Urban Areas Research Articles

Escalation to Biologics After Methotrexate Among US Veterans with Rheumatoid Arthritis Grouped by Rural Versus Urban Areas.

Racial and ethnic disparities in rheumatoid arthritis (RA) outcomes are well recognized. However, whether disparities in RA treatment selection and outcomes differ by urban versus rural residence, independent of race, have not been studied. Our objective was to evaluate whether biologic disease modifying anti-rheumatic drugs (bDMARD) initiation after methotrexate use differs by rural versus urban residence among Veterans with RA. In this retrospective cohort study utilizing national U.S. Veterans Affairs databases, we identified adult patients with RA based on presence of diagnostic codes and DMARD use. We included patients receiving an initial prescription of methotrexate (index date) between 2005 and 2014, with data through 2016 used for follow-up. Urban-rural status was categorized using the Veteran Health Administration's Urban/Rural classification. Our primary outcome of interest was time to biologic initiation within two years of starting methotrexate. Multivariable Cox proportional hazards models were conducted adjusting for demographics, comorbidities, and rheumatoid factor or anti-CCP positivity. Among 17,395 veterans with RA (88% male, 42% with rural residence) fulfilling eligibility criteria, 3,259 (19%) initiated a biologic within the first two years of follow up. In multivariable models, residence in an urban area was associated with a statistically significant higher biologic use compared to rural areas (adjusted hazard ratio (aHR) 1.10, 95% CI 1.02-1.18). Our study found only modest differences in initiation of biologic therapies among rural versus urban residing Veterans with RA in the VA healthcare system. These findings suggest that disparities are not easily explained by rurality within the VA healthcare system.

Understanding influences of cervical screening attendance among women of low socio-economic position

Abstract Women of lower socio-economic position (SEP) have a higher incidence of cervical cancer and lower uptake of cervical screening. The Integrated Screening Action Model (I-SAM) is a behaviour model aimed to guide intervention development that considers how individuals engage with screening through their environment, capability, opportunity, and motivation. The I-SAM can be used to understand behaviour of cervical screening. We aimed to understand perceptions and awareness of HPV screening among women aged 25-65 of low SEP living in an urban area in Ireland. Semi-structured interviews were conducted with women who self-reported regular or irregular screening attendance, no university-level education, low-income employment or not working, aged 25-65 and living in Dublin. Participants were recruited via community organisations. Data were analysed using I-SAM in a framework analysis to map barriers and enablers of attendance of regular and irregular attenders. Of the seventeen women interviewed, seven attended screening irregularly. Participants thought they had opportunity to attend when they were reminded and supported to attend by peers and healthcare professionals. Participants wanted to promote screening in the community and to normalise conversations on sexual health. Participants felt fear of cancer was a driver and deterrent to attend screening due to cancer running in the family, past health issues and abnormal cell treatments, and wanting to be there for their family. Few were aware of HPV or the switch to HPV screening. Irregular attenders were unsure how to book or find information on screening. Campaigns should involve communities that are less likely to attend to improve visibility of screening. Healthcare professionals could opportunistically promote HPV screening in primary care and community settings. Campaigns should be aimed at improving literacy of HPV screening, address concerns of cancer risk and support navigation through screening. Key messages • Understanding of HPV cervical screening is limited and campaigns are needed to improve awareness and literacy. • Public health campaigns should engage with communities to promote screening via community groups and healthcare professionals.

Urban Canopy Parameters’ Computation and Evaluation in an Indian Context Using Multi-Platform Remote Sensing Data

Urban Canopy Parameters (UCPs) are crucial for urban microclimate modeling; however, the scarce availability of precise UCP data in developing regions limits their application for urban climates. This study investigated the use of multi-platform remote sensing data viz. very high-resolution satellite (VHRS) optical stereo and Unmanned Aerial Vehicle (UAV) datasets for the computation of UCPs in high-density urban scenarios in India, with varied development characteristics. The results demonstrated high accuracy in terms of building height and footprint extraction from both datasets, key inputs for UCP computation. However, UCPs from UAV data have displayed relatively high accuracy for building footprints (86%), building height (RMSE ~ 0.05 m), and land use/land cover classification (90%). Performance evaluation of computed UCPs against a 3D reference geodatabase showed high prediction accuracy for most UCPs, with overall biases, mean absolute error, and root-mean-square error values significantly better than 1 m, with strong correlation (0.8–0.9). It was concluded that VHRS optical stereo and UAV datasets offer a secure, reliable, and accurate solution for UCP computation in urban areas, particularly in developing regions. These findings have significant implications for urban climate research and the sustainable development of rapidly urbanizing areas facing resource and policy constraints.

A Comparative Study on Anemia, Gestational Diabetes and Gestational Hypertension during pregnancy in Rural, Semi Urban and Urban Hospitals in Bangladesh

Most of the women in developing countries undergo health problems in full or part of the pregnancy period. Major complications of pregnancy are anemia, gestational hypertension, and Gestational Diabetes. The objective of this study was to compare the prevalence of anemia, gestational hypertension, and Gestational Diabetes among antenatal women in rural, semi-urban, and urban hospitals. The study was conducted among 384 pregnant mothers who attended for ANC in OPD of Gonosashasthaya Samaj Vittik Medical College Hospital (Savar) , Gonosasthaya Nogor Hospital, (Dhanmondi), Sub-center of Gonosasthaya Kendro (Shimulia, Panisail, Barobaria, Delduwar, Shripur ) from December 2021 to November 2022 by consecutive sampling. The age range of the patients was 18 to 40 years. Mean age was 24.74 years. In this study majority of population 169 (44%) were in age group 18 - 22 years. Most of the pregnant women 291(76%) were housewives, lived in Nuclear families 253(66%) and the maximum population were from lower middle 134 (35%) socio-economic condition. A significant number of pregnant mother ,98(26%) were anemic, 38(10%) had GDM and only 34(9%) were gestational hypertension. Anemia is comparatively more in rural and semi-urban than urban. GDM and gestational hypertension is more in urban areas than rural and semi urban followed by 14(11%) and 20(16%) respectively. Special attention of policy makers, health professional, public health researchers, and the community is required on this regards. So early diagnosis and treatment is required to avoid long-term health problems of the mother and her offspring. EWMCJ Vol. 12, No. 1&2, January-July 2024: 9-13

Diabetes mellitus EU comorbidity index: using data from EHIS 2019 and GBD disability weights

Abstract Background Individuals with diabetes mellitus (DM) exhibit several of comorbidity burdens, with lower perceived quality of life also being a factor. Literature on the impact of DM is available, including studies on the index devised by (A. Andreella et al., 2023) for the assessment of comorbidities of health conditions. This study aims to adapt and validate this index for use as a standardized DM comorbidity index within the EU. Methods A cross-sectional study was carried out using microdata from the European Health Interview Survey (EHIS) 2019. The study included adults aged 25 years or older who reported having DM (n = 20,042) from 27 EU member states. Comorbidity index was calculated to assess the comorbidity of having 9 non-communicable diseases using disability weights obtained from the Global Burden of Disease 2019 and self-perceived general health using multiplicative approach. Beta regression analysis was used to evaluate the association between comorbidity index and several demographic, socioeconomic and lifestyle variables. Comorbidity index was calculated for each nomenclature of territorial units for statistics (NUTS 2). Results The comorbidity index ranged from 0.049 to 0.993. The results indicated that having a higher education and residing in urban areas were less likely to have a high comorbidity index. Being unemployed or in other employment statuses demonstrated a significant, positive association with the index. Income exhibited a gradual, positive association with each quintile, while consuming fruits and vegetables less than once a week was found to be associated with an increased index. The highest comorbidity index was observed in Calabria (Italy), followed by Lubuskie (Poland), and the lowest was observed in Antwerp (Belgium), followed by Övre Norrland (Sweden). Conclusions By identifying comorbidity burden, targeted interventions and regional-specific strategies can be implemented to improve the quality of life for individuals with DM. Key messages • Quantifying the burden of comorbidities allows understanding of health status of DM patients. • Comorbidity index shows geographic variation in the EU which contributes to tailored policy interventions.

Prevalence and sociodemographic correlates of COVID-19 vaccine acceptance in 20 European countries

Abstract Our study aimed to analyze the prevalence and socio-economic factors associated with COVID-19 vaccine hesitancy using individual data from representative national samples of 20 European countries. Data from round 10 of the European Social Survey, collected from May 2021 to September 2022, were analyzed. Prevalence (with a 95% confidence interval (CI 95%)) of participants’ intention to get vaccinated against COVID-19 was calculated. Crude differences in vaccine hesitancy proportions across sociodemographic strata were assessed using the Chi-square test. There were 31,771 adult participants (46.0 % men). The percentage of those hesitant (i.e. those who were not already vaccinated and intended not to be) toward the COVID-19 vaccine was 18.0% (CI 95% 17.6 - 18.4). Men and women were equally hesitant (18.0% vs. 18.0%, p = 0.93). There were differences between those under 40 (22.9%), adults between 40 and 59 (18.1%), and those over 60 (14.3%, p < 0.001). The unemployed had a higher proportion of hesitancy (32.9%) compared to the employed (17.4%), retirees (14.8%), and students (21.1%, p < 0.001). People living in rural areas have higher levels of hesitancy compared to those in urban areas (19.3% vs. 17.3%, p < 0.001). The estimates indicate that the highest prevalence of vaccine hesitancy was in Bulgaria (61.6%), Slovenia (40.4%) and Slovakia (30.7%), while Iceland (2.3%), Portugal (3.6%) and Italy (4.0%) had the lowest. Our study confirms high prevalence and high variability of hesitancy towards COVID-19 vaccines in Europe and identify groups for potential targeted interventions.

Noise inequalities and cardiovascular diseases in Bulgaria

Abstract Background Social determinants of health in the physical environment are among the social determinants that greatly impact population health. At very high levels, noise can cause permanent changes in a person’s psyche but, even at lower levels, it can cause stress and disorders. Global burden of diseases studies arrange noise on the second position among the environmental risk factors, related to sleep disturbance, cardiovascular effects etc. The study aims to analyse noise pollution in Bulgaria and measure its association with cardiovascular diseases. Methods National Statistical Institute and Eurostat data were used to analyse the noise pollution in Bulgaria. The 28 regions were compared according to the proportion of surveyed points above permissible limits and the death rates due to CVD, /2022/. Data were statistically processed with SPSS v.26. To establish the correlation, the Pearson coefficient was used. Results Data provided by Eurostat reveal that 9% of the total population suffers from noise but there is a very positive trend - from 17.7% /in 2005/ to 8.7% /in 2023/. The share of surveyed points above permissible limits shows a continuing trend of maintaining a high percentage - 71.80% /2011/ and 68.62%/2022/. The district comparison shows significant variations - Blagoevgrad -17.65% and Silistra, Kyustendil and Razgrad with shares above 80%. The study found that almost all districts with the highest share of surveyed points above permissible limits have higher levels of death rate due to CVD. The results of statistical data analysis show that there is a positive moderate linear correlation between the share of surveyed points above permissible limits and the death rate due to CVD - Pearson coefficient 0.423 (p = 0.025). Conclusions The study found a moderate correlation between noise pollution and the death rate due to cardiovascular disease. CVD have a multifactorial genesis, but reducing noise in urban areas would help prevent these diseases. Key messages • As a result of the performed analysis, it can be concluded that the investigated indicators determining the degree of discomfort during the daily period remained high in Bulgaria. • The established health inequalities between regions and the increasing mortality from CVD are one of the factors for the deteriorating level of public health in Bulgaria.

Novi Sad cultural stations as healthy buildings for wellbeing concept

Abstract Creating spaces for all citizens through the cultural stations project within the Novi Sad - European Capital of Culture 2022 has set an example of applying the concept of well-being which involves integrating various elements that support physical, mental, and social health. Cultural stations project in the city of Novi Sad is a concept supporting cultural programming, healthy food options, mental health support, accessibility and inclusivity, as well as community engagement. Social interaction in urban areas is vital for mental and emotional well-being, fostering a sense of belonging and community, diverse cultural programming that appeals to different groups, cultural activities such as art exhibitions, performances, workshops, and community events provide opportunities for creativity, learning, and social engagement, enhancing overall well-being. Access to cultural stations, spending time there has been linked to reduced stress, improved mood, and increased feelings of well-being within 7 neighborhoods of Novi Sad. This includes providing barrier-free access, accommodations for individuals with disabilities, and programming that is inclusive and welcoming to everyone. Participation of the local community in the design, programming, and management of cultural stations is also important. By integrating these principles into the design, programming, and management of cultural stations, Novi Sad creates vibrant, inclusive, and healthy spaces that contribute to the overall well-being of its residents and visitors. Cultural stations are located in different parts of the city in order to provide accessibility to all citizens. Their arrangement is in accordance with the recommendations of green construction and restoration, and the interior and surroundings foster respect for nature and nature-based solutions. Also, they are developing different content in line with culture, but also science, health and smart solutions as a tool for well-being.

Evaluating a Reference Model for SAV in Urban Areas

Previous work presented a reference model for shared autonomous vehicles in urban areas supported by a systematic literature review and topic modeling. The proposed reference model was then evaluated with two real-world demonstrations: the service provided by Waymo in Phoenix and another offered by Baidu in Beijing. In this paper, we present another evaluation based on a survey conducted with a group of potential stakeholders belonging to the mobility industry who were asked about their agreement with each of the concepts in the reference model. The resulting artifact is stronger and more reliable because it reflects the feedback of mobility experts.

Bias in Evaluating Trends of Thyroid Cancer Incidence between Rural and Urban Populations

Abstract Background Diagnosis of thyroid cancer is based on fine needle aspiration cytology of thyroid nodules, based on nodules’ sonographic appearance and size. The American Thyroid Association published new guidelines for management of thyroid nodules in 2009 and 2015, where in some cases, only follow-up of thyroid nodules without any other procedure is recommended. This may lead to a decrease in diagnosed thyroid cancer cases. We studied thyroid cancer trends in Israel between the Arab population who are more likely to be living in rural areas, and the Jewish population who predominantly living in urban areas, and assesses whether these guidelines were reflected in the trends. Methods Data on new thyroid cancer cases were retrieved for Jews and Arabs separately from the Israel National Cancer Registry. Trends in age standardized incidence rates between 1996-2019 were evaluated for the two population groups using joinpoint regression model. Population group was included in the regression models to compare the trends between the two groups. We also studied trends in treatment of thyroid cancer at Rambam Health Care Campus. Results In both populations, age standardized thyroid cancer incidence rate increased between 1996 and 2013. However, between 2013-2019, Annual Percentage Change continuously increased in Arabs, but decreased in Jews. In the hospital study, we found that the Arab patients were 30% more likely to have surgery for small tumors. Conclusions The decrease in thyroid cancer incidence in the Jewish population compared with the Arab population may be related to differences in implementing the 2009 guidelines, which do not recommend fine needle aspiration cytology for very small tumors. We have found evidence that these guidelines were not followed to the same extent among Arab community clinics. This may explain the persisting increasing trend among Arabs, and could be one of the possible explanations for the differences in trends between the two groups. Key messages • Updated Guidelines regarding thyroid cancer diagnosis may be differently implemented by rural and urban populations. • Trends assessment may be biased due to differences in guidelines implementation.

Remote Sensing of Residential Landscape Irrigation in Weber County, Utah: Implications for Water Conservation, Image Analysis, and Drone Applications

Analyzing irrigation patterns to promote efficient water use in urban areas is challenging. Analysis of irrigation by remote sensing (AIRS) combines multispectral aerial imagery, evapotranspiration data, and ground-truth measurements to overcome these challenges. We demonstrate AIRS on eight neighborhoods in Weber County, Utah, using 0.6 m National Agriculture Imagery Program (NAIP) and 0.07 m drone imagery, reference evapotranspiration (ET), and water use records. We calculate the difference between the actual and hypothetical water required for each parcel and compare water use over three time periods (2018, 2021, and 2023). We find that the quantity of overwatering, as well as the number of customers overwatering, is decreasing over time. AIRS provides repeatable estimates of irrigated area and irrigation demand that allow water utilities to track water user habits and landscape changes over time and, when controlling for other variables, see if water conservation efforts are effective. In terms of image analysis, we find that (1) both NAIP and drone imagery are sufficient to measure irrigated area in urban settings, (2) the selection of a threshold value for the normalized difference vegetation index (NDVI) becomes less critical for higher-resolution imagery, and (3) irrigated area measurement can be enhanced by combining NDVI with other tools such as building footprint extraction, object classification, and deep learning.

An Innovative Public Health Solution with European Features for an American Problem

Abstract Problem The Eastern Shore of Maryland is a beautiful region that boasts a multicultural community of 455,000 year-round residents. Despite its rural location, the coastal lifestyle attracts retirees, making it the state’s oldest population. Unfortunately, the region also has the highest socioeconomic disparities in the state, which creates difficulties in accessing healthcare. This is a significant public health issue that results in costly barriers to preventive care and timely, accounting for $320 billion in unnecessary healthcare spending. Description of the problem Maryland’s healthcare funding formulas favor larger health systems in urban areas, leading to health inequities. To address this, we propose an innovative scenario analysis model partially based on European public health approaches. This model will adjust funding formulas based on each region’s specific needs and challenges, promoting fairness and equity in healthcare funding. Results Adopting this population health management approach would have built-in efficiencies: In the United States, healthcare spending tends to be higher among underserved populations due to delayed care, access challenges, missed diagnoses, and limited access to the latest scientific advances as well as proper preventive services. Lessons The proposed scenario-based public health funding approach targeting the needs of the underserved population on the Eastern Shore of Maryland could yield significant positive health outcomes and health savings generating a ripple effect across the state, and perhaps even the country. The lessons learned in how other countries handle public health funding could lead to global collaboration. Key messages • Our approach aims to provide a practical solution to unnecessary healthcare spending. • We must adapt to the changing tides to stay on course.

Advancing urban health in Portugal: exploring liveability and its association with mental morbidity

Abstract Background As cities face challenges posed by urbanisation, it becomes essential to understand how city planning can contribute to protecting public health. In this study, we aimed to assess the liveability of different areas in Lisbon, Portugal, by developing a liveability index at the parish level. Secondly, we aimed to explore its association with hospitalisation due to mental disorders. Methods The liveability index was built based on the World Health Organisation’s Urban Health Index methodology. We obtained data on liveability related to housing, socio-economic conditions and access to services (e.g. healthcare) from the 2011 census and other open data sources for Lisbon’s parishes (n = 22). Data on hospital admissions due to mental disorders was sourced at the parish level from the national database for hospital morbidity for the period 2013-2016 and sex-age-standardised. Binomial negative regression was employed to estimate the association between the liveability index tertiles and observed hospital admissions. We used the expected number of hospitalisations as the offset variable and tested for spatial autocorrelation among the regression residuals. Results Our analysis showed that living in the most liveable parishes is associated with a significant decrease in the standardised admission ratio due to mental disorders, compared to living in the least liveable areas (Incidence Relative Ratio=0.643; 95% CI: 0.427, 0.967). We did not observe any geographical pattern in the regression residuals (Moran’s I= -0.035, p = 0.427). Conclusions Our findings show disparities in liveability among Lisbon’s parishes and identify a protective association between living in higher liveability areas and hospital admissions due to mental disorders. This work should prompt further studies concerning this subject to inform urban planning policies to improve liveability and equally reduce the risk of mental health-related harm within cities. Key messages • A spatial index to assess liveability in urban areas was developed. The association between the liveability of Lisbon’s parishes and hospital admissions due to mental disorders was explored. • We found a significant protective association between higher liveability and hospital admissions due to mental disorders. This work is relevant to inform the implementation of urban planning policies.

Regional deprivation and suicide mortality in Germany

Abstract Background Regional deprivation has been shown to be an important determinant of suicide risk. However, little is known about regional differences in suicide mortality in Germany. Methods Data from cause of death statistics (2015 to 2021) were analyzed. Regression analysis for data with negative binomial distribution was used to examine the association between the German Index of Multiple Deprivation 2015, covering 401 districts and district-free cities in Germany, and suicide mortality. Results The adjusted rate ratio for suicide in the most deprived deprivation area compared to the least deprived area was 1.18 (95% CI [1.72, 2.00]). A sensitivity analysis shows similar rate ratios for men (1.99 (95% CI [1.80, 2.18])) and women (1.69 (95% CI [1.49, 1.92])), but a higher rate ratio for rural areas (2.29 (95% CI [2.04, 2.57])) compared with urban areas (1.51 (95% CI [1.36, 1.68])). Conclusions The findings suggest that regional deprivation is associated with suicide mortality, and call for a more targeted approach to suicide prevention in deprived regions. Key messages • Study reveals higher suicide rates in deprived regions in Germany. • Study calls for tailored prevention strategies to address this disparity.

What Makes a Home.Evaluating a Novel Low Support Homeless Accommodation Model Using Co-design Methods

Abstract Background Homelessness is a global challenge, with a prevalence of 4%; the problem is underestimated due to limitations in data collection. In Ireland, 1% of the population, including children, adults, and families, experience homelessness due to housing shortages and systemic complexities. Homeless accommodation is defined as emergency and temporary; the wording is used interchangeably. The ETHOS typology of homelessness comprises two dimensions - housing-focused and support-focused. Supports range from high to low levels. This study evaluated an emergency housing accommodation with low support to assess its feasibility and impact. Methods Previous residents of an urban residential area with low support [introduced in August 2021] and key stakeholders, including policymakers and health and social care professionals, were invited to collaborate in a half-day co-design workshop [February 2024]. The workshop modified Stanford D’s five-stage design thinking processes to consider ‘How might we harness strengths and abilities to create a home and beyond’. Qualitative data were captured on flip charts, post-its, and via photographs over three rounds of activities following initial reflection regarding 1) identifying emerging challenges, 2) exploring potential solutions, and 3) considering resources for advocacy and success. Results Data analyses from 16 participants highlight 1)Personal insights: silence, freedom in decision-making, feeling overwhelmed, valuing independence and understanding accommodation transitions; 2)Organisational insights: developing and promoting independent skills, managing resident preferences and personalities, balancing regulations within emergency accommodation, and staff training. Space was critical in fostering therapeutic well-being and a sense of home environment. Conclusions Effective organisational structures are required to facilitate coherent transfers and transitions. Using co-design methods enabled real-world partnerships and engagement. Key messages • Homelessness is a significant public health challenge, and a model of low support emergency accommodation has value in supporting transition through and out of services. • Engaging with people with lived experience of homelessness is essential for developing supported accommodation models.

The very long-term risk of stroke after acute coronary syndrome and geographic differences. The ABC-10* study on heart disease

Abstract Background Little is known about the very long-term risk of stroke among acute coronary syndrome (ACS) survivors. Methods In this prospective study, we enrolled 535 ACS patients admitted to hospitals in three Italian provinces, discharged alive and followed for 24 years or death. The patient's residency was classified into three urban and three nearby rural areas. Results All patients completed the follow-up (6142 Perso-years). 85 (16%) patients suffered an acute stroke. Patients median age was 67 years, 70% were male, and 318 patients were residing in rural areas. Patients who had a stroke and those who had not shared most of the demographic and clinical characteristics. The incidence rate of overall stroke was 14/1000 person-year. Cox analyses showed older age (HR 3.13;95%CI 2.31-4.26), male gender (HR 1.88;95%CI 1.20-2.95), baseline diabetes (HR 2.25 95%CI 1.37-3.69), heart failure (HR 2.69;95%CI 1.71-4.24), and higher albumin/creatinine ratio (HR 1.75;95%CI 1.33-2.30) were all associated with an increased risk of stroke. while higher baseline eGFR, reperfusion, statin and beta-blockers treatment during follow-up were associated with a decreased risk; HR (0.55 (95%CI 0.42-0.72), 0.45(95%CI 0.29-0.71), 0.21(95%CI 0.13-0.34), and 0.37(95%CI 0.23-0.57), respectively). In the multivariate analysis, only older age (HR1.55;95%CI 1.08-2.21; p=0.02) was an independent predictor of stroke while statin treatment was independently associated with a lower risk (HR 0.35;95% CI 0.21-0.58; p<0.0001). However, all these variables did not predict the risk of stroke in competing risk regression analysis where death was treated as the competing event. A sub-analysis of the 43 patients who had a fatal stroke (FS) revealed 7/1000 person-year FS IR. The Cox regression and competing risk analyses of predictors of FS showed similar results. Interestingly, we observed an association between geographic areas of residence and the long-term FS risk as the risk increased going from rural to urban (HR 2.08;95%CI 1.14-3.80; p=0.02) areas and from north to middle and south provinces (HR 1.47;95%CI 1.00-2.15; p=0.04) in the univariate Cox regression analysis. Results kept true using multivariate Cox and Competing risk regression models. Conclusion This analysis reveals the significant urban-rural difference in the very long–term risk of fatal stroke among unselected ACS patients which highlights the importance of implementing a preventive policy based on area-specific knowledge.

Inequalities in healthy life expectancy and risk factors for poor health in small geographic areas

Abstract Background Reducing inequality in healthy life expectancy (HLE) is a UK government ambition and requires more detailed knowledge of interrelated morbidity and mortality risks at smaller areas than is routinely available. We assessed HLE and risk factors in small areas. Methods We used publicly available data to estimate HLE in 2011 and 2021 at birth and age 65 for males and females for 128 Middle layer Super Output Areas (MSOA) in Norfolk and Waveney, described the distribution using geospatial mapping, and analysed associations with risk factors using linear regression. Results Mean HLE at birth was 66.5 years (standard deviation 4.3; range 52.0 to 73.0) for men and 67.5 (3.9; 56.0 to 74.0) for women, and at age 65 was 10.9 years (1.8; 6.0 to 16.0) and 12.2 (1.9; 5.0 to 15.0) respectively in 2021. The range in HLE increased between 2011 and 2021 by 2.8 years for men and 1.6 years for women. HLE was usually lower and risks higher in urban and coastal areas. Lower HLE at area level was associated with lower weekly income, physical inactivity, air pollution, alcohol admissions, living alone as an older person and diet not meeting ‘5 a Day’. HLE at age 65 in 2021 increased by: 0.2 (95% CI 0.1,0.2) years for men and 0.2 (0.2,0.3) for women for each £10 rise in weekly net income after housing expenditure; 0.1 (0.1,0.2) years for men for each 10 fewer alcohol attributable hospital admissions per 100,000 admissions; 0.66 (0.31,1.00) years for men and 0.53 (0.15,0.91) years for women per 1 μg/m3 less 2.5 mm particulate matter concentration in air pollution; 0.6 (0.2,1.0) years for men and 0.6 (0.1,1.0) years for women for each 10% fewer people being physically inactive (multiple regression). Conclusions This innovative approach can be used to monitor risks and inform targeted public health interventions at a local level more relevant to local policy makers. Stronger public health surveillance systems are needed to accurately monitor a wider variety of local data on risks. Key messages • Healthy life expectancy at age 65 varies by over 10 years for men and women between different small geographic areas in an English county, alongside local variation in risk factors for poor health. • Lower HLE at area level was associated with lower weekly income, physical inactivity, air pollution, alcohol admissions, living alone as an older person and diet not meeting ‘5 a Day’.

Seroprevalence and associated factors of toxoplasmosis in female children and adolescents in Germany

Abstract Background Toxoplasmosis is a parasitic disease that causes a high burden of disease worldwide. Infections occur mainly through the consumption of undercooked meat or the ingestion of contaminated cat feces from the environment. In Germany, seroprevalence in adults is exceptionally high by international comparison (50%), which could be due to the frequent consumption of raw pork products. Comparable analyses for children and adolescents are missing but are needed to estimate the public health problem and to suggest countermeasures. Methods As part of the second wave of the representative German Health Interview and Examination Survey for Children and Adolescents (2014-2017), serum of 1,453 girls aged 3 to 17 years was tested for the presence of T. gondii IgG antibodies using enzyme linked fluorescence assay (ELFA). We calculated overall and stratified seroprevalence and used multivariable logistic regression models based on Directed Acyclic Graphs to identify associated factors. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) are being reported. Results Overall, 94 out of 1,453 girls tested positive for T. gondii resulting in a seroprevalence of 6.3% (95% CI: 4.7-8.0). With each year of life, the chance of being seropositive increased significantly by 1.2 (95% CI 1.1-1.3). A low social status (aOr 2.7; 95% CI 1.3-5.9) and living in rural (aOR 2.6; 95% CI 1.1-5.7) or urban (aOR 2.2; 95% CI 1.1-4.4) areas were found to be associated with seropositivity. No regional distribution patterns or differences between vegetarians and non-vegetarians were seen. Conclusions Six out of 100 girls become infected with T. gondii during the first 18 years of life. Independent risk factors identified in our study have also been associated with seropositivity in other countries. Meat consumption appears to have a reduced impact on the risk of infection in children and adolescents compared to adults, calling for different prevention strategies in this population. Key messages • Toxoplasmosis causes a high infection pressure for girls and young women in Germany. • Transmission pathways might differ between age groups with more environmentally associated infections in children and adolescents.

Did the COVID-19 Pandemic Affect Suicide Rates Differently in Urban and Rural South Korea?

Abstract Background The influence of the COVID-19 pandemic on suicide rates remains a subject of debate. Despite increases in suicidal ideation and attempts reported during the pandemic, several recent meta-analyses have not demonstrated corresponding rises in suicide rates. Given the potential for substantial regional and demographic variability in the psychological consequences of COVID-19-related restrictions, this study explores differential suicide rates in urban versus rural contexts within South Korea subsequent to the pandemic outbreak. Methods This investigation employed age-standardized suicide rates from two periods, 2015-2019 and 2020-2022, across 234 administrative divisions (152 urban, 82 rural). A difference-in-differences approach was utilized to evaluate the pandemic’s impact on suicide rates, segmented by urban and rural classifications. A linear regression model was developed to examine the interaction between location (urban/rural) and time period, controlled for annual variations, perceived stress, and health status within each locale. Results Analysis revealed higher suicide rates in rural areas compared to urban counterparts (β = 1.247, p = 0.003), although no significant changes were observed during the pandemic period itself (β=-0.425, p = 0.682). Furthermore, the interaction between urban/rural status and the pandemic period did not reach statistical significance (p = 0.367). Conclusions The findings indicate no significant contribution of the COVID-19 pandemic to increased suicide rates, irrespective of the urban or rural setting. Further research is warranted to dissect the impact of more direct socioeconomic factors on this dynamic. Key messages • There in no evidence of increased suicide rates during the COVID-19 pandemic in South Korea. • The impact of the COVID-19 pandemic on suicide rates did not significantly different between urban and rural areas.

Rurality and outcomes in prostate cancer: role of socioeconomic status and educational attainment

Abstract Background/Introduction Patients diagnosed with prostate cancer (PC) have a higher cardiovascular disease (CVD) prevalence and mortality risk. Rurality have been associated with up to 33% higher CVD risk and 44% higher all-cause mortality risk in patients with PC. Purpose Analyze the impact of rurality (from both patient and provider perspectives) on the development of adverse outcomes after a PC diagnosis according to socioeconomic and educational status. Methods We included men aged ≥66 with a new primary PC diagnosis (defined as ICD-10 = C61) from 2009-2017 from the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. The primary outcomes were CVD (comprising heart failure, atrial fibrillation, acute myocardial infarction, peripheral artery disease, and ischemic stroke), PC-specific mortality (PCsm), cardiovascular disease mortality (CVDm), and all-cause mortality. Patients living in areas with a population of <2,500 or <20,000, not adjacent to a metropolitan area, were considered to have a positive rural status. The provider status (metropolitan vs. non-metropolitan) was defined according to the 2013 National Center for Health Statistics' Urban-Rural Classification Scheme for Counties. Low socioeconomic status (SES) was defined according to Yost Index quintiles. Low educational status was defined according to percentiles of people >25 years old with less than a high school diploma. Multivariable Fine-Gray models, accounting for competing mortality/type of mortality, and Cox regression models were applied. Results We included 75,221 patients with PC (Picture 1), of which 1,828 were from rural areas and 362 were from rural areas with providers from non-metropolitan areas. Among patients from rural areas under the care of non-metropolitan providers, 82.6% had low SES (Yost Index ≤ 2). In this subgroup, patients from rural areas with non-metropolitan providers had 30% higher CVD risk (sHR 1.30; 95% CI 1.04-1.62) and 44% higher all-cause mortality risk (sHR 1.44; 95% CI 1.14-1.83; Picture 2) when compared to patients with low SES from urban or rural areas with providers from metropolitan areas. Additionally, within patients from rural areas with non-metropolitan providers, the median % of people with only high school diploma was 38.3 (IQR 36.2-40.9). Among those with low educational status (≤41% of high school county-rate), patients from rural areas with non-metropolitan providers had a 35% higher associated CVD risk (sHR 1.35; 95% CI 1.06-1.71), 54% higher associated CVDm risk (sHR 1.54; 95% CI 1.01-2.36), and a 32% higher associated all-cause mortality risk (sHR 1.32; 95% CI 1.04-1.66). Conclusion Patients with PC from rural areas with non-metropolitan providers have higher rates of low SES and low educational status and suffer from up to 54% higher associated risks of adverse outcomes, emphasizing the role of multiple domains of the Social Determinants of Health in health outcomes.