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Plano de Investigação

1. Literature Review

a)  To reflect critically on the financial and economic crisis impact on living conditions, MH and other essential concepts related with MH determinants and spatial planning;

b) To establish contacts with other national and international research projects;

c) To identify all the factors (compositional and contextual) affecting MH, including healthcare provision, accessibility and utilization. The literature review accompanies all project phases.

2. Explanation of MH determinants and their impact assessment
Focuses on quantifying relationships between built environmental determinants and MH inequities. It will be developed using an integrated and coherent methodology involving the identification of factors with impact on MH (health determinants), and choosing indicators or proxies (e.g. mortality or morbidity rates: outcomes) sensitive to express the burden of ill-health of studied populations.
2.1. Identification of Mental Health determinants and indicators

a) Socio-Economic: The relation between higher levels of economic resources (income and inequality in income distribution), economic aspects of local areas (employment/unemployment) and the geographic concentration of poverty have been frequently analysed with regard to psychiatric morbidity and suicide. These facts are amplified in financial and economic crises.

b) Housing and neighbourhood conditions: encompass structural features of communities that are associated to MH, such as physical design of streets, safety structures, social cohesion and social capital (including access to health care) and also aspects related to density (inhabitants/area) and land use (green public spaces and parks).

c) Lifestyle/Behavioural: There has been increasing recognition that aspects of social, physical and cultural context can affect MH by facilitating or inhibiting behaviours that have an impact on well-being: alcohol consumption, violence, physical activity, and diet/obesity.

d) Healthcare provision and access: MH services accessibility are usually considered to be an important determinant of MH status. Therefore, provision of MH care will be assessed in each municipality through the “European Service Mapping Schedule (ESMS)”, which allows the assessment of the organization and provision of services in a given catchment area.

e) Physical environmental: components that present known associations with adverse MH outcomes (e.g. hazardous waste, climatic extremes, noise and motor traffic). f) Demographics: relevant for health, as gender and age, and immigrant population ratios.

2.2. Identification of indicators of Mental Health of the populations

a) Prevalence of psychiatric disorders at the municipality level: data base from the National Psychiatric Survey (2009) will be analysed, in order to provide the necessary evidence of the prevalence of mental disorders among the general population at country and municipalities levels.

b) Suicide mortality rates: 2010-2012 and 2000-2002 deaths and resident population in 2001 and 2011 will be analyzed in order to have information on deaths caused by suicide by place of residence, marital status, season, gender and occupation, before and during the financial crisis in Portugal.

c) Use of MH Services and characteristics of users of both inpatient and outpatient services: The use of inpatient and community MH services in the municipalities included in the study will be assessed through the “European Service Mapping Schedule (ESMS)”, an instrument to measure service provision and utilization. To assess characteristics of inpatients and outpatient mental patients, Diagnosis Related Groups (DRGs) for standardized psychiatric disorders rates (2010-2012, 2000-2002) will be analyzed in order to have information on key aspects of inpatient mental patients by place of residence (namely age, gender and comorbidities), before and during the financial crisis in Portugal. In addition to that, the characteristics of all patients that had at least one contact (inpatient and/or outpatient services) with the psychiatric departments of the studied municipalities during the last year will be assessed, through review of the participating Hospitals medical records. Variables to be studied will include diagnosis, number, types and duration of care interventions, and dropouts.

2.3. Satisfaction with the neighbourhood and the impact on Mental Health

To study the relationships of people’s perception of their neighbourhood both with objective indicators of its physical and social quality (employment/unemployment, social cohesion, access to walking areas and green spaces, services, e.g.) and with MH and wellbeing, we will assess the self-perception of mental health and satisfaction with the neighbourhood environment in:

a) a representative sub-sample of the group of patients identified; and

b) a representative sample of the regions´ population.

Perception of MH will be assessed with the “Mental Health Inventory -5”. Survey respondents will be linked to a census tract of residence using address matching software, and the census tract ID to the land-use data in a spatial overlay procedure. These data will allow us to investigate the contribution of neighbourhood urban form and of social environment to MH.

2.4. Statistical analyses

a) Association between hospital morbidity (Mental Disorders MD) and context (built and social environment): Data will be collected from different sources (routine and non-routine sources with information about outdoor and indoor physical and social environment variables: Regions´ councils, national statistics, local organizations and NGOs, etc.) to achieve neighborhood characteristics (e.g. violence and crime; employment rate; social cohesion; accessibility to health care; social network organization). Given the large amount of data, principal component and cluster analysis will be used to explore the data and to extract factor scores. Extracted factors must be strong and with internal consistency in order to assess the contextual dimensions. It will be possible to examine the association between the environmental and territorial context and MD, in the study population (a sub-sample of inpatients and outpatients records). The previous statistical analysis will allow, beyond national analysis of MD, the development of composite indexes of the hospitals’ catchment areas. This task will include the creation of the Geographical Information System (GIS) to support some further analysis and explanations about the impact of contextual determinants on MH of the residents in the catchment areas. Statistical multivariate methodologies (multiple and hierarchical regression models) will be used to explain and quantify the influence of environmental features on diagnosed mental illness and on the perception of MH and the assessment of the impact of environmental and territorial (contextual) effects and possible changes in MH, achieved by interventions in the patients’ area of residence.

b) Suicide hot-spots: To analyse the suicide inequalities in Portugal a descriptive analyses using Pearson’s chi-square test and t-test will be used to determine whether differences existed in age, marital status, year, season and between cases inside and outside high-risk spatial clusters. Annual age-adjusted cumulative incidence rates will also be calculated. Suicide incidence rates will be spatially smoothed using the Spatial Empirical Bayesian technique. Kulldorff’s spatiotemporal scan statistic will be applied to all suicide cases at the county level to identify areas (in a spatiotemporal context) with the highest risks of suicide.

3. Knowledge Translation

Knowledge to Action. Our findings will contribute to protect and promote MH, incorporating strategies to address the negative consequences of the financial crises in neighbourhood (economic deprivation, residential instability and other social determinants) and on individual MH. These results can be used as a support to regional and spatial planning aimed at promoting healthier communities and better living conditions with impact on general health and particularly in MH of the residents in the urban and rural areas. The current financial crisis makes measures of MH prevention and promotion even more important and cost-effective than during non-crisis periods. Five key activities were identified:

1) Including MH issues related with the financial crisis and with environmental and territorial context in the Health Agenda;

2) Bringing together spatial planning and MH professionals in a single forum to address MH equity;

3) Developing guidelines and tools for MH equity assessment and intervention;

4) Developing a mechanism to give information for decision makers, in a systematic and publicly available manner;

5) Assessing the impact of the above on influencing policy and practice.