A Step towards Understanding and Tackling Health Inequalities: The Use of Secondary Prevention Services and the Need for Health Promotion in a Rural Setting

Round 1

Reviewer 1 Report

This study explores of the use of and barriers to cancer prevention and public health services in deprived rural populations in Poland. The work is interesting, clear, and well-written. The introduction provides enough background. The objective is clear enough. The Methods section provides sufficient details. The Results and Discussion are correctly described. I only have some minor observations that are listed in the following lines.

1. Title: Consider rewriting.
2. Throughout the manuscript, avoid starting a sentence with a number that is not written out.
3. The conclusions section is too long. Rewrite in a more concise way to focus on the major findings of the study and future remarks.
4. Add a list of abbreviations.

Author Response

Dear Sir or Madam,

 

Thank you very much for your positive response to the manuscript and for your valuable comments. We have responded to them below.

 

Reviewer 1: This study explores of the use of and barriers to cancer prevention and public health services in deprived rural populations in Poland. The work is interesting, clear, and well-written. The introduction provides enough background. The objective is clear enough. The Methods section provides sufficient details. The Results and Discussion are correctly described. I only have some minor observations that are listed in the following lines.

 

Thank you.

 

1. Title

Reviewer 1: Title: Consider rewriting.

 

We have rethought the title and decided to change it as follows:

 

The access to secondary prevention in a rural setting: A step towards understanding and redressing health inequalities in disadvantaged populations 

 

A step towards understanding and tackling health inequalities: The use of secondary prevention services and the need for health promotion in a rural setting

 

We believe that the “use of” better reflects the scope of our study than “access to”. We have also added an important aspect of our study (“need for health promotion”).

 

2. The whole manuscript

Reviewer 1: Throughout the manuscript, avoid starting a sentence with a number that is not written out.

 

Thank you. We have corrected the manuscript as advised.

 

3. Conclusions

Reviewer 1: The conclusions section is too long. Rewrite in a more concise way to focus on the major findings of the study and future remarks.

 

We have shortened this section by about a third. We hope that it will now be easier for the reader to focus on the most important conclusions.

 

4. Abbreviations

Reviewer 1: Add a list of abbreviations.

 

We have added the list as requested.

 

We are very grateful for your input. We do hope that the corrections guided by your comments have improved the quality of our manuscript.

 

Yours faithfully,

 

The authors

Author Response File: Author Response.docx

Reviewer 2 Report

The main thing to improve this paper would be to include a more comprehensive and detailed description and analysis of the study site districts themselves, in terms of their conduciveness or lack of conduciveness for maintaining regular health-supporting behaviors. If there are walking trails, linear parks, bicycle-friendly roadways etc. that are freely and publicly accessible it makes a difference in promoting the development of local cultures of health. Rural, poor, and underdeveloped may be accurate descriptors but they don't help readers with visualizing the relevant (and geographically nested) contexts. The rural/urban differences described would seem to point to the same matter. Infrastructural development such as rails to trails (converting unused and abandoned railroad lines for bicycling and pedestrian use) can help poorer areas a lot with modest investment. For an example in my own location, see https://ecocitiesemerging.org/the-swamp-rabbit-trail-healthy-economy-and-lifestyle/

On the other hand, a motor-vehicle dominated infrastructure discourages healthy lifestyles among those with modest means. Kolo, Poland is a very different place than Greenville, South Carolina but people must move their bodies to be healthy and infrastructure can be either enabling or disabling for helping meet that need. My overall recommendation is for major revision because the context and it's effects are not adequately described and analyzed.

Minor edits: line 60, "access to health prevention" seems not to be the intended meaning--replace with "access to preventative health care".

Lines 74-75: the transitional sentence here is awkward--also, by "commune" do you mean "community"?

Line 110: replace "had been" with "was"

Line 172: never begin a sentence with a numeral. Instead phrase it something like this: "Among our respondents, 43.4% said they attended..."

Line 330: Delete "It is a pity" (readers can see that for themselves) also "the years" can be deleted because 2017-2018 implies it already. (I would insert ",actually," after "was" and before "the only"

In all instances, delete "the" from "the Wielkopolskie province" (the definite article, "the", is improper English here.

Line 363, replace "and confirm that" with "confirming our choice of target location" (and delete "had been chosen well" since that's implied).

Author Response

Dear Sir or Madam,

 

Thank you very much for your valuable comments. We have responded to them below. Please note that some changes in the text required renumbering the lines in the manuscript. Wherever we refer to line numbers below, these are the numbers in the revised .pdf version of the manuscript.

 

Introduction

 

 

We agree that population health is shaped by the social context. It is true that while we had called the study site “rural” and “deprived”, we failed to provide the reader with enough detail to illustrate the context and to let them see the study site the way we were able to see it. That is why we have now described the study site in more detail and included immediate as well as some social determinants of inhabitants’ health: access to healthcare, education, and health-supporting infrastructure (lines 79-90). This way we have attempted to show that the setting is not conducive to healthy life choices.

We admit that in our study we did not analyse a wide range of social determinants of health. We focused mainly on the determinants related to the construction and functioning of the healthcare system. We have added that as a limitation of our study (lines 642-644).

Also, we would like to thank you for the examples of inspiring solutions that could make rural settings more pedestrian- or cyclist-friendly at a low cost. They are definitely worth discussing with local communities.

 

Introduction

Reviewer 2: line 60, "access to health prevention" seems not to be the intended meaning--replace with "access to preventative health care".

 

Thank you for the comment. We have corrected this fragment (line 64 now) accordingly.

 

Introduction

Reviewer 2: Lines 74-75: the transitional sentence here is awkward--also, by "commune" do you mean "community"?

 

We have changed this fragment as suggested. By “commune”, we meant gmina, an administrative unit in Poland (the second meaning in a definition here https://www.macmillandictionary.com/dictionary/american/commune_1#commune_5). We have added a short explanation in brackets for the sake of clarity (line 78).

 

Materials and Methods

Reviewer 2: Line 110: replace "had been" with "was"

 

We have corrected the wording (line 133).

 

Results

Reviewer 2: Line 172: never begin a sentence with a numeral. Instead phrase it something like this: "Among our respondents, 43.4% said they attended..."

 

Thank you. We have corrected this and other mistakes of the same kind.

 

Results

Reviewer 2: Line 330: Delete "It is a pity" (readers can see that for themselves) also "the years" can be deleted because 2017-2018 implies it already. (I would insert ",actually," after "was" and before "the only"

 

We have corrected the sentence as advised (lines 366-368).

 

The whole manuscript

Reviewer 2: In all instances, delete "the" from "the Wielkopolskie province" (the definite article, "the", is improper English here.

 

We have made the recommended corrections throughout the manuscript.

 

Discussion

Reviewer 2: Line 363, replace "and confirm that" with "confirming our choice of target location" (and delete "had been chosen well" since that's implied).

 

Thank you. We have corrected the sentence as advised (lines 398-400).

 

We are very grateful for your input. We do hope that the corrections guided by your comments have improved the quality of our manuscript.

 

Yours faithfully,

 

The authors

Author Response File: Author Response.docx

Reviewer 3 Report

Comments

This article focuses on one of the most important aspects of our lives – the state of health – and highlights the deep inequalities that exist within each country, in this case in a small rural area of ​​Poland. The persistence of social inequalities in health is an overly proven fact: people with higher levels of education, professional status or income have morbidity (relationship between the number of cases of a disease and the total number of individuals in a given population, in a at any given time or over a period) lower and a longer life expectancy. Although this is true in all societies at a global level, the degree of inequalities varies geographically, and we can observe significant differences within the European space. (e.g., Eikemo et al. 2008 - "Health inequalities according to educational level in different welfare regimes: a comparison of 23 European countries", Sociology of Health & Illness, 30(4), 565-582; Eikemo et al. 2008 - "The potential impact of a social redistribution of specific risks on socioeconomic inequalities in mortality", https://calls.ac.uk/wp-content/uploads/120693.pdf.; Huijts et al. 2011, "The First Pan-European Sociological Health Inequalities Survey of the General Population: The European Social Survey Rotating Module on the Social Determinants of Health", Working title, https://academic.oup.com/esr/article/33/1/137/2525456.; Sarah Van de Velde, et al. 2010 - "Gender differences in depression in 23 European countries: Cross-national variation in the gender gap in depression", DOI: 10.1016/j.socscimed.2010.03.035; https://pubmed.ncbi.nlm.nih.gov/ 20483518/.)
It was concluded that individuals belonging to groups with lower socioeconomic status have worse health and that, on the other hand, there are different patterns of inequality in the cross-border comparison. The use of health care covers more precise questions, such as a) you talked about your health with a general practitioner in the last 12 months, b) talked about your health with a specialty doctor in the last 12 months, c) was unable to have the medical appointment or treatment she needed in the past 12 months, d) reasons why she was unable to have the medical appointment or treatment she needed in the past 12 months, e) alternative treatments used in the past 12 months (to be chosen out of 12 types of treatments listed), f) Health problems (according to the list provided) limiting daily activities in the past 12 months, eg) cancer (currently or in the past).

Suggestions

Despite the fact that this is a very limited rural Polish area, to better understand how and why social inequalities in health persist, it is essential, however, to consider more differentiating health indicators and a broader spectrum of social determinants. Health surveys typically look at multiple health indicators and their determinants, but rarely if ever generate sufficient data on the social stratification system of each country or region, including more in-depth data on living conditions. In the sociological field, on the other hand, there is a lack or insufficiency of relevant data on various behavioral, lifestyle and health status factors (as with chronic diseases, e.g., specified in the article). All of this motivates the construction of a module on health inequalities expressly intended to integrate the permanent nucleus that includes fundamental stratification variables. In the future, they must prioritize potentially important factors identified in national studies, such as housing conditions, the use of alternative therapies and unpaid care.
The European Social Survey (ESS - European Social Survey - “Social Inequalities in Health and its Determinants”) offers a rare opportunity to carry out a comparative study on the contribution of multiple factors explaining the relationship between socioeconomic inequalities and health inequalities. It is quite clear that health status varies according to the socioeconomic groups considered, but it is important to explain these differences between groups. Most studies carried out on the subject in European countries focus mainly on behavioral risk factors and conclude that socioeconomic differences in smoking and sedentary lifestyle are the main drivers of health inequalities and the differences in magnitude observed in their spatial distribution and inequalities. There are undoubtedly good reasons for the predominance of this approach: the risk factors analysed can be measured with relative ease, their causal relationship with mortality is reasonably well documented, and they are factors that are sensitive to public intervention. However, there is still a perspective that neglects not only the underlying individual, collective and structural mechanisms that lead to the adoption of the behaviors in question, but also certain non-behavioral factors, eg, housing conditions, access to services or working conditions, with an impact on the prevalence of problematic health states. This suggests that these types of health determinants continue to contribute strongly to explaining inequalities in subjective health between groups with different levels of education. This is because health and health inequalities are deeply anchored in the social stratification systems of modern societies. Adopting income redistribution policies or improving physical working conditions in manual professions can prove equally effective in achieving healthier lives.

As an example, with the aim of identifying successful approaches to cancer prevention in terms of equity, FISABIO (the Foundation for the Promotion of Health and Biomedical Research in Valencia Region, Spain) launched in May 2019 a Contest of Best Practices tackling social inequalities in cancer prevention (iPAAC Contest of Best Practices tackling social inequalities in cancer prevention). It should be a good read for the authors of this article.

Author Response

Dear Sir or Madam,

 

Thank you very much for your valuable comments. We have responded to them below. Please note that some changes in the text required renumbering both the lines and the references in the manuscript. Wherever we refer to line or reference numbers below, these are the numbers in the revised .pdf version of the manuscript.

 

 

We admit that in our study we did not analyse a wide range of social determinants of health. We focused mainly on the determinants related to the construction and functioning of the healthcare system. We have listed that as a limitation of our study (lines 642-644). In addition, we have now described the study site in more detail and included a few social determinants of inhabitants’ health such as access to healthcare, education, and health-supporting infrastructure (lines 79-90). This way we have attempted to show that the setting is not conducive to healthy life choices.

 

Thank you very much for all your advice. We do hope that the corrections guided by your comments have improved the quality of our manuscript.

 

Yours faithfully,

 

The authors

Author Response File: Author Response.docx