The Role of Individual and Neighborhood Characteristics on Mental Health after a Period of Economic Crisis in the Lisbon Region (Portugal): A Multilevel Analysis

2008 economic crisis impact on perinatal and infant mortality in Southern European countries

INTRODUCTION

The study of crisis events provides important lessons to prepare for upcoming events. The Great Recession's impact on perinatal health in Europe can provide relevant insights into the healthcare and social protection systems' response to the protection of the health of the most vulnerable groups.

OBJECTIVE

To assess time trends and international disparities in perinatal mortality rates (PMR) and infant mortality rates (IMR), following the Great Recession, and their association with socioeconomic indicators in Portugal, Greece, Italy and Spain.

METHODS

Associations were assessed through generalised linear models for all four countries. A Poisson joinpoint regression model was applied to explore PMR and IMR trend changes between 2000 and 2018. Country disparities were analysed using mixed-effects multilevel models.

RESULTS

IMR and PMR have decreased overall in the four selected countries between 2000 and 2018. Still, whereas in Spain, Italy and Portugal the decreasing pace was attenuated after 2009, in Greece a positive trend was found after the 2008 crisis. IMR and PMR were significantly associated with socioeconomic indicators in all four countries. National disparities in the evolution of IMR and PMR were significantly associated with most socioeconomic indicators between 2000 and 2018.

CONCLUSION

Our results confirm the impact of the Great Recession on PMR and IMR trends in all four countries, taking recurring associations between macroeconomic cycles, variations in mortality trends, macroeconomic volatility and stagnation of IMR and PMR into account. The association with socioeconomic indicators stresses the need to strengthen social protection and healthcare systems to better protect the population's health from the earliest days.

Neighbourhood income inequalities in mental health in Barcelona 2001-2016: a Bayesian smoothed estimate

OBJECTIVE

Obtaining reliable health estimates at the small area level (such as neighbourhoods) using survey data usually poses the problem of small sample sizes. To overcome this limitation, we explored smoothing techniques in order to estimate poor mental health prevalence at the neighbourhood level and analyse its profile by income in Barcelona city (Spain).

METHOD

A Bayesian smoothing model with a logit-normal transformation was applied to four repeated cross-sectional waves of the Barcelona health survey for 2001, 2006, 2011 and 2016. Mental health status was identified from the 12-item General Health Questionnaire. Income inequalities were analysed with neighbourhood income in quantiles for each year and trends in the pooled analysis.

RESULTS

The prevalence of poor mental health ranged from 14.6% in 2001 to 18.9% in 2016. The yearly difference between neighbourhoods was 12.4% in 2001, 16.7% in 2006, 14.2% in 2011, and 20.0% in 2016. The odds ratio and 95% credible interval (95%CI) of experiencing poor mental health was 1.40 times higher (95%CI: 1.02-1.91) in less advantaged neighbourhoods than in more advantaged neighbourhoods in 2001, 1.61 times higher (95%CI: 1.01-2.59) in 2006 and 2.31 times higher (95%CI: 1.57-3.40) in 2016.

CONCLUSIONS

This study shows that the Bayesian smoothed techniques allows detection of inequalities in health in neighbourhoods and monitoring of interventions against them. In Barcelona, mental health problems are more prevalent in low-income neighbourhoods and raised in 2016.

Opening the black box of the relationship between neighborhood socioeconomic status and mental health: Neighborhood social-interactive characteristics as contextual mechanisms

Previous studies have linked low neighborhood socioeconomic status (NSES) to mental health problems. However, few studies have investigated the mechanisms underlying this association and most focused on the association with negative indicators of mental health, such as symptoms of depression or anxiety. This paper investigated whether neighborhood social characteristics (social interaction, trust, safety, organization participation, and attachment) mediate the association between NSES and mental health. We combined Danish register data with survey data from the North Denmark Region Health Survey 2017. Mental health was assessed with the Rand 12-item Short-form Survey (SF-12). The sample consisted of 14,969 individuals nested in 1047 neighborhoods created with an automated redistricting algorithm. We fitted multilevel structural equation mediation models and used a Monte Carlo simulation method to estimate confidence intervals for the indirect effects. NSES was positively associated with mental health. Neighborhood trust significantly mediated this relationship, accounting for 34% of the association after controlling for other mediators. These results indicate that higher levels of mental health in more affluent neighborhoods are partially explained by higher levels of trust. Improving neighborhood trust could mitigate sociogeographic inequalities in mental health.

Influence of food environment on ultra-processed drinks consumption among an economically vulnerable population in a metropolitan area in Brazil: A multilevel analysis

Ultra-processed drinks (UPDs) consumption is increasing, and this intake has been associated with the risk of illness and death. Data on individuals (n = 430) and food stores (n = 231) were collected in an economically vulnerable area in Recife-Brazil, and multilevel regression models were applied to assess the association between UPDs consumption with food environment characteristics. The results show 29.5% of individuals consume UPDs, higher UPD consumption was significantly associated with age (OR: 0.96), lower educational levels (OR:2.06), high density of stores predominantly selling UPFs (OR:2.34) and lower availability of FV in stores (OR:0.49). The applied methodology can inform food environment interventions to reduce UPDs consumption.

Strategic Assessment of Neighbourhood Environmental Impacts on Mental Health in the Lisbon Region (Portugal): A Strategic Focus and Assessment Framework at the Local Level

Scientific evidence shows that each place/environment generates specific conditions with associated impacts on the mental health and well-being of the population. A holistic, multilevel and integrated environmental approach to mental health enhances the understanding of this phenomena, supporting the local decision-making processes to improve spatial planning of neighbourhood environments. The aim of this study is to develop a strategic assessment framework, based on four municipalities in the Lisbon Region (Portugal), that explores policy and planning initiatives capable of generating favourable neighbourhood environmental conditions for mental health while also detecting risks. Using baseline results of significant statistical associations between individuals’ perceptions of their neighbourhood environment and their mental health in the Lisbon Region, a Strategic Focus on Environmental and Mental Health Assessment framework (SEmHA) was built, by applying the methodology “Strategic Thinking for Sustainability” in Strategic Environmental Assessment, developed by Partidário in 2012. Taking into account the promotion of the population’s mental health, four critical decision factors of neighbourhood environments were identified: (1) public space quality (e.g., improving sense of place), (2) physical environment quality (e.g., low levels of noise exposure), (3) professional qualification and creation of economic activities (e.g., attracting new economic activities), and (4) services and facilities (e.g., improving access to health and education services). The proposed strategic focus and assessment framework contributes to ensuring that interventions in neighbourhood environments truly achieve community mental health benefits and reduce inequalities, thus helping policy makers to assess impacts at the local level.

Impact of macro-socioeconomic determinants on sustainable perinatal health care in Portugal: a qualitative study on the opinion of healthcare professionals and experts

BACKGROUND

The WHO identified the importance of macro-socioeconomic determinants and political context as interlinked key factors affecting healthcare quality and health equity. As a response to the recent economic and financial crisis, Portugal approved in 2011 the Economic Adjustment Programme (EAP) to obtain financial assistance from the Troika in order to reduce public debt. This study aims to analyse the impact of the economic crisis and the EAP on perinatal healthcare quality for very preterm (VPT) and/or very low birth weight (VLBW) infants, as perceived by healthcare professionals and experts, within the health administrative regions of the two major metropolitan areas in Portugal.

METHODS

A qualitative approach was applied to receive an in-depth understanding and accomplish perspective variability. A purposive sampling technique was used. Semi-structured interviews were conducted with twenty-one healthcare professionals and experts between October 2018-July 2019. Inductive thematic analysis was performed which encompassed a five-step categorization procedure. Data analysis was undertaken by utilizing Nvivo2011 software. Evolved themes were then associated with WHO's Quality Standards on Maternal and New-born Care. A framework on the impact of macro-socioeconomic determinants on perinatal health care quality was developed.

RESULTS

Although participants did not perceive the quality of perinatal care had deteriorated, the analysis of their accounts on work experience revealed that it was indeed adversely modified in all WHO Quality Standards. Health care provision was perceived as detrimental in five main areas: 1) Availability of human resources; 2) Functional referral systems; 3) Competent and motivated human resources; 4) Emotional support; and 5) Essential physical resources available. Policy reforms by the EAP resulted in reduced timeliness of care, increased waiting times, cuts in sequence and duration of consultations, and deficiencies in follow-up care for VPT/VLBW infants and their mothers. The EAP directly influenced working environment of healthcare professionals by causing stress, burnout, work absence, and brain drain.

CONCLUSION

An interrelation between macro-socioeconomic determinants and perinatal health care quality was disclosed. The economic crisis and EAP have adversely modified equitable perinatal health care quality for VPT/VLBW infants and their mothers. Our findings underlined the negative impact of austerity policies on vulnerable populations.

Area deprivation, perceived neighbourhood cohesion and mental health at older ages: A cross lagged analysis of UK longitudinal data

Previous research on neighbourhood influences on older adults' mental health shows inconsistent evidence for effects of neighbourhood deprivation but stronger evidence for effects of perceived neighbourhood social cohesion, often proposed as a mediator of the link between neighbourhood deprivation and mental well-being. However, it is possible that mental health influences perceptions of neighbourhoods; this has rarely been considered. We use data from a large UK longitudinal study to investigate these associations. Results from cross-lagged models indicate that greater neighbourhood deprivation is associated with worse perceived social cohesion and worse mental health. Associations between change in perceived social cohesion and in mental health were reciprocal-lower perceived cohesion predicted poorer mental health and vice versa. Further research including three waves of data is needed to further unravel underlying directions of association.

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.

Mental Health and Work Attitudes among People Resuming Work during the COVID-19 Pandemic: A Cross-Sectional Study in China

The unprecedented outbreak of the Coronavirus Disease 2019 (COVID-19) caused an economic downturn and increased the unemployment rate in China. In this context, employees face health and social economic stressors. To assess their mental health (i.e., anxiety, depression, insomnia and somatization) and work attitudes (i.e., work engagement, job satisfaction and turnover intention) as well as the associated factors, we conducted a cross-sectional study among people who resumed work after the Spring Festival holiday during the COVID-19 pandemic. The results show that the prevalence of anxiety, depression, insomnia and somatization among these people was 12.7%, 13.5%, 20.7% and 6.6%, respectively. The major risk factor for mental health was worrying about unemployment, and the main protective factors were psychological strengths (i.e., resilience and optimism). Regarding work attitudes, the percentage of people who felt more satisfied with their job (43.8%) was larger than that of those who felt less satisfied (26.9%), while the percentage of people who thought about quitting their job more frequently (15.7%) was smaller than that of those who considered it less frequently (63.2%). However, work engagement was lower than usual. Similar to the factors associated with mental health, the major risk factor for work attitudes was also worrying about unemployment, and the main protective factors were resilience and optimism. In addition, the nature of the organization, job status, age, position and income changes were also related to these work attitudes. Our findings shed light on the need for organization administrators to be aware of the status of and factors associated with employees’ mental health and work attitudes during the COVID-19 pandemic. Policies or interventions could be developed based on our findings.