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      Cancer prevention in people experiencing homelessness: ethical considerations and experiences from the CANCERLESS project

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          Abstract

          The incidence of cancer in Europe has been increasing in recent years. Despite this, cancer prevention has remained a low priority in health policies. Cancer is one of the main causes of mortality among people experiencing homelessness, who continue to have difficulties accessing prevention programs. A strategy that has been tested to favor cancer prevention is the health navigator figure. The objective of CANCERLESS project is to implement this model among populations experiencing homelessness in four European countries to foster the prevention and early detection of cancer. In this perspective, a presentation of CANCERLESS project is made, and its ethical aspects are discussed according to the ethics of public health, the ethics of care, solidarity, relational autonomy, and the social recognition of the virtue of just generosity. The ethical foundations of CANCERLESS project are rooted in social justice and in equity in access to health systems in general and cancer screening programs in particular. The ethics of public health guided by utilitarianism are insufficient in serving the interests of the most disadvantaged groups of the population. Hence, it is necessary to resort to relational bioethics that includes the ethics of care and solidarity and that recognizes the moral identity of socially excluded persons, reaffirming their position of equality in society. Relational autonomy therefore provides a broader conception by including the influence of living conditions in decisions. For this reason, the CANCERLESS project opts for a dialogue with those affected to incorporate their preferences and values into decisions about cancer prevention.

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          Most cited references34

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          Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018

          Europe contains 9% of the world population but has a 25% share of the global cancer burden. Up-to-date cancer statistics in Europe are key to cancer planning. Cancer incidence and mortality estimates for 25 major cancers are presented for the 40 countries in the four United Nations-defined areas of Europe and for Europe and the European Union (EU-28) for 2018.
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            A comprehensive assessment of health care utilization among homeless adults under a system of universal health insurance.

            We comprehensively assessed health care utilization in a population-based sample of homeless adults and matched controls under a universal health insurance system. We assessed health care utilization by 1165 homeless single men and women and adults in families and their age- and gender-matched low-income controls in Toronto, Ontario, from 2005 to 2009, using repeated-measures general linear models to calculate risk ratios and 95% confidence intervals (CIs). Homeless participants had mean rates of 9.1 ambulatory care encounters (maximum = 141.1), 2.0 emergency department (ED) encounters (maximum = 104.9), 0.2 medical-surgical hospitalizations (maximum = 14.9), and 0.1 psychiatric hospitalizations per person-year (maximum = 4.8). Rate ratios for homeless participants compared with matched controls were 1.76 (95% CI = 1.58, 1.96) for ambulatory care encounters, 8.48 (95% CI = 6.72, 10.70) for ED encounters, 4.22 (95% CI = 2.99, 5.94) for medical-surgical hospitalizations, and 9.27 (95% CI = 4.42, 19.43) for psychiatric hospitalizations. In a universal health insurance system, homeless people had substantially higher rates of ED and hospital use than general population controls; these rates were largely driven by a subset of homeless persons with extremely high-intensity usage of health services.
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              Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study

              Objective To examine mortality in a representative nationwide sample of homeless and marginally housed people living in shelters, rooming houses, and hotels. Design Follow-up study. Setting Canada 1991-2001. Participants 15 100 homeless and marginally housed people enumerated in 1991 census. Main outcome measures Age specific and age standardised mortality rates, remaining life expectancies at age 25, and probabilities of survival from age 25 to 75. Data were compared with data from the poorest and richest income fifths as well as with data for the entire cohort Results Of the homeless and marginally housed people, 3280 died. Mortality rates among these people were substantially higher than rates in the poorest income fifth, with the highest rate ratios seen at younger ages. Among those who were homeless or marginally housed, the probability of survival to age 75 was 32% (95% confidence interval 30% to 34%) in men and 60% (56% to 63%) in women. Remaining life expectancy at age 25 was 42 years (42 to 43) and 52 years (50 to 53), respectively. Compared with the entire cohort, mortality rate ratios for men and women, respectively, were 11.5 (8.8 to 15.0) and 9.2 (5.5 to 15.2) for drug related deaths, 6.4 (5.3 to 7.7) and 8.2 (5.0 to 13.4) for alcohol related deaths, 4.8 (3.9 to 5.9) and 3.8 (2.7 to 5.4) for mental disorders, and 2.3 (1.8 to 3.1) and 5.6 (3.2 to 9.6) for suicide. For both sexes, the largest differences in mortality rates were for smoking related diseases, ischaemic heart disease, and respiratory diseases. Conclusions Living in shelters, rooming houses, and hotels is associated with much higher mortality than expected on the basis of low income alone. Reducing the excessively high rates of premature mortality in this population would require interventions to address deaths related to smoking, alcohol, and drugs, and mental disorders and suicide, among other causes.
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                Author and article information

                Contributors
                URI : https://loop.frontiersin.org/people/2700546/overviewRole: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/2638077/overviewRole: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/2633983/overviewRole: Role: Role: Role: Role: Role: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/2324295/overviewRole: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/894225/overviewRole: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/2701737/overviewRole: Role: Role: Role: Role:
                URI : https://loop.frontiersin.org/people/872421/overviewRole: Role: Role: Role: Role:
                Journal
                Front Public Health
                Front Public Health
                Front. Public Health
                Frontiers in Public Health
                Frontiers Media S.A.
                2296-2565
                08 April 2024
                2024
                : 12
                : 1371505
                Affiliations
                [1] 1Healthcare Center Las Cortes, Gerencia 1 Healthcare Center Las Cortes, Gerencia Asistencial de Atención Primaria , Madrid, Spain
                [2] 2Facultad de Medicina, Francisco de Vitoria University , Madrid, Spain
                [3] 3B21-20R Group, Instituto Aragonés de Investigaciones Sanitarias, Universidad de Zaragoza , Zaragoza, Spain
                [4] 4Foundation for Biosanitary Research and Innovation in Primary Care (FIIBAP) , Madrid, Spain
                [5] 5Health Work Department, Complutense University of Madrid , Madrid, Spain
                [6] 6Faculty of Health, Camilo José Cela University , Madrid, Spain
                [7] 7Gregorio Marañón Health Research Institute , Madrid, Spain
                [8] 8Research Network on Chronicity, Primary Care and Prevention and Health Promotion, Carlos III Health Institute , Madrid, Spain
                [9] 9International Foundation for Integrated Care , Oxford, United Kingdom
                [10] 10International University of Valencia , Valencia, Spain
                [11] 11Complutense University of Madrid , Madrid, Spain
                [12] 12Department of Social and Preventive Medicine, Medical University of Vienna , Vienna, Austria
                Author notes

                Edited by: Andrew Scott LaJoie, University of Louisville, United States

                Reviewed by: Gabriel Madeira Werberich da Silva, National Cancer Institute (INCA), Brazil

                *Correspondence: Jaime Barrio-Cortes, jaime.barrio@ 123456salud.madrid.org
                Article
                10.3389/fpubh.2024.1371505
                11036339
                38655508
                82e8875d-759e-4311-bcd5-90495772001d
                Copyright © 2024 Coronado-Vázquez, Gómez-Trenado, Benito-Sánchez, Barrio-Cortes, Gil-Salmerón, Amengual-Pliego and Grabovac.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                : 16 January 2024
                : 25 March 2024
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 43, Pages: 6, Words: 5173
                Funding
                The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This project received a grant for English editing and publication from the Foundation for Biosanitary Research and Innovation in Primary Care. CANCERLESS has been funded by the European Union’s Horizon 2020 Programme under the Grant Agreement GA 965351. The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the opinion of the European Union.
                Categories
                Public Health
                Perspective
                Custom metadata
                Life-Course Epidemiology and Social Inequalities in Health

                homelessness,vulnerability,cancer prevention,autonomy,equity,public health,ethics,care

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