1
|
Gupta N, Crouse DL, Miah P, Takaro T. Individual physical activity, neighbourhood active living environment and mental illness hospitalisation among adults with cardiometabolic disease: a Canadian population-based cohort analysis. BMJ Open 2023; 13:e067736. [PMID: 36725097 PMCID: PMC9896238 DOI: 10.1136/bmjopen-2022-067736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES This population-based observational study explores the associations between individual-level and neighbourhood-level indices of active living with inpatient mental healthcare use among adults with an underlying chronic cardiometabolic condition. DESIGN AND SETTING Data from the 2013-2014 Canadian Community Health Survey were linked longitudinally to hospital records from the 2013/2014‒2017/2018 Discharge Abstract Database and to a geocoded measure of active living environments (ALE). Relationships between individuals' leisure-time physical activity and neighbourhood ALE with risk of hospital admission for mental health disorders were assessed using multivariable Cox regressions. PARTICIPANTS A national cohort was identified from the survey data of 24 960 respondents aged 35 years and above reporting having been diagnosed with diabetes, hypertension and/or heart disease. OUTCOME MEASURE Potentially avoidable hospitalisation for a mood, anxiety or substance use disorder over a 5-year period. RESULTS More than half (52%) of adults aged 35 years and above with a cardiometabolic disease were physically inactive in their daily lives, and one-third (34%) resided in the least activity-friendly neighbourhoods. The rate of being hospitalised at least once for a comorbid mental disorder averaged 8.1 (95% CI: 7.0 to 9.3) per 1000 person-years of exposure. Individuals who were at least moderately active were half as likely to be hospitalised for a comorbid mental health problem compared with those who were inactive (HR: 0.50 (95% CI: 0.38 to 0.65)). No statistically discernible associations between neighbourhood ALE and hospitalisation risks were found after controlling for individuals' behaviours and characteristics, including in separate models stratified by age group and by sex. CONCLUSIONS The evidence base to support prioritisation of interventions focusing on the built environment favouring mental health-promoting physical activity among higher-risk adults at the population level, independently of individual-level behaviours and characteristics, remains limited.
Collapse
Affiliation(s)
- Neeru Gupta
- University of New Brunswick, Fredericton, New Brunswick, Canada
| | | | - Pablo Miah
- University of New Brunswick, Fredericton, New Brunswick, Canada
| | - Tim Takaro
- Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
2
|
Gupta N, Crouse DL, Miah P, Takaro T. The role of neighbourhood environments in hospitalization risk for diabetes and related conditions: A population-based cohort analysis by remoteness and deprivation indices. Health Rep 2022; 33:3-13. [PMID: 36542359 DOI: 10.25318/82-003-x202201200001-eng] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Most socio-epidemiological studies on diabetes incidence, prevalence, or hospitalization focus on individual-level risk factors. This population-based cohort study sought to advance understanding on the associations of contextual characteristics and risk of diabetes-related avoidable hospitalization (DRAH) among at-risk Canadians. Data and methods A national cohort was compiled from the 2013/2014 Canadian Community Health Survey, representing 5.1 million adults aged 35 years and older, reporting having been diagnosed with diabetes, hypertension, or heart disease. Their information was linked longitudinally to hospitalization data from the 2013/14 to 2017/18 Discharge Abstract Database as well as to measures of geographic variability from the Material and Social Deprivation Index and the Index of Remoteness. Cox regression models were used to examine associations between the contextual indices and first occurrence of a DRAH. Results Residents in the most rural and remote communities were 50% more likely (hazard ratio (HR): 1.51, 95% confidence interval (95% CI): 1.26 to 1.80) to experience a DRAH than those in the most urbanized and accessible communities, and residents in the most socially deprived areas were significantly more likely (HR: 1.44, 95% CI: 1.26 to 1.65) to be hospitalized than those in the most socially privileged areas, controlling for individuals' sociodemographic characteristics and health behaviours. Neighbourhood material deprivation did not exercise a statistically significant influence on hospitalization risk after adjusting for the other residential characteristics. Interpretation There is a clear and significant gradient in diabetes-related hospitalization risk among Canadians with an underlying cardiometabolic condition by degree of residential remoteness and of neighbourhood social deprivation, independently of individual characteristics and despite Canada's universal healthcare system.
Collapse
Affiliation(s)
- Neeru Gupta
- University of New Brunswick, Fredericton, Canada
| | | | - Pablo Miah
- University of New Brunswick, Fredericton, Canada
| | - Tim Takaro
- Simon Fraser University, Vancouver, Canada
| |
Collapse
|
3
|
Brauer M, Brook JR, Christidis T, Chu Y, Crouse DL, Erickson A, Hystad P, Li C, Martin RV, Meng J, Pappin AJ, Pinault LL, Tjepkema M, van Donkelaar A, Weagle C, Weichenthal S, Burnett RT. Mortality-Air Pollution Associations in Low Exposure Environments (MAPLE): Phase 2. Res Rep Health Eff Inst 2022; 2022:1-91. [PMID: 36224709 PMCID: PMC9556709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
INTRODUCTION Mortality is associated with long-term exposure to fine particulate matter (particulate matter ≤2.5 μm in aerodynamic diameter; PM2.5), although the magnitude and form of these associations remain poorly understood at lower concentrations. Knowledge gaps include the shape of concentration-response curves and the lowest levels of exposure at which increased risks are evident and the occurrence and extent of associations with specific causes of death. Here, we applied improved estimates of exposure to ambient PM2.5 to national population-based cohorts in Canada, including a stacked cohort of 7.1 million people who responded to census year 1991, 1996, or 2001. The characterization of the shape of the concentration-response relationship for nonaccidental mortality and several specific causes of death at low levels of exposure was the focus of the Mortality-Air Pollution Associations in Low Exposure Environments (MAPLE) Phase 1 report. In the Phase 1 report we reported that associations between outdoor PM2.5 concentrations and nonaccidental mortality were attenuated with the addition of ozone (O3) or a measure of gaseous pollutant oxidant capacity (Ox), which was estimated from O3 and nitrogen dioxide (NO2) concentrations. This was motivated by our interests in understanding both the effects air pollutant mixtures may have on mortality and also the role of O3 as a copollutant that shares common sources and precursor emissions with those of PM2.5. In this Phase 2 report, we further explore the sensitivity of these associations with O3 and Ox, evaluate sensitivity to other factors, such as regional variation, and present ambient PM2.5 concentration-response relationships for specific causes of death. METHODS PM2.5 concentrations were estimated at 1 km2 spatial resolution across North America using remote sensing of aerosol optical depth (AOD) combined with chemical transport model (GEOS-Chem) simulations of the AOD:surface PM2.5 mass concentration relationship, land use information, and ground monitoring. These estimates were informed and further refined with collocated measurements of PM2.5 and AOD, including targeted measurements in areas of low PM2.5 concentrations collected at five locations across Canada. Ground measurements of PM2.5 and total suspended particulate matter (TSP) mass concentrations from 1981 to 1999 were used to backcast remote-sensing-based estimates over that same time period, resulting in modeled annual surfaces from 1981 to 2016. Annual exposures to PM2.5 were then estimated for subjects in several national population-based Canadian cohorts using residential histories derived from annual postal code entries in income tax files. These cohorts included three census-based cohorts: the 1991 Canadian Census Health and Environment Cohort (CanCHEC; 2.5 million respondents), the 1996 CanCHEC (3 million respondents), the 2001 CanCHEC (3 million respondents), and a Stacked CanCHEC where duplicate records of respondents were excluded (Stacked CanCHEC; 7.1 million respondents). The Canadian Community Health Survey (CCHS) mortality cohort (mCCHS), derived from several pooled cycles of the CCHS (540,900 respondents), included additional individual information about health behaviors. Follow-up periods were completed to the end of 2016 for all cohorts. Cox proportional hazard ratios (HRs) were estimated for nonaccidental and other major causes of death using a 10-year moving average exposure and 1-year lag. All models were stratified by age, sex, immigrant status, and where appropriate, census year or survey cycle. Models were further adjusted for income adequacy quintile, visible minority status, Indigenous identity, educational attainment, labor-force status, marital status, occupation, and ecological covariates of community size, airshed, urban form, and four dimensions of the Canadian Marginalization Index (Can-Marg; instability, deprivation, dependency, and ethnic concentration). The mCCHS analyses were also adjusted for individual-level measures of smoking, alcohol consumption, fruit and vegetable consumption, body mass index (BMI), and exercise behavior. In addition to linear models, the shape of the concentration-response function was investigated using restricted cubic splines (RCS). The number of knots were selected by minimizing the Bayesian Information Criterion (BIC). Two additional models were used to examine the association between nonaccidental mortality and PM2.5. The first is the standard threshold model defined by a transformation of concentration equaling zero if the concentration was less than a specific threshold value and concentration minus the threshold value for concentrations above the threshold. The second additional model was an extension of the Shape Constrained Health Impact Function (SCHIF), the eSCHIF, which converts RCS predictions into functions potentially more suitable for use in health impact assessments. Given the RCS parameter estimates and their covariance matrix, 1,000 realizations of the RCS were simulated at concentrations from the minimum to the maximum concentration, by increments of 0.1 μg/m3. An eSCHIF was then fit to each of these RCS realizations. Thus, 1,000 eSCHIF predictions and uncertainty intervals were determined at each concentration within the total range. Sensitivity analyses were conducted to examine associations between PM2.5 and mortality when in the presence of, or stratified by tertile of, O3 or Ox. Additionally, associations between PM2.5 and mortality were assessed for sensitivity to lower concentration thresholds, where person-years below a threshold value were assigned the mean exposure within that group. We also examined the sensitivity of the shape of the nonaccidental mortality-PM2.5 association to removal of person-years at or above 12 μg/m3 (the current U.S. National Ambient Air Quality Standard) and 10 μg/m3 (the current Canadian and former [2005] World Health Organization [WHO] guideline, and current WHO Interim Target-4). Finally, differences in the shapes of PM2.5-mortality associations were assessed across broad geographic regions (airsheds) within Canada. RESULTS The refined PM2.5 exposure estimates demonstrated improved performance relative to estimates applied previously and in the MAPLE Phase 1 report, with slightly reduced errors, including at lower ranges of concentrations (e.g., for PM2.5 <10 μg/m3). Positive associations between outdoor PM2.5 concentrations and nonaccidental mortality were consistently observed in all cohorts. In the Stacked CanCHEC analyses (1.3 million deaths), each 10-μg/m3 increase in outdoor PM2.5 concentration corresponded to an HR of 1.084 (95% confidence interval [CI]: 1.073 to 1.096) for nonaccidental mortality. For an interquartile range (IQR) increase in PM2.5 mass concentration of 4.16 μg/m3 and for a mean annual nonaccidental death rate of 92.8 per 10,000 persons (over the 1991-2016 period for cohort participants ages 25-90), this HR corresponds to an additional 31.62 deaths per 100,000 people, which is equivalent to an additional 7,848 deaths per year in Canada, based on the 2016 population. In RCS models, mean HR predictions increased from the minimum concentration of 2.5 μg/m3 to 4.5 μg/m3, flattened from 4.5 μg/m3 to 8.0 μg/m3, then increased for concentrations above 8.0 μg/m3. The threshold model results reflected this pattern with -2 log-likelihood values being equal at 2.5 μg/m3 and 8.0 μg/m3. However, mean threshold model predictions monotonically increased over the concentration range with the lower 95% CI equal to one from 2.5 μg/m3 to 8.0 μg/m3. The RCS model was a superior predictor compared with any of the threshold models, including the linear model. In the mCCHS cohort analyses inclusion of behavioral covariates did not substantially change the results for both linear and nonlinear models. We examined the sensitivity of the shape of the nonaccidental mortality-PM2.5 association to removal of person-years at or above the current U.S. and Canadian standards of 12 μg/m3 and 10 μg/m3, respectively. In the full cohort and in both restricted cohorts, a steep increase was observed from the minimum concentration of 2.5 μg/m3 to 5 μg/m3. For the full cohort and the <12 μg/m3 cohort the relationship flattened over the 5 to 9 μg/m3 range and then increased above 9 μg/m3. A similar increase was observed for the <10 μg/m3 cohort followed by a clear decline in the magnitude of predictions over the 5 to 9 μg/m3 range and an increase above 9 μg/m3. Together these results suggest that a positive association exists for concentrations >9 μg/m3 with indications of adverse effects on mortality at concentrations as low as 2.5 μg/m3. Among the other causes of death examined, PM2.5 exposures were consistently associated with an increased hazard of mortality due to ischemic heart disease, respiratory disease, cardiovascular disease, and diabetes across all cohorts. Associations were observed in the Stacked CanCHEC but not in all other cohorts for cerebrovascular disease, pneumonia, and chronic obstructive pulmonary disease (COPD) mortality. No significant associations were observed between mortality and exposure to PM2.5 for heart failure, lung cancer, and kidney failure. In sensitivity analyses, the addition of O3 and Ox attenuated associations between PM2.5 and mortality. When analyses were stratified by tertiles of copollutants, associations between PM2.5 and mortality were only observed in the highest tertile of O3 or Ox. Across broad regions of Canada, linear HR estimates and the shape of the eSCHIF varied substantially, possibly reflecting underlying differences in air pollutant mixtures not characterized by PM2.5 mass concentrations or the included gaseous pollutants. Sensitivity analyses to assess regional variation in population characteristics and access to healthcare indicated that the observed regional differences in concentration-mortality relationships, specifically the flattening of the concentration-mortality relationship over the 5 to 9 μg/m3 range, was not likely related to variation in the makeup of the cohort or its access to healthcare, lending support to the potential role of spatially varying air pollutant mixtures not sufficiently characterized by PM2.5 mass concentrations. CONCLUSIONS In several large, national Canadian cohorts, including a cohort of 7.1 million unique census respondents, associations were observed between exposure to PM2.5 with nonaccidental mortality and several specific causes of death. Associations with nonaccidental mortality were observed using the eSCHIF methodology at concentrations as low as 2.5 μg/m3, and there was no clear evidence in the observed data of a lower threshold, below which PM2.5 was not associated with nonaccidental mortality.
Collapse
Affiliation(s)
- M Brauer
- The University of British Columbia, Vancouver, British Columbia, Canada
- Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington
| | - J R Brook
- University of Toronto, Toronto, Ontario, Canada
| | - T Christidis
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - Y Chu
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - D L Crouse
- University of New Brunswick, Fredericton, New Brunswick, Canada
| | - A Erickson
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - P Hystad
- Oregon State University, Corvallis, Oregon
| | - C Li
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - R V Martin
- Dalhousie University, Halifax, Nova Scotia, Canada
- Washington University, Saint Louis, Missouri
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts
| | - J Meng
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - A J Pappin
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - L L Pinault
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - M Tjepkema
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | | | - C Weagle
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - R T Burnett
- Population Studies Division, Health Canada, Ottawa, Ontario, Canada
| |
Collapse
|
4
|
Boogaard H, Patton AP, Atkinson RW, Brook JR, Chang HH, Crouse DL, Fussell JC, Hoek G, Hoffmann B, Kappeler R, Kutlar Joss M, Ondras M, Sagiv SK, Samoli E, Shaikh R, Smargiassi A, Szpiro AA, Van Vliet EDS, Vienneau D, Weuve J, Lurmann FW, Forastiere F. Long-term exposure to traffic-related air pollution and selected health outcomes: A systematic review and meta-analysis. Environ Int 2022; 164:107262. [PMID: 35569389 DOI: 10.1016/j.envint.2022.107262] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/08/2022] [Accepted: 04/20/2022] [Indexed: 05/26/2023]
Abstract
The health effects of traffic-related air pollution (TRAP) continue to be of important public health interest. Following its well-cited 2010 critical review, the Health Effects Institute (HEI) appointed a new expert Panel to systematically evaluate the epidemiological evidence regarding the associations between long-term exposure to TRAP and selected adverse health outcomes. Health outcomes were selected based on evidence of causality for general air pollution (broader than TRAP) cited in authoritative reviews, relevance for public health and policy, and resources available. The Panel used a systematic approach to search the literature, select studies for inclusion in the review, assess study quality, summarize results, and reach conclusions about the confidence in the evidence. An extensive search was conducted of literature published between January 1980 and July 2019 on selected health outcomes. A new exposure framework was developed to determine whether a study was sufficiently specific to TRAP. In total, 353 studies were included in the review. Respiratory effects in children (118 studies) and birth outcomes (86 studies) were the most commonly studied outcomes. Fewer studies investigated cardiometabolic effects (57 studies), respiratory effects in adults (50 studies), and mortality (48 studies). The findings from the systematic review, meta-analyses, and evaluation of the quality of the studies and potential biases provided an overall high or moderate-to-high level of confidence in an association between long-term exposure to TRAP and the adverse health outcomes all-cause, circulatory, ischemic heart disease and lung cancer mortality, asthma onsetin chilldren and adults, and acute lower respiratory infections in children. The evidence was considered moderate, low or very low for the other selected outcomes. In light of the large number of people exposed to TRAP - both in and beyond the near-road environment - the Panel concluded that the overall high or moderate-to-high confidence in the evidence for an association between long-term exposure to TRAP and several adverse health outcomes indicates that exposures to TRAP remain an important public health concern and deserve greater attention from the public and from policymakers.
Collapse
Affiliation(s)
- H Boogaard
- Health Effects Institute, Boston, MA, United States.
| | - A P Patton
- Health Effects Institute, Boston, MA, United States
| | - R W Atkinson
- Epidemiology, Population Health Research Institute and MRC-PHE Centre for Environment and Health, St. George's, University of London, London, United Kingdom
| | - J R Brook
- Occupational and Environmental Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - H H Chang
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - D L Crouse
- Health Effects Institute, Boston, MA, United States
| | - J C Fussell
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - G Hoek
- Institute for Risk Assessment Sciences, Environmental Epidemiology, Utrecht University, Utrecht, the Netherlands
| | - B Hoffmann
- Institute for Occupational, Social and Environmental Medicine, Centre for Health and Society, Medical Faculty, University of Düsseldorf, Düsseldorf, Germany
| | - R Kappeler
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - M Kutlar Joss
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - M Ondras
- Health Effects Institute, Boston, MA, United States
| | - S K Sagiv
- Center for Environmental Research and Children's Health, Division of Epidemiology, University of California Berkeley School of Public Health, Berkeley, CA, United States
| | - E Samoli
- Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - R Shaikh
- Health Effects Institute, Boston, MA, United States
| | - A Smargiassi
- Department of Environmental and Occupational Health, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - A A Szpiro
- Department of Biostatistics, University of Washington, Seattle, WA, United States
| | | | - D Vienneau
- Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - J Weuve
- Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - F W Lurmann
- Sonoma Technology, Inc, Petaluma, CA, United States
| | - F Forastiere
- School of Public Health, Faculty of Medicine, Imperial College London, London, United Kingdom
| |
Collapse
|
5
|
Gupta N, Crouse DL, Foroughi I. Neighbourhood characteristics related to mental health service use among adults with diabetes: a population-based cohort study in New Brunswick, Canada. BMC Res Notes 2022; 15:79. [PMID: 35197119 PMCID: PMC8867674 DOI: 10.1186/s13104-022-05966-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/10/2022] [Indexed: 11/13/2022] Open
Abstract
Objective It has been postulated that social and economic inequalities may shape the distributions of comorbid diabetes and mental illness. This observational cohort study using linked population-based administrative and geospatial datasets aimed to describe associations between neighbourhood socioenvironments and disorder-specific mental health service use among adults with diabetes in the province of New Brunswick, Canada. Results A baseline cohort of 66,275 persons aged 19 and over living with diabetes was identified. One-quarter (26.3%) had used healthcare services for mood and anxiety disorders at least once during the six-year follow-up period 2012/2013–2017/2018. Based on Cox proportional hazards models, the risk of mental health service contacts was significantly higher among those residing in the most materially deprived neighbourhoods [HR: 1.07 (95% CI: 1.01–1.14)] compared to those in the least so, and those in areas characterized with the highest residential instability [HR: 1.13 (95% CI: 1.05–1.22)] compared to those in areas with the lowest instability. Among adults with incident diabetes (N = 4410), age and sex but not neighbourhood factors were related to differential help-seeking behaviours for mental health problems. These findings underscored the gap between theoretical postulations and population-based observations in delineating the syndemics of neighbourhood socioenvironments and mental health outcomes in populations with high diabetes prevalence.
Collapse
Affiliation(s)
- Neeru Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada.
| | | | - Ismael Foroughi
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada
| |
Collapse
|
6
|
Gupta N, Crouse DL, Foroughi I, Nikolaidou T. Gendering Neighbourhood Marginalization Metrics in Mental Health Services Research: A Cross-Sectional Exploration of a Rural and Small Urban Population. Int J Environ Res Public Health 2021; 18:ijerph182111197. [PMID: 34769718 PMCID: PMC8583697 DOI: 10.3390/ijerph182111197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 12/28/2022]
Abstract
Background: Little is known about the extent to which socioenvironmental characteristics may influence mental health outcomes in smaller population centres or differently among women and men. This study used a gender-based analysis approach to explore individual- and neighbourhood-level sex differences in mental health service use in a context of uniquely smaller urban and rural settlements. Methods: This cross-sectional analysis leveraged multiple person-based administrative health datasets linked with geospatial datasets among the population aged 1 and over in the province of New Brunswick, Canada. We used multinomial logistic regression to examine associations between neighbourhood characteristics with risk of service contacts for mood and anxiety disorders in 2015/2016, characterizing the areal measures among all residents (gender neutral) and by males and females separately (gender specific), and controlling for age group. Results: Among the province’s 707,575 eligible residents, 10.7% (females: 14.0%; males: 7.3%) used mental health services in the year of observation. In models adjusted for gender-neutral neighbourhood characteristics, service contacts were significantly more likely among persons residing in the most materially deprived areas compared with the least (OR = 1.09 [95% CI: 1.05–1.12]); when stratified by individuals’ sex, the risk pattern held for females (OR = 1.13 [95% CI: 1.09–1.17]) but not males (OR = 1.00 [95% CI: 0.96–1.05]). Residence in the most female-specific materially deprived neighbourhoods was independently associated with higher risk of mental health service use among individual females (OR = 1.08 [95% CI: 1.02–1.14]) but not among males (OR = 1.02 [95% CI: 0.95–1.10]). Conclusion: These findings emphasize that research needs to better integrate sex and gender in contextual measures aiming to inform community interventions and neighbourhood designs, notably in small urban and rural settings, to reduce socioeconomic inequalities in the burden of mental disorders.
Collapse
Affiliation(s)
- Neeru Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, NB E3B 5A3, Canada;
- Correspondence:
| | | | - Ismael Foroughi
- Department of Sociology, University of New Brunswick, PO Box 4400, Fredericton, NB E3B 5A3, Canada;
| | - Thalia Nikolaidou
- Department of Geodesy and Geomatics Engineering, University of New Brunswick, PO Box 4400, Fredericton, NB E3B 5A3, Canada;
| |
Collapse
|
7
|
Foroughi I, Gupta N, Crouse DL. Healthcare Service Use for Mood and Anxiety Disorders Following Acute Myocardial Infarction: A Cohort Study of the Role of Neighbourhood Socioenvironmental Characteristics in a Largely Rural Population. Int J Environ Res Public Health 2020; 17:ijerph17144939. [PMID: 32659904 PMCID: PMC7400273 DOI: 10.3390/ijerph17144939] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/04/2020] [Accepted: 07/07/2020] [Indexed: 12/16/2022]
Abstract
Depression and other mood and anxiety disorders are recognized as common complications following cardiac events. Some studies report poorer cardiac outcomes among patients in socioeconomically marginalized neighbourhoods. This study aimed to describe associations between socioeconomic and built environment characteristics of neighbourhood environments and mental health service contacts following an acute myocardial infarction (AMI or heart attack) among adults in the province of New Brunswick, Canada. This province is characterized largely by residents in small towns and rural areas. A cohort of all adults aged 45 and over surviving AMI and without a recent record of mental disorders was identified by linking provincial medical-administrative datasets. Residential histories were tracked over time to assign neighbourhood measures of marginalization, local climate zones, and physical activity friendliness (i.e., walkability). Cox models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of healthcare use for mood and anxiety disorders over the period 2003/04-2015/16 by neighbourhood characteristics. The baseline cohort included 13,330 post-AMI patients, among whom 32.5% were found to have used healthcare services for a diagnosed mood or anxiety disorder at least once during the period of observation. Among men, an increased risk of mental health service use was found among those living in areas characterized by high ethnic concentration (HR: 1.14 (95%CI: 1.03-1.25)). Among women, the risk was significantly higher among those in materially deprived neighbourhoods (HR: 1.16 (95%CI: 1.01-1.33)). We found no convincing evidence of associations between this outcome and the other neighbourhood characteristics considered here. These results suggest that selected features of neighbourhood environments may increase the burden on the healthcare system for mental health comorbidities among adults with cardiovascular disease. Further research is needed to understand the differing needs of socioeconomically marginalized populations to improve mental health outcomes following an acute cardiac event, specifically in the context of smaller and rural communities and of universal healthcare coverage.
Collapse
Affiliation(s)
- Ismael Foroughi
- Department of Sociology, University of New Brunswick, Fredericton, NB E3B 5A3, Canada;
| | - Neeru Gupta
- Department of Sociology, University of New Brunswick, Fredericton, NB E3B 5A3, Canada;
- Correspondence:
| | | |
Collapse
|
8
|
Crouse DL, Foroughi I, Gupta N. Neighbourhood environments and the risk of hospital admission for cardiometabolic and mental health comorbidities in multiple sclerosis: A population cohort analysis using linked administrative data. Mult Scler 2019; 27:315-319. [PMID: 31858881 DOI: 10.1177/1352458519895985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study exploits administrative data for neuroepidemiological research and examines associations between neighbourhood environments and risk of hospitalization among multiple sclerosis (MS) patients in New Brunswick, Canada. We created a provincial database of MS patients by linking administrative health records with geographic-based characteristics of local communities. Using Cox models, we found the risk of admission for cardiometabolic complications was lower among residents of ethnically homogeneous neighbourhoods (hazards ratio [HR]: 0.75 [95% confidence interval (CI): 0.60-0.95]); that for mental health disorders was higher in socioeconomically deprived (HR: 1.80 [95% CI: 1.06-3.05]) and residentially unstable (HR: 1.61 [95% CI: 1.05-2.46]) neighbourhoods. Results suggest that selected neighbourhood environments may be associated with differential hospital burden among MS patients.
Collapse
Affiliation(s)
- Dan Lawson Crouse
- Department of Sociology, University of New Brunswick, Fredericton, NB, Canada/NB Institute for Research, Data and Training, University of New Brunswick, Fredericton, NB, Canada
| | - Ismael Foroughi
- Department of Sociology, University of New Brunswick, Fredericton, NB, Canada
| | - Neeru Gupta
- Department of Sociology, University of New Brunswick, Fredericton, NB, Canada
| |
Collapse
|
9
|
Brauer M, Brook JR, Christidis T, Chu Y, Crouse DL, Erickson A, Hystad P, Li C, Martin RV, Meng J, Pappin AJ, Pinault LL, Tjepkema M, van Donkelaar A, Weichenthal S, Burnett RT. Mortality-Air Pollution Associations in Low-Exposure Environments (MAPLE): Phase 1. Res Rep Health Eff Inst 2019; 2019:1-87. [PMID: 31909580 PMCID: PMC7334864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023] Open
Abstract
INTRODUCTION Fine particulate matter (particulate matter ≤2.5 μm in aerodynamic diameter, or PM2.5) is associated with mortality, but the lower range of relevant concentrations is unknown. Novel satellite-derived estimates of outdoor PM2.5 concentrations were applied to several large population-based cohorts, and the shape of the relationship with nonaccidental mortality was characterized, with emphasis on the low concentrations (<12 μg/m3) observed throughout Canada. METHODS Annual satellite-derived estimates of outdoor PM2.5 concentrations were developed at 1-km2 spatial resolution across Canada for 2000-2016 and backcasted to 1981 using remote sensing, chemical transport models, and ground monitoring data. Targeted ground-based measurements were conducted to measure the relationship between columnar aerosol optical depth (AOD) and ground-level PM2.5. Both existing and targeted ground-based measurements were analyzed to develop improved exposure data sets for subsequent epidemiological analyses. Residential histories derived from annual tax records were used to estimate PM2.5 exposures for subjects whose ages ranged from 25 to 90 years. About 8.5 million were from three Canadian Census Health and Environment Cohort (CanCHEC) analytic files and another 540,900 were Canadian Community Health Survey (CCHS) participants. Mortality was linked through the year 2016. Hazard ratios (HR) were estimated with Cox Proportional Hazard models using a 3-year moving average exposure with a 1-year lag, with the year of follow-up as the time axis. All models were stratified by 5-year age groups, sex, and immigrant status. Covariates were based on directed acyclical graphs (DAG), and included contextual variables (airshed, community size, neighborhood dependence, neighborhood deprivation, ethnic concentration, neighborhood instability, and urban form). A second model was examined including the DAG-based covariates as well as all subject-level risk factors (income, education, marital status, indigenous identity, employment status, occupational class, and visible minority status) available in each cohort. Additional subject-level behavioral covariates (fruit and vegetable consumption, leisure exercise frequency, alcohol consumption, smoking, and body mass index [BMI]) were included in the CCHS analysis. Sensitivity analyses evaluated adjustment for covariates and gaseous copollutants (nitrogen dioxide [NO2] and ozone [O3]), as well as exposure time windows and spatial scales. Estimates were evaluated across strata of age, sex, and immigrant status. The shape of the PM2.5-mortality association was examined by first fitting restricted cubic splines (RCS) with a large number of knots and then fitting the shape-constrained health impact function (SCHIF) to the RCS predictions and their standard errors (SE). This method provides graphical results indicating the RCS predictions, as a nonparametric means of characterizing the concentration-response relationship in detail and the resulting mean SCHIF and accompanying uncertainty as a parametric summary. Sensitivity analyses were conducted in the CCHS cohort to evaluate the potential influence of unmeasured covariates on air pollution risk estimates. Specifically, survival models with all available risk factors were fit and compared with models that omitted covariates not available in the CanCHEC cohorts. In addition, the PM2.5 risk estimate in the CanCHEC cohort was indirectly adjusted for multiple individual-level risk factors by estimating the association between PM2.5 and these covariates within the CCHS. RESULTS Satellite-derived PM2.5 estimates were low and highly correlated with ground monitors. HR estimates (per 10-μg/m3 increase in PM2.5) were similar for the 1991 (1.041, 95% confidence interval [CI]: 1.016-1.066) and 1996 (1.041, 1.024-1.059) CanCHEC cohorts with a larger estimate observed for the 2001 cohort (1.084, 1.060-1.108). The pooled cohort HR estimate was 1.053 (1.041-1.065). In the CCHS an analogous model indicated a HR of 1.13 (95% CI: 1.06-1.21), which was reduced slightly with the addition of behavioral covariates (1.11, 1.04-1.18). In each of the CanCHEC cohorts, the RCS increased rapidly over lower concentrations, slightly declining between the 25th and 75th percentiles and then increasing beyond the 75th percentile. The steepness of the increase in the RCS over lower concentrations diminished as the cohort start date increased. The SCHIFs displayed a supralinear association in each of the three CanCHEC cohorts and in the CCHS cohort. In sensitivity analyses conducted with the 2001 CanCHEC, longer moving averages (1, 3, and 8 years) and smaller spatial scales (1 km2 vs. 10 km2) of exposure assignment resulted in larger associations between PM2.5 and mortality. In both the CCHS and CanCHEC analyses, the relationship between nonaccidental mortality and PM2.5 was attenuated when O3 or a weighted measure of oxidant gases was included in models. In the CCHS analysis, but not in CanCHEC, PM2.5 HRs were also attenuated by the inclusion of NO2. Application of the indirect adjustment and comparisons within the CCHS analysis suggests that missing data on behavioral risk factors for mortality had little impact on the magnitude of PM2.5-mortality associations. While immigrants displayed improved overall survival compared with those born in Canada, their sensitivity to PM2.5 was similar to or larger than that for nonimmigrants, with differences between immigrants and nonimmigrants decreasing in the more recent cohorts. CONCLUSIONS In several large population-based cohorts exposed to low levels of air pollution, consistent associations were observed between PM2.5 and nonaccidental mortality for concentrations as low as 5 μg/m3. This relationship was supralinear with no apparent threshold or sublinear association.
Collapse
Affiliation(s)
- M Brauer
- University of British Columbia, Vancouver, British Columbia, Canada
| | - J R Brook
- University of Toronto, Toronto, Ontario, Canada
| | - T Christidis
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - Y Chu
- University of British Columbia, Vancouver, British Columbia, Canada
| | - D L Crouse
- University of New Brunswick, Fredericton, New Brunswick, Canada
- New Brunswick Institute for Research, Data, and Training, Fredericton, New Brunswick, Canada
| | - A Erickson
- University of British Columbia, Vancouver, British Columbia, Canada
| | - P Hystad
- Oregon State University, Corvallis, Oregon, U.S.A
| | - C Li
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - R V Martin
- Dalhousie University, Halifax, Nova Scotia, Canada
- Harvard-Smithsonian Center for Astrophysics, Cambridge, Massachusetts, U.S.A
| | - J Meng
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - A J Pappin
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - L L Pinault
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | - M Tjepkema
- Health Analysis Division, Statistics Canada, Ottawa, Ontario, Canada
| | | | | | - R T Burnett
- Population Studies Division, Health Canada, Ottawa, Ontario, Canada
| |
Collapse
|
10
|
Cakmak S, Hebbern C, Vanos J, Crouse DL, Tjepkema M. Exposure to traffic and mortality risk in the 1991-2011 Canadian Census Health and Environment Cohort (CanCHEC). Environ Int 2019; 124:16-24. [PMID: 30639904 DOI: 10.1016/j.envint.2018.12.045] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 06/09/2023]
Abstract
There is evidence that local traffic density and living near major roads can adversely affect health outcomes. We aimed to assess the relationship between local road length, proximity to primary highways, and cause-specific mortality in the 1991 Canadian Census Health and Environment Cohort (CanCHEC). In this long-term study of 2.6 million people, based on completion of the long-form census in 1991 and followed until 2011, we used annual residential addresses to determine the total length of local roads within 200 m of postal code representative points and the postal code's distance to primary highways. The association between exposure to traffic and cause-specific non-accidental mortality was estimated using Cox proportional hazards models, adjusting for individual covariates and contextual factors, including census division-level proportion in high school, the percentage of recent immigrants, and neighborhood income. We performed sensitivity analyses, including adjustment for exposure to PM2.5, NO2, or O3, restricting to subjects in core urban areas, and spatial variation by climatic zone. The hazard ratio (HR) for all non-accidental mortality associated with an interquartile increase in length of local roads was 1.05 (95% CI 1.04, 1.05), while for an interquartile range increase in proximity to primary highways, the HR was 1.03 (95% CI 1.02, 1.04). HRs by traffic quartile increased with increasing lengths of local roads, as well as with closer proximity to primary highways, for all mortality causes. The associations were stronger within subjects' resident in urban core areas, attenuated by adjustment for PM2.5, and HRs showed limited spatial variation by climatic zone. In the CanCHEC cohort, exposure to higher road density and proximity to major traffic roads was associated with increased mortality risk from cerebrovascular and cardiovascular disease, ischemic heart disease, COPD, respiratory disease, and lung cancer, with unclear results for diabetes.
Collapse
Affiliation(s)
- Sabit Cakmak
- Population Studies Division, Environmental Health Science & Research Bureau, Health Canada, 101 Tunney's Pasture Driveway, Ottawa, ON K1A 0K9, Canada.
| | - Chris Hebbern
- Climate Change and Innovation Bureau, Health Canada, 269 Laurier Avenue, Ottawa, ON K1A 0K9, Canada
| | - Jennifer Vanos
- Climate, Atmospheric Science & Physical Oceanography, Scripps Institution of Oceanography, University of California at San Diego, 9500 Gilman Drive #0206, USA; Arizona State University, School of Sustainability, Tempe, AZ 85281, USA
| | - Dan Lawson Crouse
- New Brunswick Institute for Research, Data, and Training (NB-IRDT) and Department of Sociology University of New Brunswick Fredericton, NB PO Box 4400, E3B 5A3, Canada
| | | |
Collapse
|
11
|
Cakmak S, Hebbern C, Pinault L, Lavigne E, Vanos J, Crouse DL, Tjepkema M. Associations between long-term PM 2.5 and ozone exposure and mortality in the Canadian Census Health and Environment Cohort (CANCHEC), by spatial synoptic classification zone. Environ Int 2018; 111:200-211. [PMID: 29227849 DOI: 10.1016/j.envint.2017.11.030] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 11/07/2017] [Accepted: 11/28/2017] [Indexed: 05/23/2023]
Abstract
Studies suggest that long-term chronic exposure to fine particulate matter air pollution can increase lung cancer mortality. We analyzed the association between long term PM2.5 and ozone exposure and mortality due to lung cancer, ischemic heart disease, and chronic obstructive pulmonary disease, accounting for geographic location, socioeconomic status, and residential mobility. Subjects in the 1991 Canadian Census Health and Environment Cohort (CanCHEC) were followed for 20years, and assigned to regions across Canada based on spatial synoptic classification weather types. Hazard ratios (HR) for mortality, were related to PM2.5 and ozone using Cox proportional hazards survival models, adjusting for socioeconomic characteristics and individual confounders. An increase of 10μg/m3 in long term PM2.5 exposure resulted in an HR for lung cancer mortality of 1.26 (95% CI 1.04, 1.53); the inclusion in the model of SSC zone as a stratum increased the risk estimate to HR 1.29 (95% CI 1.06, 1.57). After adjusting for ozone, HRs increased to 1.49 (95% CI 1.23, 1.88), and HR 1.54 (95% CI 1.27, 1.87), with and without zone as a model stratum. HRs for ischemic heart disease fell from 1.25 (95% CI 1.21, 1.29) for exposure to PM2.5, to 1.13 (95% CI 1.08, 1.19) when PM2.5 was adjusted for ozone. For COPD, the 95% confidence limits included 1.0 when climate zone was included in the model. HRs for all causes of death showed spatial differences when compared to zone 3, the most populated climate zone. Exposure to PM2.5 was related to an increased risk of mortality from lung cancer, and both ozone and PM2.5 exposure were related to risk of mortality from ischemic heart disease, and the risk varied spatially by climate zone.
Collapse
Affiliation(s)
- Sabit Cakmak
- Population Studies Division, Environmental Health Science & Research Bureau, Health Canada, 101 Tunney's Pasture Driveway, Ottawa, ON K1A 0K9, Canada.
| | - Chris Hebbern
- Population Studies Division, Environmental Health Science & Research Bureau, Health Canada, 101 Tunney's Pasture Driveway, Ottawa, ON K1A 0K9, Canada
| | - Lauren Pinault
- Research Analyst, Health Analysis, Statistics Canada/Government of Canada, Canada
| | - Eric Lavigne
- Air Health Science Division Health Canada, 269 Laurier Avenue West Ottawa, Ontario K1A0K9, Canada
| | - Jennifer Vanos
- Climate, Atmospheric Science & Physical Oceanography, Scripps Institution of Oceanography University of California at San Diego 9500, Gilman, Drive #0206, USA
| | - Dan Lawson Crouse
- Epidemiologist of the New Brunswick Institute for Research, Data, and Training (NB-IRDT) and Research Associate in the Department of Sociology University of New Brunswick Fredericton, NB, PO Box 4400, E3B 5A3, Canada
| | | |
Collapse
|
12
|
Tomczak A, Miller AB, Weichenthal SA, To T, Wall C, van Donkelaar A, Martin RV, Crouse DL, Villeneuve PJ. Long-term exposure to fine particulate matter air pollution and the risk of lung cancer among participants of the Canadian National Breast Screening Study. Int J Cancer 2016; 139:1958-66. [PMID: 27380650 DOI: 10.1002/ijc.30255] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Revised: 05/09/2016] [Accepted: 06/22/2016] [Indexed: 11/07/2022]
Abstract
Recently, air pollution has been classified as a carcinogen largely on the evidence of epidemiological studies of lung cancer. However, there have been few prospective studies that have evaluated associations between fine particulate matter (PM2.5 ) and cancer at lower concentrations. We conducted a prospective analysis of 89,234 women enrolled in the Canadian National Breast Screening Study between 1980 and 1985, and for whom residential measures of PM2.5 could be assigned. The cohort was linked to the Canadian Cancer Registry to identify incident lung cancers through 2004. Surface PM2.5 concentrations were estimated using satellite data. Cox proportional hazards models were used to characterize associations between PM2.5 and lung cancer. Hazard ratios (HRs) and 95% confidence intervals (CIs) computed from these models were adjusted for several individual-level characteristics, including smoking. The cohort was composed predominantly of Canadian-born (82%), married (80%) women with a median PM2.5 exposure of 9.1 µg/m(3) . In total, 932 participants developed lung cancer. In fully adjusted models, a 10 µg/m(3) increase in PM2.5 was associated with an elevated risk of lung cancer (HR: 1.34; 95% CI = 1.10, 1.65). The strongest associations were observed with small cell carcinoma (HR: 1.53; 95% CI = 0.93, 2.53) and adenocarcinoma (HR: 1.44; 95% CI = 1.06, 1.97). Stratified analyses suggested increased PM2.5 risks were limited to those who smoked cigarettes. Our findings are consistent with previous epidemiological investigations of long-term exposure to PM2.5 and lung cancer. Importantly, they suggest associations persist at lower concentrations such as those currently found in Canadian cities.
Collapse
Affiliation(s)
- Anna Tomczak
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S5B6, Canada
| | - Anthony B Miller
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada
| | - Scott A Weichenthal
- Department of Epidemiology, Biostatistics, and Occupational Health and Gerald Bronfman Department of Oncology, McGill University, Montreal, QC, H3A 1A2, Canada
| | - Teresa To
- Child Health Evaluative Sciences, The Hospital for Sick Children, Ottawa, ON, M5G1X8, Canada
| | - Claus Wall
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada
| | - Aaron van Donkelaar
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Randall V Martin
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Dan Lawson Crouse
- NB Institute of Research, Data and Training, University of New Brunswick, Fredericton, NB, E3B 5A3, Canada
| | - Paul J Villeneuve
- Department of Health Sciences, Carleton University, Ottawa, ON, K1S5B6, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, M5T 3M7, Canada
| |
Collapse
|