factors, including the Fatigue Severity Scale (FSS), and characteristics of NE infection. Self-reported recovery time was assessed, and fatigue levels were compared across the two groups by multiple linear regression, stratified by gender. Results: In total, 1132 NE patients and 915 comparison group subjects participated. Time to complete recovery was reported to exceed 3 months for 47% and 6 months for 32% of the NE patients. Recovery time differed by gender and age. NE patients had significantly higher FSS scores than the comparison group. Differences were greater among women than men, and adjustments for current illness, body mass index, smoking and current residence only slightly modified the estimates. Conclusions: Individuals with previous NE infection show higher fatigue scores than non-infected individuals, even 5 years following the infection. Full recovery takes half a year or longer for a substantial proportion of former NE patients.

Automatic classification of pediatric pneumonia based on lung ultrasound pattern recognition.

Pneumonia is one of the major causes of child mortality, yet with a timely diagnosis, it is usually curable with antibiotic therapy. In many developing regions, diagnosing pneumonia remains a challenge, due to shortages of medical resources. Lung ultrasound has proved to be a useful tool to detect lung consolidation as evidence of pneumonia. However, diagnosis of pneumonia by ultrasound has limitations: it is operator-dependent, and it needs to be carried out and interpreted by trained personnel. Pattern recognition and image analysis is a potential tool to enable automatic diagnosis of pneumonia consolidation without requiring an expert analyst. This paper presents a method for automatic classification of pneumonia using ultrasound imaging of the lungs and pattern recognition. The approach presented here is based on the analysis of brightness distribution patterns present in rectangular segments (here called "characteristic vectors") from the ultrasound digital images. In a first step we identified and eliminated the skin and subcutaneous tissue (fat and muscle) in lung ultrasound frames, and the "characteristic vectors"were analyzed using standard neural networks using artificial intelligence methods. We analyzed 60 lung ultrasound frames corresponding to 21 children under age 5 years (15 children with confirmed pneumonia by clinical examination and X-rays, and 6 children with no pulmonary disease) from a hospital based population in Lima, Peru. Lung ultrasound images were obtained using an Ultrasonix ultrasound device. A total of 1450 positive (pneumonia) and 1605 negative (normal lung) vectors were analyzed with standard neural networks, and used to create an algorithm to differentiate lung infiltrates from healthy lung. A neural network was trained using the algorithm and it was able to correctly identify pneumonia infiltrates, with 90.9% sensitivity and 100% specificity. This approach may be used to develop operator-independent computer algorithms for pneumonia diagnosis using ultrasound in young children.

Automatic pneumonia detection based on ultrasound video analysis.

Pneumonia is a disease which causes high mortality in children under five years old, particularly in developing countries. This paper proposes a novel application of ultrasound video analysis for the detection of pneumonia. This application is based on the processing of small video chunks, in which an image processing algorithm analyzes each frame to get some overall video statistics. Then, based on these quantities, the likeness of presence of pneumonia in the video is determined. The algorithm exploits different geometrical properties of typical anatomical and pathological features that commonly appear in lung sonography and which are already clinically typified in the literature. Our technique has been tested on different transverse thoracic scanning protocols and probe's maneuvers, thus, under a variety of clinical and usage protocols. Then, it can be targeted towards screening applications. We present encouraging results (AUC measure between 0.7851 and 0.9177) based on the analysis of 346 videos with an average duration of eight seconds. The analyzed videos were taken from children who were between three and five years old. Finally, our algorithm can be used directly as a classifier, but we detail how its performance may be enhanced if used as a first stage of a larger pipeline of other complementary pneumonia detection processes.

Anemia and malnutrition in indigenous children and adolescents of the Peruvian Amazon in a context of lead exposure: a cross-sectional study.

BACKGROUND: Indigenous children and adolescents of the Peruvian Amazon live in precarious conditions that could increase the risk of malnutrition. A particular problem in the Corrientes river communities is the high exposure to lead among children and adolescents. OBJECTIVE: This study aimed to determine the nutritional status of children and adolescents in indigenous communities in the Corrientes river basin and examine risk factors for anemia, stunting, underweight, and wasting. DESIGN: This was a cross-sectional assessment in children and adolescents aged 0-17 years from six communities (n=330). Data collection included measurement of hemoglobin levels, anthropometrics, blood lead levels (BLLs); a parental questionnaire including demographic and dwelling information; parents' occupation; and the child's duration of breastfeeding and food consumption. Analysis included univariate, bivariate, and logistic regression. RESULTS: Overall, anemia prevalence was 51.0%, stunting (proxy for chronic malnutrition) 50.0%, and underweight 20.0%. Bivariate analysis showed that anemia and underweight prevalence was higher in the 0-4 years group (p<0.05). No association was found between anemia, stunting, or underweight with gender, community exposure to oil activity, or consumption of river water. Stunting prevalence was higher in the group whose BLLs were >5 µg/dL (p<0.05). In the logistic regression analysis, no variable was associated with anemia or underweight. The group 5-11 years and >12 years had 1.9 and 3.1 times higher risk of stunting than the group under five years, respectively. Children and adolescents with BLLs >5 µg/dL had twice the risk of stunting compared to those with lower BLLs. CONCLUSIONS: Half of the study population was found with anemia and stunting. Anemia was more prevalent in the 0- to 5-year age group and stunting in the 12- to 17-year group. The association between stunting and BLLs might be attributed to a direct effect of lead on human growth. Also, poor nutrition and other socioeconomic-related factors may contribute to the simultaneous existence of stunting and elevated BLLs.

Easier said than done: challenges of applying the Ecohealth approach to the study on heavy metals exposure among indigenous communities of the Peruvian Amazon.

BACKGROUND: The renewed interest in community participation in health research is linked to its potential for bridging gaps between research and practice. Its main attributes are the generation of knowledge that can lead to socially robust, long-lasting solutions and the creation of a co-learner relationship between researchers and research users. Following this philosophy, Ecohealth has evolved into a specialized framework for participatory research on the impact of pollution on ecosystems and human health. However, its principles pose considerable challenges. Its outcomes are strongly influenced by contextual factors that are impossible to control for ahead of time.This paper describes how the Ecohealth principles were applied to an epidemiological study of heavy metals exposure among indigenous communities of the Peruvian Amazon. It illustrates how knowledge generated from participatory research does not necessarily imply solving a public health problem. This study aimed to contribute to the understanding of the benefits and barriers of following the basic principles of the Ecohealth approach, and assist researchers working in similar contexts. RESEARCH PROCESS: Based upon their personal experience as participant observers, the authors describe the research process; then, they discuss the most important challenges faced, their implications, and the attempted strategies for resolution. CHALLENGES: Challenges were grouped into four themes: (1) building trust; (2) one partnership, many stakeholders, multiple agendas; (3) being a researcher; and (4) communicating complex and unexpected findings. CONCLUSIONS: Integrating the principles of transdisciplinarity and participation posed a series of challenges to the research process that were difficult, and sometimes impossible to overcome. However, positive outcomes from this experience were the lessons learned by the different actors. Despite the lack of immediate action, it is expected that useful interventions to prevent and control lead exposure in the Corrientes population will be implemented in the medium term.

Lead exposure among children from native communities of the Peruvian Amazon basin.

OBJECTIVE: To assess potential risk factors associated with elevated blood lead levels (BLLs) among children in two communities from the Corrientes River basin in the Peruvian Amazon. METHODS: Children aged 0-17 years were screened for BLLs, hemoglobin levels, and anthropometric measures. Dwelling, family, and child data were collected through a parental questionnaire. Statistical analysis included descriptive and bivariate analysis. Multiple linear and logistic regressions using generalized estimating equations were also conducted to determine associated risk factors. A map of each community was drawn to examine the spatial distribution of BLLs. RESULTS: Of 208 children (88 from 23 households of the Peruanito community and 120 from 28 households of Santa Isabel), 27.4% had BLLs > 10 µg/dL. The geometric mean (± standard deviation) BLL was 8.7 ± 4.0 µg/dL (range 3.0-26.8 µg/dL). In the total population, linear regression analysis indicated that age was positively associated with BLLs (P < 0.05). Logistic regression analysis showed that boys had 2.12 times greater odds of having BLLs > 10 µg/dL than girls (P < 0.05). Among the children 0-3 years, those whose mothers had BLLs > 10 µg/dL had 45.0% higher odds of presenting BLLs > 10 µg/dL than children whose mothers had BLLs < 10 µg/dL (P < 0.05). CONCLUSIONS: Older age, male gender, and mothers' BLL > 10 µg/dL were the main risk factors for elevated BLLs. The higher risk in boys 7-17 years suggests that exposure could be related to specific activities in this group, such as fishing and hunting. Continuous monitoring of BLLs in the Corrientes River population is recommended.

Lead exposure among children from native communities of the Peruvian Amazon basin / Exposición al plomo en niños de comunidades indígenas de la cuenca del Amazonas en el Perú

Objective. To assess potential risk factors associated with elevated blood lead levels (BLLs) among children in two communities from the Corrientes River basin in the Peruvian Amazon.Methods. Children aged 0–17 years were screened for BLLs, hemoglobin levels, and anthropometric measures. Dwelling, family, and child data were collected through a parental questionnaire. Statistical analysis included descriptive and bivariate analysis. Multiple linear and logistic regressions using generalized estimating equations were also conducted to determine associated risk factors. A map of each community was drawn to examine the spatialdistribution of BLLs. Results. Of 208 children (88 from 23 households of the Peruanito community and 120 from28 households of Santa Isabel), 27.4% had BLLs ≥ 10 μg/dL. The geometric mean (± standard deviation) BLL was 8.7 ± 4.0 μg/dL (range 3.0–26.8 μg/dL). In the total population, linearregression analysis indicated that age was positively associated with BLLs (P < 0.05). Logistic regression analysis showed that boys had 2.12 times greater odds of having BLLs ≥ 10 μg/dLthan girls (P < 0.05). Among the children 0–3 years, those whose mothers had BLLs ≥ 10 μg/ dL had 45.0% higher odds of presenting BLLs ≥ 10 μg/dL than children whose mothers had BLLs < 10 μg/dL (P < 0.05). Conclusions. Older age, male gender, and mothers’ BLL ≥ 10 μg/dL were the main risk factors for elevated BLLs. The higher risk in boys 7–17 years suggests that exposure could berelated to specific activities in this group, such as fishing and hunting. Continuous monitoring of BLLs in the Corrientes River population is recommended.

Objetivo. Evaluar los potenciales factores de riesgo asociados con niveles elevados de plomo en sangre (Pbs) en niños de dos comunidades de la cuenca del río Corrientes en la Amazonia peruana. Métodos. Se estudiaron de manera sistemática los niveles de PbS, la concentración de hemoglobina y las medidas antropométricas en niños de 0 a 17 años. A través de un cuestionario efectuado a los padres se recopilaron datos sobre la vivienda, la familiay los niños. El análisis estadístico incluyó el análisis descriptivo y de dos variables. También se llevaron a cabo análisis de regresión logística y lineal múltiple usando ecuaciones predictivas generales para determinar los factores de riesgo asociados. Se trazó un mapa de cada comunidad para examinar la distribución espacial de los niveles de PbS. Resultados. De 208 niños (88 de 23 hogares de la comunidad de Peruanito y 120 de 28 hogares de Santa Isabel), 27,4% presentaron niveles de PbS ≥ 10 μg/dL. La mediageométrica (± desviación estándar) de los niveles de PbS fue 8,7 μg/dL ± 4,0 (amplitud 3,0 a 26,8 μg/dL). En la población total, el análisis de regresión lineal indicó que la edad se asociaba de manera positiva con los niveles de PbS (P < 0,05). El análisis de regresión logística demostró que los varones presentaron una probabilidad 2,12 vecesmayor de tener niveles de PbS ≥ 10 μg/dL que las niñas (P < 0,05). En los niños de ambos sexos de 0 a 3 años, aquellos cuyas madres tuvieron niveles de PbS ≥ 10 μg/ dL presentaron 45,0% más probabilidades de exhibir niveles de PbS ≥ 10 μg/dL que los niños cuyas madres tuvieron niveles de PbS < 10 μg/dL (P < 0,05).

Sources and risk factors for lead exposure in indigenous children of the Peruvian Amazon, disentangling connections with oil activity.

INTRODUCTION: In the Corrientes river basin, Peruvian Amazon, lead exposure among indigenous communities was first reported in 2006. To address controversy regarding the main source of exposure, this study aimed to identify the sources and risk factors for lead exposure among children from the communities in question, and to clarify the potential relationship with oil activity. METHODS: This cross-sectional study was conducted in six communities. Participants were children aged 0-17 years and their mothers. Data collection included blood lead levels (BLLs) and hemoglobin determination, a questionnaire on risk factors and environmental sampling. We used age-stratified multivariate regression models, with generalized estimating equation to account for correlation within households. RESULTS: Twenty-seven percent of the children had BLLs ≥10 µg/dl. Mother's BLLs ≥10 µg/dl, playing and chewing lead scraps, fishing ≥three times/week, and living in highly oil-exposed communities increased the risk of having BLLs ≥10 µg/dl. Lead concentrations in sediment, soil, dust, and fish samples were below reference values. CONCLUSIONS: Mother's BLLs ≥10 µg/dl, playing and chewing lead scraps to manufacture fishing sinkers were the most important risk factors for children's BLLs ≥10 µg/dl. The connection with oil activity appears to be through access to metal lead from the industry's wastes.

Lead exposure in indigenous communities of the Amazon basin, Peru.

Since 2006, three studies have reported elevated levels of lead (Pb) among the indigenous population of the Corrientes river, in the Amazon basin of Peru. Due to the large evidence of environmental pollution related to oil exploitation in the area, this activity has been suggested as the source of exposure. This study aimed to evaluate Pb levels in the population and environment of two communities exposed and one community non-exposed to the oil exploitation activity. Blood lead levels (BLL) were determined by the instrument Leadcare. A comparison with the graphite furnace atomic absorption technique was performed in order to validate the Leadcare results. Environmental samples were analyzed by inductively coupled plasma atomic emission spectroscopy. Among 361 capillary samples, the mean BLL was 9.4 µg/dl. Mean BLL of the communities exposed (n=171, x¯=9.5 µg/dl) and non-exposed (n=190, x¯=9.2 µg/dl) to the oil activity were not significantly different. Pb levels in environmental samples were below the maximum permissible levels. The sources of exposure could not be identified. Elevated levels of Pb in the oil-non-exposed community pointed out at other sources not yet clarified.