Trends of amenable deaths due to healthcare within the European Union countries. Exploring the association with the economic crisis and education.

The study of premature deaths from causes that are generally preventable given the current availability of healthcare - called amenable deaths due to healthcare - provides information on the quality of services. However, they are not only impacted by healthcare characteristics: other factors are also likely to influence. Therefore, identifying the association between amenable deaths due to healthcare and health determinants, such as education, might be the key to preventing these deaths in the future. Still unclear however, is how this works and how amenable deaths due to healthcare are distributed and evolve within the European Union (EU) below the national level. We therefore studied the geographical and temporal patterns of amenable deaths due to healthcare in the 259 EU regions from 1999 to 2016, including the 2007-2008 financial crisis and the post-2008 economic downturn, and identified whether any association with education exists. A cross-sectional ecological study was carried out. Using a hierarchical Bayesian model, we estimated the average smoothed Standardized Mortality Ratios (sSMR). A regression model was also applied to measure the relative risks (RR) at 95% credible intervals for cause-specific mortality association with education. Results show that amenable deaths due to healthcare decreased globally. Nevertheless, the decrease is not the same across all regions, and inequalities within countries do persist, with lower mortality ratios seen in regions from Central European countries and higher mortality ratios in regions from Eastern European countries. Also, the evolution trend reveals that after the financial crisis, the number of these deaths increased in regions across almost all EU countries. Moreover, educational disparities in mortality emerged, and a statistical association was found between amenable deaths due to healthcare and early exit from education and training. These results confirm that identifying and understanding the background of regional differences may lead to a better understanding of the amenable deaths due to healthcare and allow for the application of more effective policies.

Inequality in mortality between Black and White Americans by age, place, and cause and in comparison to Europe, 1990 to 2018.

Although there is a large gap between Black and White American life expectancies, the gap fell 48.9% between 1990 and 2018, mainly due to mortality declines among Black Americans. We examine age-specific mortality trends and racial gaps in life expectancy in high- and low-income US areas and with reference to six European countries. Inequalities in life expectancy are starker in the United States than in Europe. In 1990, White Americans and Europeans in high-income areas had similar overall life expectancy, while life expectancy for White Americans in low-income areas was lower. However, since then, even high-income White Americans have lost ground relative to Europeans. Meanwhile, the gap in life expectancy between Black Americans and Europeans decreased by 8.3%. Black American life expectancy increased more than White American life expectancy in all US areas, but improvements in lower-income areas had the greatest impact on the racial life expectancy gap. The causes that contributed the most to Black Americans' mortality reductions included cancer, homicide, HIV, and causes originating in the fetal or infant period. Life expectancy for both Black and White Americans plateaued or slightly declined after 2012, but this stalling was most evident among Black Americans even prior to the COVID-19 pandemic. If improvements had continued at the 1990 to 2012 rate, the racial gap in life expectancy would have closed by 2036. European life expectancy also stalled after 2014. Still, the comparison with Europe suggests that mortality rates of both Black and White Americans could fall much further across all ages and in both high-income and low-income areas.

Socioeconomic Inequalities in Chronic Liver Diseases and Cirrhosis Mortality in European Urban Areas before and after the Onset of the 2008 Economic Recession.

OBJECTIVE: To analyse the trends in chronic liver diseases and cirrhosis mortality, and the associated socioeconomic inequalities, in nine European cities and urban areas before and after the onset of the 2008 financial crisis. METHODS: This is an ecological study of trends in three periods of time: two before (2000-2003 and 2004-2008), and one after (2009-2014) the onset of the economic crisis. The units of analysis were the geographical areas of nine cities or urban areas in Europe. We analysed chronic liver diseases and cirrhosis standardised mortality ratios, smoothing them with a hierarchical Bayesian model by each city, area, and sex. An ecological regression model was fitted to analyse the trends in socioeconomic inequalities, and included the socioeconomic deprivation index, the period, and their interaction. RESULTS: In general, chronic liver diseases and cirrhosis mortality rates were higher in men than in women. These rates decreased in all cities during the financial crisis, except among men in Athens (rates increased from 8.50 per 100,000 inhabitants during the second period to 9.42 during the third). Socioeconomic inequalities in chronic liver diseases and cirrhosis mortality were found in six cities/metropolitan areas among men, and in four among women. Finally, in the periods studied, such inequalities did not significantly change. However, among men they increased in Turin and Barcelona and among women, several cities had lower inequalities in the third period. CONCLUSIONS: There are geographical socioeconomic inequalities in chronic liver diseases and cirrhosis mortality, mainly among men, that did not change during the 2008 financial crisis. These results should be monitored in the long term.

Developing a tool to monitor knowledge translation in the health system: results from an international Delphi study.

BACKGROUND: It is generally accepted that evidence-informed decision making contributes to better health system performance and health outcomes, yet we are lacking benchmarks to monitor the impact of national health information systems (HIS) in policy and practice. Hence in this study, we have aimed to identify criteria for monitoring Knowledge Translation (KT) capacity within countries. METHODS: We conducted a web-based Delphi with over 120 public health professionals from 45 countries to reach agreement on criteria to monitor KT at the level of national HIS. Public health professionals participated in three survey rounds, in which they ranked 85 preselected criteria and could suggest additional criteria. RESULTS: Experts working in national (public) health agencies and statistical offices, as well as in health policy and care agreed on 29 criteria which constitute the Health Information (HI)-Impact Index. The criteria cover four essential domains of evaluation: the production of high-quality evidence, broad access and dissemination, stakeholder engagement and knowledge integration across sectors and in civil society. The HI-Impact Index was pretested by officials working in ministries of health and public health agencies in eight countries; they found the tool acceptable and user-friendly. CONCLUSIONS: The HI-Impact Index provides benchmarks to monitor KT so that countries can assess whether high-quality evidence can be easily accessed and used by the relevant stakeholders in health policy and practice, by civil society and across sectors. Next steps include further refining the procedure for conducting the assessment in routine, and sharing experiences from HIS evaluations using the HI-Impact Index.

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

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

Socio-economic inequalities on cancer mortality in nine European areas: The effect of the last economic recession.

BACKGROUND: The effect of inequalities aggravated by economic recessions in the mortality rates of certain diseases has been previously described. In this study, we analyzed the relationship between socio-economic deprivation and cancer mortality. We focused on lung, colon, prostate, and breast cancers in nine European urban areas over three periods: two before (2000-2003 and 2004-2008) and one after (2009-2014) the onset of the 2008 financial crisis. METHODS: This is an ecological study of trends. The units of analysis were small areas within nine European urban areas. We used a composite deprivation index as a socio-economic indicator. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyze the evolution of socio-economic inequalities, we fitted an ecological regression model that included the socio-economic indicator, the period of time, and the interaction between these terms. RESULTS: In men, socio-economic inequalities in all-cancer and lung cancer mortality were observed in most of the cities studied, but did not increase after the onset of the economic crisis. In women, only two cities (Stockholm and London) showed socio-economic inequalities in all-cancer and lung cancer mortality; there was also no increase in inequalities. CONCLUSIONS: Our results did not validate our hypothesis that inequalities increase in times of crisis. However, they emphasize the importance of socio-economic measurements for understanding mortality inequalities, and can be used to inform prevention strategies and help plan local health programs aimed at reducing health inequalities.

The Role of Cohesion Policy Funds in Decreasing the Health Gaps Measured by the EURO-HEALTHY Population Health Index.

Social, economic, and environmental differences across the European Union significantly affect opportunities to move forward in achieving greater equity in health. Cohesion Policy (CP) funds can contribute positively through investments in the main determinants of health. The aim of this study is to analyze to what extent the planned investments for 2014-2020 are addressing the regional health gaps, in light of the population health index (PHI), a multidimensional measure developed by the EURO-HEALTHY project. The operational programs of all regions were analyzed, namely, the CP planned investments by field of intervention. Analysis of variance was performed to examine whether the regional scores in the PHI dimensions were statistically different across regions with different levels of development (measured by gross domestic product (GDP)). Results show that 98% of regions with worse performances on the PHI are less developed regions. Overall, all regions present planned investments in intervention fields linked to dimensions appraised within the PHI (e.g., employment, income, education, pollution). Yet, more needs to be done to focus regional investments in health determinants where regions still lag behind. The PHI has the potential to inform future CP restructuring, providing evidence to extend the current eligibility criteria to other dimensions beyond the GDP.

Advancing tools to promote health equity across European Union regions: the EURO-HEALTHY project.

BACKGROUND: Population health measurements are recognised as appropriate tools to support public health monitoring. Yet, there is still a lack of tools that offer a basis for policy appraisal and for foreseeing impacts on health equity. In the context of persistent regional inequalities, it is critical to ascertain which regions are performing best, which factors might shape future health outcomes and where there is room for improvement. METHODS: Under the EURO-HEALTHY project, tools combining the technical elements of multi-criteria value models and the social elements of participatory processes were developed to measure health in multiple dimensions and to inform policies. The flagship tool is the Population Health Index (PHI), a multidimensional measure that evaluates health from the lens of equity in health determinants and health outcomes, further divided into sub-indices. Foresight tools for policy analysis were also developed, namely: (1) scenarios of future patterns of population health in Europe in 2030, combining group elicitation with the Extreme-World method and (2) a multi-criteria evaluation framework informing policy appraisal (case study of Lisbon). Finally, a WebGIS was built to map and communicate the results to wider audiences. RESULTS: The Population Health Index was applied to all European Union (EU) regions, indicating which regions are lagging behind and where investments are most needed to close the health gap. Three scenarios for 2030 were produced - (1) the 'Failing Europe' scenario (worst case/increasing inequalities), (2) the 'Sustainable Prosperity' scenario (best case/decreasing inequalities) and (3) the 'Being Stuck' scenario (the EU and Member States maintain the status quo). Finally, the policy appraisal exercise conducted in Lisbon illustrates which policies have higher potential to improve health and how their feasibility can change according to different scenarios. CONCLUSIONS: The article makes a theoretical and practical contribution to the field of population health. Theoretically, it contributes to the conceptualisation of health in a broader sense by advancing a model able to integrate multiple aspects of health, including health outcomes and multisectoral determinants. Empirically, the model and tools are closely tied to what is measurable when using the EU context but offering opportunities to be upscaled to other settings.

Effect of the recent economic crisis on socioeconomic inequalities in mortality in nine urban areas in Europe.

OBJECTIVE: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. METHOD: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. RESULTS: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. CONCLUSIONS: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders.

Socioeconomic inequalities in suicide mortality in European urban areas before and during the economic recession.

BACKGROUND: Few studies have assessed the impact of the financial crisis on inequalities in suicide mortality in European urban areas. The objective of the study was to analyse the trend in area socioeconomic inequalities in suicide mortality in nine European urban areas before and after the beginning of the financial crisis. METHODS: This ecological study of trends was based on three periods, two before the economic crisis (2000-2003, 2004-2008) and one during the crisis (2009-2014). The units of analysis were the small areas of nine European cities or metropolitan areas, with a median population ranging from 271 (Turin) to 193 630 (Berlin). For each small area and sex, we analysed smoothed standardized mortality ratios of suicide mortality and their relationship with a socioeconomic deprivation index using a hierarchical Bayesian model. RESULTS: Among men, the relative risk (RR) comparing suicide mortality of the 95th percentile value of socioeconomic deprivation (severe deprivation) to its 5th percentile value (low deprivation) were higher than 1 in Stockholm and Lisbon in the three periods. In Barcelona, the RR was 2.06 (95% credible interval: 1.24-3.21) in the first period, decreasing in the other periods. No significant changes were observed across the periods. Among women, a positive significant association was identified only in Stockholm (RR around 2 in the three periods). There were no significant changes across the periods except in London with a RR of 0.49 (95% CI: 0.35-0.68) in the third period. CONCLUSIONS: Area socioeconomic inequalities in suicide mortality did not change significantly after the onset of the crisis in the areas studied.

Evaluation of data availability on population health indicators at the regional level across the European Union.

BACKGROUND: The ability to measure regional health inequalities across Europe and to build adequate population health indices depends significantly on the availability of reliable and comparable data at the regional level. Within the scope of the EU-funded project EURO-HEALTHY, a Population Health Index (PHI) was built. This model aggregates 39 indicators considered relevant by experts and stakeholders to evaluate and monitor population health on the regional level within the European Union (269 regions). The aim of this research was to assess the data availability for those indicators. As a subsequent aim, an adequate protocol to overcome issues arising from missing data will be presented, as well as key messages for both national and European statistical authorities meant to improve data collection on population health. METHODS: The methodology for the study includes three consecutive phases: (i) assessing the data availability for the respective indicators at the regional level for the last year available (ii) applying a protocol for missing data and completing the database and (iii) developing a scoring system ranging from 0 (no data available; worst) to 1 (all data available; best) to evaluate the availability of data by indicator and EU region. RESULTS: Although the missing data on the set of the PHI indicators was significant, the mean availability score for the EURO-HEALTHY PHI indicators is 0.8 and the regional availability score is 0.7, which reveal the strength of the indicators as well as the data completeness protocol for missing data. CONCLUSIONS: This study provides a comprehensive data availability assessment for population health indicators from multiple areas of concern, at the EU regional level. The results highlight that the data completeness protocol and availability scores are suitable tools to apply on any indicator's data source mapping. It also raises awareness to the urgent need for sub-national data in several domains and for closing the data gaps between and within countries. This will require policies clearly focused on improving equity between regions and a coordinated effort from the producers of data (the EU28 national statistics offices and EUROSTAT) and the stakeholders who design policies at EU, regional and local level.

Real-Life Effectiveness of Vismodegib in Patients with Metastatic and Advanced Basal Cell Carcinoma: Characterization of Adverse Events and Assessment of Health-Related Quality of Life using the Dermatology Life Quality Index (DLQI) Test.

INTRODUCTION: Non-melanoma skin cancer (NMSC) is the most common type of human tumor, with an estimated five million new cases each year. NMSC has been described as having a major impact on the health-related quality of life of the patient. Vismodegib is a hedgehog pathway inhibitor therapy for patients who are affected by locally advanced basal cell carcinoma (laBCC) and metastatic basal cell carcinoma and are ineligible for surgery and/or radiotherapy. The objective of this study was to assess treatment-emergent adverse events reported by patients with advanced BCC who were undergoing hedgehog pathway inhibitor therapy with vismodegib, and to quantify their health-related quality of life using the Dermatology Life Quality Index (DLQI) questionnaire. METHODS: Patients with advanced and/or multiple basal cell carcinomas treated with vismodegib at the Non-Melanoma Skin Cancer Unit of the University of Naples Federico II (Italy) were consecutively enrolled. Each patient was evaluated every month until the end of the treatment cycle to assess adverse events related to the drug and the patient's quality of life. RESULTS: 48 patients (35 males and 13 females) with advanced BCC were included in the study. Muscle spasms, alopecia, and dysgeusia were the most frequently reported adverse events. 41 patients completed the DLQI questionnaire at the baseline visit and after 6 months of treatment. The average reported DLQI score decreased from a mean value of 5.7 at the baseline visit to 0.4 after 6 months of treatment. CONCLUSION: This is the first study to demonstrate a significant change in patient health-related quality of life from baseline to 6 months after hedgehog pathway inhibitor therapy initiation using the DLQI test. Interestingly, patients with BCC in visible areas such as the face or neck presented an overall DLQI score that was higher than that of patients with BCC located on the trunk and legs at the baseline visit, but the DLQI scores of these two groups were almost the same after 6 months of vismodegib therapy.

Health Disparities in Czechia and Portugal at Country and Municipality Levels.

This article investigates the health outcomes and determinants between two different European populations, Portuguese and Czech, on two hierarchical levels: country and metropolitan area. At first, the decomposition method of age and cause of death were compared on the country level, and then health was examined based on a factor analysis at the municipality level of Prague and Lisbon. The results clearly indicate problematic diabetes mortality among the Portuguese population, and especially in the Lisbon Metropolitan Area, and confirm the dominant role of circulatory mortality and cancer mortality among Czech, especially the Prague population. The social and economic deprivations were revealed as the major drivers for both metropolitan areas, although with differences between them, requiring interventions that go beyond the health sector.

Population Health Inequalities Across and Within European Metropolitan Areas through the Lens of the EURO-HEALTHY Population Health Index.

The different geographical contexts seen in European metropolitan areas are reflected in the uneven distribution of health risk factors for the population. Accumulating evidence on multiple health determinants point to the importance of individual, social, economic, physical and built environment features, which can be shaped by the local authorities. The complexity of measuring health, which at the same time underscores the level of intra-urban inequalities, calls for integrated and multidimensional approaches. The aim of this study is to analyse inequalities in health determinants and health outcomes across and within nine metropolitan areas: Athens, Barcelona, Berlin-Brandenburg, Brussels, Lisbon, London, Prague, Stockholm and Turin. We use the EURO-HEALTHY Population Health Index (PHI), a tool that measures health in two components: Health Determinants and Health Outcomes. The application of this tool revealed important inequalities between metropolitan areas: Better scores were found in Northern cities when compared with their Southern and Eastern counterparts in both components. The analysis of geographical patterns within metropolitan areas showed that there are intra-urban inequalities, and, in most cities, they appear to form spatial clusters. Identifying which urban areas are measurably worse off, in either Health Determinants or Health Outcomes, or both, provides a basis for redirecting local action and for ongoing comparisons with other metropolitan areas.

"Evolution and financial cost of socioeconomic inequalities in ambulatory care sensitive conditions: an ecological study for Portugal, 2000-2014".

BACKGROUND: Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) are specific conditions for which hospitalization is thought to be avoidable through patient education, health promotion initiatives, early diagnosis and by appropriate chronic disease management, and have been shown to be greatly influenced by socioeconomic (SE) characteristics. We examined the SE inequalities in hospitalization rates for ACSC in Portugal, their evolution over time (2000-2014), and their associated financial burden. METHODS: We modeled municipality-level ACSC hospitalization rates per 1000 inhabitants and ACSC hospitalization-related costs per inhabitant, for the 2000-2014 period (n = 4170), as a function of SE indicators (illiteracy and purchasing power, in quintiles), controlling for the proportion of elderly, sex, disease specific mortality rate, population density, PC supply, and time trend. The evolution of inequalities was measured interacting SE indicators with a time trend. Costs attributable to ACSC related hospitalization inequalities were measured by the predicted values for each quintile of the SE indicators. RESULTS: Hospitalization rate for ACSC was significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 1.97; p < 0.01), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = - 1.19; p < 0.05). ACSC hospitalization-related costs were also significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 4.04€; p < 0.05), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = - 4,69€; p < 0.01). The SE gradient significantly increased over the 2000-2014 period, and the annual cost of inequalities were estimated at more than 15 million euros for the Portuguese NHS. CONCLUSION: There was an increasing SE patterning in ACSC related hospitalizations, possibly reflecting increasing SE inequalities in early and preventive high-quality care, imposing a substantial financial burden to the Portuguese NHS.

Suicide in Portugal: Spatial determinants in a context of economic crisis.

This study compares the existing statistical association between suicide mortality and the characteristics of places of residence (municipalities), before and during the current economic crisis, in Portugal. We found that (1) the traditional culture-based North/South pattern of suicidal behaviour has faded away, while the socioeconomic urban/rural divide has become more pronounced; (2) suicide is associated with higher levels of rurality and material deprivation; and (3) recent shifts in suicidal trends may result from the current period of crisis. Strategies targeting rural areas combined with public policies that address area deprivation may have important implications for tackling suicide.

Mortality, material deprivation and urbanization: exploring the social patterns of a metropolitan area.

INTRODUCTION: Socioeconomic inequalities affecting health are of major importance in Europe. The literature enhances the role of social determinants of health, such as socioeconomic characteristics and urbanization, to achieve health equity. Yet, there is still much to know, mainly concerning the association between cause-specific mortality and several social determinants, especially in metropolitan areas. This study aims to describe the geographical pattern of cause-specific mortality in the Lisbon Metropolitan Area (LMA), at small area level (parishes), and analyses the statistical association between mortality risk and health determinants (material deprivation and urbanization level). Fourteen causes have been selected, representing almost 60% of total mortality between 1995 and 2008, particularly those associated with urbanization and material deprivation. METHODS: A cross-sectional ecological study was carried out. Using a hierarchical Bayesian spatial model, we estimated sex-specific smoothed Standardized Mortality Ratios (sSMR) and measured the relative risks (RR), and 95% credible intervals, for cause-specific mortality relative to 1. urbanization level, 2. material deprivation and 3. material deprivation adjusted by urbanization. RESULTS: The statistical association between mortality and material deprivation and between mortality and urbanization changes by cause of death and sex. Dementia and MN larynx, trachea, bronchus and lung are the causes of death showing higher relative risk associated with urbanization. Infectious and parasitic diseases, Chronic liver disease and Diabetes are the causes of death presenting higher relative risk associated with material deprivation. Ischemic heart disease was the only cause with a statistical association with both determinants, and MN female breast was the only without any statistical association. Urbanization level reduces the impact of material deprivation for most of the causes of death. Men face a higher impact of material deprivation and urbanization level, than women, in most cause-specific mortality, even when considering the adjusted model. CONCLUSIONS: Our findings explore the specific pattern of fourteen causes of death in LMA and reveals small areas with an excess risk of mortality associated with material deprivation, thereby identifying problematic areas that could potentially benefit from public policies effecting social inequalities.

Neighbourhood socioeconomic disadvantage and fruit and vegetable consumption: a seven countries comparison.

BACKGROUND: Low fruit and vegetable consumption is a risk factor for poor health. Studies have shown consumption varies across neighbourhoods, with lower intakes in disadvantaged neighbourhoods. However, findings are inconsistent, suggesting that socio-spatial inequities in diet could be context-specific, highlighting a need for international comparisons across contexts. This study examined variations in fruit and vegetable consumption among adults from neighbourhoods of varying socioeconomic status (SES) across seven countries (Australia, Canada, Netherlands, New Zealand, Portugal, Scotland, US). METHODS: Data from seven existing studies, identified through literature searches and knowledge of co-authors, which collected measures of both neighbourhood-level SES and fruit and vegetable consumption were used. Logistic regression was used to examine associations between neighbourhood-level SES and binary fruit and vegetable consumption separately, adjusting for neighbourhood clustering and age, gender and education. As much as possible, variables were treated in a consistent manner in the analysis for each study to allow the identification of patterns of association within study and to examine differences in the associations across studies. RESULTS: Adjusted analyses showed evidence of an association between neighbourhood-level SES and fruit consumption in Canada, New Zealand and Scotland, with increased odds of greater fruit intake in higher SES neighbourhoods. In Australia, Canada, New Zealand and Portugal, those residing in higher SES neighbourhoods had increased odds of greater vegetable intake. The other studies showed no evidence of a difference by neighbourhood-level SES. CONCLUSIONS: Acknowledging discrepancies across studies in terms of sampling, measures, and definitions of neighbourhoods, this opportunistic study, which treated data in a consistent manner, suggests that associations between diet and neighbourhood-level socioeconomic status vary across countries. Neighbourhood socioeconomic disadvantage may differentially impact on access to resources in which produce is available in different countries. Neighbourhood environments have the potential to influence behaviour and further research is required to examine the context in which these associations arise.

Associação espacial entre variáveis socioeconômicas e risco relativo de nascimentos pré-termo na Região Metropolitana de São Paulo (RMSP) e na Área Metropolitana de Lisboa (AML) / Spatial association between socioeconomic variables and risk related to pre-term births in metropolitan region of Sao Paulo (MRSP) and Lisbon metropolitan area (AML)

A prematuridade é um dos grandes problemas de saúde pública, contribuindo fortemente para a morbi-mortalidade infantil, tanto em países em desenvolvimento como o Brasil, quanto em países europeus como Portugal. O nascido prematuro é aquele que nasce com menos de 37 semanas de gestação. Os fatores de risco individuais associados à incidência da prematuridade são conhecidos. No entanto, os fatores contextuais que podem influenciar a sua incidência têm sido pouco estudados. O principal objetivo deste estudo foi identificar o padrão espacial do risco relativo de nascimento pré-termo e possíveis agrupamentos espaciais, assim como examinar se as condições socioeconômicas estão espacialmente associadas com o risco relativo de nascimento pré-termo em duas áreas metropolitanas: Região Metropolitana de São Paulo (RMSP), no Brasil, e Área Metropolitana de Lisboa (AML), em Portugal. Foi recolhida informação relativa aos nascidos vivos (2000-2010) de mães residentes em ambas as áreas metropolitanas e às condições socioeconômicas das mães. Para análise de associação espacial entre o risco relativo de nascimentos pré-termo e as variáveis do contexto geográfico, foram aplicados testes de associação espacial global (I Moran) para ambas as áreas metropolitanas. A distribuição geográfica do risco relativo de nascimentos pré-termo ocorreu de maneira não aleatória e heterogênea tanto na RMSP como na AML: na RMSP verificou-se existir uma associação espacial global negativa significativa entre risco relativo e taxa de desemprego; na AML, foi revelada associação global positiva significativa entre o risco relativo e a taxa de analfabetismo, o índice de privação sóciomaterial e a da taxa de desemprego...

Preterm birth is a major public health problem, contributing greatly to childhood morbidity and mortality, both in developing countries like Brazil, as in European countries like Portugal. Preterm babies are those that born with less than 37 weeks of gestation. The individual risk factors associated with the incidence of prematurity are known. However, the contextual factors that may influence its incidence have been little studied. The present study aimed to identify the spatial pattern of relative risks of preterm birth and possible spatial clusters, as well as examine if the socioeconomic conditions are spatially associated with relative risks of preterm births in two different metropolitan areas: Metropolitan Region of São Paulo (MRSP), in Brazil, and the Lisbon Metropolitan Area (LMA), in Portugal. Data related with preterm births (2000-2010) and their mothers and socioeconomic conditions from both metropolitan areas were collected. For analysis of spatial association between the relative risk of preterm birth and geographical context variables, tests of overall spatial association (Moran I) for both metropolitan areas were applied. The geographical distribution of the relative risk of preterm births occurred not random and unevenly both in MRSP as in LMA: in the MRSP, there was only a significant global spatial association between relative risk and the unemployment rate; in LMA, there was a global significant association between the relative risk and the illiteracy rate, sociomaterial deprivation index and the unemployment rate...