Risk profile: multivariate cluster analysis of urban small areas based on socioeconomic indicators - census tracts from the Greater Rio de Janeiro Metropolitan Area

A method based on small area data analysis was developed to build a health risk classification for the Greater Rio de Janeiro Metropolitan Area. The approach uses 1991 census data and studies data pertaining to sanitation, ownership and type of housing, size and occupancy of the household, demography, schooling, and income. Principal component analysis applied over each dimension allowed for the choice of 15 variables, which summarized most of the observed variances. Additional analysis with these variables suggested that just six variables are sufficient for the construction of a classification using k-means method of multivariate cluster analysis. Five classes were obtained: (A) high income; (B) lower income; (C) poor; (D) low schooling and income; (E) low-level access to sanitation. The existing inequality in each of the geopolitical established areas was clearly identified. The proposed method allowed for the construction of compound indices to evaluate quality of life, based on widespread and easily obtained data (the census). Moreover, the method contributed to the detection of socioeconomic inequality, identifying, not only the larger poor regions but also the small excluded areas.     

Socioeconomic domains and associations with preterm birth

Neighborhood socioeconomic effects on health have been estimated using multiple variables and indices. This inconsistent estimation approach makes comparison across geographic areas challenging. In this paper, we developed indices representing specific socioeconomic domains that can be reproduced in other areas to estimate elements of the neighborhood socioeconomic environment on health outcomes, specifically preterm birth. Using year 2000 U.S. census data and principal components analysis, socioeconomic indices were developed representing a priori - defined domains of education, employment, housing, occupation, poverty and residential stability. These socioeconomic indices were subsequently used in race-stratified multilevel logistic regression models of preterm birth in eight socioeconomically distinct study areas in the U.S. Maternal residence was obtained from birth records and was geocoded to census tracts. In maternal age and education adjusted models, living in tracts with high unemployment, low education, poor housing, low proportion of managerial or professional occupation and high poverty was associated with increased odds of preterm birth for non-Hispanic white women at most sites. Among non-Hispanic black women, similar associations were noted for tract-level low education, high unemployment, low occupation, and high poverty, but the effect estimates were generally smaller than those seen for white women. Increasing amounts of residential stability were not associated with preterm birth in these analyses. We combined the domain estimates across the eight study sites to produce pooled effect estimates for the socioeconomic domains on preterm birth. The research reported here suggests that specific neighborhood-level socioeconomic features may be especially influential to health outcomes. These socioeconomic domains represent potential targets for intervention or policy efforts designed to improve maternal and child health and reduce health disparities.     

Adolescent pregnancy and social exclusion: analysis of intra-urban disparities]

OBJECTIVE: To compare adolescent mothers living in four areas with different degrees of social exclusion in the city of Santo André, S?o Paulo, Brazil, in terms of the mothers' schooling, the birth weight and gestational age of their babies, and the specific fertility rate of each of the four areas in 1998. METHOD: An ecological cross-sectional study was carried out with 1 314 adolescent girls. The four areas analyzed had earlier been defined in the City of Santo André Social Exclusion/Inclusion Map. Area 1 had the highest exclusion index (worst socioeconomic conditions), and Area 4 the lowest exclusion index (best socioeconomic conditions). The data relating to the adolescent mothers and their children were collected from the National Live Birth Information System, and the socioeconomic data for Santo André were obtained from the State Data Analysis System Foundation, the Brazilian Institute of Geography and Statistics, and the city's Social Exclusion/Inclusion Map. RESULTS: Having little formal education was statistically associated with the poorest areas. Of the infants with a birthweight < 2,500 g, 76.8% of them were born in the two poorest areas of the city. The highest fertility rate (35.7 per 1,000 adolescents) was found in Area 1, the area with the worst socioeconomic conditions; the lowest fertility rate (12.1 per 1,000) was found in Area 4, the area with the best socioeconomic conditions. The proportion of births that were premature did not differ among the four areas (P = 0.81). CONCLUSIONS: The results showed that adolescent girls with little schooling and a lower socioeconomic level were more likely to give birth. Specific actions should be promoted to prevent pregnancy in this group and to foster the social inclusion of these adolescents and their children, providing them with opportunities to improve their socioeconomic situation.     

Poor maternal schooling is the main constraint to good child care practices in Accra

Life in urban areas presents special challenges for maternal child care practices. Data from a representative quantitative survey of households with children < 3 y of age in Accra, Ghana were used to test a number of hypothesized constraints to child care including various maternal (anthropometry, education, employment, marital status, age and ethnic group) and household-level factors (income, availability of food, quality of housing and asset ownership, availability of services, household size and crowding). Three care indices were created as follows: 1) a child feeding index; 2) a preventive health seeking index; and 3) a hygiene index. The first two indices were based on data from maternal recall; the hygiene index was based on spot-check observations of proxies of hygiene behaviors. Multivariate analyses (ordinary least-squares regression for the child feeding index and ordered probit for the two other indices) showed that maternal schooling was the most consistent constraint to all three categories of child care practices. None of the household-level characteristics were associated with child feeding practices, but household socioeconomic factors were associated with better preventive health seeking and hygiene behaviors. Thus, poor maternal schooling was a main constraint for child feeding, health seeking and hygiene practices in Accra, but the lack of household resources was a constraint only for health seeking and hygiene. The programmatic implications of these findings for interventions in nutrition education and behaviors in Accra are discussed.     

Utilization of maternal health-care services in Peru: the role of women's education

This article explores the hypothesis that formal education of women influences the use of maternal health-care services in Peru, net of the mother's childhood place of residence, household socioeconomic status and access to health-care services. The findings are consistent with the hypothesis; both cross-sectional and fixed-effects logit models yield quantitatively important and statistically reliable estimates of the positive effect of maternal schooling on the use of prenatal care and delivery assistance. In addition, large differentials were found in the utilization of maternal health-care services by place of residence, suggesting that much greater efforts on the part of the government are required if modern maternal health-care services are to reach women in rural areas.     

Socioeconomic inequalities and vaccination coverage: results of an immunisation coverage survey in 27 Brazilian capitals, 2007-2008

BACKGROUND: Since 1988, Brazil's Unified Health System has sought to provide universal and equal access to immunisations. Inequalities in immunisation may be examined by contrasting vaccination coverage among children in the highest versus the lowest socioeconomic strata. The authors examined coverage with routine infant immunisations from a survey of Brazilian children according to socioeconomic stratum of residence census tract. METHODS: The authors conducted a household cluster survey in census tracts systematically selected from five socioeconomic strata, according to average household income and head of household education, in 26 Brazilian capitals and the federal district. The authors calculated coverage with recommended vaccinations among children until 18 months of age, according to socioeconomic quintile of residence census tract, and examined factors associated with incomplete vaccination. RESULTS: Among 17?295 children with immunisation cards, 14?538 (82.6%) had received all recommended vaccinations by 18 months of age. Among children residing in census tracts in the highest socioeconomic stratum, 77.2% were completely immunised by 18 months of age versus 81.2%-86.2% of children residing in the four census tract quintiles with lower socioeconomic indicators (p<0.01). Census tracts in the highest socioeconomic quintile had significantly lower coverage for bacille Calmette-Guérin, oral polio and hepatitis B vaccines than those with lower socioeconomic indicators. In multivariable analysis, higher birth order and residing in the highest socioeconomic quintile were associated with incomplete vaccination. After adjusting for interaction between socioeconomic strata of residence census tract and household wealth index, only birth order remained significant. CONCLUSIONS: Evidence from Brazilian capitals shows success in achieving high immunisation coverage among poorer children. Strategies are needed to reach children in wealthier areas.     

Risk factors for overweight in children from Southern Brazil

Risk factors for overweight were investigated in a cross-sectional survey of children aged 12-59 months in the Southern Brazilian city of Porto Alegre (n = 2,660). Odds ratios (OR) for overweight, defined by weight/height > 2 z-scores of the NCHS standards, were estimated for socioeconomic and demographic conditions, social environment, and childhood health events. Prevalence of overweight was 6.5%. In the multivariate model, the odds of overweight were positively associated with maternal education (schooling > 12 years, OR = 2.36; 95%CI: 1.21-4.60; 9-11 years, OR = 2.07; 95%CI: 1.16-3.70) and family income per capita > 2 times the minimum wage (OR = 1.86; 95%CI: 1.13-3.08) and negatively associated with maternal work (OR = 0.72; 95%CI: 0.52-0.99). Odds were higher for children born large-for-gestational-age (OR = 2.29; 95%CI: 1.36-3.85) and lower for children born small (OR = 0.57; 95%CI: 0.33-0.99), as compared to those born with adequate birth weight for gestational age. Paternal schooling, parental occupation, and maternal age at the child's birth were associated with overweight in the unadjusted model only. Programs are needed to prevent overweight during childhood, with special attention to families and children at increased risk.     

The role of socioeconomic circumstances in differences in height of pre-school children within and between the Czech Republic and southern Brazil

Children's height is an important indicator of nutritional status and health of populations. Little is known about the role of individual socioeconomic factors and whether socioeconomic differences within countries can help explaining differences in children's height between countries. This paper examines the effect of socioeconomic factors on children's height in two population with different social environments. Two separate cross-sectional studies of children 36-59 months old from Southern Brazil and the Czech Republic collected data on height and socioeconomic and demographic variables. Height was converted into height-for-age Z-scores (HAZ) based on one growth standard, and the effect of socioeconomic and demographic factors on children's heights was studied by multiple regression. First, these effects were estimated separately for each country, and secondly, it was assessed whether some of the difference in height between the two countries could be explained by these factors. Czech children were 0.61 HAZ (approximately 2.6 cm) taller than Brazilian children. In Brazil, income, dwelling conditions, birth order, birth weight and maternal age were independently and significantly associated with height (multiple R-squared 0.27). In the Czech Republic, maternal education, birth order, birth weight and maternal age predicted height in a multivariate analysis (multiple R-squared 0.11). Maternal education alone explained 30% of the difference in children's height between Brazil and the Czech Republic; further adjustment for education of the father, birth weight, number of siblings and birth order slightly increased the proportion of explained difference to 41%. Our results suggest that although socioeconomic and demographic factors predicted children's growth in both countries, the role of individual factors differed and the associations were stronger in South Brazil. The finding that these factors explained a large part of the between-population difference further illustrates the importance of social environment for children's growth.     

Food insecurity as an indicator of inequity: analysis of a population survey

This study aimed to analyze the association between food insecurity and certain socioeconomic and demographic variables that measure social inequality: income, schooling, race, family structure, household characteristics, and sewage conditions. A sample of 456 families in Campinas, S?o Paulo State, was interviewed using the Brazilian Food Insecurity Scale (EBIA). Family food insecurity was associated with: more children < 18 years; precarious housing; overcrowding; lack of sewage system; low income (< 2 times the minimum wage); head-of-household with no schooling; no university graduate in the family; and race (black). Directly measuring food insecurity is important for monitoring inequality, and can be used either with other socioeconomic and demographic indicators or alone to identify social vulnerability in population groups.     

父母社会经济地位和养育效能的关系：父母第一次生育年龄的中介作用

目的 探究父母第一次生育年龄在父母社会经济地位和养育效能中是否存在中介效应,从而为提高父母养育效能提供参考依据。方法 采取分层整群抽样方法,选取蚌埠市2所幼儿园和2所小学的1～3年级共计880名3～9岁儿童,以儿童及其父母为研究对象进行问卷调查,内容包括儿童及其父母的一般人口学资料及父母养育效能的评价。基于多元线性回归分析构建中介效应模型,采用Bootstrap法对模型中的中介效应进行检验。结果 相关性分析显示,母亲社会经济地位与母亲角色满意度呈负相关(P<0.05),与母亲第一次生育年龄呈正相关(P<0.01)。母亲第一次生育年龄与母亲自我效能感和母亲角色满意度呈负相关(P<0.01)。控制儿童的性别后,中介效应模型显示,母亲社会经济地位与母亲角色满意度呈负相关(β=-0.071,t=-2.123,P<0.05),母亲社会经济地位与母亲第一次生育年龄呈正相关(β=0.252,t=7.717,P<0.01);母亲第一次生育年龄与母亲角色满意度呈负相关(β=-0.087,t=-2.365,P<0.05)。控制儿童的性别后,Bootstrap检验结果表明...     

Linear growth retardation and social factors among schoolchildren from the city of Osasco, São Paulo, Brazil

Cases and controls were selected for this retrospective investigation of the social determinants of growth retardation, from a Height Census carried out in the 1989 school year,involving children attending the first grade of all public and private schools in Osasco (in the Greater Metropolitan Area of S?o Paulo, Brazil). The cases, totalling 125 children entering school aged 7-8 years old, were characterized by a height-for-age index below -2 z score of the NCHS/WHO reference. The controls, totalling 139 children entering school at the same age, were characterized by a height-for-age index above -1 z score. Socioeconomíc variables such as family income, head-of-family's level of schooling, mother's schooling, environmental sanitation, and housing conditions were significant factors associated with the stunting process. Risk of linear growth retardation tended to be higher with lower social class (odds ratio = 7.3 for sub-proletariat vs. petit bourgeois; p < 0,001 for overall trend), suggesting the biological impact of Brazil's economic slowdown during the 1980s.     

Intergenerational evolution of stature in Pernambuco State, Brazil (1945-2006): 2 - analytical aspects

This study used multivariate regression models to identify factors associated with the height trend in residents of Pernambuco State, Brazil, in 2006, born from 1945 onward. The data were from two population-based statewide surveys. In the final model for each age bracket, year of birth, gender, schooling, and residence in urban areas were positively associated with stature in adults, as well as in children and adolescents 5 to 19 years of age. In children under five years, in addition to these variables, birth weight and prenatal care were also positively associated, while diarrhea in the two weeks prior to the interview showed a negative association. The findings show that stature was favored by settings with better socioeconomic and environmental conditions.     

Do area characteristics predict change in moderate-to-vigorous physical activity from ages 11 to 15 years?

In light of geographical and epidemiological research suggesting that the socioeconomic environment beyond the family may influence children's physical activity, this study investigated the extent to which neighbourhood socioeconomic conditions predict change in physical activity from ages 10 through 15 years, controlling for the attributes of the individual child and family. Data came from 889 children participating in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development cohort study. Accelerometers measured Moderate-to-Vigorous Physical Activity (MVPA) during the week and weekend, when the children were aged 10, 11, and 15 years. Selected US census block variables were used to create 'independent' area measures of economic deprivation and social fragmentation scores for child's area of residence at age 10 years. Also, parents' perception of neighbourhood social cohesion was measured in terms of relationships with neighbours. All analyses controlled for participant characteristics: gender, ethnicity, household income-to-needs ratio, maternal education, and for United States region of residence. Growth curve analyses indicated that whereas social fragmentation did not predict MVPA over time, greater area deprivation at age 10 years was associated with lower weekday MVPA for boys at 10 years (β=-0.5, p=0.03) and these differences persisted to age 11 and 15 years. This relationship was reversed for girls. Weekend MVPA was not significantly associated with the level of deprivation in the place of residence at age 10 years. Although the census measure of social fragmentation in the area of residence showed no significant association with MVPA, parent-reported neighbourhood social cohesion was positively associated with weekday (β=2.0, p<0.01) and weekend (β=3.1, p<0.01) MVPA minutes across time. This association was most pronounced for boys. Area level factors may be determinants of physical activity among children and youth in complex ways and parental perception of area social environment may be as important for children's activity levels as 'independently assessed' socioeconomic conditions.     

Gender inequalities in health among older Brazilian adults.

OBJECTIVE: To investigate gender differences among older Brazilians in their health status and their use of health services. METHODS: Participants were individuals aged 60 years and older included in a national household survey conducted in Brazil in 1998. Data were analyzed by multiple logistic regression, taking into account the design effect due to multistage sampling. RESULTS: There were differences in the health and living conditions of older men and older women that were not explained by age or place of residence. Older women had worse indicators of schooling and personal income but better indicators of housing standards and per capita household income. The older women also reported more chronic diseases, had poorer indicators of independence and physical mobility, sought health services more often, and reported more medical visits in the previous year. Despite their apparent worse health conditions, elderly women in urban areas had lower hospitalization rates in the previous year (odds ratio = 0.89; 95% confidence interval, 0.82-0.96) than did elderly men in urban areas. CONCLUSIONS: Our results indicate that among older Brazilians there are gender inequalities in health that cannot be explained by age and place of residence. The findings raise questions on how health, socioeconomic, and cultural factors influence gender patterns of seeking and using health care in later life in the country. As pressures on health care and health funding increase in Brazil as a result of the aging of the population, there is a need to take a gender perspective into account.     

Impact of neighborhood social conditions and household socioeconomic status on behavioral problems among US children

We examine the impact of neighborhood social conditions and household socioeconomic status (SES) on the prevalence of parent-reported behavioral problems among US children aged 6-17 years. The 2007 National Survey of Children's Health was used to develop a factor analytic index and a dichotomous measure of serious behavioral problems (SBP) in children. The outcome measures were derived from 11 items capturing parents' ratings of their children on a set of behaviors, e.g., arguing, bullying, and feelings of worthlessness, depression, and detachment. Dichotomous measures of perceived safety, presence of garbage/litter, poor/dilapidated housing, and vandalism were used to assess neighborhood social conditions. Household SES was measured using parental education and household poverty status. Logistic and least squares regression models were used to analyze neighborhood and household socioeconomic effects on the continuous and binary outcome measures after controlling for sociodemographic and psychosocial factors, including behavioral risk factors, family cohesion, social participation, and geographic mobility. Higher levels of behavioral problems were associated with socially disadvantaged neighborhoods and lower household SES. Adjusted logistic models showed that children in the most disadvantaged neighborhoods (those characterized by safety concerns, poor housing, garbage/litter in streets, and vandalism) had 1.9 times higher odds, children in poverty had 3.7 times higher odds, and children of parents with less than high school education had 1.9 times higher odds of SBP than their more advantaged counterparts. Improvements in neighborhood conditions and household SES may both help to reduce childhood behavioral problems.     

Demand for improved sanitation in an urban informal settlement in India: role of the local built environment

Sanitation uptake is a pressing challenge, especially in India, and sanitation demand in urban informal settlements and slums has been understudied relative to rural areas. Given the spatial and socioeconomic disadvantage of these settings, research suggests that the built environment may relate to sanitation demand, but this has not been tested. This study utilizes data on a large urban informal settlement in Maharashtra, India, examining built environment predictors including housing security, water access, and proximity to existing common sanitation, in association with sanitation demand. Results indicate that household size, home ownership, individual household water sources, and open defecation avoidance are significantly associated with interest in a toilet. Further, interactions between (1) water source and home ownership, and (2) open defecation and distance to shared sanitation, are associated with interest in a toilet. These findings support the role of the built environment in shaping sanitation demand in urban informal settlements.     

Determinants of linear growth retardation in Brazilian preschool children: a multilevel approach

This study focuses on the determinants of linear growth deficit in under-five children using multilevel modeling. The sample included 3,746 preschoolers from 15 Brazilian municipalities (ten from the State of Bahia and five from S?o Paulo), with a three-tier analysis (municipalities, households, and children). Municipal data were obtained from the 1991 National Census. Individual and household data were collected from 1999 to 2001 using structured questionnaires and measuring children's weight and height. Analysis used the MLwiN software. In the final multilevel model, low HDI and prenatal care at the municipal level, poor environmental and economic conditions and maternal schooling at the household level, and low birth weight, incomplete immunization, prior history of malnutrition, and no report of breastfeeding at the individual level were strongly associated with linear growth deficit. Total variability of deficit explained by the model was 27.4%, of which 51.3%, 33%, and 15.7% were explained, respectively, by individual, household, and municipal variables.     

Child overweight and undernutrition in Thailand: Is there an urban effect?

An urban advantage in terms of lower risk of child undernutrition has been observed in many developing countries, but child obesity is often more prevalent in urban than rural areas. This study aimed to assess whether urban-rural disparities in undernutrition and obesity were attributable to concentrations of socioeconomically advantaged children into urban communities or to specific aspects of the urban environment. A sample of 4610 children ages 2-10 years was derived from the 2004 Round of the Kanchanaburi Demographic Surveillance System, monitoring health and demographic change in the province of Kanchanaburi, Thailand. We used multi-level logistic regression to model the odds of short stature, underweight, and obesity for children in 102 communities. Models tested whether child socioeconomic conditions accounted for urban-rural disparities or if aspects of the social and physical environment accounted for disparities, adjusting for child characteristics. 27.8% of children were underweight, while 19.9% had short stature, and 8.3% were obese. Bivariate associations showed urban residence associated with lower risk of undernutrition and a greater risk of obesity. Urban-rural disparities in odds of short stature and underweight were accounted for by child socioeconomic characteristics. Urban residence persisted as a risk factor for obesity after adjusting for child characteristics. Community wealth concentration, television coverage, and sanitation coverage were independently associated with greater risk of obesity. Undernutrition was strongly associated with household poverty, while household affluence and characteristics of the urban environment were associated with odds of obesity. Further research is needed to characterize how urban environments contribute to children's risks of obesity in developing countries.     

Spatial ascariasis risk estimation using socioeconomic variables

Frequently, disease incidence is mapped as area data, for example, census tracts, districts or states. Spatial disease incidence can be highly heterogeneous inside these areas. Ascariasis is a highly prevalent disease, which is associated with poor sanitation and hygiene. Geostatistics was applied to model spatial distribution of Ascariasis risk and socioeconomic risk events in a poor community in Rio de Janeiro, Brazil. Data were gathered from a coproparasitologic and a domiciliary survey in 1550 children aged 1-9. Ascariasis risk and socioeconomic risk events were spatially estimated using Indicator Kriging. Cokriging models with a Linear Model of Coregionalization incorporating one socioeconomic variable were implemented. If a housewife attended school for less than four years, the non-use of a home water filter, a household density greater than one, and a household income lower than one Brazilian minimum wage increased the risk of Ascariasis. Cokriging improved spatial estimation of Ascariasis risk areas when compared to Indicator Kriging and detected more Ascariasis very-high risk areas than the GIS Overlay method.     

Overweight in children and adolescents in Pernambuco State, Brazil: prevalence and determinants

This study aimed to determine the prevalence of overweight and associated risk factors in children and adolescents in Pernambuco State, Brazil, in 2006. The cross-sectional, population-based study included 1,435 individuals from 5 to 19 years of age. Poisson regression was used to evaluate the association between selected variables and overweight. Prevalence was 13.3% for overweight (95%CI: 11.6-15.1) and 3.8% for obesity. Adjusted prevalence ratios showed that higher family income, maternal schooling, possession of household consumer goods, living in urban areas, and maternal overweight were associated with overweight in children and adolescents. The high prevalence of overweight in Pernambuco emphasizes the need for public health measures targeting all families regardless of socioeconomic status.