A vulnerabilidade ao frio em Portugal: custos sociais e económicos do excesso de mortalidade e de morbilidade durante o inverno

Tese de Doutoramento em Geografia, apresentada ao Departamento de Geografia e Turismo da Faculdade de Letras da Universidade de CoimbraO excesso de mortalidade e morbilidade durante o inverno é um fenómeno comum aos países europeus apresentando, no entanto, importantes desigualdades espaciais. Evidência científica refere que a sazonalidade da mortalidade advém dos impactos de temperaturas adversas na saúde. É, no entanto, nos países do Sul da Europa, onde os invernos são mais amenos, que se verificam os maiores valores de mortalidade em excesso no Inverno. Destacar ainda que, em comparação com os restantes países mediterrâneos, os impactos do frio são superiores em Portugal. A vulnerabilidade ao frio resulta de um vasto conjunto de fatores biológicos, epidemiológicos, socioeconómicos e comportamentais e traduz-se em impactos significativos para a saúde, sendo fundamental medir as variações sazonais das doenças e compreender os fatores que explicam a desigualdade espacial da vulnerabilidade ao frio. Esta dissertação tem como objetivo geral analisar e quantificar o impacto das variações sazonais de mortalidade e morbilidade e caracterizar os fatores que contribuem para o aumento da vulnerabilidade ao frio em Portugal, através da: i) identificação das causas de morte com maior variação sazonal e dos seus padrões geográficos; ii) avaliação das condições socioeconómicas que contribuem para um aumento da vulnerabilidade ao frio; iii) quantificação dos custos sociais e económicos (no SNS) do excesso de mortalidade e morbilidade no inverno; iv) avaliação do impacto de fatores meteorológicos na mortalidade e morbilidade; v) identificação de medidas de minimização ou de mitigação dos efeitos do frio na saúde. Para responder aos objetivos propostos foram recolhidos e utilizados dados secundários a diversas escalas (Administração Regional de Saúde e NUT III, município e para a Área Metropolitana de Lisboa) relativos a resultados em saúde, condições socioeconómicas, condições meteorológicas e de qualidade do ar. Com estes dados foram calculadas medidas de sazonalidade como o excesso de mortalidade e de morbilidade no inverno e os óbitos atribuíveis ao frio e foram aplicados métodos de análise de padrões espaciais e de séries temporais. A aplicação destes métodos permitiu verificar que as doenças do aparelho circulatório e respiratório apresentam a maior variação sazonal e são responsáveis pela maioria do excesso de mortalidade no inverno.Although excess winter mortality and morbidity are common in European countries, important spatial inequalities can be found. Scientific evidence indicates that mortality seasonality results from the impact of harmful temperatures. However, in southern European countries, where winters are milder, excess winter mortality and morbidity burden is greater. In comparison with other Mediterranean countries, cold related health impacts are higher in Portugal. Vulnerability to cold is influenced by a vast number of biological, epidemiologic, socioeconomic and behavioral factors that result in significant health impacts. Therefore, it is fundamental to measure seasonal variations of disease and to understand the factors that may be responsible for the spatial inequalities of vulnerability to cold. This dissertations main objective is to analyze and quantify the impact of the mortality and morbidity seasonal variations and to characterize the factors contributing to vulnerability to cold in Portugal, by: i) identifying mortality causes with higher seasonal variations and its geographical patterns; ii) assessing the socioeconomic conditions that contribute to vulnerability to cold; iii) quantifying social and economic costs (of the National Health Service) attributable to excess winter mortality and morbidity; iv) assessing the impact of meteorological factors on mortality and morbidity; v) identifying measures to minimize the effects of cold on health. To address the presented objectives primary and secondary data at several scales (regional: Regional Health Administration and NUT III; local: municipality and Lisbon Metropolitan Area) were collected. Data collected refers to health outcomes, socioeconomic conditions, meteorological conditions and air quality. Measures of seasonality such as excess winter mortality and morbidity, and cold related mortality were calculated; spatial analysis and time series methods were applied. Diseases of the circulatory and respiratory system were identified as the causes of death with higher seasonal variation and higher excess winter mortality. The seasonal mortality increase is more important in the municipalities of the inland and is statistically associated with the housing and socioeconomic conditions of the place of residence. The consequences of the vulnerability to seasonal cold weather (during winter) are severe and result in important social and economic costs, which was estimated to account for: i) 87 potential years of life lost per 100,000 inhabitants; ii) life expectancy decreases of one year; iii) added costs to the National Health Service of near 4.4% with excess winter hospital admissions in 2009-12. Further, it was estimated that in Lisbon mortality increases significantly when air temperature is lower than 16.5 ºC and that 5.7% of deaths are due to cold. Excess winter mortality and morbidity and cold related mortality can be avoided, or at least minimized, by adequate interventions directed towards the social determinants of health. The results presented in this dissertation may be an important contribution for the development of further effective interventions

Excess winter mortality and morbidity before, during, and after the Great Recession: the Portuguese case

Although winter mortality and morbidity are phenomena common to most European countries, their magnitude varies significantly from country to country. The geographical disparities among regions with similar climates are the result of several social, economic, demographic, and biological conditions that influence an individual's vulnerability to winter conditions. The impact of poor socioeconomic conditions may be of such magnitude that an economic recession may aggravate the seasonal mortality pattern. This paper aims to measure the seasonal winter mortality, morbidity, and their related costs during the Great Recession (2009-2012) in mainland Portugal and its Regional Health Administrations (RHAs) and to compare it with the periods preceding and following it. Monthly mortality and morbidity data were collected and clustered into three periods: Great Recession (2009-2012), Pre-Recession (2005-2008), and Post-Recession (2013-2016). The impact of seasonal winter mortality and morbidity during the Great Recession in Portugal and its Regional Health Administrations was measured through the assessment of age-standardized excess winter (EW) death and hospital admissions rate and index, expected life expectancy gains without EW deaths, EW rate of potential years of life lost, and EW rate of emergency hospital admission costs. Important increases of winter deaths and hospital admissions were identified, resulting in an important number of potential years of life lost (87 years of life lost per 100,000 inhabitants in 2009-2012), life expectancy loss (1 year in 2009-2012), and National Health Service costs with explicit temporal and spatial variations. These human and economic costs have decreased consistently during the analyzed periods, while no significant increase was found during the Great Recession. Despite its reduction, the winter excess morbidity and mortality highlight that Portugal still faces substantial challenges related to a highly vulnerable population, calling for investments in better social and health protection

Variables meteorológicas y contaminación del aire y su asociación con internamientos por enfermedades respiratorias en niños: estudio de caso en São Paulo, Brasil

As transformações no clima urbano das cidades, a excessiva poluição atmosférica e o aumento das desigualdades sociais tornaram-se fatores determinantes do alto risco de internações por doenças respiratórias. Dessa forma, o objetivo deste trabalho foi compreender como os atributos meteorológicos (temperatura do ar, umidade relativa do ar e precipitação) e a poluição do ar (material particulado com diâmetro aerodinâmico menor de 10μm - MP10) estão relacionados com as internações hospitalares por doenças respiratórias em crianças, em 14 distritos da cidade de São Paulo, Brasil. A combinação dos modelos lineares generalizados com uma distribuição binomial negativa e o modelo não linear distributed lag non-linear model (DLNM) foram utilizados como método estatístico para analisar a relação entre as internações, os atributos climáticos e a poluição no período de 2003 a 2013. Os resultados mostraram relações estatísticas significativas de alto risco relativo entre a temperatura média do ar (17,5ºC a 21ºC, para o total analisado), umidade relativa do ar (84% a 98% para o sexo feminino), precipitação (0mm a 2,3mm para o total e ambos os sexos e > 120mm para o sexo feminino) e MP10 (> 35µg/m³ para o total e para o sexo feminino). Com base nesses resultados, foi possível identificar que os atributos ambientais contribuem para o elevado risco de internações.Urban climate changes, excessive air pollution, and increasing social inequalities have become determinant factors in the high risk of hospitalizations due to respiratory diseases. The current study thus aimed to understand how meteorological factors (air temperature, relative humidity, and precipitation) and air pollution (particulate matter with aerodynamic diameter less than 10µm - PM10) are related to hospitalizations due to respiratory diseases in children in 14 districts in the city of São Paulo, Brazil. The combination of generalized linear models with a negative binomial distribution and distributed lag non-linear model (DLNM) were used as the statistical method to analyze the relationship between hospitalizations, climatic factors, and pollution from 2003 to 2013. The results show statistically significant association with high relative risk between mean air temperature (17.5ºC to 21ºC, for the total analyzed), relative humidity (84% to 98% for females), precipitation (0mm to 2.3mm for the total and both sexes and > 120mm for females), and PM10 (> 35µg/m³ for the total and for females). These results showed that environmental factors contribute to the high risk of hospitalizations.Las transformaciones en el clima urbano de las ciudades, la excesiva contaminación atmosférica y el aumento de las desigualdades sociales se convirtieron en factores determinantes para el alto riesgo de internamientos por enfermedades respiratorias. Por ello, el objetivo de este trabajo ha sido comprender cómo las condiciones meteorológicas (temperatura del aire, humedad relativa del aire y precipitaciones) y la contaminación del aire (material particulado con un diámetro aerodinámico menor de 10µm - MP10) están relacionados con internamientos hospitalarios por enfermedades respiratorias en niños, en 14 distritos de la ciudad de Sao Paulo. La combinación de los modelos lineales generalizados con una distribución binomial negativa y el modelo no lineal distributed lag non-linear model (DLNM) se utilizaron como método estadístico para analizar la relación entre los internamientos, atributos climáticos y la contaminación durante el período de 2003 a 2013. Los resultados mostraron relaciones estadísticas significativas de alto riesgo relativo entre la temperatura media del aire (17,5ºC a 21ºC, para el total analizado), humedad relativa del aire (84% a 98% para el sexo femenino), precipitaciones (0mm a 2,3mm para el total y ambos sexos y > 120mm para el sexo femenino) y MP10 (> 35µg/m³ para el total y sexo femenino). A partir de estos resultados, fue posible identificar que los atributos ambientales contribuyen al aumento del riesgo de internamientos.Fundação de Amparo à Pesquisa do Estado de São Paul

The Role of Individual and Neighborhood Characteristics on Mental Health after a Period of Economic Crisis in the Lisbon Region (Portugal): A Multilevel Analysis

Mental health is an intrinsic dimension of health influenced by individual and contextual factors. This cross-sectional study analyzes the association between the individual, neighborhood characteristics, and one's self-assessed mental health status in the Lisbon region after an economic crisis. Via the application of multilevel regression models, the study assesses the link between one's neighborhood environment-deprivation, low self-assessed social capital, and low self-assessed satisfaction with the area of residence-and mental health regardless of one's individual characteristics. Constraints related to the economic crisis play an important role in the explanation of poor mental health

Cold-related mortality in three European metropolitan areas: Athens, Lisbon and London. Implications for health promotion

The aim of this study is to estimate the mortality burden attributable to low temperature in Athens, Lisbon and London from 2002 to 2011 and to discuss related inequalities in socioeconomic conditions. We address a lack of quantitative estimates of cold-related mortality, particularly for the cities of Lisbon and Athens. To estimate the mortality burden attributable to low temperature, time-series regression analyses were carried out on daily mortality with respect to daily mean temperature for the three metropolitan areas to estimate the relative risk associated with a decrease in temperature. The number of cold-related deaths was estimated using the population Attributable Fraction. Lisbon presents higher relative risk (RR) than London and Athens; the RR for Athens is lower than for London. The coldrelated death rate is higher in Lisbon (53.2 deaths per 100,000 inhabitants) than in Athens (32.6) and London (37.6). The spatial heterogeneity between the three metropolitan areas in the risk estimates and cold-related mortality may result from the significant disparities in the built environment. Adequate public health planning and preventive measures in the built environment may help reduce cold-related deaths and decrease vulnerability to cold in European cities

Environmental public health risks in European metropolitan areas within the EURO-HEALTHY project

Urban areas in Europe are facing a range of environmental public health challenges, such as air pollution, traffic noise and road injuries. The identification and quantification of the public health risks associated with exposure to environmental conditions is important for prioritising policies and interventions that aim to diminish the risks and improve the health of the population. With this purpose in mind, the EURO-HEALTHY project used a consistent approach to assess the impact of key environmental risk factors and urban environmental determinants on public health in European metropolitan areas. A number of environmental public health indicators, which are closely tied to the physical and built environment, were identified through stakeholder consultation; data were collected from six European metropolitan areas (Athens, Barcelona, Lisbon, London, Stockholm and Turin) covering the period 2000-2014, and a health impact assessment framework enabled the quantification of health effects (attributable deaths) associated with these indicators. The key environmental public health indicators were related to air pollution and certain urban environmental conditions (urban green spaces, road safety). The air pollution was generally the highest environmental public health risk; the associated number of deaths in Athens, Barcelona and London ranged between 800 and 2300 attributable deaths per year. The number of victims of road traffic accidents and the associated deaths were lowest in the most recent year compared with previous years. We also examined the positive impacts on health associated with urban green spaces by calculating reduced mortality impacts for populations residing in areas with greater green space coverage; results in Athens showed reductions of all-cause mortality of 26 per 100,000 inhabitants for populations with benefits of local greenspace. Based on our analysis, we discuss recommendations of potential interventions that could be implemented to reduce the environmental public health risks in the European metropolitan areas covered by this study