Socioeconomic and geographic inequalities in colorectal cancer in Cyprus: An ecological study

Abstract Background Colorectal cancer (CRC) is one of the main causes of mortality and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The aim of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socio-economic inequalities in Cyprus for the periods between 2000 and 2015. Methods A small area ecological study in Cyprus, with census tracts as units of spatial analysis, for the period between 2000 and 2015. The incidence date, sex, age, post code, primary site, death date in case of death or last contact date in case of alive for all cases of CRC from 2000-2015 were obtained from the Cyprus Ministry of Health. Indirect standardization was used to calculate the sex and age Standardize Incidence Ratios (SIRs) and Standardized Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. Results There are geographical areas having 15% higher SIR and SMR, with most of those areas located at the east coast of the island. Higher M/I ratio values were found in the rural, remote, and less dense areas of the island while lower rates were observed in the metropolitan areas. An inverted U-shape pattern in CRC incidence and mortality was observed with higher rates in the areas classified in the second quartile of the socio-economic deprivation index and lower rates in rural, remote, and less dense areas. A different pattern emerged in the M/I ratio indicating a stepwise increase across increasing levels of socioeconomic deprivation. Conclusions These findings can potentially provide useful information at local and national levels and can inform public health authorities to appropriately allocate resources for geographically targeted prevention and control plans to increase CRC screening. Key messages • M/I ratio of CRC was positively associated with regional deprivation since a stepwise increase was found across increasing levels of rural-related socioeconomic deprivation. • Interventions aimed at reducing the risks of CRC should primarily focus on socially deprived communities in Cyprus.

There is great urgency for action to achieve the Sustainable Development Goals, especially in fragile settings, which face acute and complex challenges. Yet, the public sector may be limited in its capacity to address these appropriately, with devastating effects on the health of people and environment now and in the future. The challenges to sustainable health require professionals who are trained relevant competences. In 2020, Karolinska Institutet, Sweden, and Makerere University, Uganda, developed the Centre of Excellence for Sustainable Health under which a new partnership was established with Benadir University, Somalia, Kinshasa School of Public Health, the Democratic Republic of Congo, and Tinkr, Norway to develop training on innovation for sustainable health. The aim of ''Managing Innovation for Sustainable Health'' (MISH) is to strengthen the capacity to contribute to achieving sustainable health through innovation in the public sector. It targets managers in Somalia, DRC and Uganda from the public and private sector, academia, and civil society. It is one year long, part-time and delivered online with one study trip. It features three modules covering Agenda 2030 and Sustainable Health; Multisectoral Collaboration and Implementation Science; and Innovation and Innovation Management. Integration of participants' learnings into their professional role, mutual learning between participants, and an emphasis on applicability, all underpin the learning strategies of the program. Quality is monitored through expectation surveys, baseline mid and final impact assessments, module and final program evaluations. MISH has trained about 50 managers, 85% of which say that the training was useful. All partners are represented in both operational and strategic organizational bodies of the program. Our model shows what is possible through collaborative online international learning delivered by partnerships defined by teamwork, trust, and a dedication to true impact.

Key messages:
There is great urgency for action to achieve sustainable health especially in fragile settings. There is momentum for higher education to leverage the opportunities of the covid-19 to rethink learning for the global challenges.

Background:
Colorectal cancer (CRC) is one of the main causes of mortality and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The aim of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socio-economic inequalities in Cyprus for the periods between 2000 and 2015. Methods: A small area ecological study in Cyprus, with census tracts as units of spatial analysis, for the period between 2000 and 2015.
The incidence date, sex, age, post code, primary site, death date in case of death or last contact date in case of alive for all cases of CRC from 2000-2015 were obtained from the Cyprus Ministry of Health. Indirect standardization was used to calculate the sex and age Standardize Incidence Ratios (SIRs) and Standardized Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model.

Results:
There are geographical areas having 15% higher SIR and SMR, with most of those areas located at the east coast of the island. Higher M/I ratio values were found in the rural, remote, and less dense areas of the island while lower rates were observed in the metropolitan areas. An inverted U-shape pattern in CRC incidence and mortality was observed with higher rates in the areas classified in the second quartile of the socio-economic deprivation index and lower rates in rural, remote, and less dense areas. A different pattern emerged in the M/I ratio iii453 indicating a stepwise increase across increasing levels of socioeconomic deprivation.

Conclusions:
These findings can potentially provide useful information at local and national levels and can inform public health authorities to appropriately allocate resources for geographically targeted prevention and control plans to increase CRC screening. Key messages: M/I ratio of CRC was positively associated with regional deprivation since a stepwise increase was found across increasing levels of rural-related socioeconomic deprivation.
Interventions aimed at reducing the risks of CRC should primarily focus on socially deprived communities in Cyprus.

Background:
The COVID-19 pandemic caused severe disruptions in healthcare systems and societies and exacerbated existing inequalities for women and girls across every sphere. Our study explores health systems responses to gender equality goals during the COVID-19 pandemic and which role these goals play in pandemic recovery policies.

Methods:
We apply a qualitative comparative approach. Country case studies (expert information, secondary sources) were collected in March/April 2022. The sample comprised Australia, Brazil, Germany, United Kingdom and USA, reflecting conditions of high to upper-middle income countries with established public health systems, democratic political institutions and gender equality policies. Selected topics: maternity care/reproductive services, violence against women, and gender equality/female leadership.

Results:
All countries tried to keep essential maternity and reproductive services open, but strong limitations applied especially for prevention and counselling services; at the same time, digitalisation/telemedicine supported service expansion. Violence against women and children strongly increased during the pandemic. Routine services were partly kept open and new helplines occasionally established, but no action was taken to scale-up mental health support and respond to new demand. A push-back of gender equality was observed across countries in all areas of health and social care, often coupled with strong increase in intersecting social inequalities; participation of women in decision-making bodies was generally weak and not monitored.

Conclusions:
Across countries, gender equality policies cracked under the pressure of the COVID-19 pandemic; this is true for countries with male and female political leaders, and for different areas of SDG5 and health. There is an urgent need for more effective intersectional gender equality policies and improved participation of women in global health and in health system recovery plans.

Key messages:
Health systems failed to take action to protect SDG5 goals; gender and intersecting inequalities strongly increased during the pandemic. Building back better after COVID-19 will only be possible with an intersectional gender equality programme and feminist policy approaches.

Background:
Estimates suggest that numerous people live without health insurance in Germany. Existing evidence on uninsured patients' health and care use is scarce, specifically in Germany. The present study involves citizens' engagement to identify community perceptions of factors associated with health and medical care and to generate community-driven policy recommendations.

Methods:
Representatives of civil society, affected patients and citizens ('co-researchers') participate in a participatory health research project (MoveCitizenS) located in Bonn, Germany, using Photovoice and Community-based Mapping. The study is composed of five work packages over a 24-month period: (1) Photovoice workshops for co-researchers to produce, select and analyse photographs; (2) a series of workshops to conduct community-based mapping to identify barriers and facilitators of health care utilization; (3) workshops to co-design a crosssectional survey of uninsured patients (n = 300); (4) project evaluation by co-researchers; (5) a dissemination strategy (e.g. advocacy event, exhibition) will be developed.

Results:
Procedures to facilitate the active engagement of citizens and patients are discussed. Preliminary results on community perceptions of uninsured patients' health and medical care and factors influencing health outcomes and care utilization are presented at the conference.

Conclusions:
This is the first citizen science study which facilitates the understanding of barriers and enabling factors of good health and access to medical care for patients who lack health insurance coverage in Germany. This case study of a participatory project can be adapted to a range of settings to integrate local perspectives to improve population health for all. Key messages: Numerous patients in Germany are uninsured but evidence on their health and medical care is lacking. Using participatory methods to address these key questions is an important approach to generate suitable policy recommendations to meet the needs of the community and improve population health.