Identifying, Measuring, and Ranking Social Determinants of Health for Health Promotion Interventions Targeting Informal Settlement Residents

OBJECTIVES

Considering the importance of social determinants of health (SDHs) in promoting the health of residents of informal settlements and their diversity, abundance, and breadth, this study aimed to identify, measure, and rank SDHs for health promotion interventions targeting informal settlement residents in a metropolitan area in Iran.

METHODS

Using a hybrid method, this study was conducted in 3 phases from 2019 to 2020. SDHs were identified by reviewing studies and using the Delphi method. To examine the SDHs among informal settlement residents, a cross-sectional analysis was conducted using researcher-made questionnaires. Multilayer perceptron analysis using an artificial neural network was used to rank the SDHs by priority.

RESULTS

Of the 96 determinants identified in the first phase of the study, 43 were examined, and 15 were identified as high-priority SDHs for use in health-promotion interventions for informal settlement residents in the study area. They included individual health literacy, nutrition, occupational factors, housing-related factors, and access to public resources.

CONCLUSIONS

Since identifying and addressing SDHs could improve health justice and mitigate the poor health status of settlement residents, ranking these determinants by priority using artificial intelligence will enable policymakers to improve the health of settlement residents through interventions targeting the most important SDHs.

Ambient ozone effects on respiratory outcomes among smokers modified by neighborhood poverty: An analysis of SPIROMICS AIR

BACKGROUND

Neighborhood poverty has been associated with poor health outcomes. Previous studies have also identified adverse respiratory effects of long-term ambient ozone. Factors associated with neighborhood poverty may accentuate the adverse impact of ozone on respiratory health.

OBJECTIVES

To evaluate whether neighborhood poverty modifies the association between ambient ozone exposure and respiratory morbidity including symptoms, exacerbation risk, and radiologic parameters, among participants of the SPIROMICS AIR cohort study.

METHODS

Spatiotemporal models incorporating cohort-specific monitoring estimated 10-year average outdoor ozone concentrations at participants' homes. Adjusted regression models were used to determine the association of ozone exposure with respiratory outcomes, accounting for demographic factors, education, individual income, body mass index (BMI), and study site. Neighborhood poverty rate was defined by percentage of families living below federal poverty level per census tract. Interaction terms for neighborhood poverty rate with ozone were included in covariate-adjusted models to evaluate for effect modification.

RESULTS

1874 participants were included in the analysis, with mean (± SD) age 64 (± 8.8) years and FEV₁ (forced expiratory volume in one second) 74.7% (±25.8) predicted. Participants resided in neighborhoods with mean poverty rate of 9.9% (±10.3) of families below the federal poverty level and mean 10-year ambient ozone concentration of 24.7 (±5.2) ppb. There was an interaction between neighborhood poverty rate and ozone concentration for numerous respiratory outcomes, including COPD Assessment Test score, modified Medical Research Council Dyspnea Scale, six-minute walk test, and odds of COPD exacerbation in the year prior to enrollment, such that adverse effects of ozone were greater among participants in higher poverty neighborhoods.

CONCLUSION

Individuals with COPD in high poverty neighborhoods have higher susceptibility to adverse respiratory effects of ambient ozone exposure, after adjusting for individual factors. These findings highlight the interaction between exposures associated with poverty and their effect on respiratory health.

The Most Important Social Determinants of Slum Dwellers' Health: A Scoping Review

Objectives

Given the importance of social determinants of health in promoting the health of slum residents, this study was conducted with the aim of identifying the main dimensions and components of these determinants.

Methods

This scoping review study was conducted according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A comprehensive search was performed of PubMed, ProQuest, Scopus, and Web of Science for articles conducted from 2010 to the end of 2019. Studies were selected based on inclusion criteria, with a special focus on studies dealing with the social determinants of physical and mental health or illness.

Results

Thirty-three articles were selected to extract information on the social determinants of health. After reviewing the articles, 7 main dimensions (housing, socioeconomic status of the family, nutrition, neighborhood characteristics, social support and social capital, occupational factors, and health behaviors) and 87 components were extracted as social determinants of health among slum dwellers.

Conclusions

This framework could be used by planners, managers, and policy-makers when making decisions affecting the health of these settlements’ residents due to the common characteristics of slums around the world, especially in developing countries.

Use of alternative care sites during the COVID-19 pandemic in the city of Buenos Aires, Argentina

Objectives

In large cities, where a large proportion of the population live in poverty and overcrowding, orders to stay home to comply with isolation requirements are difficult to fulfil. In this article, the use of alternative care sites (ACSs) for the isolation of patients with confirmed COVID-19 or persons under investigation (PUI) in the City of Buenos Aires during the first wave of COVID-19 are described.

Study design

This is a cross-sectional study.

Methods

All patients with COVID-19 and PUI with insufficient housing resources who could not comply with orders to stay home and who were considered at low clinical risk in the initial triage were referred to refurbished hotels in the City of Buenos Aires (Ciudad Autónoma de Buenos Aires [CABA]). ACSs were divided into those for confirmed COVID-19 patients and those for PUI.

Results

From March to August 2020, there were 58,143 reported cases of COVID-19 (13,829 of whom lived in slums) in the CABA. For COVID-19 positive cases, 62.1% (n = 8587) of those living in slums and 21.4% (n = 9498) of those living outside the slums were housed in an ACS. In total, 31.1% (n = 18,085) of confirmed COVID-19 cases were housed in ACSs. In addition, 7728 PUI were housed (3178 from the slums) in an ACS. The average length of stay was 9.0 ± 2.5 days for patients with COVID-19 and 1.6 ± 0.7 days for PUI. For the individuals who were housed in an ACS, 1314 (5.1%) had to be hospitalised, 56 were in critical care units (0.22%) and there were 27 deaths (0.1%), none during their stay in an ACS.

Conclusions

Overall, about one-third of all people with COVID-19 were referred to an ACS in the CABA. For slum dwellers, the proportion was >60%. The need for hospitalisation was low and severe clinical events were rare. This strategy reduced the pressure on hospitals so their efforts could be directed to patients with moderate-to-severe disease.

Evaluation of the first level of care for tuberculosis control in Buenos Aires, Argentina

Objective.

Evaluate primary health care functions from the perspective of patients with tuberculosis from slums in the city of Buenos Aires, Argentina.

Methods.

Cross-sectional observational study with adult patients with tuberculosis (TB) and without TB (NoTB), living in slums (S) and outside them (NoS). Participants’ perceptions were evaluated using the Primary Care Assessment Tool for users (abbreviated version), which measures four main domains (first contact, ongoing care, coordination with specialists, and comprehensiveness) and selected secondary domains. A Likert scale was used, ranging from “No, not at all” (1 point) to “Yes, definitely” (4 points). Scores ≥ 3 were considered to indicate adequate performance of functions. Averages were calculated for each domain, as well as two overall scores: with and without secondary domains.

Results.

83 participants were included (20 TB-S, 21 TB-NoS, 19 NoTB-S, and 23 NoTB-NoS). The evaluated functions were perceived as inadequate. The TB-S group gave the lowest overall scores, not reaching 3 points in any domain. There were no significant differences in domains or overall scores between groups. Participants with TB gave lower scores in all domains, except in family-centered care, where they gave a significantly higher score than NoTB participants. The overall score without secondary domains was lower for TB participants than for the NoTB groups.

Conclusions.

According to the perception of participants with TB and without TB, primary health care functions are not satisfactory, either in slums or outside them.

[Evaluation of the first level of care for tuberculosis control in Buenos Aires, ArgentinaAvaliação da atenção primária à saúde no controle da tuberculose em Buenos Aires, Argentina]

Objetivo.

Evaluar las funciones de la atención primaria de salud desde la perspectiva de los pacientes con tuberculosis (TB) provenientes de villas de emergencia de la Ciudad Autónoma de Buenos Aires, Argentina.

Métodos.

Estudio observacional transversal con pacientes adultos con TB y sin TB (NoTB), residentes en villas de emergencia (V) y fuera de ellas (NoV). La percepción de los participantes se evaluó mediante el cuestionario Primary Care Assessment Tool-usuarios (versión abreviada) que mide cuatro dimensiones principales (primer contacto, longitudinalidad de los cuidados, coordinación entre servicios e integralidad) y algunas secundarias. Se utilizó una escala de Likert, desde “No, en absoluto” (1 punto) hasta “Sí, sin duda” (4 puntos). Puntajes ≥ 3 se consideraron como cumplimiento adecuado de las funciones. Se calcularon promedios para cada dominio y dos puntajes globales: con y sin dominios secundarios.

Resultados.

Se incluyeron 83 participantes (20 TB-V, 21 TB-NV, 19 NoTB-V y 23 NoTB-NV). Las funciones evaluadas se percibieron como no adecuadas. El grupo TB-V tuvo los puntajes globales más bajos y en ningún dominio alcanzó 3 puntos. No hubo diferencias significativas en los dominios ni los puntajes globales entre grupos. Los participantes con TB dieron menores puntajes en todos los dominios, excepto en enfoque familiar que fue significativamente mayor que los de los participantes NoTB; el puntaje global sin dominios secundarios fue menor en los participantes con TB que en los NoTB.

Conclusiones.

Según la percepción de los participantes con TB y sin TB, las funciones de la atención primaria de salud no son satisfactorias, tanto dentro de las villas de emergencia como fuera de ellas.

Socioeconomic deprivation and blood lipids in first-episode psychosis patients with minimal antipsychotic exposure: Implications for cardiovascular risk

BACKGROUND

The influence of socioeconomic deprivation on the cardiovascular health of patients with psychosis-spectrum disorders (PSD) has not been investigated despite the growing recognition of social factors as determinants of health, and the disproportionate rates of cardiovascular mortality observed in PSD. Discordant results have been documented when studying dyslipidemia -a core cardiovascular risk factor- in first-episode psychosis (FEP), before chronic exposure to antipsychotic medications. The objective of the present study is to determine the extent to which socioeconomic deprivation affects blood lipids in patients with FEP, and examine its implications for cardiovascular risk in PSD.

METHODS

Linear regression models, controlling for age, sex, exposure to pharmacotherapy, and physical anergia, were used to test the association between area-based measures of material and social deprivation and blood lipid levels in a sample of FEP patients (n = 208).

RESULTS

Social, but not material deprivation, was associated with lower levels of total and HDL cholesterol. This effect was statistically significant in patients with affective psychoses, but not in schizophrenia-spectrum disorders.

CONCLUSIONS

Contrary to other reports from the literature, the relationship between socioeconomic disadvantage and blood lipid levels was contingent on the social rather than the material aspects of deprivation. Furthermore, this association also depended on the main diagnostic category of psychosis, suggesting a complex interaction between the environment, psychopathology, and physical health. Future studies exploring health issues in psychosis might benefit from taking these associations into consideration. A better understanding of the biology of blood lipids in this context is necessary.

[A study on the association between the infant anemia and the utilization of maternal and child health services in ethnic minorities gathering in poverty-stricken rural areas of two provinces in Western China]

In this study, 1 065 infants and young children aged 24 months below in ethnic minorities gathering in poor rural areas in poor rural areas of Liangshan Yi Autonomous Prefecture of Sichuan Province and Gannan Tibetan Autonomous Prefecture of Gansu Province were investigated for their anemia status from October to November 2014, and the association between anemia and the utilization of maternal and child health services was analyzed. The prevalence of anemia in this area was 52.68%(561/1 065). After the adjustment of socio-demographic characteristics of mothers and infants, compared with infants aged 2-5 months, Han ethnic group, and infants whose mother was not anemic, the OR(95%CI) values of infant anemia for infants aged 6-12 months, 13-8 months, 19-24 months, ethnic minorities group, and infants whose mother was anemic were 11.65 (7.09-19.14), 9.91 (5.99-16.38), 5.87 (3.39-10.16), 1.55 (1.10-2.18) and 1.52 (1.14-2.04), respectively; Compared with infants whose child examination times not up to standard, and who were not only non-hospital delivered but also received inadequate number of inoculation, the OR (95%CI) values of infant anemia for infants whose child examination times up to standard, and who were not only hospital delivered but also received adequate number of inoculation were 0.60 (0.38-0.94) and 0.71 (0.52-0.98), respectively. The infants anemia is associated with the utilization of maternal and child health services.

Epidemiology of HIV, syphilis, and hepatitis B and C among manual cane cutters in low-income regions of Brazil

Background

In recent decades the epidemic of asymptomatic sexually transmitted infections has extended deep into Brazil, including small towns and rural areas. The purpose of this study was to investigate the epidemiology of HIV, syphilis, and hepatitis B (HBV) and hepatitis C viruses (HCV), and to evaluate immunization coverage against hepatitis B in a group of rural workers in Brazil.

Methods

In 2016, a cross-sectional study was conducted with 937 manual sugarcane cutters of the Midwest and Northeast Regions of Brazil. All individuals were interviewed and screened for HIV, syphilis, HBV and HCV. Correlating factors with lifetime HBV infection were investigated using logistic regression. Positive Predictive Values, Negative Predictive Values, sensitivity and specificity were also calculated relative to vaccination against Hepatitis B, comparing anti-HBs titers to vaccination reports.

Results

Most reported previous hospitalization (55%), occupational injuries (54%), sharing of personal items (45.8%), alcohol consumption (77.2%), multiple sexual partners in previous 12 months (39.8%), and no condom use during sexual intercourse in last 12 months (46.5%). Only 0.2% reported using injection drugs. Anti-HIV-1 was detected in three individuals (0.3%). Serological markers of lifetime syphilis (treponemal test) were detected in 2.5% (95% CI: 1.6–3.6) of participants, and active syphilis (treponemal test and VDRL) present in 1.2%. No samples were positive for anti-HCV. The prevalence of lifetime HBV infection (current or past infection) was 15.9%, and 0.7% (95% CI 0.4 to 1.5) were HBsAg-positive. Previous hospitalization (OR 1.53, CI 1.05–2.24, p < 0.01) and multiple sexual partners in the last 12 months (OR 1.80, CI 1.25–2.60, p < 0.01) were predictors for lifetime HBV infection. Although 46.7% (95% CI 43.4–49.9) of individuals reported having been vaccinated against hepatitis B, only 20.6% (95% CI 18.1–23.3) showed serological evidence of previous hepatitis B vaccination (positive for anti-HBs alone).

Conclusions

The high prevalence of syphilis and HBV compared to the general population and the high frequency of risk behaviors show the potential for sexual and parenteral dissemination of these agents in this rural population. In addition, the low frequency of hepatitis B vaccinated individuals suggests a need for improved vaccination services.

Parents' use of physical and verbal punishment: cross-sectional study in underprivileged neighborhoods

OBJECTIVE

To estimate the past-year prevalence of parental use of verbal and physical discipline in an urban sample.

METHOD

A cross-sectional study was conducted in two underprivileged neighborhoods with nearly 80,000 inhabitants. Complex sampling was used. The households were selected by applying two-stage probabilistic sampling with stratification. A total of 401 households (sample error=0.1) were selected by maximizing the variance (p=0.5). The cluster sampling indicated 33 census units (sample error=0.05). The Brazilian Portuguese version of the WorldSAFE Core Questionnaire was used to assess parental use of moderate verbal discipline, harsh verbal discipline, moderate physical discipline, and harsh physical discipline. This questionnaire asks how often mothers (respondent) and/or their husband or partner use specific disciplinary tactics.

RESULTS

The mean age of children and adolescents was 9 years (SD: 4.5). The prevalence of harsh verbal discipline was approximately 37% (28.3% [95% CI: 23.4-33.3%] for more than three times). The prevalence of harsh physical discipline was approximately 30% (21.8% [CI: 18.2-25.4%] for more than three times). Boys had higher odds of receiving harsh physical discipline [OR: 1.56, p<0.05]. Children and adolescents with learning problems and developmental delays had higher odds of being exposed to harsh discipline than their peers without these problems. Children and adolescents with chronic health conditions (e.g., asthma) had lower odds of receiving harsh physical discipline (OR: 0.4; p<0.05).

CONCLUSIONS

Parental abuse was embedded within children and adolescents rearing practices in these two underprivileged neighborhoods.

The association of fitness and school absenteeism across gender and poverty: a prospective multilevel analysis in New York City middle schools

PURPOSE

One-fifth to one-third of students in high poverty, urban school districts do not attend school regularly (missing ≥6 days/year). Fitness is shown to be associated with absenteeism, although this relationship may differ across poverty and gender subgroups.

METHODS

Six cohorts of New York City public school students were followed up from grades 5 to 8 during 2006/2007-2012/2013 (n = 349,381). Stratified three-level longitudinal generalized linear mixed models were used to test the association between changes in fitness and 1-year lagged child-specific days absent across gender and poverty.

RESULTS

In girls attending schools in high/very high poverty areas, greater improvements in fitness the prior year were associated with greater reductions in absenteeism (P = .034). Relative to the reference group (>20% decrease in fitness composite percentile scores from the prior year), girls with a large increase in fitness (>20%) demonstrated 10.3% fewer days absent (incidence rate ratio [IRR] 95% confidence interval [CI]: 0.834, 0.964), followed by those who had a 10%-20% increase in fitness (9.2%; IRR 95% CI: 0.835, 0.987), no change (5.4%; IRR 95% CI: 0.887, 1.007), and a 10%-20% decrease in fitness (3.8%; IRR 95% CI: 0.885, 1.045). In girls attending schools in low/mid poverty areas, fitness and absenteeism also had an inverse relationship, but no clear trend emerged. In boys, fitness and absenteeism had an inverse relationship but was not significant in either poverty group.

CONCLUSIONS

Fitness improvements may be more important to reducing absenteeism in high/very high poverty girls compared with low/mid poverty girls and both high/very high and low/mid poverty boys. Expanding school-based physical activity programs for youth particularly in high poverty neighborhoods may increase student attendance.

[Influence of postcode on paediatric admissions in Seville]

INTRODUCTION

The postcode (where the home is situated) is an indicator of socioeconomic status and is associated with morbidity, mortality, and the use of health services. The aim of this study was to analyse its effects on paediatric admissions and to determine the rates of the most common causes of paediatric admissions in Seville.

MATHERIAL AND METHODS

An observational cross-sectional study with two analysis units: under 15 year-old "admissions" in public hospitals in Seville (n=2,660) and "city districts" of Seville (n=11). The independent variable analysed was whether the postcode of the admitted patients was within a Regional Government designated "area with social transformation needs". The analysis of the admissions was performed using X²-test, Fisher test and Student-t test, with the description of rates using the calculation of crude and specific rates, and by rate ratio.

RESULTS

Children living in districts with a lower socioeconomic status were on average 7 months younger (P<.001), and they were significantly more likely to be admitted via the emergency department (P<.001). There was no statistical difference detected in either the length of hospital stay or mortality. The crude admission rate ratio was higher in districts with a lower socioeconomic status (1.8), with a higher specific rate ratio detected in admissions due to asthma, respiratory infections, inguinal hernia, and epilepsy/convulsions.

CONCLUSIONS

Paediatric hospital admission rates of the main diagnoses were higher in districts with a lower socioeconomic status. Children living in these districts were more likely to be admitted younger and via the emergency department.

Classifying neighbourhoods by level of access to stores selling fresh fruit and vegetables and groceries: identifying problematic areas in the city of Gatineau, Quebec

OBJECTIVES

Physical access to stores selling groceries, fresh fruit and vegetables (FV) is essential for urban dwellers. In Canadian cities where low-density development practices are common, social and material deprivation may be compounded by poor geographic access to healthy food. This case study examines access to food stores selling fresh FV in Gatineau, Quebec, to identify areas where poor access is coincident with high deprivation.

METHOD

Food retailers were identified using two secondary sources and each store was visited to establish the total surface area devoted to the sale of fresh FV. Four population-weighted accessibility measures were then calculated for each dissemination area (DA) using road network distances. A deprivation index was created using variables from the 2006 Statistics Canada census, also at the scale of the DA. Finally, six classes of accessibility to a healthy diet were constructed using a k-means classification procedure. These were mapped and superimposed over high deprivation areas.

RESULTS

Overall, deprivation is positively correlated with better accessibility. However, more than 18,000 residents (7.5% of the population) live in high deprivation areas characterized by large distances to the nearest retail food store (means of 1.4 km or greater) and virtually no access to fresh FV within walking distance (radius of 1 km).

CONCLUSION

In this research, we identified areas where poor geographic access may introduce an additional constraint for residents already dealing with the challenges of limited financial and social resources. Our results may help guide local food security policies and initiatives.

Classifying neighbourhoods by level of access to stores selling fresh fruit and vegetables and groceries: identifying problematic areas in the city of Gatineau, Quebec

OBJECTIVES

Physical access to stores selling groceries, fresh fruit and vegetables (FV) is essential for urban dwellers. In Canadian cities where low-density development practices are common, social and material deprivation may be compounded by poor geographic access to healthy food. This case study examines access to food stores selling fresh FV in Gatineau, Quebec, to identify areas where poor access is coincident with high deprivation.

METHOD

Food retailers were identified using two secondary sources and each store was visited to establish the total surface area devoted to the sale of fresh FV. Four population-weighted accessibility measures were then calculated for each dissemination area (DA) using road network distances. A deprivation index was created using variables from the 2006 Statistics Canada census, also at the scale of the DA. Finally, six classes of accessibility to a healthy diet were constructed using a k-means classification procedure. These were mapped and superimposed over high deprivation areas.

RESULTS

Overall, deprivation is positively correlated with better accessibility. However, more than 18,000 residents (7.5% of the population) live in high deprivation areas characterized by large distances to the nearest retail food store (means of 1.4 km or greater) and virtually no access to fresh FV within walking distance (radius of 1 km).

CONCLUSION

In this research, we identified areas where poor geographic access may introduce an additional constraint for residents already dealing with the challenges of limited financial and social resources. Our results may help guide local food security policies and initiatives.