title: A multilevel analysis to explain self-reported adverse health effects and adaptation to urban heat: a cross-sectional survey in the deprived areas of 9 Canadian cities.
abstract: BACKGROUND
  This study identifies the characteristics and perceptions related to the individual, the dwelling and the neighbourhood of residence associated with the prevalence of self-reported adverse health impacts and an adaptation index when it is very hot and humid in summer in the most disadvantaged sectors of the nine most populous cities of Québec, Canada, in 2011.
  
  
  METHODS
  The study uses a cross-sectional design and a stratified representative sample; 3485 people (individual-level) were interviewed in their residence. They lived in 1647 buildings (building-level) in 87 most materially and socially disadvantaged census dissemination areas (DA-level). Multilevel analysis was used to perform 3-level models nested one in the other to examine individual impacts as well as the adaptation index.
  
  
  RESULTS
  For the prevalence of impacts, which is 46 %, the logistic model includes 13 individual-level indicators (including air conditioning and the adaptation index) and 1 building-level indicator. For the adaptation index, with values ranging from -3 to +3, the linear model has 10 individual-level indicators, 1 building-level indicator and 2 DA-level indicators. Of all these indicators, 9 were associated to the prevalence of impacts only and 8 to the adaptation index only.
  
  
  CONCLUSIONS
  This 3-level analysis shows the differential importance of the characteristics of residents, buildings and their surroundings on self-reported adverse health impacts and on adaptation (other than air conditioning) under hot and humid summer conditions. It also identifies indicators specific to impacts or adaptation. People with negative health impacts from heat rely more on adaptation strategies while low physical activity and good dwelling/building insulation lead to lower adaptation. Better neighbourhood walkability favors adaptations other than air conditioning. Thus, adaptation to heat in these neighbourhoods seems reactive rather than preventive. These first multi-level insights pave the way for the development of a theoretical framework of the process from heat exposure to impacts and adaptation for research, surveillance and public health interventions at all relevant levels.
authors.affiliation: Institut national de la recherche scientifique (INRS) Centre Eau Terre Environnement, 490, rue de la Couronne, Québec, Québec, G1K 9A9, Canada.|Centre de recherche du Centre hospitalier universitaire (CHU) de Québec, 2705, boulevard Laurier, Québec, Québec, G1V 4G2, Canada.
authors.forename: Diane
authors.initials: D
authors.lastname: Bélanger
authors.affiliation: Centre de recherche du Centre hospitalier universitaire (CHU) de Québec, 2705, boulevard Laurier, Québec, Québec, G1V 4G2, Canada.|Université Laval, 2325 rue de l'Université, Québec, Québec, G1V 0A6, Canada.
authors.forename: Belkacem
authors.initials: B
authors.lastname: Abdous
authors.affiliation: Université Laval, 2325 rue de l'Université, Québec, Québec, G1V 0A6, Canada.
authors.forename: Pierre
authors.initials: P
authors.lastname: Valois
authors.affiliation: Institut national de la recherche scientifique (INRS) Centre Eau Terre Environnement, 490, rue de la Couronne, Québec, Québec, G1K 9A9, Canada. pierre.gosselin@inspq.qc.ca.|Centre de recherche du Centre hospitalier universitaire (CHU) de Québec, 2705, boulevard Laurier, Québec, Québec, G1V 4G2, Canada. pierre.gosselin@inspq.qc.ca.|Institut national de santé publique du Québec (INSPQ), 945, avenue Wolfe, Québec, Québec, G1V 5B3, Canada. pierre.gosselin@inspq.qc.ca.|Ouranos, 550, Sherbrooke Ouest, Tour Ouest, 19e étage, Montréal, Québec, H3A 1B9, Canada. pierre.gosselin@inspq.qc.ca.
authors.forename: Pierre
authors.initials: P
authors.lastname: Gosselin
authors.affiliation: Centre de recherche du Centre hospitalier universitaire (CHU) de Québec, 2705, boulevard Laurier, Québec, Québec, G1V 4G2, Canada.
authors.forename: Elhadji A Laouan
authors.initials: EAL
authors.lastname: Sidi
mesh_terms: D000064:Acclimatization; D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D002170:Canada; D002947:Cities; D003430:Cross-Sectional Studies; D005260:Female; D006358:Hot Temperature / Q000009:adverse effects*; D006798:Housing / Q000706:statistics & numerical data; D006801:Humans; D008875:Middle Aged; D055361:Multilevel Analysis; D015995:Prevalence; D011792:Quebec; D012111:Residence Characteristics / Q000706:statistics & numerical data*; D057566:Self Report; D012959:Socioeconomic Factors; D055815:Young Adult