The influence of the COVID-19 pandemic on physical activity in Stockholm County - Evidence from time series models of smartphone measured daily steps data spanning over 3 years.

BACKGROUND: It has been reported that physical activity levels decreased during the COVID-19 pandemic. Previous studies often relied on self-reported physical activity, which has low accuracy. Studies based on objectively measured physical activity have had short data collection periods, thereby not allowing the consideration of pre-pandemic levels of physical activity or the influence over the different waves of the pandemic. METHODS: In this study, we utilize smartphone-measured step data from a nonprobability sample in Stockholm County, Sweden, where measures to limit the spread of COVID-19 differed from those in many other countries. The results are based on 522 individuals and 532,739 person-days with step data spanning from 2019 to 2021. Generalized additive models were fitted for each individual, and meta-regression was used to combine the results from individual models. RESULTS: Daily steps decreased during the first wave but increased during the third wave compared to individual pre-pandemic levels. The decrease in daily steps occurred primarily in young individuals and those with occupations allowing remote work. Individuals of retirement age on the contrary increased their daily steps during the same period. CONCLUSIONS: This study reveal that the influence of the COVID-19 pandemic was temporary and that younger age and the possibility of working from home were associated with a decreasing trend in physical activity.

Characterization of data-driven clusters in diabetes-free adults and their utility for risk stratification of type 2 diabetes.

BACKGROUND: The prevention of type 2 diabetes is challenging due to the variable effects of risk factors at an individual level. Data-driven methods could be useful to detect more homogeneous groups based on risk factor variability. The aim of this study was to derive characteristic phenotypes using cluster analysis of common risk factors and to assess their utility to stratify the risk of type 2 diabetes. METHODS: Data on 7317 diabetes-free adults from Sweden were used in the main analysis and on 2332 diabetes-free adults from Mexico for external validation. Clusters were based on sex, family history of diabetes, educational attainment, fasting blood glucose and insulin levels, estimated insulin resistance and ß-cell function, systolic and diastolic blood pressure, and BMI. The risk of type 2 diabetes was assessed using Cox proportional hazards models. The predictive accuracy and long-term stability of the clusters were then compared to different definitions of prediabetes. RESULTS: Six risk phenotypes were identified independently in both cohorts: very low-risk (VLR), low-risk low ß-cell function (LRLB), low-risk high ß-cell function (LRHB), high-risk high blood pressure (HRHBP), high-risk ß-cell failure (HRBF), and high-risk insulin-resistant (HRIR). Compared to the LRHB cluster, the VLR and LRLB clusters showed a lower risk, while the HRHBP, HRBF, and HRIR clusters showed a higher risk of developing type 2 diabetes. The high-risk clusters, as a group, had a better predictive accuracy than prediabetes and adequate stability after 20 years. CONCLUSIONS: Phenotypes derived using cluster analysis were useful in stratifying the risk of type 2 diabetes among diabetes-free adults in two independent cohorts. These results could be used to develop more precise public health interventions.

Effects of NO2 exposure on daily mortality in São Paulo, Brazil.

BACKGROUND: Recent reports have suggested that air pollution mixtures represented by nitrogen dioxide (NO2) may have effects on human health, which are independent from those of particulate matter mass. We evaluate the association between NO2 and daily mortality among elderly using one- and multipollutant models. METHODS: This study was a daily time series of non-accidental and cause-specific mortality among the elderly living in São Paulo, Brazil, between 2000 and 2011. Effects of NO2, particulate matter smaller than 10µm (PM10), carbon monoxide (CO) and ozone (O3) were estimated in Poisson generalized additive models. The single lag effect at lags 0 and 1 days and the cumulative effect from 0 to lag 10 days were evaluated in one-, two-, three- and four-pollutant models. The cumulative risk index (CRI) recently proposed to analyze associations with health of multiple correlated pollutants was additionally estimated for each multipollutant model. RESULTS: An association between NO2, PM10, CO and O3 exposures and non-accidental and cause-specific deaths was found in one-pollutant models. NO2 effects remained significant in multipollutant models for non-accidental and circulatory deaths. The estimated CRIs suggested that circulatory deaths were mainly associated with NO2, and respiratory deaths mainly with CO and O3, regardless the lag. For non-accidental deaths, multipollutant models were associated with the highest CRI, with the main pollutants depending on the chosen lag. CONCLUSIONS: The results suggest that air pollution mixtures represented by NO2 have an effect on non-accidental and circulatory mortality, which is independent from PM10, CO and O3. The CRI was always larger than the risks associated with single pollutants.

Direct and indirect exposure to violence and psychological distress among civil servants in Rio de Janeiro, Brazil: a prospective cohort study.

BACKGROUND: Important social and economic changes accompanying the recent fast rate of urbanization have been considered a major factor in triggering and sustaining urban violence in Brazil. The purpose of this paper is to investigate the effects of exposure to direct, indirect, and contextual violence on the risk of psychological distress. METHODS: Prospective longitudinal study carried out among 3,058 civil servants working at university campuses in Rio de Janeiro. Psychological distress was measured using the General Health Questionnaire, and exposure to individual violence was assessed as direct (DV), indirect (IV), and both direct and indirect (DIV). Contextual violence was assessed through the geocoding of residential addresses of study participants and the rates of homicides in 2005 at the corresponding weighting area. Multiple logistic regression was used to evaluate individual and contextual correlates of psychological distress. RESULTS: Exposure to DIV increased more than six times (95% CI 2.7-16.0) the odds of psychological distress occurrence at the six-year follow-up. Regarding persistence of psychological distress, the association with violence exposure was 1.6 (95% CI 1.0-2.4) for DV and 2.7 (95% CI 1.3-5.3) for IV. Contextual violence was not associated with psychological distress, and no interaction effect was found between exposure to individual and contextual violence in the occurrence/persistence of psychological distress. CONCLUSIONS: Results of this study highlight the importance of assessing multiple forms of violence in research on the social determinants of mental disorders and support the view that individual exposure to different forms of violence increases the risk of psychological distress.

Equity impact of a choice reform and change in reimbursement system in primary care in Stockholm County Council.

BACKGROUND: In 2008 reforms were introduced in primary care in Stockholm County Council to increase patient choice. These reforms included changes to the reimbursement system from one that was primarily based on need-weighted capitation system (75%) to a system largely based on fee-for-service (60%) and freedom of establishment of primary care clinics. The new reimbursement system created incentives for producing many visits and additional primary care clinics were established, particularly in areas that were already well served. This study analyses if and how the choice reform and change of reimbursement system has affected equity in primary care consumption by investigating whether the increase in visits reflects levels of need and to what extent the reform have affected equity in health care between areas. METHODS: Cross-sectional data from the public health survey in Stockholm County 2006 (n = 34,707) and 2010 (n = 30,767) were linked to individual register data on socio-demographic characteristics and health care utilization in 2007 and 2011. Information on self-reported health status and disability pension was used as indicators of need of health care. Negative binomial regression was used to analyse the differences in GP visits between the two years. RESULTS: The total number of visits to GPs increased by 46 % from 2007 to 2011 and the proportion visiting a GP increased by 17%. Both men and women reporting poor mental health and women with limiting longstanding illness and poor self-rated health had significantly smaller increase in number of visits than healthy women and men. Men with poor health status living in disadvantaged areas had a smaller increase than men with poor health status living in other areas of Stockholm County. CONCLUSIONS: The reform did not particularly benefit those with greater health care needs, and there are indications of a negative impact on equity in primary care after the introduction of the reform. There were signs of a lesser increase in total number of visits to GPs among those with poor mental health, among women with poor self-rated health and limiting longstanding illness, and among men living in disadvantaged areas.

Socioeconomic differences in healthcare utilization, with and without adjustment for need: an example from Stockholm, Sweden.

AIM: Previous studies have shown varying degrees of inequity of utilization of healthcare in Sweden. Studies based solely on register data cannot take into account differences in health status while studies based solely on self-reported data from surveys may potentially have biased data on healthcare utilization. The aim of this study was to investigate socioeconomic differences in utilization of outpatient healthcare services in Stockholm County, comparing analysis based on only register data, with analysis based on health survey data linked to register data. METHODS: We linked data from a public health survey in Stockholm County 2006 (n = 34,707) to register data on sociodemographic background characteristics and outpatient healthcare utilization in 2007. Negative binomial regression analysis was used to estimate income differentials in healthcare utilization adjusting for self-rated health and limiting longstanding illness. RESULTS: Income differentials in the number of visits to doctors were found in favour of lower-income groups among people aged 25-64 years when only controlling for age. When controlling for health status, income differentials in favour of higher-income groups were observed among men (all ages) and among women aged 65+ years, with higher-income groups having 11-49% more visits than the lowest income group. CONCLUSIONS: The findings suggest that health status should be taken into account when analysing socioeconomic differences in healthcare utilization. When using only register based data there is a risk of underestimating or disregarding differences.

The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro.

Lack of skilled human resources in primary care remains a major concern for policymakers in low- and middle-income countries. There is little evidence supporting the impact of residency training in family medicine in the quality of care, and it perpetuates misconceptions among policymakers that the provision of primary care can be easily done by any physician without special training. This article compares the risk of patients being hospitalized due to Ambulatory care sensitive conditions and the odds of having follow-up visits in primary care after hospital discharge, according to the type of their medical provider: (1) Generalists (reference), (2) Family physicians; and, (3) patients with no consultations prior to the event. Multilevel multivariate binomial regression models estimated the relative risks of a patient being hospitalized in a given month and the relative risks for the occurrence of a follow-up visit in primary care in a retrospective cohort of 636.640 patients between January 2013 and July 2018 in Rio de Janeiro. For all 14 conditions, there was a higher risk of hospitalization when patients had no consultation in primary care prior to the event. Except for Ear, Nose and Throat infections, patients seen by family physicians had a lower risk of being hospitalized, compared to patients seen by Generalists. Follow-up visits were more likely to happen among patients treated by family physicians for almost every condition analyzed. With two years of training in family medicine, Family physicians can reduce the risk of their patients being hospitalized and increase the likelihood of those patients having a follow-up consultation in primary care. Investments in residency training in family medicine should be made to fix the shortage of skilled physicians in primary care, reduce hospitalizations and improve quality and continuity of care.

Seasonal and Temporal Patterns of Homicides and Suicides in Cali and Manizales, Colombia: A Times-Series Analysis 2008-2015.

OBJECTIVE: To identify seasonal and temporal variations in daily incidence of homicides and suicides in Cali and Manizales, Colombia during 2008-2015. MATERIALS AND METHODS: An ecological time series study was performed using negative binomial regression models for daily incidence of homicides and suicides; analyses were controlled for yearly trends and temporal autocorrelations. RESULTS: Saturdays, Sundays, December holidays as well as New Year and New Year's Eve were associated with an increased risk of homicides in both cities. Suicide risk increased during December holidays and New Year in both cities. In addition, the suicide risk increased on paydays, Saturdays, Sundays, and Mondays in Cali, and it decreased during the Holy Week holidays in Manizales. December patterns of suicides and homicides are the opposite in each city, and between cities. CONCLUSIONS: The incidences of homicides and suicides are not homogeneous over time. These patterns can be explained partially by alcohol consumption and changes in people's routine activities which may modify exposure to violent circumstances.

Association between fine particulate matter and the peak expiratory flow of schoolchildren in the Brazilian subequatorial Amazon: a panel study.

BACKGROUND: Exposure to high levels of particulate matter with an aerodynamic diameter less than 2.5 µm (PM(2.5)) resulting from biomass burning is frequent in the subequatorial Amazon region. OBJECTIVE: To investigate whether or not current exposure to PM(2.5) in the Brazilian Amazon has adverse effects on the daily peak expiratory flow (PEF) of schoolchildren. METHODS: The study design consisted of a panel comprising 309 children aged 6 to 15 years from the same school. PEF was measured daily, except weekends and holidays, from August to December 2006. Each child contributed to the study up to 67 daily measurements. All together there were 19115 PEF measures. Participation rate was 90%. Daily measurements of PM(2.5), temperature, and humidity as well as passive smoking, and subject features were regarded in the statistical analysis. Various exposures of PM(2.5) were considered throughout the analysis, among them 24-hour, 12-hour, 6-hour, and 5-hour means. To account for subject responses to confounders, mixed effects models were applied. The effects were evaluated considering air pollution levels on the current day or at 1- or 2-day lags and the averages of 0-1-day lags, 1-2-day lags and 0-, 1-, and 2-day lags. RESULTS: The 24-hour PM(2.5) means ranged from 6.39 to 99.91 µg/m(3). The adjusted models for the entire group of children revealed adverse effects. For instance, for an increase of 10 µg/m(3) in PM(2.5,) the reduction in the PEF average varied between 0.26 l/min (95% Confidence Interval (CI): -0.49; -0.04) and 0.38 l/min (95% CI: -0.71; -0.04). Restricted to the subgroup of non-asthmatic children, classified as such according to the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, there was a reduction in the PEF ranging from 0.38 l/min (95% CI: -0.63; -0.13) to 0.53 l/min (95% CI: -0.90; -0.16) for an increase of 10 µg/m(3) in PM(2.5). There was no significant effect in the asthmatic group. When stratified by time of the day children were at school, the concurrent effects of air pollution on PEF were not significant, whereas the 6-hour exposure from 0 am to 5:30 am was significant for both morning and afternoon groups. Finally, the 24-hour mean lagged effect was only significant for the afternoon group of children. For an increase of 10 µg/m(3) in PM(2.5,) there was a reduction in the PEF that ranged from 0.41 l/min (95% CI: -0.76; -0.06) to 0.49 l/min (95% CI: -0.91; -0.07). CONCLUSION: Exposure to current levels of PM(2.5) in the Brazilian Amazon was associated with reductions in the lung function of schoolchildren. The adverse effects were more consistent in non-asthmatic children and with respect to the 6-hour mean from 0 am to 5.30 am.

Residency training in family medicine and its impact on coordination and continuity of care: an analysis of referrals to secondary care in Rio de Janeiro.

OBJECTIVE: To measure the effect that residency training in family medicine (RTFM) has on continuity and coordination of care. DESIGN: Observational cohort study using electronic health records. SETTING: Rio de Janeiro, Brazil, public primary care system. PARTICIPANTS: 504 940 patients, 633 generalists (physicians without RTFM) and 204 family physicians (FP-doctors with 2 years of RTFM) from one health district between January 2015 and December 2018. INTERVENTION: Two years of RTFM. MAIN OUTCOME MEASURES: Relative risks of patients being referred to secondary care for outpatient consultations and diagnostics tests; and having a follow-up medical consultation in primary care within 3 and 6 months after being referred. RESULTS: We examined 2 414 508 medical consultations and 284 754 referrals to secondary care. FPs were less likely to request ambulatory care services (including surgical specialties), but were more likely to request ophthalmology, physiotherapy, rehabilitationand surgical evaluations for their patients. Patients referred to secondary care by FPs were more likely to have a follow-up visit in primary care for almost every service requested. If all medical consultations were performed by FPs, a 37.6% (95% CI 32.4% to 42.4%) increased demand for rehabilitation services would be noticed. Oppositely, 1532 (95% CI 1458 to 1602) fewer requests for dermatology would happen every year. CONCLUSIONS: RTFM improves coordination and continuity of care by making FPs more competent to retain those health conditions that can be properly managed in primary care and making FPs more competent to detect health conditions that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of patients having follow-up visits in primary care. Policy-makers in low-income and middle-income countries must consider investing in RTFM to make primary care systems more comprehensive, with better coordination and continuity of care.

Mortality from chronic respiratory disease in Brazil: time trend and forecasts.

OBJECTIVE: To analyze the time trend of monthly mortality rates from chronic respiratory diseases in Brazil from 1996 to 2017, with forecasts for 2022, besides analyzing the possibility of achieving the goal of the Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas Não Transmissíveis no Brasil (Strategic Action Plan to Tackle Chronic Noncommunicable Diseases in Brazil) from 2011 to 2022. METHODS: This is an ecological study that uses data from Sistema de Informações sobre Mortalidade (SIM - Mortality Information System), Sistema de Informações Demográficas e Socioeconômicas (Demographic and Socioeconomic Information System) and Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD Contínua - Continuous National Household Sample Survey). We established the age range between 30 and 69 years old and the evolution of the rates over time was made by autoregressive integrated moving average models in R statistical tool. RESULTS: Premature mortality rates from chronic respiratory diseases are decreasing in Brazil as a whole, mostly in state capitals. There is also a trend to reach the Ministry of Health's goal in most of the country. For capitals that tend not to reach the goal, there is an association between mortality and social indicators, healthcare network and frequency of smoking. CONCLUSION: This study intends to improve planning of the public health system for the control of chronic respiratory diseases.

Life-course trajectories of weight and their impact on the incidence of type 2 diabetes.

Although exposure to overweight and obesity at different ages is associated to a higher risk of type 2 diabetes, the effect of different patterns of exposure through life remains unclear. We aimed to characterize life-course trajectories of weight categories and estimate their impact on the incidence of type 2 diabetes. We categorized the weight of 7203 participants as lean, normal or overweight at five time-points from ages 7-55 using retrospective data. Participants were followed for an average of 19 years for the development of type 2 diabetes. We used latent class analysis to describe distinctive trajectories and estimated the risk ratio, absolute risk difference and population attributable fraction (PAF) associated to different trajectories using Poisson regression. We found five distinctive life-course trajectories. Using the stable-normal weight trajectory as reference, the stable overweight, lean increasing weight, overweight from early adulthood and overweight from late adulthood trajectories were associated to higher risk of type 2 diabetes. The estimated risk ratios and absolute risk differences were statistically significant for all trajectories, except for the risk ratio of the lean increasing trajectory group among men. Of the 981 incident cases of type 2 diabetes, 47.4% among women and 42.9% among men were attributable to exposure to any life-course trajectory different from stable normal weight. Most of the risk was attributable to trajectories including overweight or obesity at any point of life (36.8% of the cases among women and 36.7% among men). The overweight from early adulthood trajectory had the highest impact (PAF: 23.2% for woman and 28.5% for men). We described five distinctive life-course trajectories of weight that were associated to increased risk of type 2 diabetes over 19 years of follow-up. The variability of the effect of exposure to overweight and obesity on the risk of developing type 2 diabetes was largely explained by exposure to the different life-course trajectories of weight.

[Association between particulate matter from biomass burning and respiratory diseases in the southern region of the Brazilian Amazon]. / Associação entre material particulado de queimadas e doenças respiratórias na região sul da Amazônia brasileira.

OBJECTIVE: To investigate the short-term effects of exposure to particulate matter from biomass burning in the Amazon on the daily demand for outpatient care due to respiratory diseases in children and the elderly. METHODS: Epidemiologic study with ecologic time series design. Daily consultation records were obtained from the 14 primary health care clinics in the municipality of Alta Floresta, state of Mato Grosso, in the southern region of the Brazilian Amazon, between January 2004 and December 2005. Information on the daily levels of fine particulate matter was made available by the Brazilian National Institute for Spatial Research. To control for confounding factors (situations in which a non-causal association between exposure and disease is observed due to a third variable), variables related to time trends, seasonality, temperature, relative humidity, rainfall, and calendar effects (such as occurrence of holidays and weekends) were included in the model. Poisson regression with generalized additive models was used. RESULTS: A 10 microg/m3 increase in the level of exposure to particulate matter was associated with increases of 2.9% and 2.6% in outpatient consultations due to respiratory diseases in children on the 6th and 7th days following exposure. Significant associations were not observed for elderly individuals. CONCLUSIONS: The results suggest that the levels of particulate matter from biomass burning in the Amazon are associated with adverse effects on the respiratory health of children.

Neighborhood Socioeconomic Characteristics and Utilization of ADHD Medication in Schoolchildren: A Population Multilevel Study in Stockholm County.

Objective: To examine the effects of neighborhood socioeconomic disadvantage and ethnic composition on the utilization of ADHD medication in schoolchildren after accounting for individual- and family-level characteristics. Method: A cohort of all schoolchildren living in Stockholm County was prospectively followed for new prescriptions of ADHD medication (N = 276,955). Three-level logistic regression models were used with individual/family characteristics (e.g., immigrant background) at the first level and small area market statistics (SAMS) and municipality characteristics (i.e., socioeconomic disadvantage and ethnic composition) at the second and third level. Results: SAMS socioeconomic disadvantage was associated with increased utilization of ADHD medication. The utilization of ADHD medication was lower among immigrant children as compared with natives, and their odds of not utilizing medication increased as the degree of concentration of foreign-born increased. Conclusion: These results suggest that interventions at the neighborhood level may offer an additional route for the prevention of the disorder and/or alleviation of its consequences.

Frailty is associated with myosteatosis in obese patients with colorectal cancer.

BACKGROUND & AIMS: We aimed to explore the determinants of muscle fat infiltration and to investigate whether myosteatosis, assessed as muscle fat infiltration percentage (%MFI) and muscle attenuation from computed tomography (CT), is associated with frailty in a group of patients with colorectal cancer (CRC). METHODS: Cross sectional study including CRC patients. CT scan of the third lumbar vertebra was used to quantify body composition and the degree of %MFI (reported as percentage of fat within muscle area). Frailty was defined by Fried et al. (2001) as the presence of more than 3 criteria: unintentional weight loss, self-reported exhaustion, weakness (low handgrip strength), slow walking speed (gait speed) and low physical activity. Obesity was defined according to sex-and-age-specific body fat percentage (%BF) cutoff. RESULTS: A sample of 184 patients (age 60 ± 11 years; 58% men; 29% of patients with frailty) was studied. The sample was divided according to tertiles of MFI% (1st tertile 0 to 2.89%, n = 60; 2nd tertile ≥ 3.9-8.19%, n = 64; 3rd tertile ≥ 8.2-26%, n = 60). Age, females, body mass index, %BF, subcutaneous and visceral adipose tissue and the proportion of patients with frailty were significantly higher in the 3rd %MFI tertile. Phase angle and muscle attenuation were significantly lower in the 3rd %MFI tertile. The determinants of %MFI (r2 = 0.49), which was log transformed due to its normal distribution, were %BF (ß = 0.54; eß = 1.72; 95% CI: 0.032 to 0.051; P < 0.01), age (ß = 0.34; eß = 1.40; 95% CI: 0.016 to 0.032; P < 0.01) and gait speed (ß = -0.12; eß = 0.87; 95% CI: -0.84 to -0.001; P = 0.049). In addition, in obese patients (n = 74) presenting 4 or 5 frailty criteria increased the chance of having higher %MFI and lower muscle attenuation, after adjustment for sex, age and comorbidities when compared to none or 1 criteria. CONCLUSIONS: In a sample of CRC patients, %BF and gait speed were the determinants of %MFI. In addition, markers of myostetatosis were associated with frailty in the obese patients.

Social determinants of child and adolescent traffic-related and intentional injuries: a multilevel study in Stockholm County.

Several significant developmental and socialisation processes in the life of children and adolescents take place in the area where they live. The extent to which they can feel and be safe in this environment is an important component of the success of those processes. This study highlights the independent contribution of neighbourhood and individual-level demographic and socioeconomic attributes to child and adolescent injuries. All individuals between the ages of 7 and 16 years living in Stockholm County in January 1998 (n=184 545) were followed up for their injuries during a five-year period considering injuries sustained as a pedestrian/cyclist/motor-vehicle rider and intentional injuries (violence-related and self-inflicted). A series of two-level logistic regressions were conducted to examine the association between the occurrence of injuries and individual (compositional) characteristics nested into parish of residence as well as contextual characteristics. For children and adolescents living in Stockholm County, contextual socioeconomic and social attributes of their place of residence were significant for injuries sustained as motor-vehicle riders but not for those sustained as pedestrians/cyclists or those inflicted intentionally. In the latter case, only the highest concentration of social benefit recipients was associated with significantly higher odds ratios. This emphasises that each injury mechanism has its own socioeconomic and social pathway, where contextual and compositional factors come into play to varying degrees.

Impact evaluation of camera enforcement for traffic violations in Cali, Colombia, 2008-2014.

INTRODUCTION: Cameras for detecting traffic violations have been used as a measure to improve road safety in different countries around the world. In Cali, Colombia, fixed cameras were installed in March 2012 on a number of roads and intersections. All camera devices are capable of detecting simultaneously the following traffic violations: driving over the speed limit, running a red light or stop sign, violation of the traffic ban schedule, and blocking the pedestrian crosswalk. OBJECTIVE: To evaluate the impact of camera enforcement of traffic violations in Cali, Colombia. METHODS: A quasi-experimental difference-in-differences study with before and after measurements and a comparison group was conducted. We observed 38 intervention areas and 50 comparison areas (250 m radius), during 42 months before and 34 months after the installation of cameras. Effects were estimated with mixed negative binomial regression models. RESULTS: In intervention areas, after 12 months, there was a reduction of 19.2% of all crashes and a 24.7% reduction of injury and fatal crashes. In comparison areas, this reduction was 15.0% for all crashes and 20.1% for injury and fatal crashes. After adjusted comparisons, intervention sites outperformed comparison sites with an additional yearly reduction of 5.3% (p = 0.045) for all crashes. CONCLUSIONS: The use of cameras for detecting traffic violations seems to have a positive effect on the reduction of crashes in intervention areas. A beneficial spillover effect was found as well in comparison areas; but more evaluations are needed.

Ethnic heterogeneity, social capital and psychological distress in Sweden.

INTRODUCTION: Ethnic heterogeneity has been linked to both protective and detrimental effects on mental health. Few studies have investigated the role of social capital in this relationship and none have found that it has an explanatory role. The aim of this study is to investigate the relationship between two measures of ethnic heterogeneity and psychological distress in Stockholm County, as well as the explanatory role of social capital for individuals with Swedish-background, foreign-background and those who are foreign-born. METHODS: This study used data collected from respondents aged 18-64 to the 2002, 2006, 2010 baseline questionnaires of the Stockholm Public Health Cohort and was linked with individual and area-level register information. Ethnic heterogeneity was the main exposure, measured by: 1) ethnic density, defined as the proportion of first and second generation immigrants with 2 foreign-born parents; and 2) ethnic diversity, using the fragmentation index. Social capital measures of individual and contextual-level social support and horizontal trust were the main explanatory factors of interest. The outcome, psychological distress, was assessed using the General Health Questionnaire-12 with a 2/3 cut-off. Prevalence ratios with 95% confidence intervals were estimated using multi-level poisson regression with robust variances. RESULTS: Age and sex adjusted analyses for the whole study population demonstrated that a 10% increase in ethnic density or diversity was associated with a 1.06 (1.05-1.07) times higher prevalence of psychological distress. In the stratified analyses, both foreign-born respondents and those with Swedish-background showed increasing prevalence of psychological distress with increasing ethnic heterogeneity. However, this trend was entirely explained by socioeconomic factors in the Swedish-background respondents and by additional adjustments for individual and contextual social support and horizontal trust for the foreign-born. Further adjustment for contextual horizontal trust showed ethnic heterogeneity to be protective for respondents Swedish-background. There was no clear trend between ethnic heterogeneity and psychological distress for respondents with foreign-background. CONCLUSION: The association between ethnic heterogeneity and psychological distress differs by ethnic background. There was no difference in this association based on the measure of ethnic heterogeneity used, nor in the explanatory role of social capital between ethnic heterogeneity measures. Socioeconomic indicators and some elements of individual and contextual social capital are important explanatory factors of the excess risk of psychological distress with regards to ethnic heterogeneity.

Physical Activity and Incident Depression: A Meta-Analysis of Prospective Cohort Studies.

OBJECTIVE: The authors examined the prospective relationship between physical activity and incident depression and explored potential moderators. METHOD: Prospective cohort studies evaluating incident depression were searched from database inception through Oct. 18, 2017, on PubMed, PsycINFO, Embase, and SPORTDiscus. Demographic and clinical data, data on physical activity and depression assessments, and odds ratios, relative risks, and hazard ratios with 95% confidence intervals were extracted. Random-effects meta-analyses were conducted, and the potential sources of heterogeneity were explored. Methodological quality was assessed using the Newcastle-Ottawa Scale. RESULTS: A total of 49 unique prospective studies (N=266,939; median proportion of males across studies, 47%) were followed up for 1,837,794 person-years. Compared with people with low levels of physical activity, those with high levels had lower odds of developing depression (adjusted odds ratio=0.83, 95% CI=0.79, 0.88; I2=0.00). Furthermore, physical activity had a protective effect against the emergence of depression in youths (adjusted odds ratio=0.90, 95% CI=0.83, 0.98), in adults (adjusted odds ratio=0.78, 95% CI=0.70, 0.87), and in elderly persons (adjusted odds ratio=0.79, 95% CI=0.72, 0.86). Protective effects against depression were found across geographical regions, with adjusted odds ratios ranging from 0.65 to 0.84 in Asia, Europe, North America, and Oceania, and against increased incidence of positive screen for depressive symptoms (adjusted odds ratio=0.84, 95% CI=0.79, 0.89) or major depression diagnosis (adjusted odds ratio=0.86, 95% CI=0.75, 0.98). No moderators were identified. Results were consistent for unadjusted odds ratios and for adjusted and unadjusted relative risks/hazard ratios. Overall study quality was moderate to high (Newcastle-Ottawa Scale score, 6.3). Although significant publication bias was found, adjusting for this did not change the magnitude of the associations. CONCLUSIONS: Available evidence supports the notion that physical activity can confer protection against the emergence of depression regardless of age and geographical region.

[Correction approach for underreporting of deaths and hospital admissions due to ill-defined causes]. / Correção de sub-registros de óbitos e proporção de internações por causas mal definidas.

OBJECTIVE: To propose a correction approach for underreporting and relocation of ill-defined causes of morbidity and mortality in the National Health System Mortality and Hospital Information Systems. METHODS: Modified James-Stein empirical Bayes estimators for events in delimited geographic areas were applied as a correction approach for underreporting in Brazilian municipalities in 2001. RESULTS: There was an increase of 55,671 deaths in the Mortality Information System, an underreporting correction of 5.85%. It was more effective at the age groups under five (8.1%) and 70 years old and more (6.4%); for neonatal (8.7%) and ill-defined (8.0%) causes of death; and in the states of Maranhão (10.6%), Bahia (9.5%) and Alagoas (8.8%). Relocation of ill-defined causes of mortality changed the structure of proportional mortality in the Northern and Northeastern regions, and increased the proportion of deaths due to cardiovascular diseases and reduced those due to external and neonatal causes. Relocation of ill-defined causes of hospital admissions did not affect hospital proportional morbidity. CONCLUSIONS: The results of underreporting correction were consistent with previous studies, in terms of age groups, causes and geographic areas. Relocation of ill-defined causes of death was spatially consistent. The approach studied may be applicable on Brazilian Health Information since it can be implemented in computational algorithms. Some improvements, however, may be considered, like estimation approaches based on time-space event distribution.