Small-area socioeconomic deprivation indices in Cyprus: development and association with premature mortality

The association between education and premature mortality in the Chinese population: a 10-year cohort study

Background

Recent studies have shown significant associations between education and premature mortality. However, the relationship differs across countries. We aimed to present the latest evidence on the educational inequalities in premature mortality in the Chinese population.

Methods

We linked two databases, to establish a population-based, ten-year cohort spanning 2010 to 2020. Cox proportional hazard regression analyses adjusting for age, sex and urbanicity were conducted for all-cause mortality, and competing risk models were fitted for cause-specific mortality. We calculated population attributable fraction (PAF) using the hazard ratios (HRs) obtained by regression analyses. Additionally, we fitted models adjusting for risk factors and investigated the mediating effect of income, smoking, alcohol consumption and diets.

Findings

Compared with individuals with upper secondary and above education, the HR for premature all-cause mortality for those with less than primary education was 1.93 (95% CI: 1.72-2.19). The HRs were the highest for deaths from respiratory diseases (HR = 3.09, 95% CI 1.82-5.27). The excess risk of premature mortality associated with low education was higher among women and urban population. The association of education remained significant after accounting for risk factors, and income was the main mediator, which accounted for 23.0% of mediation in men and 11.1% in women.

Interpretation

The study's findings support the increased risk of premature mortality associated with low education, particularly in women and urban populations. The considerable number of deaths attributed to educational inequality underscores the necessity for more effective and targeted public health interventions.

Funding

Chinese Central Government.

The complex link between socioeconomic deprivation and COVID-19. Evidence from small areas of Catalonia

This ecological study assesses the association between the incidence rate of COVID-19 confirmed cases and socioeconomic deprivation in the Catalan small areas for the first six waves of the pandemic. The association is estimated using Poisson regressions and, in contrast to previous studies, considering that the relationship is not linear but rather depends on the degree of deprivation. The results show that the association between deprivation and incidence varied between waves, not only in intensity but also in its sign. Although it was insignificant in the first, third and fourth waves, the association was positive and significant in the second, becoming significantly negative in the fifth and sixth waves. Interestingly, the evidence suggests that the link between both magnitudes was not homogeneous throughout the distribution of deprivation, the pattern also varying between waves. The results are discussed in view of the role of non-pharmacological interventions and vaccination, as well as potential biases (for example that associated with differences between population groups in the propensity to be tested in each wave).

Validation and Cultural Adaptation of the Problem Areas in Diabetes-5 (PAID-5) Scale to European Portuguese

INTRODUCTION

Diabetes distress syndrome (DDS) can lead to poor outcomes and should be assessed with adapted and validated tools. One of these tools is the Problem Areas in Diabetes (PAID) scale, which assesses diabetes distress in people suffering from diabetes (PsD). A short five-item form, PAID-5, is an easier and quicker alternative to be used in clinical and research practices, than the previous one with 20-items and has been validated by the original authors. This study intended to perform the cultural adaptation and validation of the PAID-5 scale in European Portuguese.

METHODS

To create the Portuguese version of PAID-5, translation-back translation, a clinical review, and a cognitive debriefing panel were performed. A convenience sample of 90 PsD was studied in three primary healthcare units for reliability and validity tests. Reliability was studied by the internal consistency (Cronbach's alpha) and the interval coefficient correlation (ICC) under a test-retest design. Structural validity was studied by principal component analysis. The construct validity was tested by the sensitivity of the PAID-5 total score with age, most recent HbA1c test, and socioeconomic class by the Socio-Economic Deprivation Index (SEDI). Criterion validity was tested by correlating the PAID-5 total score with the psychological distress questions of the Diabetes Health Profile 18 Questions (DHP-PDQ).

RESULTS

A Cronbach's alpha coefficient value of 0.905 and an ICC of 0.905 were computed. In a sample of n = 90 PsD, 55.6% were males, 63.3% aged 65 years or more, SEDI was 5.2 ± 0.8 [3 to 6], 44.4% studied for less than 4 years, and 18.9% were living alone. The Spearman correlation between PAID-5 and DHP-PDQ total scores was ρ = 0.382, p < 0.001, between PAID-5 total score and age was ρ = -0.207, p = 0.050 and between PAID-5 total score and most recent HbA1c knowledge was ρ = 0.275, p = 0.040. There was no significant relationship between PAID-5 total score and SEDI ρ = 0.080, p = 0.452.

CONCLUSION

DDS can now be assessed in the Portuguese context, accounting for better intervention by primary care teams. PAID-5 has good psychometric properties and is a reliable scale to identify diabetes-specific distress in the Portuguese diabetic population.

Construction and validation of the area level deprivation index for health research: A methodological study based on Nepal Demographic and Health Survey

Area-level factors may partly explain the heterogeneity in risk factors and disease distribution. Yet, there are a limited number of studies that focus on the development and validation of the area level construct and are primarily from high-income countries. The main objective of the study is to provide a methodological approach to construct and validate the area level construct, the Area Level Deprivation Index in low resource setting. A total of 14652 individuals from 11,203 households within 383 clusters (or areas) were selected from 2016-Nepal Demographic and Health survey. The index development involved sequential steps that included identification and screening of variables, variable reduction and extraction of the factors, and assessment of reliability and validity. Variables that could explain the underlying latent structure of area-level deprivation were selected from the dataset. These variables included: housing structure, household assets, and availability and accessibility of physical infrastructures such as roads, health care facilities, nearby towns, and geographic terrain. Initially, 26-variables were selected for the index development. A unifactorial model with 15-variables had the best fit to represent the underlying structure for area-level deprivation evidencing strong internal consistency (Cronbach's alpha = 0.93). Standardized scores for index ranged from 58.0 to 140.0, with higher scores signifying greater area-level deprivation. The newly constructed index showed relatively strong criterion validity with multi-dimensional poverty index (Pearson's correlation coefficient = 0.77) and relatively strong construct validity (Comparative Fit Index = 0.96; Tucker-Lewis Index = 0.94; standardized root mean square residual = 0.05; Root mean square error of approximation = 0.079). The factor structure was relatively consistent across different administrative regions. Area level deprivation index was constructed, and its validity and reliability was assessed. The index provides an opportunity to explore the area-level influence on disease outcome and health disparity.

Spatial-temporal analysis of suicide clusters for suicide prevention in Hong Kong: a territory-wide study using 2014-2018 Hong Kong Coroner's Court reports

Background

This study aimed to (i) identify high-risk suicide-methods clusters, based on location of residence and suicide incidence; and (ii) compare the characteristics of cases and spatial units inside and outside clusters.

Methods

Suicide data of 4672 cases was obtained from the Coroner's Court reports in Hong Kong (2014-2018). Monthly aggregated suicide numbers based on location of residence, and suicide incidence, were obtained in small tertiary planning units (STPUs). Community-level characteristics and population of STPUs were retrieved from 2016 Census. Retrospective space-time analyses were performed to identify locations with elevated suicide rates over specific time periods, i.e., spatial-temporal clusters. Clusters were evaluated for overall suicide (any method), as well as jumping, hanging, and charcoal burning methods, in location of residence and suicide incidence. Bi-variate analysis was performed to compare the characteristics of cases, and spatial units, inside and outside the clusters.

Findings

Suicide clusters involving jumping and charcoal burning were identified, but no hanging clusters were found. The within-cluster distribution of types of housing was different from that of outside. For most of the overall suicide and suicide by jumping clusters, spatial units within the clusters were more socially disadvantaged compared to those outside.

Interpretation

Clusters varied by suicide methods, location of residence and location of incidence. The findings highlighted the need for consistent and concerted support from different stakeholders within suicide clusters, to ensure appropriate design, implementation and sustainability of effective suicide prevention programs.

Funding

General Research Fund (37000320) and seed fund from the University of Hong Kong (104006710).

How do hospitals address health inequalities experienced by children and young people: a grey literature scoping review protocol

INTRODUCTION

Health inequalities are unfair, systematic differences in health between people. In the UK, the Health and Social Care Act 2012 recognised health inequalities as a responsibility of the National Health Service (NHS). Health inequalities were foregrounded in the publication of 2019 NHS Long Term Plan and during the SARS-CoV-2/COVID-19 pandemic. Hospitals are well placed to address health inequalities through their role as anchor institutions. While many hospitals have begun to address inequalities, children are often overlooked or assumed to have the same needs as adult populations. This grey literature scoping review aims to identify, collate and present approaches taken by hospitals to address health inequalities in children and young people.

METHODS AND ANALYSIS

This scoping review will follow Joanna Briggs Institute guidance. A four-step approach to identifying grey literature will be used. Literature will be examined to identify approaches that aim to address health inequalities. Literature must describe the health inequality they aim to address and be initiated by the hospital. It will exclude literature not available in English and published before 2010. Two reviewers will independently review the results of the searches using the inclusion and exclusion criteria. Data will be extracted using a data extraction tool. Study findings will be presented in tabular form detailing the interventions identified.

DISSEMINATION

The review will synthesise information on worldwide hospital approaches to addressing child health inequalities. The findings will be used to inform guidelines for children's hospitals in the UK and will be disseminated through national and international professional bodies, conferences and research papers.

Does the place of residence influence your risk of being hypertensive? A study-based on Nepal Demographic and Health Survey

Even though several studies have examined various risk factors for hypertension, residential influence is poorly explored especially in the low-income countries. We aim to investigate the association between residential characteristics and hypertension in resource limited and transitional settings like Nepal. A total of 14,652 individuals aged 15 and above were selected from 2016-Nepal Demographic and Health Survey. Individuals with blood pressure ≥140/90 mmHg or a history of hypertension (as identified by physicians/health professionals) or under antihypertensive medication were defined as hypertensive. Residential characteristics were represented by area level deprivation index, with a higher score representing higher level of deprivation. Association was explored using a two-level logistic regression. We also assessed if residential area modifies the association between individual socio-economic status and hypertension. Area deprivation had a significant inverse association with the risk of hypertension. Individuals from the least deprived areas had higher odds of hypertension compared to highly deprived areas 1.59 (95% CI 1.30, 1.89). Additionally, the association between literacy a proxy of socio-economic status and hypertension varied with a place of residence. Literate individuals from highly deprived areas were likely to have a higher odds of hypertension compared to those with no formal education. In contrast, literate from the least deprived areas had lower odds of hypertension. These results identify counterintuitive patterns of associations between residential characteristics and hypertension in Nepal, as compared with most of the epidemiological data from high-income countries. Differential stages of demographic and nutritional transitions between and within the countries might explain these associations.

Small-Area Geographic and Socioeconomic Inequalities in Colorectal Cancer in Cyprus

Colorectal cancer (CRC) is one of the leading causes of death and morbidity worldwide. To date, the relationship between regional deprivation and CRC incidence or mortality has not been studied in the population of Cyprus. The objective of this study was to analyse the geographical variation of CRC incidence and mortality and its possible association with socioeconomic inequalities in Cyprus for the time period of 2000-2015. This is a small-area ecological study in Cyprus, with census tracts as units of spatial analysis. The incidence date, sex, age, postcode, primary site, death date in case of death, or last contact date of all alive CRC cases from 2000-2015 were obtained from the Cyprus Ministry of Health's Health Monitoring Unit. Indirect standardisation was used to calculate the sex and age Standardise Incidence Ratios (SIRs) and Standardised Mortality Ratios (SMRs) of CRC while the smoothed values of SIRs, SMRs, and Mortality to Incidence ratio (M/I ratio) were estimated using the univariate Bayesian Poisson log-linear spatial model. To evaluate the association of CRC incidence and mortality rate with socioeconomic deprivation, we included the national socioeconomic deprivation index as a covariate variable entering in the model either as a continuous variable or as a categorical variable representing quartiles of areas with increasing levels of socioeconomic deprivation. The results showed that there are geographical areas having 15% higher SIR and SMR, with most of those areas located on the east coast of the island. We found higher M/I ratio values in the rural, remote, and less dense areas of the island, while lower rates were observed in the metropolitan areas. We also discovered an inverted U-shape pattern in CRC incidence and mortality with higher rates in the areas classified in the second quartile (Q2-areas) of the socioeconomic deprivation index and lower rates in rural, remote, and less dense areas (Q4-areas). These findings provide useful information at local and national levels and inform decisions about resource allocation to geographically targeted prevention and control plans to increase CRC screening and management.

Analysis of association between low birth weight and socioeconomic deprivation level in Japan: an ecological study using nationwide municipal data

BACKGROUND

Several international studies have indicated an association between socioeconomic deprivation levels and adverse birth outcomes. In contrast, those investigating an association between socioeconomic status and low birth weight using nationwide data are limited in Japan. In this study, we investigated an association between municipal socioeconomic deprivation level and low birth weight by an ecological study.

METHODS

Nationwide municipal-specific Vital Statistics data from 2013 to 2017 were used. We calculated the low birth weight rate and standardized incidence ratio (SIR) for low birth weight for each municipality and plotted them on a Japanese map. Furthermore, the correlation coefficient between them and the deprivation level were calculated. In addition, a spatial regression model including other municipal characteristics was used to investigate an association between low birth weight and the deprivation level.

RESULTS

Municipalities with relatively high SIR for low birth weight were dispersed across all of Japan. The correlation coefficient between the socioeconomic deprivation level and low birth weight rate was 0.196 (p-value < 0.001) among municipalities, and that between the socioeconomic deprivation level and the SIR for low birth weight was 0.260 (p-value < 0.001). In addition, the spatial regression analysis showed the deprivation level was significantly and positively associated with low birth weight.

CONCLUSIONS

The socioeconomic deprivation level and low birth weight were positively associated, and a further study using individual data is warranted to verify reasons for the association.

Neighbourhood Socioeconomic Processes and Dynamics and Healthy Ageing: A Scoping Review

Elderly citizens are concentrated in urban areas and are particularly affected by the immediate residential environment. Cities are unequal and segregated places, where there is an intensification of urban change processes such as gentrification and displacement. We aimed to understand how neighbourhood socioeconomic processes and dynamics influence older people’s health. Three bibliographic databases—PubMed, Web of Science, and Scopus—were used to identify evidence of the influence of neighbourhood socioeconomic deprivation, socio-spatial segregation, urban renewal, and gentrification on healthy ageing. We followed the method of Arksey and O’Malley, Levac and colleagues, the Joanna Briggs Institute, and the PRISMA-ScR. The included studies (n = 122) were published between 2001 and 2021. Most evaluated neighbourhood deprivation (n = 114), followed by gentrification (n = 5), segregation (n = 2), and urban renewal (n = 1). Overall, older people living in deprived neighbourhoods had worse healthy ageing outcomes than their counterparts living in more advantaged neighbourhoods. Older adults pointed out more negative comments than positive ones for gentrification and urban renewal. As to segregation, the direction of the association was not entirely clear. In conclusion, the literature has not extensively analysed the effects of segregation, gentrification, and urban renewal on healthy ageing, and more quantitative and longitudinal studies should be conducted to draw better inferences.

Association of Esophageal Cancer Mortality with Municipal Socioeconomic Deprivation Level in Japan, 2013–2017: An Ecological Study Using Nationwide Data

This study aimed to show geographical differences in esophageal cancer mortality in Japan and reveal an association of esophageal cancer mortality with municipal socioeconomic deprivation level. Esophageal cancer mortality data in the Vital Statistics from 2013 to 2017 for each municipality and corresponding population data were analyzed. The deprivation level was derived from the municipal socioeconomic variables by principal component analysis. Municipalities were classified into five quintiles based on the deprivation level, and an association between the level and esophageal cancer mortality was evaluated using a Bayesian spatial model. As a result of regression analysis, the relative risk of esophageal cancer mortality tended to become larger as the deprivation level increased irrespective of sex, and the relative risk of esophageal cancer mortality was significantly higher in quintile 5 (most deprived) than quintile 1 (least deprived) among men and women. These results suggest that the deprivation level increases the risk of esophageal cancer mortality in Japan.

Analysis of the association between areal socioeconomic deprivation levels and viral hepatitis B and C infections in Japanese municipalities

Background

We investigated the association between municipal socioeconomic deprivation levels and the positivity of hepatitis B surface antigen (HBsAg) and the prevalence of hepatitis C virus (HCV) among individuals who have never participated in hepatitis screening using Japanese national screening data.

Methods

The hepatitis virus screening data analyzed included the 5-year age group-specific number of participants aged 40 years or older, number of HBsAg-positive persons, and number of HCV carriers for each municipality from 2013 to 2017. Principal component analysis was used to derive a socioeconomic deprivation level using the socioeconomic characteristics of municipalities. Bayesian spatial Poisson regression analysis was conducted to investigate the association between the socioeconomic deprivation level and the results of screening. Data on 1,660 municipalities were used in the analysis.

Results

The data of 4,233,819 participants in the HBV screening and 4,216,720 in the HCV screening were used in the analysis. A principal component interpreted as level of rurality (principal component 1) and another principal component interpreted as level of low socioeconomic status among individuals (principal component 2) were extracted as the major principal components. Their principal component scores were used as the deprivation levels of municipalities. Spatial regression analysis showed that the deprivation level derived from the sum of the scores of principal components 1 and 2 was significantly and positively associated with HBsAg positivity and HCV prevalence. In addition, the deprivation level derived only from the score of principal component 2 was also significantly and positively associated with the outcomes. Conversely, the deprivation level derived only from the score of principal component 1 was not associated with the outcomes. Moreover, population density was significantly and positively associated with HBsAg positivity and HCV prevalence.

Conclusions

This study suggested that participation in hepatitis virus screening is important and meaningful, particularly for areas with a higher lower socioeconomic level in Japan.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13089-w.

Can an Ecological Index of Deprivation Be Used at the Country Level? The Case of the French Version of the European Deprivation Index (F-EDI)

Most ecological indices of deprivation are constructed from census data at the national level, which raises questions about the relevance of their use, and their comparability across a country. We aimed to determine whether a national index can account for deprivation regardless of location characteristics. In Metropolitan France, 43,853 residential census block groups (IRIS) were divided into eight area types based on quality of life. We calculated score deprivation for each IRIS using the French version of the European Deprivation Index (F-EDI). We decomposed the score by calculating the contribution of each of its components by area type, and we assessed the impact of removing each component and recalculating the weights on the identification of deprived IRIS. The set of components most contributing to the score changed according to the area type, but the identification of deprived IRIS remained stable regardless of the component removed for recalculating the score. Not all components of the F-EDI are markers of deprivation according to location characteristics, but the multidimensional nature of the index ensures its robustness. Further research is needed to examine the limitations of using these indices depending on the purpose of the study, particularly in relation to the geographical grid used to calculate deprivation scores.

Profiling the variability and inequity in the residential environment in Cyprus according to citizens' ratings: a cross-sectional internet-based "Place Standard" survey

Background

The “Place Standard Tool” (PST) offers a practical framework for structuring conversations about physical and social dimensions of Place which impact on health and well-being. The aim of this study was to survey citizens’ perceptions of Place across diverse settings in Cyprus. While the PST has been extensively used in the context of community engagement, its properties as a measurement tool haven’t been explored.

Methods

An open call was addressed to citizens to rate their neighbourhood environment across the 14 PST items (1: large to 7: little room for improvement). Exploratory factor, cluster and regression analyses were used to explore the dimensionality of the scale, depict neighbourhood profiles and explore differences in ratings according to socio-demographic characteristics, area-level census indicators and residents’ assessment of neighbourhood social position (10-step ladder).

Results

With the exception of safety (M = 4.4, SD = 1.7), 492 participants (mean age 42, 50% residents for > 10 years) from 254 postcodes (21.7% islandwide) did not rate other features favourably, with lowest scores for “influence and sense of control” and “public transport”. A stepwise pattern of dissatisfaction was observed along the social position continuum both for features rated less as well as more favourably (e.g. social contact). For instance, among participants who placed their neighbourhood at the three top steps of the ladder, 48.8% gave a low rating for “influence and sense of control”, while the equivalent figure was 81.0% at the bottom three steps (OR = 4.5, 95% CI 2.3, 8.6). A clear dimensionality of Built (6 items, Cronbach’s α = 0.798), Physical (3 items, α = 0.765), Social (2 items, α = 0.749) and Service (3 items, α = 0.58) environment was identified. A social gradient was evident according to census measures of socio-economic disadvantage (e.g. pre-1980 housing, single-parent households) with larger differences in terms of the built than the social environment.

Conclusions

The study profiled the variability and documented the inequity in the health-related neighbourhood environment across Cypriot communities. The readily interpretable dimensionality of the scale supports its construct validity, allowing calculation of composite scores. The PST can be used as measurement tool in research as well as public health practice to advocate for neighbourhood initiatives which support and enhance citizens’ participation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12706-y.

Neighborhood Socioeconomic Deprivation and Depression Symptoms in Adults From the Hispanic Community Health Study/Study of Latinos (HCHS/SOL)

Socioeconomic factors appear to impact mental health conditions such as depression, but little is known about the relative and combined role of neighborhood and personal socioeconomic deprivation among Hispanics/Latinos. This study examined cross-sectional associations of neighborhood and personal socioeconomic deprivation with depression symptoms in a US Hispanic/Latino population from the San Diego Field Center of the Hispanic Community Health Study/Study of Latinos (n = 3,851). Depression symptoms were assessed with the ten-item Centers for Epidemiological Studies in Depression Scale. Neighborhood socioeconomic deprivation was a composite of eleven variables (e.g., neighborhood income, education, employment, household crowding). Greater personal socioeconomic deprivation based on education, income, and employment was generally associated with higher depression symptoms, including after adjusting for neighborhood socioeconomic deprivation. Greater neighborhood socioeconomic deprivation was associated with higher depression symptoms in females but not males, but the association in females became non-significant when adjusting for personal socioeconomic deprivation. Neighborhood socioeconomic deprivation did not significantly interact with personal socioeconomic deprivation in relation to depression symptoms. The present findings support the association of personal socioeconomic status with mental health (indicated by depression symptoms) among Hispanic/Latino populations, whereas neighborhood socioeconomic deprivation did not relate to depression beyond the impact of personal indicators.

What Regional Living Conditions Affect Individual Smoking of Adults in Russia

Objectives: Our study evaluated the impact of a wide range of characteristics of large administrative regions on the individual level of cigarette smoking in the Russian adult population. Methods: The pool of participants included 20,303 individuals aged 25-64 years. We applied 64 characteristics of the 12 Russian regions under study for 2010-2014. Using principal component analysis, we deduced five evidence-based composite indices of the regions. We applied the generalized estimating equation to determine associations between the regional indices and the individual level of smoking. Results: The increased Industrial index in the region is associated with the probability of smoking (odds ratio = 1.15; 95% confidence interval = 1.06-1.24). The other indices show associations with smoking only in separate gender and educational groups. Surprisingly, it was found that the Economic index has no associations with the probability of smoking. Conclusion: We evaluated the key associations of the territorial indices with the individual probability of smoking, as well as the mutual influence between the territorial indices and individual factors.

Measuring health-related social deprivation in small areas: development of an index and examination of its association with cancer mortality

BACKGROUND

The small-area deprivation indices are varied across countries due to different social context and data availability. Due to lack of chronic disease-related social deprivation index (SDI) in Hong Kong, China, this study aimed to develop a new SDI and examine its association with cancer mortality.

METHODS

A total of 14 socio-economic variables of 154 large Tertiary Planning Unit groups (LTPUGs) in Hong Kong were obtained from 2016 population by-census. LTPUG-specific all-cause and chronic condition-related mortality and chronic condition inpatient episodes were calculated as health outcomes. Association of socio-economic variables with health outcomes was estimated for variable selection. Candidates for SDI were constructed with selected socio-economic variables and tested for criterion validity using health outcomes. Ecological association between the selected SDI and cancer mortality were examined using zero-inflated negative binomial regression.

RESULTS

A chronic disease-related SDI constructed by six area-level socio-economic variables was selected based on its criterion validity with health outcomes in Hong Kong. It was found that social deprivation was associated with higher cancer mortality during 2011-2016 (most deprived areas: incidence relative risk [IRR] = 1.40, 95% confidence interval [CI]: 1.27-1.55; second most deprived areas: IRR = 1.34, 95%CI: 1.21-1.48; least deprived areas as reference), and the cancer mortality gap became larger in more recent years. Excess cancer death related to social deprivation was found to have increased through 2011-2016.

CONCLUSIONS

Our newly developed SDI is a valid and routinely available measurement of social deprivation in small areas and is useful in resource allocation and policy-making for public health purpose in communities. There is a potential large improvement in cancer mortality by offering relevant policies and interventions to reduce health-related deprivation. Further studies can be done to design strategies to reduce the expanding health inequalities between more and less deprived areas.

Health Status and Chronic Disease Burden of the Homeless Population: An Analysis of Two Decades of Multi-Institutional Electronic Medical Records

Using a multi-institutional EMR registry, we extracted housing status and evaluated the presence of several important comorbidities in order to describe the demographics and comorbidity burden of persons experiencing homelessness in northeast Ohio and compare this to non-homeless individuals of varying socioeconomic position. Of 1,974,766 patients in the EMR registry, we identified 15,920 (0.8%) as homeless, 351,279 (17.8%) as non-homeless and in the top quintile of area deprivation index (ADI), and 1,607,567 (81.4%) as non-homeless and in the lower four quintiles of area deprivation. The comorbidity burden was highest in the homeless population with depression (48.1%), anxiety (45.8%), hypertension (44.2%), cardiovascular disease (18.4%), and hepatitis (18.1%) among the most prevalent conditions. We conclude that it is possible to identify homeless individuals and document their comorbidity burden using a multi-institutional EMR registry, in order to guide future interventions to address the health of the homeless at the health-system and community level.

Geodemographic Area Classification and Association with Mortality: An Ecological Study of Small Areas of Cyprus

Geographical investigations are a core function of public health monitoring, providing the foundation for resource allocation and policies for reducing health inequalities. The aim of this study was to develop geodemographic area classification based on several area-level indicators and to explore the extent of geographical inequalities in mortality. A series of 19 area-level socioeconomic indicators were used from the 2011 national population census. After normalization and standardization of the geographically smoothed indicators, the k-means cluster algorithm was implemented to classify communities into groups based on similar characteristics. The association between geodemographic area classification and the spatial distribution of mortality was estimated in Poisson log-linear spatial models. The k-means algorithm resulted in four distinct clusters of areas. The most characteristic distinction was between the ageing, socially isolated, and resource-scarce rural communities versus metropolitan areas with younger population, higher educational attainment, and professional occupations. By comparison to metropolitan areas, premature mortality appeared to be 44% (95% Credible Intervals [CrI] of Rate Ratio (RR): 1.06-1.91) higher in traditional rural areas and 36% (95% CrI of RR: 1.13-1.62) higher in young semi-rural areas. These findings warrant future epidemiological studies investigating various causes of the urban-rural differences in premature mortality and implementation policies to reduce the mortality gap between urban and rural areas.