title: Development of a measure of multiple physical environmental deprivation. After United Kingdom and New Zealand, Portugal.
abstract: BACKGROUND
  Spatial inequalities in health have been identified, but the contribution of physical environment has been largely ignored. In Portugal, strong spatial differences in morbidity and mortality remain unexplained. Based on previous United Kingdom (UK) and New Zealand (NZ) research, we aimed to develop a Portuguese measure of multiple environmental deprivation (PT-MEDIx) to assist in understanding spatial inequalities in health.
  
  
  METHODS
  PT-MEDIx was built at municipality level in four stages: (i) identify health-relevant environmental factors; (ii) acquire datasets about selected environmental factors and calculate municipality-level measures using Geographical Information Systems; (iii) test associations between selected environmental factors and mortality using negative binomial models, adjusting for age, sex, socioeconomic deprivation and interactions and (iv) construct a summary measure and assess its association with mortality.
  
  
  RESULTS
  We included five dimensions of the physical environment: air pollution, climate, drinking water quality, green space availability and industry proximity. PT-MEDIx score ranged from -1 (least environmental deprivation) to +4 (most) and depicted a clear spatial pattern: least deprived municipalities in the depopulated rural areas and most deprived in urban and industrial settings. Comparing with those in the intermediate category of environment deprivation, less deprived municipalities showed lower mortality rate ratios (MRRs) and vice versa: MRRs for all-cause mortality were 0.962 (95% confidence interval: 0.934-0.991) and 1.209 (1.086-1.344), in the least and most deprived municipalities, respectively, and for cancer, 0.957 (0.911-1.006) and 1.345 (1.123-1.598).
  
  
  CONCLUSIONS
  The methods used to create UK and NZ indexes have good transferability to Portugal. MEDIx might contribute to untangle the complex pathways that link health, socioeconomic and physical environment.
authors: 1 INEB, Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal 2 Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública, Faculdade de Medicina, Universidade do Porto, Porto, Portugal 3 ISPUP, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal ana.isabel.ribeiro@ineb.up.pt.
authors: Ana Isabel
authors: AI
authors: Ribeiro
authors: 1 INEB, Instituto de Engenharia Biomédica, Universidade do Porto, Porto, Portugal 2 Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública, Faculdade de Medicina, Universidade do Porto, Porto, Portugal 3 ISPUP, Instituto de Saúde Pública da Universidade do Porto, Porto, Portugal.
authors: Maria de Fátima
authors: Mde F
authors: de Pina
authors: 4 Centre for Population Health Sciences, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
authors: Richard
authors: R
authors: Mitchell
mesh_terms: D017677:Age Distribution; D004777:Environment; D004781:Environmental Exposure; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D009026:Mortality; D009520:New Zealand / Q000453:epidemiology; D011174:Portugal / Q000453:epidemiology; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D017678:Sex Distribution; D012959:Socioeconomic Factors; D006113:United Kingdom / Q000453:epidemiology