The Portuguese version of the European Deprivation Index: Development and association with all-cause mortality

Long-term Exposure to Ambient Air Pollution and its Association with Mental Well-Being, Depression and Anxiety: A Nationally Representative Study

INTRODUCTION

Exposure to ambient air pollution may play a role in the onset of common mental disorders like depressive and anxiety disorders. The association of long-term exposure to particles smaller than 10 μm (PM10) with these diseases remains unclear. This study aimed to estimate the association of long-term exposure to PM10 with mental well-being and the frequency of probable diagnosis of common mental disorders.

METHODS

A nationally representative cross-sectional study was done in mainland Portugal. Long-term exposure was estimated through one-year average concentrations of PM10, calculated with data from the Portuguese Environment Agency, attributed individually considering individuals' postal codes of residence. The mental well-being and the probable diagnosis of common mental disorders were ascertained through the five-item Mental Health Inventory scale. Linear and Robust Poisson regression models were computed to estimate change percentages, prevalence ratios (PR), and their 95% confidence intervals (95% CI).

RESULTS

The median (interquartile range) concentration of PM10 was 18.6 (15.3 - 19.3) μg/m3. The mental well-being score was 72 (56 - 84) points, on a scale from 0 to 100. A probable diagnosis of common mental disorders was found in 22.7% (95% CI: 20.0 to 25.6). Long-term exposure to PM10 was associated with a non-statistically significant decrease in the mental well-being score [for each 10 μg/m³ increment in one-year average PM10 concentrations, there was a 2% (95% CI: -8 to 4) decrease], and with a non-statistically significant increase in the common mental health frequency (PR = 1.012, 95% CI: 0.979 to 1.045).

CONCLUSION

We did not find statistically significant associations between long-term exposure to PM10 and mental well-being or the frequency of probable diagnosis of common mental disorders. These results may be explained by the reduced variability in the exposure values, given the geographical distribution and functioning of the network of air quality monitoring stations. This study contributes with evidence for low levels of air pollutants, being one of the first to adjust for individual and aggregate-level variables. Moreover, to the best of our knowledge, this was the first nationally representative, population-based study conducted on the Portuguese population using real-life data. Maintaining a robust and nationwide air quality monitoring network is essential for obtaining quality exposure data.

Impacts of social deprivation on mortality and protective effects of greenness exposure in Hong Kong, 1999-2018: A spatiotemporal perspective

Addressing health inequality is crucial for fostering healthy city development. However, there is a dearth of literature simultaneously investigating the effects of social deprivation and greenness exposure on mortality risks, as well as how greenness exposure may mitigate the adverse effect of social deprivation on mortality risks from a spatiotemporal perspective. Drawing on socioeconomic, remote sensing, and mortality record data, this study presents spatiotemporal patterns of social deprivation, population weighted greenness exposure, and all-cause and cause-specific mortality in Hong Kong. A Bayesian regression model was applied to investigate the impacts of social deprivation and greenness exposure on mortality and examine how socioeconomic inequalities in mortality may vary across areas with different greenness levels in Hong Kong from 1999 to 2018. We observed a decline in social deprivation (0.67-0.56), and an increase in greenness exposure (0.34-0.41) in Hong Kong during 1999-2018. Areas with high mortality gradually clustered in the Kowloon Peninsula and the northern regions of Hong Kong Island. Adverse impacts of social deprivation on all-cause mortality weakened in recent years (RR from 2009 to 2013: 1.103, 95%CI: 1.051-1.159, RR from 2014 to 2018: 1.041 95%CI: 0.950-1.139), while the protective impacts of greenness exposure consistently strengthened (RR from 1999 to 2003: 0.903, 95%CI: 0.827-0.984, RR from 2014 to 2018: 0.859, 95%CI: 0.763-0.965). Moreover, the adverse effects of social deprivation on mortality risks were found to be higher in areas with lower greenness exposure. These findings provide evidence of associations between social deprivation, greenness exposure, and mortality risks in Hong Kong over the past decades, and highlight the potential of greenness exposure to mitigate health inequalities. Our study provides valuable implications for policymakers to develop a healthy city.

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Spatial Analysis of Determinants of COVID-19 Vaccine Hesitancy in Portugal

Vaccine hesitancy tends to exhibit geographical patterns and is often associated with social deprivation and migrant status. We aimed to estimate COVID-19 vaccination hesitancy in a high-vaccination-acceptance country, Portugal, and determine its association with sociodemographic risk factors. We used the Registry of National Health System Users to determine the eligible population and the Vaccination Registry to determine individuals without COVID-19 vaccine doses. Individuals older than five with no COVID-19 vaccine dose administered by 31 March 2022 were considered hesitant. We calculated hesitancy rates by municipality, gender, and age group for all municipalities in mainland Portugal. We used the spatial statistical scan method to identify spatial clusters and the Besag, Yorke, and Mollié (BYM) model to estimate the effect of age, gender, social deprivation, and migrant proportion across all mainland municipalities. The eligible population was 9,852,283, with 1,212,565 (12%) COVID-19 vaccine-hesitant individuals. We found high-hesitancy spatial clusters in the Lisbon metropolitan area and the country's southwest. Our model showed that municipalities with higher proportions of migrants are associated with an increased relative risk (RR) of vaccine hesitancy (RR = 8.0; CI 95% 4.6; 14.0). Social deprivation and gender were not associated with vaccine hesitancy rates. We found COVID-19 vaccine hesitancy has a heterogeneous distribution across Portugal and has a strong association with the proportion of migrants per municipality.

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.

Geographic patterns and hotspots of pediatric tuberculosis: the role of socioeconomic determinants

OBJECTIVE

Children are an important demographic group for understanding overall tuberculosis epidemiology, and monitoring of childhood tuberculosis is essential for appropriate prevention. The present study sought to characterize the spatial distribution of childhood tuberculosis notification rates in continental Portugal; identify high-risk areas; and evaluate the association between childhood tuberculosis notification rates and socioeconomic deprivation.

METHODS

Using hierarchical Bayesian spatial models, we analyzed the geographic distribution of pediatric tuberculosis notification rates across 278 municipalities between 2016 and 2020 and determined high-risk and low-risk areas. We used the Portuguese version of the European Deprivation Index to estimate the association between childhood tuberculosis and area-level socioeconomic deprivation.

RESULTS

Notification rates ranged from 1.8 to 13.15 per 100,000 children under 5 years of age. We identified seven high-risk areas, the relative risk of which was significantly above the study area average. All seven high-risk areas were located in the metropolitan area of Porto or Lisbon. There was a significant relationship between socioeconomic deprivation and pediatric tuberculosis notification rates (relative risk = 1.16; Bayesian credible interval, 1.05-1.29).

CONCLUSIONS

Identified high-risk and socioeconomically deprived areas should constitute target areas for tuberculosis control, and these data should be integrated with other risk factors to define more precise criteria for BCG vaccination.

The role of early functional neuroimaging in predicting neurodevelopmental outcomes in neonatal encephalopathy

Reliably assessing the early neurodevelopmental outcomes in infants with neonatal encephalopathy (NE) is of utmost importance to advise parents and implement early and personalized interventions. We aimed to evaluate the accuracy of neuroimaging modalities, including functional magnetic resonance imaging (fMRI) in predicting neurodevelopmental outcomes in NE. Eighteen newborns with NE due to presumed perinatal asphyxia (PA) were included in the study, 16 of whom underwent therapeutic hypothermia. Structural magnetic resonance imaging (MRI), and fMRI during passive visual, auditory, and sensorimotor stimulation were acquired between the 10th and 14th day of age. Clinical follow-up protocol included visual and auditory evoked potentials and a detailed neurodevelopmental evaluation at 12 and 18 months of age. Infants were divided according to sensory and neurodevelopmental outcome: severe, moderate disability, or normal. Structural MRI findings were the best predictor of severe disability with an AUC close to 1.0. There were no good predictors to discriminate between moderate disability versus normal outcome. Nevertheless, structural MRI measures showed a significant correlation with the scores of neurodevelopmental assessments. During sensorimotor stimulation, the fMRI signal in the right hemisphere had an AUC of 0.9 to predict absence of cerebral palsy (CP). fMRI measures during auditory and visual stimulation did not predict sensorineural hearing loss or cerebral visual impairment.

CONCLUSION

In addition to structural MRI, fMRI with sensorimotor stimulation may open the gate to improve the knowledge of neurodevelopmental/motor prognosis if proven in a larger cohort of newborns with NE.

WHAT IS KNOWN

• Establishing an early, accurate neurodevelopmental prognosis in neonatal encephalopathy remains challenging. • Although structural MRI has a central role in neonatal encephalopathy, advanced MRI modalities are gradually being explored to optimize neurodevelopmental outcome knowledge.

WHAT IS NEW

• Newborns who later developed cerebral palsy had a trend towards lower fMRI measures in the right sensorimotor area during sensorimotor stimulation. • These preliminary fMRI results may improve future early delineation of motor prognosis in neonatal encephalopathy.

Spatiotemporal evolution of COVID-19 in Portugal's Mainland with self-organizing maps

BACKGROUND

Self-Organizing Maps (SOM) are an unsupervised learning clustering and dimensionality reduction algorithm capable of mapping an initial complex high-dimensional data set into a low-dimensional domain, such as a two-dimensional grid of neurons. In the reduced space, the original complex patterns and their interactions can be better visualized, interpreted and understood.

METHODS

We use SOM to simultaneously couple the spatial and temporal domains of the COVID-19 evolution in the 278 municipalities of mainland Portugal during the first year of the pandemic. Temporal 14-days cumulative incidence time series along with socio-economic and demographic indicators per municipality were analyzed with SOM to identify regions of the country with similar behavior and infer the possible common origins of the incidence evolution.

RESULTS

The results show how neighbor municipalities tend to share a similar behavior of the disease, revealing the strong spatiotemporal relationship of the COVID-19 spreading beyond the administrative borders of each municipality. Additionally, we demonstrate how local socio-economic and demographic characteristics evolved as determinants of COVID-19 transmission, during the 1st wave school density per municipality was more relevant, where during 2nd wave jobs in the secondary sector and the deprivation score were more relevant.

CONCLUSIONS

The results show that SOM can be an effective tool to analysing the spatiotemporal behavior of COVID-19 and synthetize the history of the disease in mainland Portugal during the period in analysis. While SOM have been applied to diverse scientific fields, the application of SOM to study the spatiotemporal evolution of COVID-19 is still limited. This work illustrates how SOM can be used to describe the spatiotemporal behavior of epidemic events. While the example shown herein uses 14-days cumulative incidence curves, the same analysis can be performed using other relevant data such as mortality data, vaccination rates or even infection rates of other disease of infectious nature.

Green and blue spaces and lung function in the Generation XXI cohort: a life-course approach

BACKGROUND

Exposure to natural environments may affect respiratory health. This study examined the association of exposure to green and blue spaces with lung function in children, and assessed the mediation effect of air pollution and physical activity.

METHODS

The study used data from the Generation XXI, a population-based birth cohort from the Porto Metropolitan Area (Portugal). Residential Normalised Difference Vegetation Index (NDVI) at different buffers (100, 250 and 500 m), the accessibility to urban green spaces (UGS) within 400 and 800 m and the minimum distance to the nearest UGS and to the nearest blue spaces were assessed at birth, 4, 7 and 10 years of age. Three life-course measures were calculated: averaged exposure, early-life exposure (birth) and exposure trend over time (change in exposure). Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1) and forced expiratory flow between 25% and 75% of FVC (FEF25-75%) at 10 years were used as outcomes. To assess associations, linear regression models and path analysis were used.

RESULTS

This study included 3278 children. The adjusted models showed that increasing the NDVI exposure over time within 100 m of the child's residence was associated with higher values of FEV1 (L) and FEF25-75% (L·s-1) (β 0.01, 95% CI 0.0002-0.03 and β 0.02, 95% CI 0.001-0.05, respectively). No significant associations were observed for the remaining measures of exposure, and no mediation effect was found for pollution or physical activity.

CONCLUSION

Increasing exposure to greenness at close proximity from residences was associated with improved lung function. While the mechanism remains unknown, this study brings evidence that city greening may improve children's respiratory health.

COVID-19 mRNA vaccine effectiveness (second and first booster dose) against hospitalisation and death during Omicron BA.5 circulation: cohort study based on electronic health records, Portugal, May to July 2022

We measured vaccine effectiveness (VE) against COVID-19-related severe outcomes in elderly people in Portugal between May and July 2022. In ≥ 80 year-olds, the second booster dose VE was 81% (95% CI: 75–85) and 82% (95% CI: 77–85), respectively, against COVID-19-related hospitalisation and death. The first booster dose VE was 63% (95% CI: 55–70) in ≥ 80 year-olds and 74% (95% CI: 66–80) in 60–79 year-olds against hospitalisation, and 63% (95% CI: 57–69) and 65% (95% CI: 54–74) against death.

Classification of Deprivation Indices That Applied to Detect Health Inequality: A Scoping Review

INTRODUCTION

Many studies around the world are undertaken to establish the association between deprivation and public health indicators. Both separate indicators (e.g., income, education, occupation, public security and social support) and complex models (indices) include several indicators. Deprivation indices are actively used in public health since the mid 1980s. There is currently no clear classification of indices.

METHODS

In the current review, data related to deprivation indices are combined and analyzed in order to create a taxonomy of indices based on the results obtained. The search was carried out using two bibliographic databases. After conducting a full-text review of the articles and searching and adding relevant articles from the bibliography, and articles that were already known to the authors, sixty studies describing the use of sixty deprivation indices in seventeen countries were included in the narrative synthesis, resulting in development of a taxonomy of indices. When creating the taxonomy, an integrative approach was used that allows integrating new classes and sub-classes in the event that new information appears.

RESULTS

In the review, 68% (41/60) of indices were classified as socio-economic, 7% (4/60) of indices as material deprivation, 5% (3/60) of indices as environmental deprivation and 20% (12/60) as multidimensional indices.

CONCLUSIONS

The data stimulates the use of a competent approach, and will help researchers and public health specialist in resolving conflicts or inconsistencies that arise during the construction and use of indices.

Machine learning methods to predict attrition in a population-based cohort of very preterm infants

The timely identification of cohort participants at higher risk for attrition is important to earlier interventions and efficient use of research resources. Machine learning may have advantages over the conventional approaches to improve discrimination by analysing complex interactions among predictors. We developed predictive models of attrition applying a conventional regression model and different machine learning methods. A total of 542 very preterm (< 32 gestational weeks) infants born in Portugal as part of the European Effective Perinatal Intensive Care in Europe (EPICE) cohort were included. We tested a model with a fixed number of predictors (Baseline) and a second with a dynamic number of variables added from each follow-up (Incremental). Eight classification methods were applied: AdaBoost, Artificial Neural Networks, Functional Trees, J48, J48Consolidated, K-Nearest Neighbours, Random Forest and Logistic Regression. Performance was compared using AUC- PR (Area Under the Curve—Precision Recall), Accuracy, Sensitivity and F-measure. Attrition at the four follow-ups were, respectively: 16%, 25%, 13% and 17%. Both models demonstrated good predictive performance, AUC-PR ranging between 69 and 94.1 in Baseline and from 72.5 to 97.1 in Incremental model. Of the whole set of methods, Random Forest presented the best performance at all follow-ups [AUC-PR₁: 94.1 (2.0); AUC-PR₂: 91.2 (1.2); AUC-PR₃: 97.1 (1.0); AUC-PR₄: 96.5 (1.7)]. Logistic Regression performed well below Random Forest. The top-ranked predictors were common for both models in all follow-ups: birthweight, gestational age, maternal age, and length of hospital stay. Random Forest presented the highest capacity for prediction and provided interpretable predictors. Researchers involved in cohorts can benefit from our robust models to prepare for and prevent loss to follow-up by directing efforts toward individuals at higher risk.

Association between Land Use Mix and Respiratory Symptoms and Asthma in Children from the Generation XXI Birth Cohort

Land use mix (LUM) in the neighbourhoods has been associated with healthier lifestyles. However, less is known about the association between LUM and health outcomes, namely during childhood. The objective of this study was to evaluate the association between different LUM indexes for Porto Metropolitan Area and asthma and respiratory symptoms in children. A cross-sectional analysis was performed involving 6260 children enrolled in Generation XXI. Land use around the child's residence was assessed with the Portuguese official map of land cover using a GIS. Generalized linear mixed-effects models were fitted to estimate the association between LUM and respiratory symptoms and asthma at 7 years of age. Adjusted associations were quantified using odds ratio (OR) and 95% confidence interval (95% CI). After adjustment, LUM was associated with a lower odds of wheezing in the last 12 months [OR (95% CI) = 0.37 (0.15; 0.93) using Shannon's Evenness Index within 500 m; and OR = 0.93 (0.89; 0.98) using the number of different land use types within 250 m]. Living in neighbourhoods with high LUM has a protective effect on current wheezing symptoms. Our results highlight the association between LUM and respiratory symptoms among children, suggesting that public health considerations should be incorporated in land use decision-making.

Intra-urban variation in tuberculosis and community socioeconomic deprivation in Lisbon metropolitan area: a Bayesian approach

Background

Multidrug resistant tuberculosis (MDR-TB) is a recognized threat to global efforts to TB control and remains a priority of the National Tuberculosis Programs. Additionally, social determinants and socioeconomic deprivation have since long been associated with worse health and perceived as important risk factors for TB. This study aimed to analyze the spatial distribution of non-MDR-TB and MDR-TB across parishes of the Lisbon metropolitan area of Portugal and to estimate the association between non-MDR-TB and MDR-TB and socioeconomic deprivation.

Methods

In this study, we used hierarchical Bayesian spatial models to analyze the spatial distribution of notification of non-MDR-TB and MDR-TB cases for the period from 2000 to 2016 across 127 parishes of the seven municipalities of the Lisbon metropolitan area (Almada, Amadora, Lisboa, Loures, Odivelas, Oeiras, Sintra), using the Portuguese TB Surveillance System (SVIG-TB). In order to characterise the populations, we used the European Deprivation Index for Portugal (EDI-PT) as an indicator of poverty and estimated the association between non-MDR-TB and MDR-TB and socioeconomic deprivation.

Results

The notification rates per 10,000 population of non-MDR TB ranged from 18.95 to 217.49 notifications and that of MDR TB ranged from 0.83 to 3.70. We identified 54 high-risk areas for non-MDR-TB and 13 high-risk areas for MDR-TB. Parishes in the third [relative risk (RR) = 1.281, 95% credible interval (CrI): 1.021–1.606], fourth (RR = 1.786, 95% CrI: 1.420–2.241) and fifth (RR = 1.935, 95% CrI: 1.536–2.438) quintile of socioeconomic deprivation presented higher non-MDR-TB notifications rates. Parishes in the fourth (RR = 2.246, 95% CrI: 1.374–3.684) and fifth (RR = 1.828, 95% CrI: 1.049–3.155) quintile of socioeconomic deprivation also presented higher MDR-TB notifications rates.

Conclusions

We demonstrated significant heterogeneity in the spatial distribution of both non-MDR-TB and MDR-TB at the parish level and we found that socioeconomically disadvantaged parishes are disproportionally affected by both non-MDR-TB and MDR-TB. Our findings suggest that the emergence of MDR-TB and transmission are specific from each location and often different from the non-MDR-TB settings. We identified priority areas for intervention for a more efficient plan of control and prevention of non-MDR-TB and MDR-TB.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-022-00949-1.

Residential and school green and blue spaces and intelligence in children: The Generation XXI birth cohort

Green and blue spaces have numerous health benefits. It has been hypothesized that contact with these spaces can have an important role in cognitive development, because it provides children with unique stimuli that can help develop curiosity, creativity, awareness, and control. This study aimed to estimate the association between exposure to green and blue spaces and the various measures of intelligence quotient (IQ) among children from Porto Metropolitan Area (Portugal). This investigation used data from the Generation XXI birth cohort. Exposure was assessed by Geographic Information Systems using vegetation indexes and measures of accessibility to urban green spaces and blue spaces in the surroundings of the residence and school, measured at 0, 4, 7 and 10 years. The outcome was the verbal, performance, and global IQ, measured using the Wechsler Intelligence Scale for Children (WISC-III), administered at age 10. Associations were estimated using crude and adjusted multilevel models. The mediation role of air pollution and physical activity was quantified. This study included 3827 children. The adjusted models showed that having green spaces up to 800 m of the residence was positively associated with performance IQ (1.30 95%CI [0.26; 2.35]) and global IQ (1.27 [0.18; 2.36]). No clear associations were observed regarding accessibility to blue spaces. Physical activity appeared to have a minor mediation role. Children with urban green spaces around their residences had higher performance and global IQ. Local actors in the sectors of public health and urban planning should promote the creation of green spaces close to residential areas.

A national population-based study of patients, bystanders and contextual factors associated with resuscitation in witnessed cardiac arrest: insight from the french RéAC registry

Background

In out-of-hospital cardiac arrest (OHCA), bystander initiated cardiopulmonary resuscitation (CPR) increases the chance of return of spontaneous circulation and survival with a favourable neurological status. Socioeconomic disparities have been highlighted in OHCA field. In areas with the lowest average socioeconomic status, OHCA incidence increased, and bystander CPR decreased. Evaluations were performed on restricted geographical area, and European evaluation is lacking. We aimed to analyse, at a national level, the impact of area-level social deprivation on the initiation of CPR in case of a witnessed OHCA.

Methods

We included all witnessed OHCA cases with age over 18 years from July 2011 to July 2018 form the OHCA French national registry. We excluded OHCA occurred in front of rescue teams or in nursing home, and patients with incomplete address or partial geocoding. We collected data from context, bystander and patient. The area-level social deprivation was estimated by the French version of the European Deprivation Index (in quintile) associated with the place where OHCA occurred. We assessed the associations between Utstein variables and social deprivation level using a mixed-effect logit model with bystander-initiated CPR.

Results

We included 23,979 witnessed OHCA of which 12,299 (51%) had a bystander-initiated CPR. More than one third of the OHCA (8,326 (35%)) occurred in an area from the highest quintile of social deprivation. The higher the area-level deprivation, the less the proportion of bystander-initiated CPR (56% in Quintile 1 versus 48% in Quintile 5). The In the multivariable analysis, bystander less often began CPR in areas with the highest deprivation level, compared to those with the lowest deprivation level (OR=0.69, IC95%: 0.63-0.75).

Conclusions

The level of social deprivation of the area where OHCA occurred was associated with bystander-initiated CPR. It decreased in the more deprived areas although these areas also concentrate more younger patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12269-4.

Community socioeconomic deprivation and SARS-CoV-2 infection risk: findings from Portugal

Background

Socioeconomic differences have been observed in the risk of acquiring infectious diseases, but evidence regarding SARS-CoV-2 remains sparse. Hence, this study aimed to investigate the association between SARS-CoV-2 infection risk and socioeconomic deprivation, exploring whether this association varied according to different phases of the national pandemic response.

Methods

A cross-sectional study was conducted. Data routinely collected for patients with a laboratorial result recorded in SINAVE^®, between 2 March and 14 June 2020, were analysed. Socioeconomic deprivation was assessed using quintiles of the European Deprivation Index (Q1-least deprived to Q5-most deprived). Response phases were defined as before, during and after the national State of Emergency. Associations were estimated using multilevel analyses.

Results

The study included 223 333 individuals (14.7% were SARS-CoV-2 positive cases). SARS-CoV-2 infection prevalence ratio increased with deprivation [PR(Q1)=Ref; PR(Q2)=1.37 (95% CI 1.19–1.58), PR(Q3)=1.48 (95% CI 1.26–1.73), PR(Q4)=1.73 (95% CI 1.47–2.04), PR(Q5)=2.24 (95% CI 1.83–2.75)]. This was observed during the State of Emergency [PR(Q5)=2.09 (95% CI 1.67–2.62)] and more pronounced after the State of Emergency [PR(Q5)= 3.43 (95% CI 2.66–4.44)].

Conclusion

The effect of socioeconomic deprivation in the SARS-CoV-2 infection risk emerged after the implementation of the first State of Emergency in Portugal, and became more pronounced as social distancing policies eased. Decision-makers should consider these results when deliberating future mitigation measures.

mRNA vaccine effectiveness against COVID-19-related hospitalisations and deaths in older adults: a cohort study based on data linkage of national health registries in Portugal, February to August 2021

Through deterministic data linkage of health registries, mRNA vaccine effectiveness (VE) against COVID-19-related hospitalisations and deaths was measured in 1,880,351 older adults. VE against hospitalisations was 94% (95% confidence interval (CI): 88–97) and 82% (95% CI: 72–89) for those 65–79 and ≥ 80 years old, with no evidence of waning 98 days after dose two. VE against mortality was 96% (95% CI: 92–98) and 81% (95% CI: 74–87) in these two age groups.

Do Current Measures of Social Exclusion Depict the Multidimensional Challenges of Marginalized Urban Areas? Insights, Gaps and Future Research

According to the United Nations, 70% of the world's population will live in cities by 2050, increasing the proliferation of areas of social exclusion and thus polarization and segregation. The establishment of multidimensional measures seeks to identify such situations of social exclusion to inform social policies and interventions. However, some concerns emerge: Are these measures catching the needs of people living in particularly disadvantages areas? Do they offer a human-centred approach or a territorial focus? Is the multidimensionality of such measures reflecting nonmaterial aspects such as health, access to liveable environments or political participation? To analyse how the scientific literature is addressing the measurement of social exclusion to tackle such urban challenges, a systematic review following the PRISMA guidelines was performed in the Web of Science database. After screening following the inclusion criteria, 28 studies were identified that analysed systems of indicators that multidimensionally examined social exclusion at the individual and/or family level in urban contexts. Despite studies being eminently limited to some Western countries, the results revealed a broad diversity. However, very few of them fully focused on the specific characteristics of marginalized urban areas, and most found serious difficulties in overcoming a material approach.

Urban Green Spaces, Greenness Exposure and Species Richness in Residential Environments and Relations with Physical Activity and BMI in Portuguese Adolescents

Environmental factors play an important role in obesity-related behaviors. Evidence indicates significant associations between weight and urban green spaces in adults, but it is not clear whether this relationship applies to adolescents. Therefore, our aim was to determine the associations between urban green spaces, greenness exposure and species richness in residential environments with physical activity and body mass index. Sixty-two adolescents between 12 and 18 years of age answered a self-administered questionnaire, providing information on height, weight, age, sex and home address. Data on socioeconomic deprivation were obtained from the European Index of Deprivation for Small Portuguese Areas. Physical activity levels were assessed using accelerometers. Urban green space counts and the normalized difference vegetation index values were measured using buffers along the roads with distances of 300, 500, 1000 and 1500 m from each participant's residence. To quantify the species richness, the species richness index was used. Linear regression models were fitted to analyze whether urban green spaces, exposure to green spaces and species richness counts for each distance were associated with physical activity and self-reported body mass index. We did not find significant associations between the independent variables and the probability of overweight or obesity. The relationship between environmental variables, adolescents' physical activity and body weight seems to be complex and further studies may contribute to better understanding of the topic.

Neighbourhood green and blue spaces and allergic sensitization in children: A longitudinal study based on repeated measures from the Generation XXI cohort

Evidence on the effect of natural environments on atopy in children is limited and inconsistent, disregarding the time-varying and cumulative exposures throughout the life course. To assess critical periods of exposure as well as the effect of longitudinal trajectories of exposure to green and blue spaces on the development of allergic sensitization in children at the age of 10 years. A longitudinal study was conducted involving 730 children enrolled in Generation XXI, a population-based birth cohort from the Porto Metropolitan Area (Portugal). Food and aeroallergens sensitization were evaluated at 10 years of age using Phadiatop Infant, Phadiatop fx1 and fx22 ImmunoCAP (Thermo Fisher Scientific, Uppsala, Sweden). Residential Normalized Difference Vegetation Index (NDVI) and distance to the nearest blue space (sea, river) were assessed using a Geographic Information System. Latent class linear mixed models were fitted to determine longitudinal trajectories of exposure. Associations were estimated using Cox proportional hazards regression models and expressed using hazard ratios (HR) and 95% confidence intervals (95% CI). Residing in neighbourhoods surrounded by more vegetation at 10 years, as well as lifetime exposure to a trajectory of higher levels of NDVI, were associated with a lower risk of allergic sensitization [HR (95% CI) = 0.095 (0.011, 0.823) and HR (95% CI) = 0.539 (0.301, 0.965), respectively]. Our findings support a role for both longitudinal, but particularly late-childhood, exposure to green spaces, in the prevention of allergic sensitization in children.

Strategies for assessing the impact of loss to follow-up on estimates of neurodevelopmental impairment in a very preterm cohort at 2 years of age

BACKGROUND

Loss to follow-up is a major challenge for very preterm (VPT) cohorts; attrition is associated with social disadvantage and parents with impaired children may participate less in research. We investigated the impact of loss to follow-up on the estimated prevalence of neurodevelopmental impairment in a VPT cohort using different methodological approaches.

METHODS

This study includes births < 32 weeks of gestational age (GA) from 4 regions in the UK and Portugal participating in a European birth cohort (N = 1737 survivors). Data on maternal characteristics, pregnancy complications, neonatal outcomes and neighborhood deprivation were collected at baseline. Neurodevelopment was assessed at 2 years of corrected age (CA) using standardized parent-report measures. We applied (1) multiple imputation (MI) and (2) inverse probability weighting (IPW) to estimate the impact of non-response on the prevalence of moderate to severe neurodevelopmental impairment and assessed violations of the missing at random (MAR) assumption using the delta method.

RESULTS

54.2% of children were followed-up. Follow-up was less likely when mothers were younger, multiparous, foreign-born, did not breastfeed and came from deprived areas. The prevalence of neurodevelopmental impairment was 18.4% (95% confidence interval (CI):15.9-21.1) and increased to 20.4% (95%CI: 17.3-23.4) and 20.0% (95%CI:16.9-23.1) for MI and IPW models, respectively. Simulating strong violations of MAR (children with impairments being 50% less likely to be followed-up) raised estimates to 23.6 (95%CI:20.1-27.1) CONCLUSIONS: In a VPT cohort with high loss to follow-up, correcting for attrition yielded modest increased estimates of neurodevelopmental impairment at 2 years CA; estimates were relatively robust to violations of the MAR assumption.

Mapping Geographical Patterns and High Rate Areas for Sexually Transmitted Infections in Portugal: A Retrospective Study Based on the National Epidemiological Surveillance System

OBJECTIVE

Monitoring disease variation using finer scales to identify high-rate communities is a critical aspect for precision public health and for efficient resource allocation. This study aimed to map the spatial patterns of chlamydia, gonorrhea, and syphilis; identify high-rate areas across Portuguese municipalities; and determine the association of these sexually transmitted infections (STIs) with socioeconomic deprivation, urbanicity level, and population density.

METHODS

The STI notifications at municipality level for the period 2015 to 2017 were obtained from Portugal's Epidemiologic Surveillance System (Sistema Nacional de Vigilância Epidemiológica). Spatial Bayesian models were used to calculate smoothed standardized notification rates, identify high- and low-rate areas and estimate associations (relative risk [RR], 95% credible intervals [95%CrI]).

RESULTS

There were 4819 cases of chlamydia, gonorrhea, and syphilis reported, accounting for 15.3%, 33.2%, and 51.5% of the notifications, respectively. The STI notification rates were substantially higher in Porto and Lisbon Metropolitan Areas and concentrically disperse around those. Notification rates of the 3 STIs were strongly correlated (r > 0.8). Rates of gonorrhea (Q1-lowest density vs. Q5-highest RR, 2.10; 95% CrI, 1.08-4.25) and syphilis (RR, 3.16; 95% CrI, 2.00-5.13) were associated with population density. Notifications of chlamydia (Q1-least urban vs. Q5-most RR, 9.64; 95% CrI, 1.73-93.59) and syphilis (RR, 1.92; 95% CrI, 1.30-2.88) increased with urbanicity level. We also found that notification rates of gonorrhea were associated with socioeconomic deprivation (Q1-least vs. Q5-most deprived RR, 1.75; 95% CrI, 1.07-2.88).

CONCLUSIONS

Wide spatial inequalities in STI notification rates were observed, which were predominantly concentrated in the 2 metropolitan areas of the country. Our findings can help guide more targeted interventions to reduce STIs incidence.

Urban Rail Transportation and SARS-Cov-2 Infections: An Ecological Study in the Lisbon Metropolitan Area

Introduction: The large number of passengers, limited space and shared surfaces can transform public transportation into a hub of epidemic spread. This study was conducted to investigate whether proximity to railway stations, a proxy for utilization, was associated with higher rates of SARS-CoV-2 infection across small-areas of the Lisbon Metropolitan Area (Portugal). Methods: The number of SARS-CoV-2 confirmed infections from March 2 until July 5, 2020 at the parish-level was obtained from the National Epidemiological Surveillance System. A Geographic Information System was used to estimate proximity to railway stations of the six railway lines operating in the area. A quasi-Poisson generalized linear regression model was fitted to estimate the relative risks (RR) and corresponding 95% confidence intervals (95%CI). Results: Between May 2 and July 5, 2020, there were a total of 17,168 SARS-CoV-2 infections in the Lisbon Metropolitan Area, with wide disparities between parishes. Overall, parishes near any of the railway stations of the Sintra line presented significantly higher SARS-CoV-2 infection rates (RR = 1.42, 95%CI 1.16, 1.75) compared to parishes located farther away from railway stations, while the opposite was observed for parishes near other railway stations (Sado and Fertagus lines), where infection rates were significantly lower than those observed in parishes located farther away from railway stations (RR = 0.66, 95%CI 0.50, 0.87). The associations varied according to the stage of the epidemic and to the mitigation measures enforced. Regression results also revealed an increasing influence of socioeconomic deprivation on SARS-CoV-2 infections. Conclusions: No consistent association between proximity to railway stations and SARS-CoV-2 infection rates in the most affected metropolitan area of Portugal was observed, suggesting that other factors (e.g., socioeconomic deprivation) may play a more prominent role in the epidemic dynamics.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Assessing inequalities in geographical access to emergency medical services in metropolitan Lisbon: a cross-sectional and ecological study

OBJECTIVES

Studies have suggested that material deprivation is strongly associated with negative health outcomes, and lower usage of various levels of healthcare. We aim to analyse geographical access to emergency medical services (EMSs) and hospital emergency units by EMS in relation to deprivation in the Lisbon Metropolitan Area (LMA), Portugal.

DESIGN

This study estimates road network-based access times from the centroids of statistical sections (census block groups equivalent) to locations of EMS and hospital emergency services. Each statistical section has been linked to a Material Deprivation Index (MDI). A non-parametric analysis of variance (ANOVA) was undertaken to compare MDI-linked statistical sections in terms of access to emergency care. Geographical access analysis was conducted for 2018.

PRIMARY OUTCOME MEASURE

Road network-based access time (in minutes) for EMSs to statistical sections and then on to emergency units in hospitals.

RESULTS

Overall, 82.4% of the LMA population is located less than a 10 min drive from an EMS without transport, and 99.1% from an EMS with transport. Travel time from EMS with transport to hospital is potentially less than 20 min for 95.2% of the population. However, 63.1% of residents living beyond a 30 min threshold (total time from emergency call to hospital arrival) are in areas with very high MDI (18.8% in high MDI, 13.3% in medium MDI, 4.7% in low MDI, 0% in very low MDI). Kruskal-Wallis ANOVA confirms discrepancies in access times between better-off and poorer areas.

CONCLUSION

Poorer areas experience worse geographical access to EMS and hospital emergency units. More research is needed to explore the quality of services and their outcomes, and to refine the analysis by focusing on specific vulnerable groups.

The importance of socioeconomic position in smoking, cessation and environmental tobacco smoke exposure during pregnancy

Tobacco is still a leading cause of premature death and morbidity. Particular attention has been given to pregnant women due to the scientific evidence on the importance of early life exposures for disease onset later in life. The purpose of this study was to assess smoking prevalence, smoking cessation rate and environmental tobacco smoke (ETS) exposure, and the role of socioeconomic position (SEP) on these behaviors among pregnant women. Cross-sectional data of 619 pregnant women, aged between 18 and 46 years, from Porto Metropolitan Area, Portugal, on current smoking, ETS exposure and SEP indicators was collected, face-to-face, using a questionnaire filled in during a personal interview at the postpartum hospital stay. The smoking prevalence, and ETS exposure among non-smokers before pregnancy was 27.6% and 57.4%, respectively. 4.1% of the participants reported to have stopped smoking before pregnancy, whereas about 41% quitted along pregnancy, resulting in a smoking prevalence at birth of 14.6%. Exposure to ETS also decreased throughout pregnancy to 49.8% at birth. Lower educational level was significantly associated with both higher smoking prevalence and exposure to ETS and lower smoking cessation. This study demonstrates that smoking and ETS exposure during pregnancy remains high, and that there are still significant socioeconomic inequalities in smoking; thus tobacco-focused preventive interventions need to be reinforced.

Hotspots of childhood obesity in a large metropolitan area: does neighbourhood social and built environment play a part?

BACKGROUND

Effective place-based interventions for childhood obesity call for the recognition of the high-risk neighbourhoods and an understanding of the determinants present locally. However, such an approach is uncommon. In this study, we identified neighbourhoods with elevated prevalence of childhood obesity ('hotspots') in the Porto Metropolitan Area and investigated to what extent the socio-economic and built environment characteristics of the neighbourhoods explained such hotspots.

METHODS

We used data on 5203 7-year-old children from a population-based birth cohort, Generation XXI. To identify hotspots, we estimated local obesity odds ratios (OR) and 95% confidence intervals (95%CI) using generalized additive models with a non-parametric smooth for location. Measures of the socio-economic and built environment were determined using a Geographic Information System. Associations between obesity and neighbourhood characteristics were expressed as OR and 95%CI after accounting for individual-level variables.

RESULTS

At 7 years of age, 803 (15.4%) children were obese. The prevalence of obesity varied across neighbourhoods and two hotspots were identified, partially explained by individual-level variables. Adjustment for neighbourhood characteristics attenuated the ORs and further explained the geographic variation. This model revealed an association between neighbourhood socio-economic deprivation score and obesity (OR = 1.014, 95%CI 1.004-1.025), as well as with the presence of fast-food restaurants at a walkable distance from the residence (OR = 1.37, 1.06-1.77).

CONCLUSIONS

In our geographic area it was possible to identify neighbourhoods with elevated prevalence of childhood obesity and to suggest that targeting such high-priority neighbourhoods and their environmental characteristics may help reduce childhood obesity.

Affordable, Social, and Substandard Housing and Mortality: The EPIPorto Cohort Study, 1999-2019

Objectives. To examine the association between residence in different housing typologies and all-cause and cause-specific mortality, and to compare with the 25 × 25 risk factors defined by the World Health Organization.Methods. We used data from EPIPorto cohort (Porto, Portugal; n = 2485). We georeferenced and matched participants to a housing type-conventional, affordable, social, or substandard housing (locally called ilhas). We used Poisson regression models to estimate mortality rates and associations.Results. Age- and sex-adjusted mortality rates (per 100 000 person-years) were 713 (95% confidence interval [CI] = 584, 863) for individuals residing in conventional housing, and 1019 (95% CI = 637, 1551), 1200 (95% CI = 916, 1551), and 1239 (95% CI = 839, 1772) for individuals residing in affordable housing, social housing, and ilhas, respectively. After further adjustment, the associations between mortality and residence in social housing (rate ratio [RR] = 1.59; 95% CI = 1.22, 2.06) and in ilhas (RR = 1.64; 95% CI = 1.12, 2.33) remained. The association between disadvantaged housing and mortality was stronger than that observed for well-established risk factors such as hypertension, sedentariness, heavy drinking, manual occupation, or obesity.Conclusions. Disadvantaged housing is a major risk factor for mortality that should be accounted for by health policies and surveillance systems.

Is self-care dialysis associated with social deprivation in a universal health care system? A cohort study with data from the Renal Epidemiology and Information Network Registry

BACKGROUND

Socioeconomic status is associated with dialysis modality in developed countries. The main objective of this study was to investigate whether social deprivation, estimated by the European Deprivation Index (EDI), was associated with self-care dialysis in France.

METHODS

The EDI was calculated for patients who started dialysis in 2017. The event of interest was self-care dialysis 3 months after dialysis initiation [self-care peritoneal dialysis (PD) or satellite haemodialysis (HD)]. A logistic model was used for the statistical analysis, and a counterfactual approach was used for the causal mediation analysis.

RESULTS

Among the 9588 patients included, 2894 (30%) were in the most deprived quintile of the EDI. A total of 1402 patients were treated with self-care dialysis. In the multivariable analysis with the EDI in quintiles, there was no association between social deprivation and self-care dialysis. Compared with the other EDI quintiles, patients from Quintile 5 (most deprived quintile) were less likely to be on self-care dialysis (odds ratio 0.81, 95% confidence interval 0.71-0.93). Age, sex, emergency start, cardiovascular disease, chronic respiratory disease, cancer, severe disability, serum albumin and registration on the waiting list were associated with self-care dialysis. The EDI was not associated with self-care dialysis in either the HD or in the PD subgroups.

CONCLUSIONS

In France, social deprivation estimated by the EDI is associated with self-care dialysis in end-stage renal disease patients undergoing replacement therapy.

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

BACKGROUND

Area-level measures of socioeconomic deprivation are important for understanding and describing health inequalities. The aim of this study was the development and validation of a small-area index of socioeconomic deprivation for Cypriot communities and the investigation of its association with the spatial distribution of all-cause premature adult mortality.

METHODS

Six area-level socioeconomic indicators were used from the 2011 national population census (low educational attainment, unemployment, not owner occupied household, single-person household, divorced or widowed and single-parent households). After normalization and standardization of the geographically smoothed indicators, Principal Component Analysis (PCA) was used to construct indicator weights. The association between deprivation indices and the spatial distribution of all-cause premature adult mortality was estimated in Poisson log-linear spatial models.

RESULTS

PCA resulted in two principal components explaining the 65.7% of the total variance. The first principal component included four indicators (low educational attainment, single-person households, divorced or widowed and single-parent households, the latter however with a negative loading) and it thought more likely to capture rural-related aspects of deprivation. The second principal component included the other two indicators (unemployment and not owner occupied households) and it is more likely to capture urban-related aspects of material deprivation. Restricting the analysis in the metropolitan areas of the island resulted in a different set of indicators for the urban-specific deprivation index. All developed indices were linearly associated with all-cause premature adult mortality. The all-cause premature adult mortality increased by 17% per 1 standard deviation (SD) increase in rural-related socioeconomic deprivation (95% CrI: 8-27%) and 8% per 1 SD increase in urban-related aspects of material deprivation (95% CrI: 3-15%) in the nationwide analysis and 9% per 1 SD increase in urban-specific socioeconomic deprivation (95% CrI: 4-15%) across metropolitan areas.

CONCLUSIONS

The results of this study demonstrate that a set of small-area indices of socioeconomic deprivation across Cypriot communities have good construct and predictive validity. However, the study indicates that different aspects of socioeconomic deprivation may be important in rural and urban areas in Cyprus. The developed socioeconomic deprivation indices could offer a valid new tool for Cypriot public health research and policy in terms of identifying areas in greatest need, guiding resource allocation and developing area-targeted public health programmes and policies.