The association of long-term exposure to outdoor air pollution with all-cause GP visits and hospital admissions by ethnicity and country of birth in the United Kingdom

Funding: The work presented in this paper was funded by the Royal Society of Edinburgh (RSE) Saltire Early Career Fellowships grant (RSE Grant Reference Number: 1846).Background Air pollution is associated with poor health. Yet, more research is needed to reveal the association of long-term exposure to outdoor air pollution with less studied health outcomes like hospital admissions and general-practitioner (GP) visits and whether this association is stronger for ethnic minorities compared to the rest of population. This study investigates the association between air pollution and all-cause GP visits and hospital admissions by ethnicity in the United-Kingdom (UK). Methods We used individual-level longitudinal data from the “UK Household Longitudinal Study” including 46,442 adult individuals who provided 140,466 responses across five years (2015–2019). This data was linked to yearly concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) outdoor pollution using the Lower Super Output Area (LSOA) of residence for each individual. Multilevel mixed-effects ordered logistic models were used to assess the association between air pollution and all-cause GP visits and hospital admissions. Results We found higher odds of hospital admissions per 1 μg/m3 increase in annual concentrations of NO2 (OR = 1.008; 95%CI = 1.004–1.012), SO2 (OR = 1.048; 95%CI = 1.014–1.083), PM10 (OR = 1.011; 95%CI = 1.003–1.018), and PM2.5 (OR = 1.018; 95%CI = 1.007–1.029) pollutants. Higher odds of GP visits were also observed with increased exposure to NO2 (OR = 1.010; 95%CI = 1.006–1.014) and SO2 (OR = 1.114; 95%CI = 1.077–1.152) pollutants. The observed associations did not differ across ethnic groups, but by country of birth, they were more pronounced in individuals born outside UK than those born in UK. Conclusion This study supports an association between higher exposure to outdoor air pollution and increased all-cause hospital admissions and GP visits. Further longitudinal studies with longer follow-up time periods may be able to reveal more definite conclusions on the influence of ethnicity on the association between long-term outdoor air pollution and both hospital admissions and GP visits.Publisher PDFPeer reviewe

Air pollution reduces the individuals’ life satisfaction through health impairment

Funding: This paper was funded by the Royal Society of Edinburgh (RSE) Saltire Early Career Fellow- ships grant (RSE Reference Number: 1846).The impact of air pollution on individuals’ happiness and life satisfaction (LS), and its relationship to other factors became the focus of recent research. Though, the underlying mechanism of how air pollution impacts LS remains unclear. In this study, we examined the direct and indirect effect of air pollution on individuals’ LS through health mediation. We used longitudinal individual-level data from “Understanding-Society: the UK Household-Longitudinal Study” on 59,492 individuals with 347,377 repeated responses across 11 years (2009–2019) that was linked to yearly concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) pollution. Generalized structural equation models with multilevel ordered-logistic regression were used to examine the direct effect of air pollution on LS and the indirect effect from health impairment. Higher concentrations of NO2 (coefficient = 0.009, 95%CI = 0.007,0.012, p < 0.001), SO2 (coefficient = 0.025, 95%CI = 0.017,0.034, p < 0.001), PM10 (coefficient = 0.019, 95%CI = 0.013,0.025, p < 0.001), and PM2.5 (coefficient = 0.025, 95%CI = 0.017,0.033, p < 0.001) pollutants were associated with poorer health, while poorer health was associated with reduced LS (coefficient = -0.605, 95%CI = -0.614,-0.595, p < 0.001). Mediation path analysis showed that air pollution impacted individuals’ LS directly and indirectly. The percent of total effect mediated through health was 44.03% for NO2, 73.95% for SO2, 49.88% for PM10, and 45.42% for PM2.5 and the ratio of indirect to direct effect was 0.79 for NO2, 2.84 for SO2, 0.99 for PM10, and 0.83 for PM2.5. Health plays a major mediating role in the relationship between air pollution and LS. To alleviate the impact of air pollution on LS, future strategies should focus on health promotion besides reducing air pollution emissions.Publisher PDFPeer reviewe

Long-term exposure to air pollution and mortality in Scotland : a register-based individual-level longitudinal study

Funding: This study is funded by the St Leonard’s interdisciplinary PhD scholarship, School of Geography and Sustainable Development, and School of Medicine, University of St Andrews, Scotland, UK.Background Air pollution is associated with several adverse health outcomes. However, heterogeneity in the size of effect estimates between cohort studies for long-term exposures exist and pollutants like SO2 and mental/behavioural health outcomes are little studied. This study examines the association between long-term exposure to multiple ambient air pollutants and all-cause and cause-specific mortality from both physical and mental illnesses. Methods We used individual-level administrative data from the Scottish-Longitudinal-Study (SLS) on 202,237 individuals aged 17 and older, followed between 2002 and 2017. The SLS dataset was linked to annual concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) pollution at 1 km2 spatial resolution using the individuals’ residential postcode. We applied survival analysis to assess the association between air pollution and all-cause, cardiovascular, respiratory, cancer, mental/behavioural disorders/suicides, and other-causes mortality. Results Higher all-cause mortality was associated with increasing concentrations of PM2.5, PM10, NO2, and SO2 pollutants. NO2, PM10, and PM2.5 were also associated with cardiovascular, respiratory, cancer and other-causes mortality. For example, the mortality hazard from respiratory diseases was 1.062 (95%CI = 1.028–1.096), 1.025 (95%CI = 1.005–1.045), and 1.013 (95%CI = 1.007–1.020) per 1 μg/m3 increase in PM2.5, PM10 and NO2 pollutants, respectively. In contrast, mortality from mental and behavioural disorders was associated with 1 μg/m3 higher exposure to SO2 pollutant (HR = 1.042; 95%CI = 1.015–1.069). Conclusion This study revealed an association between long-term (16-years) exposure to ambient air pollution and all-cause and cause-specific mortality. The results suggest that policies and interventions to enhance air quality would reduce the mortality hazard from cardio-respiratory, cancer, and mental/behavioural disorders in the long-term.Publisher PDFPeer reviewe

Air pollution and individuals’ mental well-being in the adult population in United Kingdom : a spatial-temporal longitudinal study and the moderating effect of ethnicity

This paper is part of a PhD project that is funded by the St Leonard’s PhD scholarship, University of St Andrews, Scotland, United Kingdom.Background Recent studies suggest an association between ambient air pollution and mental well-being, though evidence is mostly fragmented and inconclusive. Research also suffers from methodological limitations related to study design and moderating effect of key demographics (e.g., ethnicity). This study examines the effect of air pollution on reported mental well-being in United Kingdom (UK) using spatial-temporal (between-within) longitudinal design and assesses the moderating effect of ethnicity. Methods Data for 60,146 adult individuals (age:16+) with 349,748 repeated responses across 10-data collection waves (2009–2019) from “Understanding-Society: The-UK-Household-Longitudinal-Study” were linked to annual concentrations of NO2, SO2, PM10, and PM2.5 pollutants using the individuals’ place of residence, given at the local-authority and at the finer Lower-Super-Output-Areas (LSOAs) levels; allowing for analysis at two geographical scales across time. The association between air pollution and mental well-being (assessed through general-health-questionnaire-GHQ12) and its modification by ethnicity and being non-UK born was assessed using multilevel mixed-effect logit models. Results Higher odds of poor mental well-being was observed with every 10μg/m3 increase in NO2, SO2, PM10 and PM2.5 pollutants at both LSOAs and local-authority levels. Decomposing air pollution into spatial-temporal (between-within) effects showed significant between, but not within effects; thus, residing in more polluted local-authorities/LSOAs have higher impact on poor mental well-being than the air pollution variation across time within each geographical area. Analysis by ethnicity revealed higher odds of poor mental well-being with increasing concentrations of SO2, PM10, and PM2.5 only for Pakistani/Bangladeshi, other-ethnicities and non-UK born individuals compared to British-white and natives, but not for other ethnic groups. Conclusion Using longitudinal individual-level and contextual-linked data, this study highlights the negative effect of air pollution on individuals’ mental well-being. Environmental policies to reduce air pollution emissions can eventually improve the mental well-being of people in UK. However, there is inconclusive evidence on the moderating effect of ethnicity.Publisher PDFPeer reviewe

Does long-term air pollution exposure affect self-reported health and limiting long term illness disproportionately for ethnic minorities in the UK? A census-based individual level analysis

This study is part of a PhD project that was supported by the St Leonard’s interdisciplinary PhD scholarship, University of St Andrews, Scotland, UK.Previous studies have investigated the impact of air pollution on health and mortality. However, there is little research on how this impact varies by individuals’ ethnicity. Using a sample of more than 2.5-million individuals aged 16 and older from the 2011 UK census linked to 10-years air pollution data, this article investigates the effect of air pollution on self-reported general health and limiting long-term illness (LLTI) in five main ethnic groups and by country of birth in UK. The association of air pollution with self-reported health and LLTI by individual’s ethnicity was examined using two levels mixed-effects generalised-linear models. Pakistani/Bangladeshi, Indian, Black/African/Caribbean, and other ethnic minorities and people born outside UK/Ireland were more likely to report poorer health and the presence of LLTI than White-group and UK/Ireland born individuals. Higher concentrations of NO2, SO2 and CO pollutants were associated with poorer self-reported health and the presence of LLTI in the UK population. Analysis by ethnicity showed a more pronounced effect of NO2, PM10, PM2.5, and CO air pollution on poor self-reported health and the presence of LLTI among ethnic minorities, mostly for people from Black/African/Caribbean origin compared to White people, and among non-UK/Ireland born individuals compared to natives. Using a large-scale individual-level census data linked to air pollution spatial data, our study supports the long-term deteriorating effect of air pollution on self-reported health and LLTI, which is more pronounced for ethnic minorities and non-natives.Publisher PDFPeer reviewe

Air pollution, mortality, and hospital admissions in Scotland: A 16 years register-based study

Background Air pollution is associated with poor health and higher mortality. However, studies that link high spatial resolution air pollution data for several pollutants to individual-level data over prolonged period (>10 years) and assess multiple health outcomes are limited. In this study, we investigated the association between 16-years exposure to air pollution and all-cause and cause-specific (cardiovascular, respiratory, cancer, infectious, and mental/behavioural disorders) mortality and hospital admissions in Scotland. Methods Individual-level data from the “Scottish Longitudinal Study” for 202,237 individuals (2002-2017) were linked to yearly concentrations of NO2, SO2, PM10, and PM2.5 pollutants at 1-Km2 spatial resolution using the individual’s residential postcode. The association between air pollution and mortality and hospital admissions was examined using Cox Proportional-Hazards and multilevel mixed-effects negative binomial models, respectively. Results Increasing concentrations of PM2.5, PM10, and NO2 pollutants were associated with higher rates of all-cause, cardiovascular, respiratory, cancer, and infectious mortality and hospital admissions. Mortality from respiratory diseases increased by 6.2% (95%CI=2.8%-9.6%), 2.5% (95%CI=0.5%-4.5%), and 1.2% (95%CI=0.5%-1.9%) per 1 µg/m3 increase in PM2.5, PM10 and NO2 pollutants, respectively. Exposure to SO2 was mainly linked to mental/behavioural disorders mortality (HR=1.05; 95%CI=1.02-1.07) and respiratory hospital admissions (IRR=1.02; 95%CI=1.01-1.03). Conclusions This study revealed a positive association between air pollution and mortality and hospital admissions in Scotland. Interventions on air pollution through stricter environmental regulations could help ease the mortality and hospital admission burden, for both physical and mental illness

Trends and variability of implicit rationing of care across time and shifts in an acute care hospital : a longitudinal study

The proposed study was funded for 2 years (2018‐2020) by the Medical Practice Plan, Faculty of Medicine, American University of Beirut, Lebanon.Background Implicit rationing of nursing care is associated with work environment factors. Yet a deeper understanding of trends and variability is needed. Aims To explore the trends and variability of rationing of care per shift between individual nurses, services over time, and its relationship with work environment factors. Methods Longitudinal study including 1,329 responses from 90 nurses. Intraclass correlation coefficients (ICC) were computed to examine variability of rationing per shift between individual nurses, services, and data collection time; generalized linear mixed models were used to explore the relationship with work environment factors. Results Percentage of rationing of nursing activities exceeded 10% during day and night shifts. Significant variability in rationing items was observed between nurses, with ICCs ranging between 0.20 and 0.59 in day shifts, and between 0.35 and 0.85 in night shifts. Rationing of care was positively associated with nurses’ self‐perceived workload in both shifts, but not with patient‐to‐nurse ratios. Conclusion Most variability in rationing over time was explained by the individual.PostprintPeer reviewe

Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance : a study of urinary tract infection patients in Kenya, Tanzania and Uganda

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviour, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Using data from 6,388 patients, we analysed patterns of self-reported treatment seeking behaviours (‘patient pathways’) using process mining and single-channel sequence analysis. Among those with microbiologically confirmed UTI (n = 1,946), we used logistic regression to assess the relationship between treatment seeking behaviour, AB use, and the likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathway for UTI-like symptoms in this sample involved attending health facilities, rather than other providers like drug sellers. Patients from sites in Tanzania and Uganda, where over 50% of patients had an MDR UTI, were more likely to report treatment failures, and have repeat visits to providers than those from Kenyan sites, where MDR UTI proportions were lower (33%). There was no strong or consistent relationship between individual AB use and likelihood of MDR UTI, after accounting for country context. The results highlight the hurdles East African patients face in accessing effective UTI care. These challenges are exacerbated by high rates of MDR UTI, suggesting a vicious cycle of failed treatment attempts and sustained selection for drug resistance. Whilst individual AB use may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of variations in ABR.Peer reviewe

Air pollution, health, mortality, and ethnicity: analysis of individual-level longitudinal and census data linked to high-resolution spatial data from the United Kingdom

This thesis investigates the association between air pollution and health in the UK and examines how this association varies by ethnicity and country of birth. It links high-resolution spatial data on air pollution to individual-level longitudinal data at different geographical scales. The thesis shows that higher concentrations of NO₂, SO₂, CO, PM10, and PM2.5 ambient air pollutants are associated with limiting long-term illness, poor self-reported health, lower ratings of mental well-being, and increased mortality rates and hospital admissions. Particulate matter is mainly associated with all-cause, respiratory, cardiovascular, infectious and cancer mortality and hospital admissions, while SO₂ is mostly related to mental/behavioural disorders/suicide mortality and respiratory hospital admissions. NO₂ is associated with all mortality and hospital admission causes. The analysis further shows that non-UK-born and ethnic minorities report poorer health with higher exposure to air pollution than UK-born and British-white individuals. Ethnic differences are not observed in the association between air pollution and mental well-being. This thesis supports the association between long-term exposure to air pollution and poor health and increased mortality and hospital admissions and shows that the effect of air pollution on health is exacerbated for ethnic minorities in the UK

The spatial-temporal effect of air pollution on GP visits and hospital admissions by ethnicity in the United Kingdom: An individual-level analysis

Background Air pollution has been associated with increased rates of hospital admissions and general-practitioner (GP) visits. Yet, more research is to be done to reveal the spatial-temporal dimension of this association and whether ethnic minorities experience greater effects from exposure to air pollution compared to the rest of population. This study investigates the spatial-temporal effect of air pollution on GP visits and hospital admissions by ethnicity in the United-Kingdom (UK).Methods We used individual-level longitudinal data from the “UK Household Longitudinal Study” including 46,442 adult individuals who provided 140,466 responses across five years (2015-2019). This data was linked to yearly concentrations of NO2, SO2, and particulate-matter (PM10, PM2.5) pollution using the Lower-Super-Output-Area (LSOA) of residence for each individual. We distinguished between spatial (between areas) and temporal (across time within each area) effects of air pollution on GP visits and hospital admissions and we used multilevel mixed-effects ordered logistic models for analysis.Results Results showed higher odds of outpatient hospital admissions with increasing concentrations of NO2 (OR=1.009; 95%CI=1.006-1.013), SO2 (OR=1.063; 95%CI=1.030-1.097), PM10 (OR=1.013; 95%CI=1.006-1.021), and PM2.5 (OR=1.022; 95%CI=1.012-1.032) pollutants. Higher odds of GP visits were also observed with increasing concentrations of NO2 (OR=1.011; 95%CI=1.007-1.015) and SO2 (OR=1.123; 95%CI=1.087-1.160) pollutants. Decomposing air pollution into between (spatial: across LSOAs) and within (temporal: across years within each LSOA) effects, showed significant between effects for air pollution on GP visits and hospital admissions, but not within effects. We observed no differences between ethnic minorities and British-white for the association between air pollution and hospital admissions and GP visits.Conclusion Using individual-level longitudinal data, our study supports the presence of a spatial-temporal association between air pollution and hospital admissions and GP visits. However, ethnic minorities do not seem to experience greater health-related effects from exposure to air pollution compared to the rest of population.</p