Role of cardiovascular health factors in mediating social inequalities in the incidence of dementia in the UK: two prospective, population-based cohort studies.

Background: The contribution of modifiable risk factors to social inequalities in dementia, observed in longitudinal studies, remains unclear. We aimed to quantify the role of cardiovascular health factors, assessed using Life's Essential 8 (LE8) score, in mediating social inequalities in incidence of dementia and, for comparison, in incidence of stroke, coronary heart disease, and mortality. Methods: In this prospective, population-based cohort study, we collected data from the UK Whitehall II Study and UK Biobank databases. Participants were included if data were available on SEP, outcomes and LE8 (smoking, physical activity, diet, body mass index, blood pressure, fasting blood glucose, lipid levels, sleep duration). The primary outcome was incident dementia and secondary outcomes were stroke, coronary heart disease, and mortality. Outcomes were derived from electronic healthcare records. Socioeconomic position (SEP) was measured by occupation in Whitehall II and education in UK Biobank. Counterfactual mediation analysis was used to quantify the extent to which LE8 score explained the associations of SEP with all outcomes. Analyses involved Cox regression, accelerated failure time models, and linear regression; and were adjusted for age, sex, and ethnicity. Findings: Between 10.09.1985 and 29.03.1988, a total of 9688 participants (mean age ± SD 44.9 ± 6.0; 67% men) from the Whitehall II study, and between 19.12.2006 and 01.10.2010, 278,215 participants (mean age ± SD 56.0 ± 8.1; 47% men) from the UK Biobank were included. There were 606 and 4649 incident dementia cases over a median (interquartile range) follow-up of 31.7 (31.1-32.7) and 13.5 (12.7-14.1) years respectively in Whitehall II and UK Biobank. In Whitehall II, the hazard ratio was 1.85 [95% CI 1.42, 2.32] for the total effect of SEP on dementia and 1.20 [1.12, 1.28] for the indirect effect via the LE8, the proportion mediated being 36%. In UK Biobank, the total effect of SEP on dementia was 1.65 [1.54, 1.78]; the indirect effect was 1.11 [1.09, 1.12], and the proportion mediated was 24%. The proportions mediated for stroke, coronary heart disease, and mortality were higher, ranging between 34% and 63% in Whitehall II and between 36% and 50% in UK Biobank. Interpretation: In two well-characterised cohort studies, up to one third of the social inequalities in incidence of dementia was attributable to cardiovascular health factors. Promotion of cardiovascular health in midlife may contribute to reducing social inequalities in risk of dementia, in addition to cardiovascular diseases and all-cause mortality. This study used adult measures of SEP, further research is warranted using lifecourse measures of SEP. Funding: NIH (RF1AG062553).

Measures of fragmentation of rest activity patterns: mathematical properties and interpretability based on accelerometer real life data.

Accelerometers, devices that measure body movements, have become valuable tools for studying the fragmentation of rest-activity patterns, a core circadian rhythm dimension, using metrics such as inter-daily stability (IS), intradaily variability (IV), transition probability (TP), and self-similarity parameter (named α). However, their use remains mainly empirical. Therefore, we investigated the mathematical properties and interpretability of rest-activity fragmentation metrics by providing mathematical proofs for the ranges of IS and IV, proposing maximum likelihood and Bayesian estimators for TP, introducing the activity balance index metric, an adaptation of α, and describing distributions of these metrics in real-life setting. Analysis of accelerometer data from 2,859 individuals (age=60-83 years, 21.1% women) from the Whitehall II cohort (UK) shows modest correlations between the metrics, except for ABI and α. Sociodemographic (age, sex, education, employment status) and clinical (body mass index (BMI), and number of morbidities) factors were associated with these metrics, with differences observed according to metrics. For example, a difference of 5 units in BMI was associated with all metrics (differences ranging between -0.261 (95% CI -0.302, -0.220) to 0.228 (0.18, 0.268) for standardised TP rest to activity during the awake period and TP activity to rest during the awake period, respectively). These results reinforce the value of these rest-activity fragmentation metrics in epidemiological and clinical studies to examine their role for health. This paper expands on a set of methods that have previously demonstrated empirical value, improves the theoretical foundation for these methods, and evaluates their empirical worth in a large dataset.

[Femicide in borderline Brazilian municipalities]. / Feminicídios em municípios de fronteira no Brasil.

This quantitative study analyzed female deaths due to agression in the 122 municipalities that are part of the Brazilian borderline. Borders are territories of conquest, conflict and violence and Brazilian border cities have high rates of male and female homicides. This study aimed to quantify female deaths from agression in border towns and identify factors associated with these deaths. Female deaths from agression are considered an indirect indicator of femicides and were the outcome of a multivariate analysis using the Poisson model. In the 2000-2015 period, 1,384 women died from agression, which represent a mean rate of 5.8/100,000 women; of these, 181 were in indigenous women (13%). We observed the pattern of distribution of these deaths, which occurred predominantly in the Central Arch, larger municipalities, and where there are more migrants. There is heterogeneity in the rates of violence in the municipalities that are part of the borderline, indicating a close look at the most populous places, with a high presence of migration and female deaths due to agression. However, we should also pay attention to the small municipalities where there has been a change in pattern, with an abrupt increase in the number of female murders.

Estudo quantitativo que analisou as mortes de mulheres por agressão nos 122 municípios que fazem parte da linha de fronteira brasileira. As fronteiras são territórios de conquista, conflito e violência, e nos municípios de fronteira brasileiros há taxas elevadas de homicídios masculinos e femininos. O objetivo do estudo foi quantificar as mortes femininas por agressão nesses municípios e identificar fatores a elas associados. As mortes femininas por agressão, consideradas um indicador indireto dos feminicídios, foram o desfecho de uma análise multivariada utilizando o modelo de Poisson. No período de 2000 a 2015, ocorreram 1.384 mortes de mulheres por agressão, representando uma taxa média de 5,8/100.000 mulheres; dessas, 181 eram indígenas (13%). Observou-se o padrão de distribuição desses óbitos, que aconteceram predominantemente no Arco Central, em municípios maiores e onde há mais migrantes. Há uma heterogeneidade nas taxas de violência nos municípios que fazem parte da linha de fronteira, indicando um olhar atento aos locais mais populosos, com alta presença de migração e taxas elevadas de mortes femininas por agressão. Mas também se recomenda atentar para municípios pequenos em que houve mudança de padrão, com elevação abrupta no número de assassinatos de mulheres.

Feminicídios em municípios de fronteira no Brasil / Femicide in borderline Brazilian municipalities

Resumo Estudo quantitativo que analisou as mortes de mulheres por agressão nos 122 municípios que fazem parte da linha de fronteira brasileira. As fronteiras são territórios de conquista, conflito e violência, e nos municípios de fronteira brasileiros há taxas elevadas de homicídios masculinos e femininos. O objetivo do estudo foi quantificar as mortes femininas por agressão nesses municípios e identificar fatores a elas associados. As mortes femininas por agressão, consideradas um indicador indireto dos feminicídios, foram o desfecho de uma análise multivariada utilizando o modelo de Poisson. No período de 2000 a 2015, ocorreram 1.384 mortes de mulheres por agressão, representando uma taxa média de 5,8/100.000 mulheres; dessas, 181 eram indígenas (13%). Observou-se o padrão de distribuição desses óbitos, que aconteceram predominantemente no Arco Central, em municípios maiores e onde há mais migrantes. Há uma heterogeneidade nas taxas de violência nos municípios que fazem parte da linha de fronteira, indicando um olhar atento aos locais mais populosos, com alta presença de migração e taxas elevadas de mortes femininas por agressão. Mas também se recomenda atentar para municípios pequenos em que houve mudança de padrão, com elevação abrupta no número de assassinatos de mulheres.

Abstract This quantitative study analyzed female deaths due to agression in the 122 municipalities that are part of the Brazilian borderline. Borders are territories of conquest, conflict and violence and Brazilian border cities have high rates of male and female homicides. This study aimed to quantify female deaths from agression in border towns and identify factors associated with these deaths. Female deaths from agression are considered an indirect indicator of femicides and were the outcome of a multivariate analysis using the Poisson model. In the 2000-2015 period, 1,384 women died from agression, which represent a mean rate of 5.8/100,000 women; of these, 181 were in indigenous women (13%). We observed the pattern of distribution of these deaths, which occurred predominantly in the Central Arch, larger municipalities, and where there are more migrants. There is heterogeneity in the rates of violence in the municipalities that are part of the borderline, indicating a close look at the most populous places, with a high presence of migration and female deaths due to agression. However, we should also pay attention to the small municipalities where there has been a change in pattern, with an abrupt increase in the number of female murders.

Femicides: a study in Brazilian state capital cities and large municipalities. / Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional.

This study analyses the relationship between femicides and indicators of socio-economic condition, demography, access to communications, and health situation, in Brazilian state capitals and large-population municipalities. It is an ecological study using the standardized mean coefficient of female mortality due to aggression as a marker for femicide in the years 2007-09 and 2011-13. The Pearson Correlation test was used for the statistical analysis between the outcome and 17 independent variables, and those that were statistically significant (p < 0.05) were introduced into a multivariate linear regression model, using backward elimination. In the first three-year period the average rate of femicide was 4.5 deaths per 100,000 women, and in the second period it was 4.9/100,000. Poverty (ß = -0.330; p = 0.006), Pentecostalism (ß = 0.237; p = 0.002) and male mortality by aggression (ß = 0.841; p = 0.000) were associated with femicides. The negative association between poverty and feminine deaths indicates a paradoxical relationship, in that women who die in the richer regions are mostly poor. A relationship was also found between gender violence, fundamentalist religious beliefs, and urban violence.

Feminicídios: estudo em capitais e municípios brasileiros de grande porte populacional / Femicides: a study in Brazilian state capital cities and large municipalities

Resumo Este estudo objetiva analisar a relação entre feminicídios e indicadores socioeconômicos, demográficos, de acesso e saúde em capitais e municípios brasileiros de grande porte populacional. Trata-se de um estudo ecológico que utilizou o coeficiente médio padronizado da mortalidade feminina por agressão como marcador de feminicídio nos triênios de 2007-2009 e 2011-2013. Para a análise estatística foi utilizado o teste de Correlação de Pearson entre o desfecho e 17 variáveis independentes, e as que apresentaram significância estatística (p < 0,05) foram introduzidas em um modelo de regressão linear multivariada, método Backward. No primeiro triênio a taxa média de feminicídio foi de 4,5 óbitos por 100 mil mulheres, e no segundo período foi de 4,9/100 mil. Pobreza (β = -0,330; p = 0,006), pentecostalismo (β = 0,237; p = 0,002) e mortalidade masculina por agressão (β = 0,841; p = 0,000) estiveram associados aos feminicídios. A associação negativa entre pobreza e mortes femininas indica uma relação paradoxal, na medida em que as mulheres que morrem nas regiões mais ricas são pobres em sua maioria. Ainda, encontrou-se relação entre violência de gênero, fundamentalismos e violência urbana.

Abstract This study analyses the relationship between femicides and indicators of socio-economic condition, demography, access to communications, and health situation, in Brazilian state capitals and large-population municipalities. It is an ecological study using the standardized mean coefficient of female mortality due to aggression as a marker for femicide in the years 2007-09 and 2011-13. The Pearson Correlation test was used for the statistical analysis between the outcome and 17 independent variables, and those that were statistically significant (p < 0.05) were introduced into a multivariate linear regression model, using backward elimination. In the first three-year period the average rate of femicide was 4.5 deaths per 100,000 women, and in the second period it was 4.9/100,000. Poverty (β = -0.330; p = 0.006), Pentecostalism (β = 0.237; p = 0.002) and male mortality by aggression (β = 0.841; p = 0.000) were associated with femicides. The negative association between poverty and feminine deaths indicates a paradoxical relationship, in that women who die in the richer regions are mostly poor. A relationship was also found between gender violence, fundamentalist religious beliefs, and urban violence.

Equidade na atenção à saúde de mulheres no Haiti / Health equity for women in Haiti

Objetivo. Descrever a atenção básica em saúde prestada às mulheres no Haiti e avaliar a equidade da atenção. Métodos. Neste estudo transversal, 114 mulheres atendidas na atenção básica nos 10 departamentos de saúde do país foram entrevistadas. Para analisar a equidade, foram utilizados dois grupos de indicadores: acesso (tempo de caminhada para chegar aos serviços, tempo de espera na fila de consultas e necessidade de pagamento) e qualidade (conhecer o nome do prestador de serviços, tempo de consulta e discriminação). Pagamento e preconceito foram escolhidos como desfechos respectivamente para acesso e qualidade da atenção. Resultados. A maioria das mulheres tinha menos de 30 anos (59,0%), era negra (92,1%) e migrante (63,2%); apenas 21,3% souberam informar a renda familiar e 47,4% eram alfabetizadas. A maioria das consultas foi realizada em menos de 10 minutos (68,3%). O nome do profissional que prestou o serviço não era conhecido por 72,7% das mulheres. As consultas foram pagas por 63,4%, especialmente na região Sul (P = 0,016). Ainda, as mulheres no Sul levaram mais tempo para chegar aos serviços. Aquelas que não pagaram tiveram consultas com menor duração (P < 0,001). A discriminação nos serviços de saúde foi detectada em 28,9% das entrevistadas. Conclusões. Esta pesquisa mostrou dificuldades no acesso e discriminação na atenção primária em saúde prestada a mulheres no Haiti e indica o gênero como uma categoria de análise importante para avaliar a equidade nos serviços de saúde.

Objective. To describe primary health care provided to women in Haiti and evaluate equity in the care provided to this group. Methods. In this cross-sectional study, 114 women receiving primary health care services in the country’s 10 health departments were interviewed. Two groups of indicators were used for analysis of equity: access indicators (walking time to reach services, waiting time, and need to pay for the service) and quality (knowing the name of the healthcare provider, length of the consultation, and discrimination). Payment and discrimination were used as outcomes for access and quality, respectively. Results. Most women were younger than 30 years of age (59.0%), black (92.1%), and migrants (63.2%). Family income was known by only 21.3%, and 47,4% were literate. Most consultations lasted less than 10 minutes (68.3%). The provider’s name was not known by 72.7% of the women interviewed. Consultations were paid by 63.4%, especially in the South (P = 0.016). Also, women in the South spent more time walking to reach health services. Those who did not pay had shorter consultations (P < 0.001). Finally, discrimination was detected in 28.9% of the women interviewed. Conclusions. This research revealed difficulties in the access to and discrimination in the care provided to women in Haiti, and suggests that gender is an important category of analysis to evaluate health equity.

[Health equity for women in Haiti]. / Equidade na atenção à saúde de mulheres no Haiti.

OBJECTIVE: To describe primary health care provided to women in Haiti and evaluate equity in the care provided to this group. METHODS: In this cross-sectional study, 114 women receiving primary health care services in the country's 10 health departments were interviewed. Two groups of indicators were used for analysis of equity: access indicators (walking time to reach services, waiting time, and need to pay for the service) and quality (knowing the name of the healthcare provider, length of the consultation, and discrimination). Payment and discrimination were used as outcomes for access and quality, respectively. RESULTS: Most women were younger than 30 years of age (59.0%), black (92.1%), and migrants (63.2%). Family income was known by only 21.3%, and 47,4% were literate. Most consultations lasted less than 10 minutes (68.3%). The provider's name was not known by 72.7% of the women interviewed. Consultations were paid by 63.4%, especially in the South (P = 0.016). Also, women in the South spent more time walking to reach health services. Those who did not pay had shorter consultations (P < 0.001). Finally, discrimination was detected in 28.9% of the women interviewed. CONCLUSIONS: This research revealed difficulties in the access to and discrimination in the care provided to women in Haiti, and suggests that gender is an important category of analysis to evaluate health equity.

Equidade na atenção à saúde de mulheres no Haiti / Health equity for women in Haiti

RESUMO Objetivo Descrever a atenção básica em saúde prestada às mulheres no Haiti e avaliar a equidade da atenção. Métodos Neste estudo transversal, 114 mulheres atendidas na atenção básica nos 10 departamentos de saúde do país foram entrevistadas. Para analisar a equidade, foram utilizados dois grupos de indicadores: acesso (tempo de caminhada para chegar aos serviços, tempo de espera na fila de consultas e necessidade de pagamento) e qualidade (conhecer o nome do prestador de serviços, tempo de consulta e discriminação). Pagamento e preconceito foram escolhidos como desfechos respectivamente para acesso e qualidade da atenção. Resultados A maioria das mulheres tinha menos de 30 anos (59,0%), era negra (92,1%) e migrante (63,2%); apenas 21,3% souberam informar a renda familiar e 47,4% eram alfabetizadas. A maioria das consultas foi realizada em menos de 10 minutos (68,3%). O nome do profissional que prestou o serviço não era conhecido por 72,7% das mulheres. As consultas foram pagas por 63,4%, especialmente na região Sul (P = 0,016). Ainda, as mulheres no Sul levaram mais tempo para chegar aos serviços. Aquelas que não pagaram tiveram consultas com menor duração (P < 0,001). A discriminação nos serviços de saúde foi detectada em 28,9% das entrevistadas. Conclusões Esta pesquisa mostrou dificuldades no acesso e discriminação na atenção primária em saúde prestada a mulheres no Haiti e indica o gênero como uma categoria de análise importante para avaliar a equidade nos serviços de saúde.

ABSTRACT Objective To describe primary health care provided to women in Haiti and evaluate equity in the care provided to this group. Methods In this cross-sectional study, 114 women receiving primary health care services in the country's 10 health departments were interviewed. Two groups of indicators were used for analysis of equity: access indicators (walking time to reach services, waiting time, and need to pay for the service) and quality (knowing the name of the healthcare provider, length of the consultation, and discrimination). Payment and discrimination were used as outcomes for access and quality, respectively. Results Most women were younger than 30 years of age (59.0%), black (92.1%), and migrants (63.2%). Family income was known by only 21.3%, and 47,4% were literate. Most consultations lasted less than 10 minutes (68.3%). The provider's name was not known by 72.7% of the women interviewed. Consultations were paid by 63.4%, especially in the South (P = 0.016). Also, women in the South spent more time walking to reach health services. Those who did not pay had shorter consultations (P < 0.001). Finally, discrimination was detected in 28.9% of the women interviewed. Conclusions This research revealed difficulties in the access to and discrimination in the care provided to women in Haiti, and suggests that gender is an important category of analysis to evaluate health equity.