Focusing neighborhood context and self-rated health in the Pró-Saúde Study.

The influence of neighborhood characteristics on self-rated health has been little studied. A multilevel approach using hierarchical models was applied to analyze the relationship between the socioeconomic characteristics in 621 neighborhoods (level 2) in the city of Rio de Janeiro, Brazil, and the self-rated health of 3,054 university employees (level 1) from the baseline of the Pró-Saúde Study. Neighborhoods were created using the SKATER algorithm (Spatial 'K'luster Analysis by Tree Edge Removal) to cluster census tracts according to four indicators and a minimum population of 5,000 people. After adjustment for individual factors (per capita income, schooling, age, sex, ethnicity, health-related behavior and chronic diseases), low level of neighborhood income and higher numbers of members per household were significantly associated with poor self-rated health. Participants living in medium income-level neighborhoods were 34% more likely to self-rate their health as being poor. Those living in areas with a higher density of members per household were 50% more likely to present poor self-rated health. Neighborhood context influences self-rated health, beyond the effect of individual factors. Worsening neighborhood socioeconomic conditions affect health adversely, which in turn increasing the chance of poor self-rated health.

Focusing neighborhood context and self-rated health in the Pró-Saúde Study / O foco no contexto da vizinhança na autoavaliação da saúde no Estudo Pró-Saúde / Analizando el contexto del vecindario y autoevaluación de salud en el Estudio Pró-Saúde

The influence of neighborhood characteristics on self-rated health has been little studied. A multilevel approach using hierarchical models was applied to analyze the relationship between the socioeconomic characteristics in 621 neighborhoods (level 2) in the city of Rio de Janeiro, Brazil, and the self-rated health of 3,054 university employees (level 1) from the baseline of the Pró-Saúde Study. Neighborhoods were created using the SKATER algorithm (Spatial 'K'luster Analysis by Tree Edge Removal) to cluster census tracts according to four indicators and a minimum population of 5,000 people. After adjustment for individual factors (per capita income, schooling, age, sex, ethnicity, health-related behavior and chronic diseases), low level of neighborhood income and higher numbers of members per household were significantly associated with poor self-rated health. Participants living in medium income-level neighborhoods were 34% more likely to self-rate their health as being poor. Those living in areas with a higher density of members per household were 50% more likely to present poor self-rated health. Neighborhood context influences self-rated health, beyond the effect of individual factors. Worsening neighborhood socioeconomic conditions affect health adversely, which in turn increasing the chance of poor self-rated health.

Existem relativamente poucos estudos sobre a influência das características de vizinhança sobre a auto-avaliação da saúde. Foi aplicada uma abordagem multinível com modelos hierárquicos para analisar a relação entre as características socioeconômicas de 621 vizinhanças (nível 2) da cidade do Rio de Janeiro, Brasil, e a auto-avaliação da saúde de 3.054 servidores universitários (nível 1) da linha de base do Estudo Pró-Saúde. As vizinhanças foram criadas pela aplicação do algoritmo SKATER (Spatial 'K'luster Analysis by Tree Edge Removal) aos setores censitários, de acordo com quatro indicadores e uma população mínima de 5 mil habitantes. Depois de ajustar para fatores individuais (renda per capita, escolaridade, idade, sexo, raça/cor, comportamentos relacionados à saúde e doenças crônicas), houve uma associação significativa entre renda baixa e número maior de pessoas por domicílio na vizinhança e autoavaliação da saúde "ruim". Os residentes de vizinhanças de renda média apresentaram probabilidade 34% maior de avaliar a própria saúde como "ruim". Aqueles que viviam em vizinhanças com maior número médio de pessoas por domicílio mostraram uma probabilidade 50% maior de autoavaliação da saúde "ruim". Para além de fatores individuais, o contexto de vizinhança influencia a autoavaliação da saúde. Piores condições socioeconômicas da vizinhança afetam negativamente a saúde, que por sua vez aumenta as chances de autoavaliação da saúde "ruim".

La influencia de las características del vecindario en la salud autoevaluada se ha estudiado escasamente. Se aplicó un análisis multinivel usando modelos jerárquicos para analizar la relación entre las características socioeconómicas en 621 vecindarios (nivel 2), dentro de la ciudad de Río de Janeiro, Brasil, y la salud autoevaluada de 3.054 empleados universitarios (nivel 1), procedentes de la base de referencia del Estudio Pró-Saúde. Se crearon vecindarios con el uso del algoritmo SKATER (Spatial 'K'luster Analysis by Tree Edge Removal), con el fin de agrupar secciones del censo, de acuerdo con cuatro indicadores y una población mínima de 5.000 personas. Tras el ajuste por factores individuales (ingresos per cápita, escolarización, edad, sexo, etnia, comportamiento informado de salud y enfermedades crónicas), el bajo nivel de ingresos en el vecindario y el alto número de miembros por hogar estuvieron significativamente asociados a un escasa salud autoevaluada. Los participantes que vivían en vecindarios con un nivel de ingresos medios tuvieron una probabilidad un 34% mayor de autoevaluar su salud más bien como mala. Quienes estaban viviendo en vecindarios con una densidad más alta de miembros por vivienda tuvieron una probabilidad de un 50% mayor de presentar una salud autoevaluada mala. El contexto del vecindario influencia la salud autoevaluada, además del efecto de los factores individuales. Un empeoramiento de las condiciones socioeconómicas en el vecindario afecta adversamente a la salud, que a su vez aumenta la oportunidad de una salud autoevaluada como mala.

Assessment of participation bias in cohort studies: systematic review and meta-regression analysis / Avaliação do viés de participação em estudos de coorte: uma revisão sistemática e metarregressão / Evaluación del sesgo de participación en estudiosde cohortes: una revisión sistemática y metarregresión

Abstract The proportion of non-participation in cohort studies, if associated with both the exposure and the probability of occurrence of the event, can introduce bias in the estimates of interest. The aim of this study is to evaluate the impact of participation and its characteristics in longitudinal studies. A systematic review (MEDLINE, Scopus and Web of Science) for articles describing the proportion of participation in the baseline of cohort studies was performed. Among the 2,964 initially identified, 50 were selected. The average proportion of participation was 64.7%. Using a meta-regression model with mixed effects, only age, year of baseline contact and study region (borderline) were associated with participation. Considering the decrease in participation in recent years, and the cost of cohort studies, it is essential to gather information to assess the potential for non-participation, before committing resources. Finally, journals should require the presentation of this information in the papers.

Resumo A proporção de não-participação em estudos de coorte está associada também à exposição e à probabilidade de ocorrência do evento poder gerar viés nas estimativas de interesse. O objetivo do presente trabalho é realizar uma revisão sistemática e metanálise de artigos que descrevem a participação em estudos de coorte e avaliar as características associadas à participação. Foi realizada uma revisão sistemática (MEDLINE, Scopus e Web of Science), buscando-se artigos que descrevessem a proporção de participação na linha de base de estudos de coorte. De 2.964 artigos inicialmente identificados, foram selecionados 50. Entre esses, a proporção média de participação foi de 64,7%. Utilizando-se o modelo de metarregressão com efeitos mistos, somente a idade, ano da linha de base e a região do estudo (limítrofe) estiveram associados à participação. Considerando a diminuição na participação em anos mais recentes e o custo dos estudos de coorte, é essencial buscar informações que permitam avaliar o potencial de não-participação antes de comprometer os recursos.

Resumen La proporción de no participación en estudios de cohorte se asocia también con la exposición y probabilidad de ocurrencia de hechos que pueden generar sesgos en las estimaciones de interés. El objetivo de este estudio es realizar una revisión sistemática y un metaanálisis de artículos que describen la participación en estudios de cohortes y evaluar las características asociadas con la participación. Una revisión sistemática fue realizada (MEDLINE, Scopus y Web of Science), en busca de artículos que describen la relación de participación basada en estudios de cohortes. Se seleccionaron 2964 artículos, de los cuales se identificaron preliminarmente 50. Entre estos, la proporción promedio de participación fue de un 64,7%. Utilizando la metarregresión, sólo la edad, años de referencia y la región de estudio (borderline) se asociaron con la participación. Teniendo en cuenta la disminución de la participación en los últimos años, y el coste de los estudios de cohortes, es esencial buscar información para evaluar el potencial de la no participación antes de comprometer recursos.

Assessment of participation bias in cohort studies: systematic review and meta-regression analysis.

The proportion of non-participation in cohort studies, if associated with both the exposure and the probability of occurrence of the event, can introduce bias in the estimates of interest. The aim of this study is to evaluate the impact of participation and its characteristics in longitudinal studies. A systematic review (MEDLINE, Scopus and Web of Science) for articles describing the proportion of participation in the baseline of cohort studies was performed. Among the 2,964 initially identified, 50 were selected. The average proportion of participation was 64.7%. Using a meta-regression model with mixed effects, only age, year of baseline contact and study region (borderline) were associated with participation. Considering the decrease in participation in recent years, and the cost of cohort studies, it is essential to gather information to assess the potential for non-participation, before committing resources. Finally, journals should require the presentation of this information in the papers.

[Ethical issues in longitudinal studies: the case of ELSA-Brasil]. / Aspectos éticos em estudos longitudinais: o caso do ELSA-Brasil.

The debate about ethics in research with human beings has historically emphasized experimental studies because of their greater potential to harm the subjects involved. However, observational studies also include risks and relevant questions to be discussed. This article aims to present and discuss the ethical aspects involved in the implementation of ELSA-Brasil, a longitudinal multicenter study, with public funding, in which the research subjects and investigators are employees of the same institutions. The procedures adopted to meet the ethical requirements and commitments are described, as well as the casuistics that guided the actions according to their guiding principles (beneficence, autonomy and social justice). We present some moral problems that required consideration of risks and benefits at the confluence with the study's objectives, and we conclude with comments on the peculiarities and the potential benefits of a longitudinal study.

[Social capital in ELSA-Brasil: test-retest reliability of the Resource Generator scale]. / Capital social no ELSA-Brasil: confiabilidade teste-reteste do Resource Generator scale.

OBJECTIVE: To estimate the test-retest reliability of items of the Resource Generator scale for assessing social capital in the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). METHODS: The social capital was applied in a subsample of 281 participants from six ELSA investigation centers, on two occasions with an interval of seven to 14 days. The instrument consists of 31 items that represent concrete situations to evaluate the access to different types of resources. In addition, it evaluates the strength of ties (family, friends or acquaintances) for the available resources. Statistical analyses were performed through use of the kappa statistic (k) and prevalence-adjusted kappa (ka). RESULTS: A high frequency was found for social resources (above 50%). Regarding the presence or absence of resources, prevalence-adjusted reliability (ka) varied from 0.54 to 0.97. With regard to the source for the resource, the reliability estimates ranged from ka = 0.45 ("someone who has good contacts with the media") to ka = 0.86 ("someone who completed secondary education"). CONCLUSIONS: The scale presented adequate levels of reliability, which varied according to the type of resource.

Questionario do ELSA-Brasil: desafios na elaboracao de instrumento multidimensional / Questionnaire development in ELSA-Brasil: challenges of a multidimensional instrument

O artigo apresenta o processo de elaboração do questionário utilizado no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). Iniciamos pelo relato sobre a "Seleção de Temas" abordados no questionário, cujo conteúdo teria que abranger o conhecimento disponível acerca da complexa rede de causalidade dos desfechos de interesse, assim como possibilitar a comparabilidade com estudos semelhantes. Contextualizamos a "tradução e a adaptação de instrumentos de medida", necessárias no caso de escalas de avaliação de vizinhanças, do instrumento para diagnóstico de transtornos depressivos e de ansiedade, e do questionário de frequência alimentar. A seguir, comentamos os critérios que nortearam a "ordem dos blocos temáticos" e finalmente a importância prática dos "pré-testes e estudos-piloto". As relações entre o conjunto de informações reunidas no ELSA poderão constituir contribuição original sobre os fatores que causam ou agravam os desfechos de interesse no contexto brasileiro, assim como sobre seus fatores de proteção.

This article describes the development of the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil) questionnaire. We first address the selection of topics whose contents have to cover the knowledge available on the complex causal network of outcomes and allow comparability with similar studies. Then we deal with the "translation and adaptation of measurement instruments" including neighborhood environment rating scales, depression and anxiety disorder rating scale and a food frequency questionnaire and discuss criteria that guided "theme block sequencing". And finally we focus on the practical importance of "pretesting and pilot studies". The ELSA may provide an original contribution regarding factors that cause or aggravate the outcomes of interest in the Brazilian population, as well as protective factors.

Aspectos eticos em estudos longitudinais: o caso do ELSA-Brasil / Ethical issues in longitudinal studies: the case of ELSA-Brasil

Historicamente a discussão acerca da eticidade dos atos em pesquisas com seres humanos privilegiou os estudos experimentais, pelo maior potencial de danos aos sujeitos envolvidos. Todavia, os estudos observacionais também envolvem riscos e suscitam questões relevantes. Neste artigo pretende-se apresentar e discutir aspectos éticos do desenvolvimento do ELSA-Brasil, um estudo longitudinal e multicêntrico, com financiamento público, no qual os sujeitos da pesquisa e pesquisadores pertencem às mesmas instituições. São descritos os procedimentos adotados para atender às exigências e compromissos éticos e a casuística que orientou as ações segundo seus princípios norteadores (beneficência, autonomia e justiça social). São apresentados alguns problemas morais que exigiram ponderação sobre riscos e benefícios na confluência com os objetivos do estudo e comentam-se peculiaridades de um estudo longitudinal e seus potenciais benefícios.

The debate about ethics in research with human beings has historically emphasized experimental studies because of their greater potential to harm the subjects involved. However, observational studies also include risks and relevant questions to be discussed. This article aims to present and discuss the ethical aspects involved in the implementation of ELSA-Brasil, a longitudinal multicenter study, with public funding, in which the research subjects and investigators are employees of the same institutions. The procedures adopted to meet the ethical requirements and commitments are described, as well as the casuistics that guided the actions according to their guiding principles (beneficence, autonomy and social justice). We present some moral problems that required consideration of risks and benefits at the confluence with the study's objectives, and we conclude with comments on the peculiarities and the potential benefits of a longitudinal study.

Capital social no ELSA-Brasil: confiabilidade teste-reteste do Resource Generator scale / Social capital in ELSA-Brasil: test-retest reliability of the Resource Generator scale

OBJETIVO: Estimar a confiabilidade teste-reteste dos itens do Resource Generator scale para avaliação de capital social no Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil). MÉTODOS: A escala de capital social foi aplicada em subamostra de 281 participantes dos seis Centros de Investigação do ELSA, em duas oportunidades, com intervalo de sete a 14 dias. O instrumento é constituído por 31 itens que representam situações concretas para avaliar o acesso a diferentes tipos de recursos, além de avaliar a fonte dos recursos disponíveis (familiares, amigos ou conhecidos). A análise estatística foi realizada por meio de estatísticas kappa (k) e kappa ajustado pela prevalência (ka). RESULTADOS: Os recursos sociais investigados foram encontrados com grande frequência (acima de 50%). Em relação à presença ou ausência dos recursos, as estimativas de confiabilidade ajustadas pela prevalência (ka) variaram de 0,54 a 0,97. No que se refere à fonte de recurso, essas estimativas variaram de ka = 0,45 (alguém que tenha bons contatos com a mídia) a ka = 0,86 (alguém que se formou no Ensino Médio). CONCLUSÕES: A escala apresentou níveis adequados de confiabilidade, que variaram de acordo com o tipo de recurso. .

OBJECTIVE: To estimate the test-retest reliability of items of the Resource Generator scale for assessing social capital in the Brazilian Longitudinal Study for Adult Health (ELSA-Brasil). METHODS: The social capital was applied in a subsample of 281 participants from six ELSA investigation centers, on two occasions with an interval of seven to 14 days. The instrument consists of 31 items that represent concrete situations to evaluate the access to different types of resources. In addition, it evaluates the strength of ties (family, friends or acquaintances) for the available resources. Statistical analyses were performed through use of the kappa statistic (k) and prevalence-adjusted kappa (ka). RESULTS: A high frequency was found for social resources (above 50%). Regarding the presence or absence of resources, prevalence-adjusted reliability (ka) varied from 0.54 to 0.97. With regard to the source for the resource, the reliability estimates ranged from ka = 0.45 ("someone who has good contacts with the media") to ka = 0.86 ("someone who completed secondary education"). CONCLUSIONS: The scale presentedadequate levels of reliability, which varied according to the type of resource. .

Demarcation of local neighborhoods to study relations between contextual factors and health.

BACKGROUND: Several studies have highlighted the importance of collective social factors for population health. One of the major challenges is an adequate definition of the spatial units of analysis which present properties potentially related to the target outcomes. Political and administrative divisions of urban areas are the most commonly used definition, although they suffer limitations in their ability to fully express the neighborhoods as social and spatial units. OBJECTIVE: This study presents a proposal for defining the boundaries of local neighborhoods in Rio de Janeiro city. Local neighborhoods are constructed by means of aggregation of contiguous census tracts which are homogeneous regarding socioeconomic indicators. METHODOLOGY: Local neighborhoods were created using the SKATER method (TerraView software). Criteria used for socioeconomic homogeneity were based on four census tract indicators (income, education, persons per household, and percentage of population in the 0-4-year age bracket) considering a minimum population of 5,000 people living in each local neighborhood. The process took into account the geographic boundaries between administrative neighborhoods (a political-administrative division larger than a local neighborhood, but smaller than a borough) and natural geographic barriers. RESULTS: The original 8,145 census tracts were collapsed into 794 local neighborhoods, distributed along 158 administrative neighborhoods. Local neighborhoods contained a mean of 10 census tracts, and there were an average of five local neighborhoods per administrative neighborhood.The local neighborhood units demarcated in this study are less socioeconomically heterogeneous than the administrative neighborhoods and provide a means for decreasing the well-known statistical variability of indicators based on census tracts. The local neighborhoods were able to distinguish between different areas within administrative neighborhoods, particularly in relation to squatter settlements. CONCLUSION: Although the literature on neighborhood and health is increasing, little attention has been paid to criteria for demarcating neighborhoods. The proposed method is well-structured, available in open-access software, and easily reproducible, so we expect that new experiments will be conducted to evaluate its potential use in other settings. The method is thus a potentially important contribution to research on intra-urban differentials, particularly concerning contextual factors and their implications for different health outcomes.

Associação entre fatores contextuais e auto-avaliação de saúde: uma revisão sistemática de estudos multinível / Association between contextual factors and self-rated health: a systematic review of multilevel studies

A influência de características do local de moradia na auto-avaliação de saúde ainda é um tema pouco estudado, especialmente no Brasil. Neste trabalho realizou-se uma síntese das evidências disponíveis a respeito da associação entre fatores contextuais e auto-avaliação de saúde. Foi realizada uma revisão sistemática de artigos publicados entre janeiro de 1995 e agosto de 2005, nas bases ISI, PubMed e LILACS, utilizando-se os termos neighbourhood ou neighborhood, ecological, contextual, environment, community, em combinação com self-rated health, self-reported health, e também com multilevel ou hierarchical. Foram revisados 18 artigos, cuja maior parte analisou características sócio-econômicas; alguns investigaram variáveis psicossociais, poucos incluíram indicadores do ambiente físico. As unidades de referência espacial variaram desde setores censitários até estados. As diferenças entre as escalas de análise do nível contextual, o uso de diversos indicadores e suas diferentes categorizações dificultaram a comparação direta entre os resultados encontrados. As associações encontradas corroboram a hipótese de que o contexto de moradia influencia a auto-avaliação de saúde, para além do efeito dos fatores individuais. Piores condições sócio-econômicas do ambiente afetam negativamente a saúde, aumentando a chance de auto-avaliação de saúde ruim. Areas mais carentes, com mais pobreza ou menos riqueza, com maior desigualdade de renda, aumentaram a prevalência de auto-avaliação de saúde pior. As características físicas e psicossociais da vizinhança também são fatores importantes na determinação da auto-avaliação de saúde.

The influence of residential characteristics on self-rated health has received little research attention, especially in Brazil. This study summarizes the available evidence on the association between contextual factors and self-rated health, using a systematic review of articles published from January 1995 to August 2005. We searched for the terms neighbourhood or neighborhood, ecological, contextual, environment, and community, combined with self-rated health, self-reported health, and multilevel or hierarchical in digital bases. Most of the 18 reviewed studies analyzed socioeconomic indicators, while some investigated psychosocial variables and a few included physical environmental indicators. Spatial units of reference varied from census tracts to States. Differences among scales of contextual analysis and several indicators, with different categories, were identified. The associations corroborate the hypothesis that neighborhood context influences self-rated health, beyond the effect of individual factors. Physical and psychosocial neighborhood characteristics are important contextual factors in the determination of self-rated health. Worse socioeconomic neighborhood conditions have a negative effect on health, thereby increasing the odds of worse self-rated health.

[Association between contextual factors and self-rated health: a systematic review of multilevel studies]. / Associação entre fatores contextuais e auto-avaliação de saúde: uma revisão sistemática de estudos multinível.

The influence of residential characteristics on self-rated health has received little research attention, especially in Brazil. This study summarizes the available evidence on the association between contextual factors and self-rated health, using a systematic review of articles published from January 1995 to August 2005. We searched for the terms neighbourhood or neighborhood, ecological, contextual, environment, and community, combined with self-rated health, self-reported health, and multilevel or hierarchical in digital bases. Most of the 18 reviewed studies analyzed socioeconomic indicators, while some investigated psychosocial variables and a few included physical environmental indicators. Spatial units of reference varied from census tracts to States. Differences among scales of contextual analysis and several indicators, with different categories, were identified. The associations corroborate the hypothesis that neighborhood context influences self-rated health, beyond the effect of individual factors. Physical and psychosocial neighborhood characteristics are important contextual factors in the determination of self-rated health. Worse socioeconomic neighborhood conditions have a negative effect on health, thereby increasing the odds of worse self-rated health.