Physical activity and gestational weight gain: a systematic review of observational studies.

BACKGROUND: Now that excessive weight gain during pregnancy is recognized as leading to complications during pregnancy that affect foetal growth, limiting weight gain during pregnancy has become a public health concern. Our aim was to perform a systematic review to assess whether observational studies reported associations between Physical Activity (PA) and Gestational Weight Gain (GWG). We were particularly interested in whether insufficient PA might be associated with high GWG. METHODS: Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we searched the MEDLINE ® databases for articles published up to February 2020 concerning case-control, cohort, and ecological studies assessing the association between PA during pregnancy and the risk of excessive and/or inadequate GWG. RESULTS: 21 observational studies on the PA of pregnant women were screened. 11 of these focused on excessive GWG, and of these a majority tend to show a significant association between various aspects of PA and excessive GWG. However, the results were more mitigated when it came to rate of GWG: three studies found that neither meeting PA recommendations nor high levels of total PA nor time spent in moderate vigorous physical activity (MVPA) or engaged in sedentary behaviour were associated with weekly GWG, while two others suggested that pregnant women not meeting PA guidelines in late pregnancy did have a higher rate of GWG. Of the seven studies investigating total GWG, only one found no association with PA. All studies suggested an inverse association between PA and total GWG - yet not all studies are statistically significant. CONCLUSION: Despite the small number of observational studies selected for our research, our findings support the main international findings, suggesting that active pregnant women gained less weight than inactive women; a lack of PA may therefore contribute to excessive GWG. The limitations of this body of evidence impede the formulation of firm conclusions. Further studies focusing clearly on the general PA assessment classification scheme are called for, to address limitations capable of affecting the strength of association.

Efficiency of fine scale and spatial regression in modelling associations between healthcare service spatial accessibility and their utilization.

BACKGROUND: Healthcare accessibility, a key public health issue, includes potential (spatial accessibility) and realized access (healthcare utilization) dimensions. Moreover, the assessment of healthcare service potential access and utilization should take into account the care provided by primary and secondary services. Previous studies on the relationship between healthcare spatial accessibility and utilization often used conventional statistical methods without addressing the scale effect and spatial processes. This study investigated the impact of spatial accessibility to primary and secondary healthcare services on length of hospital stay (LOS), and the efficiency of using a geospatial approach to model this relationship. METHODS: This study focused on the ≥ 75-year-old population of the Nord administrative region of France. Inpatient hospital spatial accessibility was computed with the E2SFCA method, and then the LOS was calculated from the French national hospital activity and patient discharge database. Ordinary least squares (OLS), spatial autoregressive (SAR), and geographically weighted regression (GWR) were used to analyse the relationship between LOS and spatial accessibility to inpatient hospital care and to three primary care service types (general practitioners, physiotherapists, and home-visiting nurses). Each model performance was assessed with measures of goodness of fit. Spatial statistical methods to reduce or eliminate spatial autocorrelation in the residuals were also explored. RESULTS: GWR performed best (highest R2 and lowest Akaike information criterion). Depending on global model (OLS and SAR), LOS was negatively associated with spatial accessibility to general practitioners and physiotherapists. GWR highlighted local patterns of spatial variation in LOS estimates. The distribution of areas in which LOS was positively or negatively associated with spatial accessibility varied when considering accessibility to general practitioners and physiotherapists. CONCLUSIONS: Our findings suggest that spatial regressions could be useful for analysing the relationship between healthcare spatial accessibility and utilization. In our case study, hospitalization of elderly people was shorter in areas with better accessibility to general practitioners and physiotherapists. This may be related to the presence of effective community healthcare services. GWR performed better than LOS and SAR. The identification by GWR of how these relationships vary spatially could bring important information for public healthcare policies, hospital decision-making, and healthcare resource allocation.

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay.

BACKGROUND: Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS). METHODS: Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models. RESULTS: The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility. CONCLUSIONS: This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population's healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

Asthma and Indoor Environment: Usefulness of a Global Allergen Avoidance Method on Asthma Control and Exposure to Molds.

The usefulness and feasibility of a global allergens avoidance method with counselors visiting patients' home for allergens measures and adapted advices were prospectively evaluated through asthma control and environment evaluation. Twenty seven patients were prospectively included and compared to a cohort of 30 control patients. The level of control of asthma at inclusion and after 1 year was evaluated by the clinical signs, the evolution of the FEV1, and the healthcare use. Environmental measurements included the fungal load of 5 surfaces of the dwellings and the evaluation of moisture. A significant clinical improvement in the population that benefited from the home counselors visit was observed compared to the baseline (p < 0.0001), as well as a decreased number of hospitalizations for asthma and of the consumption of anti-asthma drugs (p < 0.01). Dampness markers slightly improved with an improvement of the fungal loads in two-third of the dwellings.

Does residential mobility during pregnancy induce exposure misclassification for air pollution?

BACKGROUND: Prenatal exposure to outdoor air pollution has been shown to have health effects in many studies; low birth weight, preterm delivery, small for gestational age, and stillbirth are the most often cited. However, exposure of pregnant women is difficult to quantify, especially with regard to their mobility, which is rarely taken into account in epidemiological studies. This study aimed to assess the impact of mobility of pregnant women living in Paris, France, on their exposure estimates to nitrogen dioxide (NO2). METHODS: A total of 486 pregnant women were recruited in 5 maternity hospitals in Paris between January and April 2016. A questionnaire was used to collect mothers' characteristics (demography, education, etc.) and to assess their daily mobility during pregnancy (time spent at work, commuting time and mode used to move from residential to occupational places). Daily NO2 concentrations were estimated based on the combination of annual average concentrations modeled at the census block scale and daily concentrations measured from fixed monitoring stations. Different models were used to compare the exposure of pregnant women in residential and occupational places, also taking into account travel time and travel mode. The socioeconomic profile of the census blocks was characterized using a multi-component index. RESULTS: During the first trimester of pregnancy, women living in the least deprived census blocks were exposed to higher concentrations of NO2 than those living in the most deprived ones. Occupational mobility had a small impact on exposure levels (average increase after taking account of mobility: + 0.52 µg/m3) which was not related to the socioeconomic profile of the women. The commuting mode made a greater difference (+ 1.46 µg/m3 on average), in particular among women living in the most deprived census blocks. CONCLUSIONS: Our study illustrates that air pollution exposure can be underestimated when ignoring occupational mobility and commuting mode of pregnant women. This effect might be differential according to the neighborhood deprivation profile.

Does the edge effect impact on the measure of spatial accessibility to healthcare providers?

BACKGROUND: Spatial accessibility indices are increasingly applied when investigating inequalities in health. Although most studies are making mentions of potential errors caused by the edge effect, many acknowledge having neglected to consider this concern by establishing spatial analyses within a finite region, settling for hypothesizing that accessibility to facilities will be under-reported. Our study seeks to assess the effect of edge on the accuracy of defining healthcare provider access by comparing healthcare provider accessibility accounting or not for the edge effect, in a real-world application. METHODS: This study was carried out in the department of Nord, France. The statistical unit we use is the French census block known as 'IRIS' (Ilot Regroupé pour l'Information Statistique), defined by the National Institute of Statistics and Economic Studies. The geographical accessibility indicator used is the "Index of Spatial Accessibility" (ISA), based on the E2SFCA algorithm. We calculated ISA for the pregnant women population by selecting three types of healthcare providers: general practitioners, gynecologists and midwives. We compared ISA variation when accounting or not edge effect in urban and rural zones. The GIS method was then employed to determine global and local autocorrelation. Lastly, we compared the relationship between socioeconomic distress index and ISA, when accounting or not for the edge effect, to fully evaluate its impact. RESULTS: The results revealed that on average ISA when offer and demand beyond the boundary were included is slightly below ISA when not accounting for the edge effect, and we found that the IRIS value was more likely to deteriorate than improve. Moreover, edge effect impact can vary widely by health provider type. There is greater variability within the rural IRIS group than within the urban IRIS group. We found a positive correlation between socioeconomic distress variables and composite ISA. Spatial analysis results (such as Moran's spatial autocorrelation index and local indicators of spatial autocorrelation) are not really impacted. CONCLUSION: Our research has revealed minor accessibility variation when edge effect has been considered in a French context. No general statement can be set up because intensity of impact varies according to healthcare provider type, territorial organization and methodology used to measure the accessibility to healthcare. Additional researches are required in order to distinguish what findings are specific to a territory and others common to different countries. It constitute a promising direction to determine more precisely healthcare shortage areas and then to fight against social health inequalities.

Systematic literature review of reproductive outcome associated with residential proximity to polluted sites.

This study aims to assess the evidence on adverse pregnancy outcome associated with living close to polluted industrial sites, and identify the strengths and weaknesses of published epidemiological studies. A systematic literature search has been performed on all epidemiological studies published in developed countries since 1990, on the association between residential proximity to industrial sites (hazardous waste sites, industrial facilities and landfill sites) and adverse pregnancy outcome (low birth weight, preterm birth, small for gestational age, intrauterine growth retardation, infant mortality, congenital malformation). Based on 41 papers, our review reveals an excess risk of reproductive morbidity. However, no studies show significant excess risk of mortality including fetal death, neonatal or infant mortality and stillbirth. All published studies tend to show an increased risk of congenital abnormalities, yet not all are statistically significant. All but two of these studies revealed an excess risk of low birth weight. Results for preterm birth, small for gestational age and intrauterine growth retardation show the same pattern. There is suggestive evidence from the post-1990 literature that residential proximity to polluted sites (including landfills, hazardous waste sites and industrial facilities) might contribute to adverse reproductive outcomes, especially congenital malformations and low birth weight-though not mortality. This body of evidence has limitations that impede the formulation of firm conclusions, and new, well-focused studies are called for. The review findings suggest that continued strengthening of rules governing industrial emissions as well as industrial waste management and improved land use planning are needed.

Developing a data-driven spatial approach to assessment of neighbourhood influences on the spatial distribution of myocardial infarction.

BACKGROUND: There is a growing understanding of the role played by 'neighbourhood' in influencing health status. Various neighbourhood characteristics-such as socioeconomic environment, availability of amenities, and social cohesion, may be combined-and this could contribute to rising health inequalities. This study aims to combine a data-driven approach with clustering analysis techniques, to investigate neighbourhood characteristics that may explain the geographical distribution of the onset of myocardial infarction (MI) risk. METHODS: All MI events in patients aged 35-74 years occurring in the Strasbourg metropolitan area (SMA), from January 1, 2000 to December 31, 2007 were obtained from the Bas-Rhin coronary heart disease register. All cases were geocoded to the census block for the residential address. Each areal unit, characterized by contextual neighbourhood profile, included socioeconomic environment, availability of amenities (including leisure centres, libraries and parks, and transport) and psychosocial environment as well as specific annual rates standardized (per 100,000 inhabitants). A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of high and low risk of MI. RESULT: MI incidence was non-randomly spatially distributed, with a cluster of high risk of MI in the northern part of the SMA [relative risk (RR) = 1.70, p = 0.001] and a cluster of low risk of MI located in the first and second periphery of SMA (RR 0.04, p value  =  0.001). Our findings suggest that the location of low MI risk is characterized by a high socioeconomic level and a low level of access to various amenities; conversely, the location of high MI risk is characterized by a high level of socioeconomic deprivation-despite the fact that inhabitants have good access to the local recreational and leisure infrastructure. CONCLUSION: Our data-driven approach highlights how the different contextual dimensions were inter-combined in the SMA. Our spatial approach allowed us to identify the neighbourhood characteristics of inhabitants living within a cluster of high versus low MI risk. Therefore, spatial data-driven analyses of routinely-collected data georeferenced by various sources may serve to guide policymakers in defining and promoting targeted actions at fine spatial level.

Estimating indoor galaxolide concentrations using predictive models based on objective assessments and data about dwelling characteristics.

BACKGROUND: Galaxolide (HHCB) is used for fragrance in many consumer products. The aim of the current study was to use objective assessments of HHCB to build a predictive model in order to estimate indoor-measured HHCB concentrations from questionnaire-based data on dwelling characteristics and occupants' habits and activities. METHODS: Environmental assessments of indoor HHCB, dwelling characteristics were carried out in 150 dwellings in Brittany (France). Among the various models that were tested, the best predictive model for the reduced set of characteristics was identified on the basis of the coefficient of determination (R2) criterion. RESULTS: Linear regression model showed among the best performances (R2 = 0.48), together with some more complex models. According to the estimated results, the main variables that significantly increased HHCB concentrations were: living in rural area, drying clothes inside dwellings, painted walls, chipboard furniture, double glazing, damaged floors and duration of bathroom door being kept open. Laminated floors and presence of indoor plants were found to significantly decrease HHCB concentrations. DISCUSSION: The linear model based on objective assessments and questionnaire-derived data about dwelling characteristics and occupants' activities constituted an easy method for predicting indoor air HHCB concentrations. For studies including a large number of dwellings, modeling of HHCB concentrations is cheaper than measuring it in every location. Our methodological procedure can be applied to other indoor air pollutants.

Assessment of the spatial accessibility to health professionals at French census block level.

BACKGROUND: The evaluation of geographical healthcare accessibility in residential areas provides crucial information to public policy. Traditional methods - such as Physician Population Ratios (PPR) or shortest travel time - offer only a one-dimensional view of accessibility. This paper developed an improved indicator: the Index of Spatial Accessibility (ISA) to measure geographical healthcare accessibility at the smallest available infra-urban level, that is, the Îlot Regroupé pour des Indicateurs Statistiques. METHODS: This study was carried out in the department of Nord, France. Healthcare professionals are geolocalized using postal addresses available on the French state health insurance website. ISA is derived from an Enhanced Two-Step Floating Catchment Area (E2FCA). We have constructed a catchment for each healthcare provider, by taking into account residential building centroids, car travel time as calculated by Google Maps and the edge effect. Principal Component Analyses (PCA) were used to build a composite ISA to describe the global accessibility of different kinds of health professionals. RESULTS: We applied our method to studying geographical healthcare accessibility for pregnant women, by selecting three types of healthcare provider: general practitioners, gynecologists and midwives. A total of 3587 healthcare providers are potentially able to provide care for inhabitants of the department of Nord. On average there are 92 general practitioners, 22 midwives and 21 gynecologists per 100,000 residents. The composite ISA for the three types of healthcare provider is 39 per 100,000 residents. A comparative analysis between ISA and physician-population ratios indicates that ISA represents a more even distribution whereas the physician-population ratios show an 'all-or-nothing' approach. CONCLUSION: ISA is a multidimensional and improved measure, which combines the volume of services relative to population size with the proximity of services relative to the population's location, available at the smallest feasible geographical scale. It could guide policy makers towards highlighting critical areas in need of more healthcare providers, and these areas should be earmarked for further knowledge-based policy making.

Use of geographic indicators of healthcare, environment and socioeconomic factors to characterize environmental health disparities.

BACKGROUND: An environmental health inequality is a major public health concern in Europe. However just few studies take into account a large set of characteristics to analyze this problematic. The aim of this study was to identify and describe how socioeconomic, health accessibility and exposure factors accumulate and interact in small areas in a French urban context, to assess environmental health inequalities related to infant and neonatal mortality. METHODS: Environmental indicators on deprivation index, proximity to high-traffic roads, green space, and healthcare accessibility were created using the Geographical Information System. Cases were collected from death certificates in the city hall of each municipality in the Nice metropolitan area. Using the parental addresses, cases were geocoded to their census block of residence. A classification using a Multiple Component Analysis following by a Hierarchical Clustering allow us to characterize the census blocks in terms of level of socioeconomic, environmental and accessibility to healthcare, which are very diverse definition by nature. Relation between infant and neonatal mortality rate and the three environmental patterns which categorize the census blocks after the classification was performed using a standard Poisson regression model for count data after checking the assumption of dispersion. RESULTS: Based on geographic indicators, three environmental patterns were identified. We found environmental inequalities and social health inequalities in Nice metropolitan area. Moreover these inequalities are counterbalance by the close proximity of deprived census blocks to healthcare facilities related to mother and newborn. So therefore we demonstrate no environmental health inequalities related to infant and neonatal mortality. CONCLUSION: Examination of patterns of social, environmental and in relation with healthcare access is useful to identify census blocks with needs and their effects on health. Similar analyzes could be implemented and considered in other cities or related to other birth outcomes.

Review Article: Vulnerability to Heat-related Mortality: A Systematic Review, Meta-analysis, and Meta-regression Analysis.

BACKGROUND: Addressing vulnerability to heat-related mortality is a necessary step in the development of policies dictated by heat action plans. We aimed to provide a systematic assessment of the epidemiologic evidence regarding vulnerability to heat-related mortality. METHODS: Studies assessing the association between high ambient temperature or heat waves and mortality among different subgroups and published between January 1980 and August 2014 were selected. Estimates of association for all the included subgroups were extracted. We assessed the presence of heterogeneous effects between subgroups conducting Cochran Q tests. We conducted random effect meta-analyses of ratios of relative risks (RRR) for high ambient temperature studies. We performed random effects meta-regression analyses to investigate factors associated with the magnitude of the RRR. RESULTS: Sixty-one studies were included. Using the Cochran Q test, we consistently found evidence of vulnerability for the elderly ages >85 years. We found a pooled RRR of 0.99 (95% confidence interval [CI] = 0.97, 1.01) for male sex, 1.02 (95% CI = 1.01, 1.03) for age >65 years, 1.04 (95% CI = 1.02, 1.07) for ages >75 years, 1.03 (95% CI = 1.01, 1.05) for low individual socioeconomic status (SES), and 1.01 (95% CI = 0.99, 1.02) for low ecologic SES. CONCLUSIONS: We found strongest evidence of heat-related vulnerability for the elderly ages >65 and >75 years and low SES groups (at the individual level). Studies are needed to clarify if other subgroups (e.g., children, people living alone) are also vulnerable to heat to inform public health programs.

Air quality and social deprivation in four French metropolitan areas--a localized spatio-temporal environmental inequality analysis.

Several studies have documented that more deprived populations tend to live in areas characterized by higher levels of environmental pollution. Yet, time trends and geographic patterns of this disproportionate distribution of environmental burden remain poorly assessed, especially in Europe. We investigated the spatial and temporal relationship between ambient air nitrogen dioxide (NO2) concentrations and socioeconomic and demographic data in four French metropolitan areas (Lille in the North, Lyon in the center, Marseille in the South, and Paris) during two different time periods. The geographical unit used was the census block. The dependent variable was the NO2 annual average concentration (µg/m(3)) per census block, and the explanatory variables were a neighborhood deprivation index and socioeconomic and demographic data derived from the national census. Generalized additive models were used to account for spatial autocorrelation. We found that the strength and direction of the association between deprivation and NO2 estimates varied between cities. In Paris, census blocks with the higher social categories are exposed to higher mean concentrations of NO2. However, in Lille and Marseille, the most deprived census blocks are the most exposed to NO2. In Lyon, the census blocks in the middle social categories were more likely to have higher concentrations than in the lower social categories. Despite a general reduction in NO2 concentrations over the study period in the four metropolitan areas, we found contrasting results in the temporal trend of environmental inequalities. There is clear evidence of city-specific spatial and temporal environmental inequalities that relate to the historical socioeconomic make-up of the cities and its evolution. Hence, general statements about environmental and social inequalities can be made.

Chronic air pollution and social deprivation as modifiers of the association between high temperature and daily mortality.

BACKGROUND: Heat and air pollution are both associated with increases in mortality. However, the interactive effect of temperature and air pollution on mortality remains unsettled. Similarly, the relationship between air pollution, air temperature, and social deprivation has never been explored. METHODS: We used daily mortality data from 2004 to 2009, daily mean temperature variables and relative humidity, for Paris, France. Estimates of chronic exposure to air pollution and social deprivation at a small spatial scale were calculated and split into three strata. We developed a stratified Poisson regression models to assess daily temperature and mortality associations, and tested the heterogeneity of the regression coefficients of the different strata. Deaths due to ambient temperature were calculated from attributable fractions and mortality rates were estimated. RESULTS: We found that chronic air pollution exposure and social deprivation are effect modifiers of the association between daily temperature and mortality. We found a potential interactive effect between social deprivation and chronic exposure with regards to air pollution in the mortality-temperature relationship. CONCLUSION: Our results may have implications in considering chronically polluted areas as vulnerable in heat action plans and in the long-term measures to reduce the burden of heat stress especially in the context of climate change.

Maternal employment characteristics as a structural social determinant of breastfeeding after return to work in the European Region: a scoping review.

BACKGROUND: The European Region has the lowest rate of exclusive breastfeeding at 6 months worldwide. Improving work-related breastfeeding issues is important given that women may have difficulties combining work and breastfeeding, especially those in precarious working situations, which adds to their adversity. This scoping review overviews research on the maternal employment characteristics that support breastfeeding continuation after return to work in the European Region. METHODS: Studies published from 2013 to 2023 were collected from Scopus, PubMed, and PsycInfo. Quantitative and qualitative studies published in English or French that explored the association between maternal employment characteristics and any breastfeeding status, duration, or experience were included. Participants included were mothers of healthy children who continued breastfeeding after resuming work. The main determinants were work-related factors that can lead to socially differentiated working conditions, including type of employment (e.g., occupation, employed/self-employed status, type of contract, working time, occupational prestige), working conditions (e.g., work schedule, decision latitude, latitude to organize worktime), and work environment (e.g., occupational exposure, family-friendly workplace policy, social support). The geographic area encompassed countries included in the World Health Organization European Region. RESULTS: Of the 693 single studies retrieved and screened, 13 were included in the review. Eight studies focused on combining work and breastfeeding, while the others had a broader spectrum by investigating breastfeeding determinants. The represented countries were Spain (n = 4), France (n = 4), UK (n = 2), Ireland (n = 2), and the Netherlands (n = 1). Results highlighted the heterogeneity of measures, time frames, and fields of inquiry, thus revealing a lack of conceptual framework regarding the links between work, breastfeeding, and social health inequalities. Nonetheless, being self-employed, working in a non-manual profession with time flexibility, having lactation rooms at work, being supported by co-workers, and having a breastfeeding workplace policy were salient factors that supported breastfeeding in working mothers. CONCLUSIONS: Supporting working mothers who choose to breastfeed is important given the myriad of adverse factors faced by mothers and their children. These results advocate for targeted actions at the workplace such as time flexibility, breastfeeding facilities, and the promotion of breastfeeding-friendly policies.

A statistical procedure to create a neighborhood socioeconomic index for health inequalities analysis.

INTRODUCTION: In order to study social health inequalities, contextual (or ecologic) data may constitute an appropriate alternative to individual socioeconomic characteristics. Indices can be used to summarize the multiple dimensions of the neighborhood socioeconomic status. This work proposes a statistical procedure to create a neighborhood socioeconomic index. METHODS: The study setting is composed of three French urban areas. Socioeconomic data at the census block scale come from the 1999 census. Successive principal components analyses are used to select variables and create the index. Both metropolitan area-specific and global indices are tested and compared. Socioeconomic categories are drawn with hierarchical clustering as a reference to determine "optimal" thresholds able to create categories along a one-dimensional index. RESULTS: Among the twenty variables finally selected in the index, 15 are common to the three metropolitan areas. The index explains at least 57% of the variance of these variables in each metropolitan area, with a contribution of more than 80% of the 15 common variables. CONCLUSIONS: The proposed procedure is statistically justified and robust. It can be applied to multiple geographical areas or socioeconomic variables and provides meaningful information to public health bodies. We highlight the importance of the classification method. We propose an R package in order to use this procedure.

An exploratory spatial analysis to assess the relationship between deprivation, noise and infant mortality: an ecological study.

BACKGROUND: Few studies have explored how noise might contribute to social health inequalities, and even fewer have considered infant mortality or its risk factors as the health event of interest.In this paper, we investigate the impact of neighbourhood characteristics - both socio-economic status and ambient noise levels - on the spatial distribution of infant mortality in the Lyon metropolitan area, in France. METHODS: All infant deaths (n = 715) occurring between 2000 and 2009 were geocoded at census block level. Each census block was assigned multi-component socio-economic characteristics and Lden levels, which measure exposure to noise. Using a spatial-scan statistic, we examined whether there were significant clusters of high risk of infant mortality according to neighbourhood characteristics. RESULTS: Our results highlight the fact that infant mortality is non-randomly distributed spatially, with clusters of high risk in the south-east of the Lyon metropolitan area (RR = 1.44; p = 0.09). After adjustments for socio-economic characteristics and noise levels, this cluster disappears or shifts according to in line with different scenarios, suggesting that noise and socio-economic characteristics can partially explain the spatial distribution of infant mortality. CONCLUSION: Our findings show that noise does have an impact on the spatial distribution of mortality after adjustments for socio-economic characteristics. A link between noise and infant mortality seems plausible in view of the three hypothetical, non-exclusive, pathways we propose in our conceptual framework: (i) a psychological pathway, (ii) a physiological disruption process and (iii) an unhealthy behaviours pathway. The lack of studies makes it is difficult to compare our findings with others. They require further research for confirmation and interpretation.

Green space, social inequalities and neonatal mortality in France.

BACKGROUND: Few studies have considered using environmental amenities to explain social health inequalities.Nevertheless, Green spaces that promote good health may have an effect on socioeconomic health inequalities. In developed countries, there is considerable evidence that green spaces have a beneficial effect on the health of urban populations and recent studies suggest they can have a positive effect on pregnancy outcomes. To investigate the relationship between green spaces and the spatial distribution of infant mortality taking account neighborhood deprivation levels. METHODS: The study took place in Lyon metropolitan area, France. All infant deaths that occurred between 2000 and 2009 were geocoded at census block level. Each census block was assigned greenness and socioeconomic deprivation levels. The spatial-scan statistic was used to identify high risk cluster of infant mortality according to these neighborhood characteristics. RESULTS: The spatial distribution of infant mortality was not random with a high risk cluster in the south east of the Lyon metropolitan area (p<0.003). This cluster disappeared (p=0.12) after adjustment for greenness level and socioeconomic deprivation, suggesting that these factors explain part of the spatial distribution of infant mortality. These results are discussed using a conceptual framework with 3 hypothetical pathways by which green spaces may have a beneficial effect on adverse pregnancy outcomes: (i) a psychological pathway, (ii) a physiological disruption process and (iii) an environmental pathway. CONCLUSIONS: These results add some evidence to the hypothesis that there is a relationship between access to green spaces and pregnancy outcomes but further research is required to confirm this.

A new air quality perception scale for global assessment of air pollution health effects.

Despite improvements in air quality in developed countries, air pollution remains a major public health issue. To fully assess the health impact, we must consider that air pollution exposure has both physical and psychological effects; this latter dimension, less documented, is more difficult to measure and subjective indicators constitute an appropriate alternative. In this context, this work presents the methodological development of a new scale to measure the perception of air quality, useful as an exposure or risk appraisal metric in public health contexts. On the basis of the responses from 2,522 subjects in eight French cities, psychometric methods are used to construct the scale from 22 items that assess risk perception (anxiety about health and quality of life) and the extent to which air pollution is a nuisance (sensorial perception and symptoms). The scale is robust, reproducible, and discriminates between subpopulations more susceptible to poor air pollution perception. The individual risk factors of poor air pollution perception are coherent with those findings in the risk perception literature. Perception of air pollution by the general public is a key issue in the development of comprehensive risk assessment studies as well as in air pollution risk management and policy. This study offers a useful new tool to measure such efforts and to help set priorities for air quality improvements in combination with air quality measurements.

Health Equity Impact Assessment Related to Air Pollution Reduction.

Despite considerable improvements in terms of prevention, management, and regulation, air pollution remains a leading environmental health issue worldwide [...].