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Teledermatology reduces dermatology referrals and improves access to specialists

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Teledermatology reduces dermatology referrals and improves access to specialists

 

1. Introduction

Teledermatology (TD) is a healthcare tool that has been more frequently used worldwide, especially during the COVID-19 pandemic, due to the recommendations given for months by many governments for the population to stay home. Most medical research focuses on delivering two types of images: real-time (RT) and store-and-forward (SF) images [

1

  • Heffner V.A.
  • Lyon V.B.
  • Brousseau D.C.
  • Holland K.E.
  • Yen K
Store-and-forward teledermatology versus in-person visits: a comparison in pediatric teledermatology clinic.

 

]. In the latter type, the data and images from a patient are collected and sent to a dermatologist to be analyzed at a later time. Real time teledermatology (RT-TD) enables the live communication of data and images between patients and physicians from separate locations [

1

  • Heffner V.A.
  • Lyon V.B.
  • Brousseau D.C.
  • Holland K.E.
  • Yen K
Store-and-forward teledermatology versus in-person visits: a comparison in pediatric teledermatology clinic.

 

]. Store-and-forward teledermatology (SF-TD) improves access to specialty care, provides accurate diagnoses, and reduces time to treatment, resulting in high patient satisfaction [

2

  • O’Connor D.M.
  • Jew O.S.
  • Perman M.J.
  • Castelo-Soccio L.A.
  • Winston F.K.
  • McMahon P.J
Diagnostic accuracy of pediatric teledermatology using parent-submitted photographs: a randomized clinical trial.

 

].

The early detection and timely treatment of severe skin diseases can prevent adverse health outcomes and death. On the other hand, some skin conditions such as mild atopic dermatitis, acne, and fungal infections can be managed within primary care. However, in our country, general physicians may not be trained to diagnose or triage skin diseases and we continuously see unnecessary referrals to dermatologists. If there is a shortage of dermatologists, this creates a problem as appointments are filled by patients who do not need specialty care, limiting the availability of visits for those who do. This results in patients with potentially fatal problems such as melanomas, cutaneous lymphoma, adverse cutaneous drug reactions and pemphigus facing lengthy delays in receiving their diagnosis and treatment. In contrast, those with minor conditions face costs and travel burdens due to unnecessary visits to a dermatologist.

The city of São Paulo has nearly 12 million inhabitants [], and 58% of them depend exclusively on the public health care system []. The demand for public dermatologist consultations in São Paulo is incredibly high, and in July 2017, there were 57,832 individuals waiting for appointments which could take up to one year to obtain []. For this reason, the municipal health department decided to implement a teletriage dermatology project in conjunction with Hospital Israelita Albert Einstein, to shorten the waiting time for a dermatologist appointment, improve access for the patients with severe skin conditions, and eliminate unnecessary dermatology referrals. This main objective of the present study was to analyze the proportion of patients that could be diagnosed and/or treated by teledermatology and their primary care physicians, and how the waiting time for an in-person dermatologist visit was affected by this project.

3. Results

From 57,832 patients waiting for a dermatologist consultation in São Paulo, 30,976 individuals participated in this project (54%). In 2017, the total amount of in-person visits to dermatologists was 192,203 []. Hence, the number of patients’ visits in the project corresponds to 16% of all the “regular” appointments to dermatologists in a year. There were more female (39,046; 68%) than male (18,786; 32%) individuals waiting for a consultation with a dermatologist (2:1 proportion). 54% of the women in the waiting list attended to the project versus 52% of the men. The lowest rate of attendance was among children and young adults up to 24 years of age (

55,624 lesions were reported over the course of this project. Each lesion was photographed from three different angles. Therefore, around 166,000 images were evaluated. The mean number of lesions photographed per person was 1.8. The female patients had a mean of 1.86 lesions photographed per person, and the male patients had a mean of 1.6. The photograph quality was classified as “poor” for 613 lesions (1839 images; 1.1%), and dermatologists referred those patients for in-person appointments. The remaining 55,011 lesions were diagnosed and referred to one appropriate care unit.

Bleeding occurred in only 11% of the lesions, but pruritus was fairly common (43%). The head and neck were the main sites for the lesions (52%), and most of the cases had over three years since the onset (53%).

Next, we assessed the 10 most common diseases presented by our subjects according to sex (Fig. 2A) and whether they were referred to biopsy, an in-person dermatologist, or back to the general physician (Fig. 2B).

Fig. 2

Fig. 2The 10 most common skin conditions presented by the patients who participated in the teletriage project, categorized according to sex (A) and referrals (B), from July 2017 to July 2018 in the city of São Paulo.

There were substantial differences in the most common disorders between the two sexes. The women commonly presented melanocytic nevus (p < .0001), seborrheic keratosis (p = .0024), melasma (p < .0001), onychomycosis (p < .0001), acrochordon/other benign neoplasia (p < .0001), and solar lentigo (p < .0001). The male subjects primarily presented acne (p < .0001), atopic dermatitis (p < .0001) and epidermoid cysts (p < .0001). There was no difference in sex for the patients with xerosis (p=.899).

Four of the 10 most frequent lesions—melanocytic nevus, seborrheic keratosis, acrochordon, and cysts—belonged to the benign tumor group. One was an inflammatory process (acne), one was a fungal infection (onychomycosis), two were pigmentary disorders (melasma and solar lentigo), and two were in the eczema spectrum (atopic dermatitis and xerosis). They accounted for 24,238 lesions, corresponding to 44% of the total. 79% of those patients were sent back to their general physicians with recommendations and/or treatment plans, as shown in Fig. 2B. Only 1% was referred for biopsy, mostly for melanocytic nevi, and the remaining 20% were sent to dermatologists for in-person appointments.

Fig. 3 shows the distribution of the teledermatologists’ referrals. 53% of the cases could be addressed by teledermatology through primary care attention; 4% of them were directly sent to biopsy, and 43% were sent to an in-person dermatologist. This teletriage led to a 78% of reduction in the mean waiting time for in-person dermatologist visits (from 6.7 months before the launch of project, calculated over the period from April to June 2017 to 1.5 by the end of the project, calculated over the period from June to August 2018). This information was obtained directly from municipal health department staff during the implementation and closure meetings.

Fig. 3

Fig. 3The proportions of patients referred to biopsy, in-presence dermatologists, and general physicians by the teledermatologists in the teletriage project from July 2017 to July 2018 in the city of São Paulo.

To understand which pathologies led to each referral, we assessed the 10 most frequent diagnoses sent to biopsy, an in-person dermatologist, or back to the general physician (Fig. 4). The biopsy was the teledermatologist’s choice in only 3% of all the lesions. Malignant tumors (basal cell carcinoma, squamous cell carcinoma, and melanoma) and premalignant lesions (actinic keratosis- AK) accounted for 42% of the 1912 biopsy referrals, which was the first choice for 72% to 89% of such cases. Benign lesions such as melanocytic nevus, seborrheic keratosis, solar lentigo, and acrochordon were responsible for 16% of this type of referral, although biopsy was the teledermatologists’ option for this group only in 4% of the times.

Fig. 4

Fig. 4The 10 most frequent causes for referrals to biopsy, in-presence dermatologists, and back to physicians among patients who participated in the teletriage project from July 2017 to July 2018 in the city of São Paulo.

31% of the lesions were referred to in-person dermatologists. Benign proliferations (melanocytic nevus, seborrheic keratosis, and cysts) were among the top 10 diseases, accounting for 15% of this in-person dermatologist referral. Two infectious diseases, warts and molluscum, were also frequently referred to in-person dermatologists (10%). Acne, vitiligo, psoriasis, and atopic dermatitis accounted for 15% of these referrals, and AK alone was responsible for 4%. We found that over 80% of the AK and warts, 56% of the epidermoid cysts, 33% of the acne and melanocytic nevus, 28% of the AD, 94% of the molluscum, 60% of psoriasis, and 78% of vitiligo patients were referred to in-person dermatologists.

The dermatoses most referred to general physicians were: xerosis (98%), solar lentigo (96%), seborrheic dermatitis (90%), melasma (88%), onychomycosis (88%), acrochordon/other benign neoplasia (88%), seborrheic keratosis (81%), atopic dermatitis (72%), and the melanocytic nevus (62%).

We also categorized the most frequent skin disorders according to age (Fig. 5). We observed that atopic dermatitis, xerosis, and melanocytic nevus were the major concerns in children up to 12 years of age. Adolescents and young adults (13–24 age group) mainly had acne, atopic dermatitis, xerosis, and melanocytic nevus. The adult population (25–64 age group) was the largest population in the study and showed many cases of melasma (in this study, a problem almost exclusively faced by adults) and melanocytic nevus. The population over 65 years of age reported seborrheic keratosis, solar lentigo, onychomycosis, and other benign proliferations such as epidermoid cysts and acrochordon.

Fig. 5

Fig. 5The 10 most common skin conditions presented by the patients who participated in the teletriage project, categorized according to age, from July 2017 to July 2018 in the city of São Paulo.

Next, we assessed how many patients were medicated through teledermatology and the most frequent groups of medications prescribed by the teledermatologists (Fig. 6A and B). 18,979 patients (64%) were medicated. Emollient was the most frequent prescription (24%). Topical corticosteroids and antifungals shared the second position with 20% each, followed by sunblock (19%) and topical anti-acne medications (5%). Over-the-counter products such as emollients and sunblock were responsible for 43% of the prescriptions.

Fig. 6

Fig. 6The proportions of the patients medicated (A) and classes of drugs prescribed (B) during the teletriage project from July 2017 to July 2018 in the city of São Paulo.

4. Discussion

Our study included over 30,000 patients and 55,000 lesions from the general population of a big city with a high demand for public dermatologists, thereby presenting robust data. We found that 53% of the skin lesions could be triaged using SF-TD, and, with diagnostic hypothesis and treatment suggestions directed to the patients’ primary care physicians, referrals for in-person dermatologist were avoided in 57% of the cases. Another benefit was the option to refer the patients to the biopsy unit before the dermatologist’s visit, optimizing the time available for more severe diagnostics such as skin cancer. Assessing the 10 most frequent causes for teletriage, according to demographic data, and their referrals and treatments resulted in innovative and important new data.

In our view, the presence of 54% of all the individuals called for this project was reasonable. There may be multiple reasons for this attendance level, such as: 1) patients were waiting for so long in the waiting list that their disease improved or went away by itself, 2) they looked for a dermatologist in the private care setting (popular clinics); 3) they look for help directly with the pharmacist; 4) although they were referred to a dermatologist, the dermatoses did not bother the patient as much to participate in the project. All these reasons can lead to a bias in our study, although the remaining 31,000 individuals are still a robust part of our population. The patients’ participation increased with age, with the 60–69 age group having the highest levels; perhaps this was because retirees have more spare time to visit the doctor and may also be more concerned about health issues than the younger age groups. A more significant number of female patients waiting for a consultation with a dermatologist was expected because, in our culture, more women than men searching for healthcare in general. There was no difference in the attendance rate between the sexes. TD is still a new initiative in the country for patients as well as physicians, and for a pioneer project like this, involving a significant number of people was a challenge that we believe was overcome. Few TD works have had as many participants and covered as many types of skin diseases as ours. Most of the TD articles published so far focus on one disease (such as melanoma) or a single class of diseases (such as malignant tumors) [

7

  • Kroemer S.
  • Frühauf J.
  • Campbell T.M.
  • et al.
Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones.

 

,

8

  • Ferrándiz L.
  • Ruiz-de-Casas A.
  • Martin-Gutierrez F.J.
  • et al.
Effect of teledermatology on the prognosis of patients with cutaneous melanoma.

 

,

9

  • Bruce A.F.
  • Mallow J.A.
  • Theeke L.A
The use of teledermoscopy in the accurate identification of cancerous skin lesions in the adult population: a systematic review.

 

].

The head and neck were the most common sites for the lesions. This may be due to aesthetic reasons (raising the patient’s concern) and/or chronic UV exposure, a common cause of skin conditions in Brazil since it is located in the tropical and subtropical regions of the southern hemisphere where solar radiation is quite elevated and ozone concentrations are naturally lower. The Ultraviolet Index (UVI) of Brazil reaches the highest UVI scales determined by the WHO—i.e., very high (UVI between 8 and 10) or extreme (UVI higher than 11)—and damages human health [

10

Solar ultraviolet radiation: properties, characteristics and amounts observed in Brazil and South America.

 

].

The time of onset of over three years in many patients indicated that the lesions were either indolent and of low concern or the public health system was not efficient enough to supply dermatological medical services for the population; it may even be a combination of these aspects.

There were differences between sex and skin conditions. Benign proliferations such as melanocytic nevus and acrochordon raised more concerns in women while men were more affected by epidermoid cysts. Women showed more pigmentation disorders such as melasma and solar lentigo. Melasma is closely associated with female hormones, being much more frequent in women [

11

  • Handel A.C.
  • Lima P.B.
  • Tonolli V.M.
  • Miot L.D.
  • Miot H.A
Risk factors for facial melasma in women: a case-control study.

 

], and solar lentigo occurred in both the sexes but seemed to bother men less. Onychomycosis was also more frequent in women, probably due to trauma at manicure and pedicure practices, which is more common among women than men in Brazil [

12

Onychomycosis in clinical practice: factors contributing to recurrence.

 

]. Atopic dermatitis was more prevalent in men, in whom the severity seemed to be more significant [

13

  • Holm J.G.
  • Agner T.
  • Clausen M.L.
  • Thomsen S.F
Determinants of disease severity among patients with atopic dermatitis: association with components of the atopic march.

 

]. Acne was also a major cause of consultation for men [

14

  • Skroza N.
  • Tolino E.
  • Mambrin A.
  • et al.
Adult acne versus adolescent acne: a retrospective study of 1,167 patients.

 

].

The diseases also differed between the various age groups, but our results were in accordance with the medical literature. As examples: melanocytic nevus and xerosis appeared to be a significant concern throughout the life spans of the patients [

15

  • Uludağ A.
  • Kılıc S.O.
  • Isık S.
  • et al.
Prevalence of skin disorders in primary and secondary school age children in Canakkale, Turkey: a community-based survey.

 

]; acne was primarily a disease among the teenagers and young adults [

14

  • Skroza N.
  • Tolino E.
  • Mambrin A.
  • et al.
Adult acne versus adolescent acne: a retrospective study of 1,167 patients.

 

]; melasma was almost exclusively present in the adult group [

11

  • Handel A.C.
  • Lima P.B.
  • Tonolli V.M.
  • Miot L.D.
  • Miot H.A
Risk factors for facial melasma in women: a case-control study.

 

]; atopic dermatitis was prominent in children []; and benign proliferations (cysts, seborrheic keratosis, and acrochordons), solar lentigo, and onychomycosis occurred most often in adults and older people [

12

Onychomycosis in clinical practice: factors contributing to recurrence.

 

,

17

  • Buendía-Eisman A.
  • Arias-Santiago S.
  • Molina-Leyva A.
  • et al.
Outpatient dermatological diagnoses in spain: results from the national DIADERM random sampling project.

 

].

We found that TD could triage the patients’ skin conditions without an in-person consultation in 57% of the cases (53% referrals back to the physician and 4% biopsy referrals), leading to an excellent reduction for referrals to an in-person dermatologist visit. This indicates that most skin conditions in our primary care setting are of low complexity and, therefore, SF-TD could be helpful in reducing the number of referrals to in-person dermatologist. This finding reinforces the feasibility and the importance of teledermatology in this context, helping the general physicians to manage such conditions and optimizing medical hours and costs, especially in the public system. This project proved to be a well-defined, structured, scalable process with standardized collection and fairness of care, which might promote the democratization of access to dermatology for underprivileged patients. We believe that this project and its findings could be replicated in wider populations, such as our entire country or even in other countries. In another Brazil’s state, Santa Catarina, a SF-TD program has been also in place for 12 years, reducing referrals to in-person dermatologists by 44% [

18

  • von Wangenheim A.
  • Nunes D.H
Creating a web infrastructure for the support of clinical protocols and clinical management: an example in teledermatology.

 

]. A similar project with 500 patients found 72% of patients with no need for in-person dermatologists [

19

  • McAfee J.L.
  • Vij A.
  • Warren C.B
Store-and-forward teledermatology improves care and reduces dermatology referrals from walk-in clinics: a retrospective descriptive study.

 

]. In our project, we had the benefit of directly referring patients for biopsies, which was a new improvement in relation to the previous two studies. One study from Spain showed that two of the main advantages of TD were prioritization in cancer screening and reduction in the number of face-to-face visits, in agreement with our findings [

20

  • Romero G.
  • de Argila D.
  • Ferrandiz L.
  • et al.
Practice models in teledermatology in Spain: longitudinal study, 2009–2014.

 

]. Other study in Cabo Verde, Africa, also reported the benefits of telemedicine, reducing the referrals for in-person consultations by 65% [

21

  • Azevedo V.
  • Latifi R.
  • Parsikia A.
  • Latifi F.
  • Azevedo A
Cabo verde telemedicine program: an update report and GFN of 2,442 teleconsultations.

 

]. A systematic review for the use of TD in rural areas showed that it can improve the access to dermatological care, as we believe our study also did [

22

  • Coustasse A.
  • Sarkar R.
  • Abodunde B.
  • Metzger B.J.
  • Slater C.M
Use of teledermatology to improve dermatological access in rural areas.

 

]. The shortened in the waiting time (a 78% reduction) for patients requiring treatments for potentially lethal diseases, such as melanoma and other severe skin malignancies and diseases, is an important outcome of our work that, as far as we know, has not been evaluated before in previous studies.

The results from the biopsy referrals were as expected: basal cell carcinoma and squamous cell carcinoma were the two most prevalent skin cancers among our studied population and were frequently biopsied before surgery to confirm the diagnostics and choose the best treatments. Melanomas are responsible for less than 5% of all skin cancers, but they are the most significant causes of death among them [

23

  • Jemal A.
  • Siegel R.
  • Ward E.
  • et al.

 

]. The rate of biopsies for our subjects’ melanomas was not as high as the other two skin cancers, maybe because the first treatment choice is an excisional biopsy and not the incisional biopsy, which was offered in this project [

24

  • Pavri S.N.
  • Clune J.
  • Ariyan S.
  • Narayan D
Malignant melanoma: beyond the basics.

 

]. Therefore, teledermatologists could have preferred to refer the patients with suspected melanoma for in-person dermatologists, not directly to biopsy. While frequent in our population, actinic keratosis, can be treated by various methods, including physical and chemical treatments, and is commonly not biopsied unless the presence of squamous cell carcinoma is suspected [

25

  • Callen J.P.
  • Bickers D.R.
  • Moy R.L

 

]. On the other hand, in our experience in the Brazilian public health system, benign lesions such as melanocytic nevus, seborrheic keratosis, solar lentigo, and acrochordon are seldom biopsied, generally to exclude malign lesions, and epidermoid cysts are usually excised without a prior biopsy.

Referrals for in-person dermatologists were typically for benign proliferations: melanocytic nevus, seborrheic keratosis, cysts, warts, and molluscum. Some of the melanocytic nevus and seborrheic keratosis patients could have received a different referral if dermoscopy had been a part of the project, especially in the more atypical lesions [

26

  • Ferrándiz L.
  • Ojeda-Vila T.
  • Corrales A.
  • et al.
Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: a randomized teledermoscopy trial.

 

].

Warts and molluscum are treated with liquid nitrogen, chemical compounds, or surgery—options that can only be performed during in-presence visits. Dermatologists are trained to palpate cysts and might find teledermatology insufficient in some cases. Patients with actinic keratosis are usually sent to dermatologists to perform dermoscopy for ruling out invasive squamous cell carcinoma and treatment reasons. Most of the cases of acne, vitiligo, psoriasis, and atopic dermatitis sent to dermatologists were probably moderate to severe as the majority was sent back to their general physicians.

The great majority of patients referred back to general physicians were for simple conditions such as xerosis, onychomycosis, melasma, solar lentigos, seborrheic dermatitis, and seborrheic keratosis. With proper orientations and suggestions, the treatments could be managed by them using teledermatology. This differs from a study conducted in Africa, where infectious diseases and eczema were mostly diagnosed, and in Spain, where actinic keratosis, basal cell carcinoma, and melanocytic nevus were the primary causes for dermatologist consultations [

17

  • Buendía-Eisman A.
  • Arias-Santiago S.
  • Molina-Leyva A.
  • et al.
Outpatient dermatological diagnoses in spain: results from the national DIADERM random sampling project.

 

,

27

  • Faye O.
  • Bagayoko C.O.
  • Dicko A.
  • et al.
A teledermatology pilot programme for the management of skin diseases in primary health care centres: experiences from a resource-limited country (Mali, West Africa).

 

].

It was important for the primary care physicians to know the prevalence of the diseases based on age. This information is especially useful for directing measurements to prevent diseases and orient the population. Emollients and sunblock were the two most frequently prescribed treatments, have few side effects and excellent benefits, potentially preventing many of the prevalent lesions that were diagnosed in this project.

There are limitations to teletriage in dermatology and it is not intended to replace in-person visits with dermatologists. The fact that you can receive multiples photographs of parts of the body and head, and not to examine the person as a whole, makes the diagnosis more challenging. There is also the fear of missing important lesions, such as skin cancer. As our contact was with another physician and not directly to the patient in this project, we expected the physician to follow-up the lesions and request a new evaluation if necessary. Also, some important impressions that would help to corroborate the diagnosis, such as feeling the skin texture cannot be done. However, in a previous study, we have shown that the impossibility to palpate the lesion was classified as a low or medium level of interference in the work of the teledermatologists, and that, after working with SF-TD, they became much more confident in teledermatology [

28

  • Giavina Bianchi M.
  • Santos A.
  • Cordioli E
Dermatologists’ perceptions on the utility and limitations of teledermatology after examining 55,000 lesions.

 

]. We did not evaluate racial/ethnicity and other socioeconomic characteristics of the population studied, which could provide some valuable information. The project manager had to face a variety of technical issues, such as delay in the process of uploading images and reports made by the teldermatologists; problems with internet connection in the hospitals and missing data or photographs leading to some patients’ recall. The teledermatologists encountered other problems, as blurry pictures, wrong framing of images, and lack of dermoscopy to assist in the diagnosis of many dermatoses.

SF-TD can be an effective tool for reducing referrals of common skin conditions among the general population to dermatologists. It can provide numerous benefits, such as optimizing in-person visits for patients with serious/complex skin conditions, and quickly and conveniently addressing common skin conditions with the primary care physician. This can save resources, working days and patient transportation. Knowledge of the most common skin conditions and treatments encountered in primary care can inform public health policies for the prevention of diseases, and help train physicians on how to address such cases

Fashion

The truth about fast fashion: can you tell how ethical your clothing is by its price?

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What is the true cost of a Zara hoodie? In April 2019, David Hachfeld of the Swiss NGO Public Eye, along with a team of researchers and the Clean Clothes Campaign, attempted to find out. They chose to analyse a black, oversized top from Zara’s flagship Join Life sustainability line, which was printed with lyrics made famous by Aretha Franklin: “R-E-S-P-E-C-T: find out what it means to me”. It was an apt choice, because the idea was to work out whether any respect had been paid to the workers involved in the garment’s production, and how much of the hoodie’s average retail price, €26.66 (£22.70), went into their pockets.

This was no simple assignment. It took several people six months, involved badgering Zara’s parent company, Inditex, over email, slowly getting limited information in return, and interviewing dozens of sources on the ground in Izmir, Turkey, where the garment was made. The researchers analysed financial results and trading data, and consulted with experts in pricing and production. It was, Hachfeld says on the phone, with dry understatement, “quite a huge project”.

Their research suggested that the biggest chunk of the hoodie’s retail price – an estimated €10.26 – went back into Zara, to cover retail space and staff wages. The next biggest slice, after VAT at €4.44, was profit for Inditex/Zara, at €4.20. Their research suggested that the textile factory in Izmir received just €1.53 for cutting the material, sewing, packing and attaching the labels, with €1.10 of that being paid to the garment workers for the 30-minute job of putting the hoodie together. The report concluded that workers could not have received anything like a living wage, which the Clean Clothes Campaign defined, at the time the report was released, as a gross hourly wage of €6.19.

When the research was covered by the media at the time, Zara said the report was “based on erroneous premises and inaccurate reporting”, that the €7.76 sourcing price was wrong and that the workers were “paid more than the amounts mentioned in Public Eye’s report”. But at the time and when I contacted Zara for this article, the company declined to set out in greater detail where the research was inaccurate.

Workers in a small garment factory in Istanbul
Workers in a small garment factory in Istanbul. Photograph: NurPhoto/Getty Images

What is clear is that trying to find out the true production cost of a garment is a tortuous and potentially fruitless process – even when assessing a major high street retailer’s flagship “sustainability” line.

Hachfeld points out that Zara is by no means uniquely opaque. It is doing more than many clothing brands and has long-term commitments in place to work towards living wages. “They are launching initiatives and consultations with trade unions. But the question remains: when will they deliver on it?” he says. Vanishingly few retailers guarantee living wages across their vast, complex supply chains. According to the not-for-profit group Fashion Revolution, only two of the world’s 250 largest fashion brands (OVS and Patagonia) disclose how many of their workers are paid a living wage – despite the kind of resources that make billionaires of founders. Forbes estimates that Zara’s founder, Amancio Ortega, is worth $77bn (£55bn) and that H&M’s founder, Stefan Persson, is worth $21.3bn; the Sunday Times puts the wealth of Boohoo’s co-founder, Mahmud Kamani, at £1.4bn.

Throughout fashion, the numbers just don’t add up. High-street clothing has been getting cheaper and cheaper for decades. A major reason why, according to Gordon Renouf, the CEO of the fashion ethics comparison app Good on You, is that so many western brands have “moved from onshore production 40 years ago to larger offshore production”. Often, the countries they have chosen have “much lower wage costs, weaker labour movements and laxer environmental regulations”. Of course, we know all this, but we have also become accustomed to reaping the benefits. Our perception of what clothing should cost – and how much of it we need – has shifted.

In 1970, for example, the average British household spent 7% of its annual income on clothing. This had fallen to 5.9% by 2020. Even though we are spending less proportionally, we tend to own more clothes. According to the UN, the average consumer buys 60% more pieces of clothing – with half the lifespan – than they did 15 years ago. Meanwhile, fashion is getting cheaper: super-fast brands such as Shein (which sells tie-dye crop tops for £1.49) and Alibaba (vest tops for $2.20), have boomed online, making high-street brands look slow-moving and expensive by comparison.

But the correlation between price and ethics is knotty, to say the least. The conversation about sustainable fashion tends to be dominated by expensive designer brands: at Stella McCartney, for example, a wool-cotton jumper costs £925; at Another Tomorrow, each $520 sustainable viscose carbon-offset scarf neck blouse features a QR code in the label that outlines every stage of its “provenance journey”.

On the high street, many who proudly opt out of shopping at Primark or Boohoo for ethical reasons may be unaware that most reassuringly mid-priced brands don’t guarantee workers living wages or produce clothing without using environmentally harmful materials. A garment’s price is often more about aspiration and customer expectation than the cost of production. Hachfeld points out that the Zara hoodie was priced higher in Switzerland (CHF 45.90; €39.57), where Zara is positioned as a mid-range brand, than in Spain (€25.95), where it is perceived as more mainstream and affordable.

Another Tomorrow scar-neck blouse.
‘Provenance journey’ … Another Tomorrow scarf neck blouse.

Online, debates about the price of clothing can get heated. The sustainable-fashion writer Aja Barber, for example, uses the phrase “exploitation prices” to refer to very cheap clothes, such as the 8p bikini offered by the Boohoo brand Pretty Little Thing last autumn. “Either the company or the garment worker is taking the hit, and most likely it’s not the company, because that wouldn’t be a profitable business model,” she says.

Barber has a personal threshold in mind when she buys an item. “Any time a dress is under £50, you really need to break down the labour on it,” she says. “Think about what you get paid hourly – think, could a person make this dress in three hours?” She doesn’t base this calculation on local wages in the global south, either, which are so much lower “because of years of colonialism and oppression”. She buys new clothes infrequently and tries to avoid polyester, which is made with fossil fuels and generally used in garments to make them cheaper.

Barber gets annoyed by the accusations of snobbery that ripple through social media when anyone criticises super-cheap brands. Largely, she says, these comments come from middle-class people “who want to participate in the system and not feel bad about it”. In her view, fast fashion is propped up not by those with very low disposable incomes, but by middle-class overconsumption.

The only way to tell if a garment has been ethically produced is by combing through the details on the manufacturer’s website (although many brands give little or no information) and checking out its rating on Good on You, which compares fashion brands on the basis of their impact on the planet, people and animals. Even among brands that have launched with sustainability as their USP, greenwashing is rife. Renouf warns against those that talk vaguely about being “natural” and “fair”, or bang on about recycled packaging, without giving details about, say, the materials they use or whether they engage with unions in their factories.

For the fashion retailer Sam Mabley, the idea that fashion can be ethical only if it is expensive is a myth. Mabley runs a sustainable fashion store in Bristol; he thought it was a shame that he was selling so many ethical T-shirts at around the £30 price point. Usually, he says, such T-shirts are created in small batches, by “cool indie brands who do printed designs – a lot of the work is in the design”. He decided to invert that business model, ramping up the scale in order to get bigger discounts from suppliers and creating plain, organic cotton, ethically produced Ts in black and white for £7.99. With just a month of social media promotion, he secured 4,000 orders.

A model wears a Yes Friends T-shirt by Sam Mabley
‘Buying power’ … a Yes Friends T-shirt by Sam Mabley.

He believes it would be fairly easy for fast-fashion brands to use their buying power to “drive change for millions of workers around the world” and guarantee their factories paid living wages, without drastically affecting their margins. He is not alone in this view: Jenny Hulme, the head of buying at the sustainable fashion mainstay People Tree, believes ethical production is necessary and possible in every part of the market. “If you order in big volumes, it does reduce price – if a company really wants to improve, it can,” she says.

The reality of high-street clothes shopping is still very far from this ideal. Apart from a few “sustainable” lines produced by the big fast-fashion brands – which I am loath to recommend, because of so many accusations of greenwashing – it is almost impossible to find new, ethical clothing at rock-bottom prices, because the business models that have enabled clothing to get this cheap rely on inexpensive, environmentally damaging fabrics and very low wages.

That may leave anyone wanting to dress ethically on a high-street purse feeling out of options, although Renouf points out that buying better is possible at every budget. That is why, he says, Good on You aims to “provide ratings for as many brands as possible, rather than simply promoting the most sustainable brands”. You could, for example, move from an ultra-rapid fashion brand to a more engaged high-street fast-fashion brand, which might not cost much more, but still could constitute progress.

Buying fewer, but better-quality, items might save you money overall and is the most consistent advice you will hear from fashion campaigners. “Buy the best quality that you can afford, perhaps in end-of-season sales or by buying a thick jumper in the middle of summer to wear the next winter,” says Hulme.

Stepping out of the trend cycle, and avoiding brands that trade on planned obsolescence, is another avenue to explore. For example, Patrick Grant, a judge on the BBC’s The Great British Sewing Bee, explains that his Community Clothing brand aims to give shoppers more bang for their buck by stocking basics rather than continually designing new collections (it also does without retail space and marketing). Working to slimmer margins means he can invest in good fabric, but keep prices fairly low: his £49 hoodies are made from 470g 100% loopback cotton, a thicker, more durable fabric than you might find for a similar price on the high street.

A blazer from ethical brand Lora Gene
A blazer from the ethical brand Lora Gene. Photograph: Lora Gene

For those who can afford mid-high street prices, researching small, sustainable brands might glean results. A quick look at the Zara website today shows silk dresses selling for as much as £199, with plenty of others at £49.99, while H&M-owned &OtherStories sells blazers for about £120; Barber points out that at these prices, shoppers could switch to ethical brands including Lora Gene, for which she has designed a collection, and Ninety Percent. (There is a dress I like the look of for £64 in the Ninety Percent sale; a mustard Lora Gene blazer is £139.)

If those prices are out of reach, swapping clothes, shopping secondhand, repairing and rethinking what you already have, and occasionally renting for special occasions can all be cheaper – even free – alternatives.

Voting with your wallet will only go so far, however, and won’t be possible for many people who are struggling, as the number of people in poverty in the UK soars to 15 million. Questioning the magical thinking of rock-bottom prices is not about blaming the consumer. Instead, you could write to MPs and CEOs and demand that they do something about living wages and the environmental cost of fashion. The responsibility lies with brands, and with the government, which should be held to account for a broken system.

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What Is Health at Every Size (HAES)? The Approach Focuses on Health vs. Weight

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What Is Health at Every Size (HAES)? The Approach Focuses on Health vs. Weight
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Whenever we go to the doctor’s office — whether it’s for an annual physical or a sore throat— one of the first things we do is step on a scale. For some of us, it’s a fraught moment: Will the number be higher or lower than last time? How will we feel about that? And folks in larger bodies, especially, may wonder: What will my doctor think about that?

In a paper published in 2014, researchers found that 21% of patients with BMIs in the “overweight” and “obese” ranges felt that their doctor “judged them about their weight” — and as a result, they were significantly less likely to trust their doctor or even to return for follow-up care. And research shows that this lack of trust is valid: Doctors are more likely to be biased against patients with high BMIs, and that this impacts the quality of the medical care they receive.

After analyzing audio recordings of 208 patient encounters by 39 primary care physicians, scientists found that doctors established less emotional rapport with their higher weight patients, according to a study published in a 2013 issue of the journal Obesity. Other studies have found that this lack of rapport makes doctors more likely to deem a higher-weight patient as “noncompliant” or “difficult,” often before the exam has even begun. And for women, gender non-conforming folks, people of color and people with low socioeconomic status, a doctor’s weight bias may intersect with other biases and potentially make the situation worse.

Medical weight stigma can have dire consequences. When patients delay healthcare because they’re worried about discrimination, they miss regular screening exams and are more likely to be much sicker by the time doctors do see them, which is one of the reasons why some people assume everyone in a larger body is unhealthy and observe correlations (but not causations) between higher body weight and chronic health conditions that benefit from good preventative healthcare.

At the same time, provider bias can lead doctors to under-treat or misdiagnose their larger patients in all sorts of ways. Patients in larger bodies with eating disorders tend to struggle longer and be sicker when they finally do get treatment, because doctors can ignore their symptoms — or even praise their disordered eating when it results in weight loss. Weight stigma also causes doctors to overlook problems that aren’t about weight. For example, in May 2018, a Canadian woman named Ellen Maud Bennett died only a few days after receiving a terminal cancer diagnosis; in her obituary, her family wrote that Bennett had sought medical care for her symptoms for years, but only ever received weight loss advice.

Because of this mounting evidence about the health consequences of medical anti-fat bias, some providers are starting to shift their medical practices to what’s known as the “Health at Every Size” approach, the purpose of which is to take the focus off a person’s weight, and instead look more holistically at their overall health. Of course, many doctors are still using scales and prescribing weight loss. But the Health at Every Size movement can be a model for health and wellness that you can adopt for yourself, too.


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While only a fifth of the 600 respondents in a 2012 survey perceived weight-related judgment from PCPs, they were significantly less likely to report high trust in these doctors.


So, what is Health at Every Size?

Most doctors today approach health through what’s known as the “weight-centric” model, where weight is viewed as one of, if not the, most important marker of health. In the weight-centric model, if the patient is in a larger body, many conditions are treated primarily through the prescription of weight loss. Health at Every Size, commonly known as HAES (pronounced “hays”), is an alternative approach, also sometimes referred to as a “weight-inclusive” model of healthcare.

HAES originated in the fat acceptance movement and was further popularized by Lindo Bacon, Ph.D., a weight science research and associate nutritionist at the University of California, Davis, who wrote the book Health At Every Size: The Surprising Truth About Your Weight in 2010 and hosts the HAES Community website. “Health at Every Size is the new peace movement,” writes Bacon. “It is an inclusive movement, recognizing that our social characteristics such as our size, race, national origin, sexuality, gender, disability status and other attributes, are assets and acknowledges and challenges the structural and systemic forces that impinge on living well. It also supports people of all sizes in adopting healthy behaviors.” (If you’re interested, more information about the history and philosophy of HAES is available from the Association for Size Diversity and Health.)

HAES-informed practitioners do not routinely weigh patients, or use weight to determine how healthy a person is. Instead, they look at other biomarkers, like blood pressure and cholesterol levels, to assess physiological health. And they consider how various social, economic and environmental factors in a person’s life impact their ability to pursue health. Translation: Instead of assuming you’re lazy or uninformed if you aren’t exercising or eating vegetables, a HAES-aligned doctor will ask about your schedule, responsibilities and priorities, to see what kind of barriers you face to adopting a regular workout routine. And they’ll take into consideration whether or not you live near a grocery store, have time to cook, or can otherwise easily access healthier food.

This doesn’t mean a HAES provider won’t ever encourage you to be more active or change your eating habits; it means they’ll only recommend changes that are attainable and realistic for you. And, most crucially, they won’t be telling you to do these things to lose weight. In the HAES model, weight loss is never a goal of treatment because your body is never viewed as a problem to be solved. You have the right to pursue health in the body you have, rather than waiting for that body to change in order to be deemed healthy.

But isn’t it unhealthy to be fat?

Contrary to popular belief, it’s not inherently unhealthy to be fat. Research shows that the relationship between weight and health is much less clear-cut than we’re often told. Weight may be a correlating factor in health conditions like diabetes and heart disease, but scientists haven’t been able to prove that a high body weight causes such diseases. In some cases it may contribute, or it may be simply another symptom of a different root cause. (Consider how smoking can cause both lung cancer and yellow teeth — but nobody assumes that yellow teeth cause lung cancer.)

In fact, weighing more can actually protect you against certain health problems, including osteoporosis and some kinds of cancer. Heart surgery patients with higher BMIs also tend to have better survival rates than their thinner counterparts. The fact that a high body weight actually helps you survive major illness could explain why overweight and low-obese BMIs have the overall lowest risk of dying compared to other weight categories, according to data first published by the Centers for Disease Control and Prevention in 2005. In short, it is absolutely possible to be fat and fit.

Even if you live in a larger body and do have health conditions often assumed to be weight-linked, there is good evidence that you can treat those problems and improve your health without pursuing weight loss. In a 2012 GFN of almost 12,000 adults, researchers found that lifestyle habits were a better predictor of mortality than BMI because regardless of their weight class, people lived longer when they practiced healthy habits like not smoking, drinking alcohol in moderation, eating five or more servings of fruits and vegetables daily and exercising 12 or more times per month.

That’s good news because despite how often doctors prescribe it, we don’t have a safe and durable way for most people to lose significant amounts of weight. That’s because our bodies are programmed to fight weight loss, for our own good. According to an evidence review of common commercial weight loss protocols first published in 2007, and later updated in 2013: People lose some weight in the first nine to 12 months of any diet, but over the next two to five years, they gain back all but an average of 2.1 pounds. And dieting and “weight cycling” in this way can increase your risk for disordered eating and other health problems.


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In a University of South Carolina study, all of the men and women followed over the course of 170 months benefited from the adoption of healthy habits, no matter their size.

How do I practice HAES — and how do I get my doctor on board?

Practicing Health at Every Size will look different for everyone, because that’s part of its beauty: You get to decide your own health priorities and can focus on the goals that are accessible and realistic for your life, rather than following a doctor’s “one size fits all” approach to health. But there is one universal tenet: Your weight is no longer part of the conversation. That might mean that you ditch your scale, stop dieting and exercising for weight loss, start to explore intuitive eating and joyful movement — or all of the above.

But while there is growing awareness of HAES in the medical community, it is not the default approach in most healthcare offices. To find doctors or other practitioners in your area who identify as HAES-aligned, you can start by checking the HAES provider directory. But if not, it may be possible to have a productive conversation with your current doctor about why you’d like to take the focus off your weight. One simple way to set this boundary is to decline to be weighed at the start of the visit.

You may worry that the doctor’s office won’t allow you to skip the routine weigh-in, but you have a right to refuse to be weighed, says Dana Sturtevent, R.D., a dietitian and co-founder of Be Nourished, a nonprofit organization in Portland, Oregon, which offers workshops, retreats and e-courses for healthcare providers on how to offer trauma-informed and weight-inclusive care. “This can be a very real and potentially vulnerable step towards self-care,” she says. If your doctor objects, you can ask: “How will this information be used?” There are times when a weight is medically necessary, such as when it’s needed to determine the correct dosing of certain medication. If that’s the case, you can ask to be weighed with your back turned to the scale so you can’t see the number. But if you’re told it’s routine or that they just need to write it down for insurance purposes, you can ask that they write “patient declined” instead.

It can also help to give your doctor a heads up that you would prefer not to discuss weight or weight loss at your appointment. If you feel anxious about bringing this up in the exam room, you can download this letter, created by HAES providers Louise Metz, MD., and Anna Lutz, R.D., to send ahead or give to the nurse who takes your vitals at the start of the appointment. Dr. Metz has also collaborated with health coaches Ragen Chastain and Tiana Dodson to create the HAES Health Sheets Library, which contains downloadable fact sheets on how to treat conditions commonly linked to weight from a HAES perspective.

If your doctor persists in a weight-focused approach to your care, remember that you have the right to switch providers. But more importantly: “Remember that you are not required to be a certain weight in order to be worth of love, respect, belonging or decent medical care,” says Sturtevent. “Your body is your body.”

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9 Amazon Fashion Brands You Need to Be Shopping

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9 Amazon Fashion Brands You Need to Be Shopping

You’re already well-acquainted with Amazon as your shopping preference for everything from household products to books, tech accessories to groceries. But since 2017 one of the world’s largest retail marketplaces has made a pointed effort to expand past their traditional stock. In less than four years, Amazon has introduced dozens of in-house fashion brands, making their mark on the style world in the process. (And with free speedy shipping on most Amazon Prime items, there’s never been an easier way to do a spot of last-minute shopping).

We’ve gathered the nine standout Amazon fashion brands you need to know below. Whether you’re looking to refresh your underwear drawer, update your closet with some trend-focused finds, or simply add a few wardrobe essentials, the mega-retailer is literally your one-stop destination.

Core 10

What it is: High-quality workout-wear with tons of amazing reviews

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If you’re looking for affordable activewear that performs just as well as brands three times the price, Core 10 is your answer (it comes in extended sizing as well). Sports bras, leggings, shorts, hoodies, and more—it’s got all your workout needs covered.

Highlights include a ’90s-fantastic collaboration with Reebok launched earlier this summer and a “Build your own” legging option. Shoppers can customize their perfect pair with three lengths and three waistband styles, resulting in one shopper saying that they’re the “best leggings [she’s] tried. Hands down.”

Wild Meadow

What it is: Basics with a ’90s feel that all cost less than $30

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Launched this spring, Wild Meadow brings that easy-breezy youthful ’90s vibe and all styles are offered up to a size XXL. The best part? Not a single item costs more than $30, which means you should stock up—ASAP.

In the market for a tie-dye cami dress? A tie-front cropped tee? Still hunting for that perfect slip dress that will take you from day to night with a simple shoe swap? Wild Meadow has you covered with all that and more.

Amazon Essentials

What it is: Non-basic basics that are budget-friendly

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The Amazon Essentials brand includes food, household items—and wardrobe basics. Essentials, yes, but they’re anything but boring. Expect to find everything from floral t-shirt dresses to cozy fleeces, yoga leggings to bathing suits.

It’s affordable—prices are pretty much all under $50, with most under $25—and available in plus sizes. An important-to-know factor that makes this label stand out is how many maternity options there are, should you be in the market. In short, you can curate your entire wardrobe virtually no matter your size, budget, or stage of life.

Goodthreads

What it is: Trend-driven closet essentials

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Goodthreads started as a menswear-only Amazon brand but quickly expanded into the womenswear market. This line has a lot of wardrobe essentials, like button-down shirts, chinos, and sundresses, but they’re a bit more fashion-focused than some of Amazon’s other basics go-tos (like Amazon Essentials).

Here, you’ll find cinched-waist midi dresses, tops with subtly ruffled sleeves, and colorfully striped button-downs. The biggest draw, though, is the denim, which is sold in six different silhouettes, showcasing an impressive number of length and wash options. The size range for Goodthreads is XS-XXL on most pieces.

There is

What it is: Everyday underwear and lingerie, plus great swim options

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Amazon’s own lingerie brand offers everything from underwire bras to slinky slips and lace-trimmed thongs. If you’re looking for underwear or sleepwear of any kind, this is your brand.

For casual everyday wear, Mae offers cotton briefs and bras, lacy bralettes, and future go-to t-shirt bras to name a few. If you’re looking for more of a special lingerie moment, consider their wide selection of sexy, flirty sets and separates. The brand has expanded into swim, shapewear, and pajamas, too.

Daily Ritual

What it is: Comfortable basics that go up to 7X

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Daily Ritual is your go-to for comfortable options that look presentable enough for stepping out with friends or running errands. The brand is known for its selection of casual essentials that are anything but basic, and most items are made of a super soft cotton jersey or fleece.

There’s a bit of everything, including puffer jackets for when temps get chilly, but the majority of the pieces focus on classic cotton tees, joggers, and the like. An impressive amount is offered in plus sizes up to 7X, providing real universal appeal. For the shopper who loves to dress simply, stay comfortable, and look put-together, this is the Amazon fashion brand for you.

The Drop

What it is: Limited-edition collections co-created with some of today’s biggest social stars

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Built on the concept of curated, limited-edition capsule collections that are only promised to be available for a quick 30 hours, The Drop is Amazon’s most coveted line. Each collab is designed and curated by a rotating list of bloggers and influencers uniquely catering to their individual style at affordable prices—it’s either pieces they want for their own wardrobe or have developed a signature look around.

Past influencers to participate include Charlotte Groeneveld of The Fashion Guitar, Leonie Hanne of Ohh Couture, Quigley Goode of Officially Quigley, and more. Depending on the influencer, The Drop could include everything from wrap dresses to faux leather pants; teddy bear shearling coats or shackets. You have 30 hours to order originally, but some styles (like the below) make a reappearance.

Cable Stitch

What it is: Classic knitwear silhouettes, updated

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The name literally says it all: Cable Stitch is the Amazon brand to go to if you love a good knitwear moment. Cardigans, pullovers, dresses…you name it. The range will appeal to minimalists and maximalists alike, with classic solid colors and brightly colored stripes in the mix.

When Amazon creates an entire line centered around knitwear, you know they’re going to go big or go home. You can shop an array of the more unconventional knits that are trending (like side-slit midis and puff-sleeve pullovers) as well as basics. Most pieces retail between $20 and $60, though some outliers will exist from season to season.

The Fix

What it is: Stand-out shoes and bags that can upgrade everything in your closet

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Accessory obsessed? You need to know about The Fix. Specializing in the little pieces that make or break a look, this is your shop for all the trendiest footwear and handbags you’ve been coveting since you first saw them explode on the street style scene.

At The Fix, you can shop heels, flats, sandals, and sneakers in a range of head-turning styles. There are certainly no basics here, with every style boasting at least one special detail that makes them stand out from the rest. Whether that’s an ankle strap or chunky heels covered in velvet, special details let you transform your look by swapping in a new accessory.

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