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Revisiting patch test data reporting: Towards equity

Dear Sir/Madam The impact of demographic and clinical characteristics on patch test data is qualified by an index which started as the acronym “MOHL” (male, occupational dermatitis, hand dermatitis, leg dermatitis) in the 1970s, and has since expanded to “MOAHLFAP” (with the addition of atopic dermatitis, facial dermatitis, age > 40 years, and allergen positivity rate). Characteristics included in the index independently impact allergen positivity rates and changes to this index have been supported by studies demonstrating associations of the variables with allergen sensitization. Ethically and scientifically, it is important that clinical research accurately reports to whom the data apply. We suggest consideration be given to presenting ethnicity data “E” and gender identity “G” with patch test data. The “GOAHLFAPE” index would be in keeping with the World Health Organization's (WHO) global movement to promote health equity, which encourages a stronger emphasis on social determinants of health and removing gender bias in medical research. From the perspective of both completeness of data and an equity standpoint, it is unfortunate that many patch test studies do not report ethnicity. Ethnicity may impact allergen exposure and subsequent sensitization via social, cultural, socioeconomic, and genetic factors. There are existing data to support the notion that ethnicity impacts patterns of sensitization; Deleo and colleagues have documented different allergen sensitization rates by ethnicity, with p-phenylenediamine (PPD), bacitracin, and thiuram being more frequently positive in Blacks compared with Whites. PPD exposure and subsequent sensitization are increased in East African and Indian communities due to both hair dye and black henna use. However, large patch test studies have not routinely presented ethnicity data and so the relationship between ethnicity and contact allergy remains largely uncharacterized. Patch testing is often performed in tertiary centres with barriers to referral, financial, and geographical access. These barriers perpetuate racial inequity with corresponding poor utilization of healthcare services and poor health outcomes. In New Zealand, the “Reducing Inequalities in Health Framework” advocates a strong emphasis on ethnicity data recording to provide academics and policy makers with evidence on which programmes can be based regionally and globally to reduce health inequity. The WHO has outlined that epidemiological health research is required for ethnic minorities and this work should be given high priority. This research should not solely focus on social determinants of health but how ethnicity and migrant status relate to health outcomes. Given the global importance of these goals, it would be beneficial for patch testing journals to champion reporting of ethnicity with baseline demographic variables (despite the paucity of high-quality data on how ethnicity impacts contact sensitization). Transparent reporting of ethnicity among patients accessing patch testing is the first step towards identifying and reducing inequitable access and improving knowledge on how allergen sensitization rates vary with ethnicity. Reporting of ethnicity in a consistent fashion to allow comparison of international patch test results is likely to be challenging. Classification of ethnicity varies internationally based on local reporting systems. Practically, self-reported ethnicity is most likely to reflect cultural factors with influence on contact sensitization. The impact of other social determinants of health such as migrant status is also worth exploring, especially in Europe, where statistics on ethnicity are harder to obtain. Like ethnicity, migrant status has an impact on socioeconomic status, occupation, discrimination, and other determinants of health. Furthermore, the current system of reporting gender in the patch testing population could be optimized. The use of “M” (proportion of males) in the “MOAHLFAP” index is historical in nature, rather than having justification from academic writing guidelines. Females consistently predominate in patch-test populations and have increased rates of allergic contact dermatitis. Therefore, it would be more illustrative to report the proportion of patients identifying as female if only one gender is reported, consistent with the current dichotomous reporting format of the MOAHLFAP index. Of course, it is known gender is not a binary outcome and participants may identify as other than male/ female and gender identity may change over time. Gender is a complex entity comprising social, cultural, and behavioural factors and may differ from biological sex at birth. In research, the term “sex” most often relates to biological factors and “gender” correlates with behavioural and social factors. Consistency in the use of these terms helps with aggregation of research data and meta-analysis. The Sex and Gender Equity in Research (SAGER) guidelines recommend that study methodology specifies how gender is determined in research, for example, self-reported, via medical examination or genetic testing. Therefore, it would be useful to clarify the definition of gender in the MOAHLFAP index. Current self-reported gender identity is most likely to reflect allergen exposures and reporting all gender categories reported by participants should be considered to avoid the problems with binary gender reporting. Given the established role of the MOAHLFAP index in patch test research, modifications require careful consideration and justification. However, there is an ethical imperative that contact dermatitis in minority ethnic groups be studied and that gender bias in research is minimized. In summary, we propose that ethnicity and gender identity be included when reporting baseline characteristics Received: 22 June 2021 Revised: 15 July 2021 Accepted: 26 July 2021