Resumo O estudo analisou a distribuição espacial e as desigualdades sociais na cobertura vacinal para COVID-19 entre crianças de 5 a 11 anos no Brasil. As coberturas vacinais foram calculadas para os municípios brasileiros e analisadas por região geográfica e decis com base no Índice de Desenvolvimento Humano (IDH-M) e expectativa de escolaridade aos 18 anos. Modelos multiníveis foram usados para determinar o coeficiente de partição da variância, e a estatística local bivariada de Moran I foi usada para avaliar a associação espacial. Os resultados mostraram diferenças significativas nas taxas de cobertura vacinal entre os municípios, com menor cobertura nas regiões Norte e Centro-Oeste. Municípios com menor IDH e anos de escolaridade esperados apresentaram menores taxas de cobertura vacinal. A análise de agrupamento bivariado identificou extensas concentrações de municípios nas regiões Norte e Nordeste com baixa cobertura vacinal e baixo desenvolvimento humano, enquanto alguns aglomerados de municípios nas regiões Sudeste e Sul com baixa cobertura localizavam-se em áreas com alto IDH-M. Essas descobertas destacam as desigualdades persistentes em nível municipal na cobertura vacinal entre crianças e a necessidade de intervenções para melhorar o acesso e a cobertura vacinal em áreas mais vulneráveis. COVID19 COVID 19 COVID-1 1 Brasil IDHM M (IDH-M variância CentroOeste. CentroOeste Centro Oeste. Oeste Centro-Oeste humano localizavamse localizavam se IDHM. M. IDH-M vulneráveis COVID1 COVID-

Abstract This study examined the spatial distribution and social inequalities in COVID-19 vaccine coverage among children aged 5-11 in Brazil. First and second dose vaccine coverage was calculated for all Brazilian municipalities and analyzed by geographic region and deciles based on human development index (HDI-M) and expected years of schooling at 18 years of age. Multilevel models were used to determine the variance partition coefficient, and bivariate local Moran’s I statistic was used to assess spatial association. Results showed significant differences in vaccine coverage rates among Brazilian municipalities, with lower coverage in the North and Midwest regions. Municipalities with lower HDI and expected years of schooling had consistently lower vaccine coverage rates. Bivariate clustering analysis identified extensive concentrations of municipalities in the Northern and Northeastern regions with low vaccine coverage and low human development, while some clusters of municipalities in the Southeast and South regions with low coverage were located in areas with high HDI-M. These findings highlight the persistent municipal-level inequalities in vaccine coverage among children in Brazil and the need for targeted interventions to improve vaccine access and coverage in underserved areas. COVID19 COVID 19 COVID-1 511 5 11 5-1 HDIM M (HDI-M 1 age coefficient Morans Moran s association HDIM. M. HDI-M municipallevel municipal level COVID1 COVID- 51 5-

Resumo O estudo analisou a distribuição espacial e as desigualdades sociais na cobertura vacinal para COVID-19 entre crianças de 5 a 11 anos no Brasil. As coberturas vacinais foram calculadas para os municípios brasileiros e analisadas por região geográfica e decis com base no Índice de Desenvolvimento Humano (IDH-M) e expectativa de escolaridade aos 18 anos. Modelos multiníveis foram usados para determinar o coeficiente de partição da variância, e a estatística local bivariada de Moran I foi usada para avaliar a associação espacial. Os resultados mostraram diferenças significativas nas taxas de cobertura vacinal entre os municípios, com menor cobertura nas regiões Norte e Centro-Oeste. Municípios com menor IDH e anos de escolaridade esperados apresentaram menores taxas de cobertura vacinal. A análise de agrupamento bivariado identificou extensas concentrações de municípios nas regiões Norte e Nordeste com baixa cobertura vacinal e baixo desenvolvimento humano, enquanto alguns aglomerados de municípios nas regiões Sudeste e Sul com baixa cobertura localizavam-se em áreas com alto IDH-M. Essas descobertas destacam as desigualdades persistentes em nível municipal na cobertura vacinal entre crianças e a necessidade de intervenções para melhorar o acesso e a cobertura vacinal em áreas mais vulneráveis.

Abstract This study examined the spatial distribution and social inequalities in COVID-19 vaccine coverage among children aged 5-11 in Brazil. First and second dose vaccine coverage was calculated for all Brazilian municipalities and analyzed by geographic region and deciles based on human development index (HDI-M) and expected years of schooling at 18 years of age. Multilevel models were used to determine the variance partition coefficient, and bivariate local Moran’s I statistic was used to assess spatial association. Results showed significant differences in vaccine coverage rates among Brazilian municipalities, with lower coverage in the North and Midwest regions. Municipalities with lower HDI and expected years of schooling had consistently lower vaccine coverage rates. Bivariate clustering analysis identified extensive concentrations of municipalities in the Northern and Northeastern regions with low vaccine coverage and low human development, while some clusters of municipalities in the Southeast and South regions with low coverage were located in areas with high HDI-M. These findings highlight the persistent municipal-level inequalities in vaccine coverage among children in Brazil and the need for targeted interventions to improve vaccine access and coverage in underserved areas.

ABSTRACT We analyzed data from the National School-based Health Survey (PeNSE) carried out in Brazil in 2015 (n = 102,072 adolescents) to estimate how much of the individual variance in the prevalence of health behaviors is attributable to the school level. Multilevel logistic regression models were calculated to estimate the variance partitional coefficient (VPC) of the use of drugs, intake of unhealthy food, leisure physical activity and weight-related behaviors. The between-schools variance was significant in all tested models. The highest VPCs were observed when the use of drugs was analyzed (15%-20% of the total variance of smoking and use of illegal drugs). Lower, but still significant, values were observed in the other outcomes. The school context plays an important role in the adolescents’ health and should be considered in the design of public policies and actions in public health.

RESUMO: Introdução: O objetivo do presente estudo foi investigar a associação de quatro diferentes fatores de risco para doenças crônicas e seu acúmulo com o nível educacional da vizinhança de moradia, controlando-se por características individuais. Métodos: Um estudo transversal de base populacional foi realizado no sul do Brasil com 1.720 adultos, em 2009/2010. A ocorrência simultânea de tabagismo, uso abusivo de álcool, hábitos alimentares não saudáveis e inatividade física foi investigada. Modelos multiníveis testaram se a educação da vizinhança estava associada com cada fator de risco e com a co-ocorrência deles, ajustando-se por variáveis individuais. Resultados: Houve variância entregrupos (VPC) de 7,79, 7,11, 6,84 e 1,08% para inatividade física, uso problemático de álcool, hábitos alimentares não saudáveis e tabagismo, respectivamente. O VPC para a combinação dos quatro comportamentos foi de 14,2%. A educação da vizinhança explicou significativa proporção da variância da inatividade física e dos hábitos alimentares não saudáveis. Residentes de vizinhanças que tinham baixo nível educacional mostraram 2,40 (IC95% 1.58 - 3.66) vezes mais chance de hábitos alimentares não saudáveis e 1,78 (IC95% 1.19 - 2.67) vez mais chance de inatividade física. A probabilidade de indivíduos terem dois ou mais fatores de risco simultâneos foi maior entre residentes de vizinhanças com nível educacional mais baixo. Conclusão: Políticas públicas devem considerar características da vizinhança, incluindo a educação, quando tiverem como objetivo controlar os fatores de risco para doenças crônicas.

ABSTRACT: Introduction: This study aimed to investigate the association of four different risk factors for chronic diseases and accumulation of these health behaviors with area-level education, regardless of individual-level characteristics in Brazil. Methods: A population-based cross-sectional study was carried out in Southern Brazil including 1,720 adults in 2009/2010. The simultaneous occurrence of tobacco smoking, abusive drinking, unhealthy eating habits, and physical inactivity was investigated. Using multilevel models, we tested whether area-level education was associated with each risk factor and with the co-occurrence of them after controlling sociodemographic individual-level variables. Results: We observed a between-group variance of 7.79, 7.11, 6.84 and 1.08% for physical inactivity, problematic use of alcohol, unhealthy eating habits, and smoking, respectively. The between-group variance for the combination of four behaviors was 14.2%. Area-level education explained a significant proportion of the variance observed in physical inactivity and unhealthy eating habits. Residents of low educational level neighborhoods showed a 2.40 (95%CI 1.58 - 3.66) times higher chance of unhealthy eating and 1.78 (95%CI 1.19 - 2.67) times higher chance of physical inactivity. The likelihood of individuals with two or three/four risk factors was simultaneously higher among residents of low educational level neighborhoods. Conclusion: Public policies should consider the area-level characteristics, including education to control risk factors for chronic diseases.

RESUMO: Introdução: O objetivo do presente estudo foi investigar a associação de quatro diferentes fatores de risco para doenças crônicas e seu acúmulo com o nível educacional da vizinhança de moradia, controlando-se por características individuais. Métodos: Um estudo transversal de base populacional foi realizado no sul do Brasil com 1.720 adultos, em 2009/2010. A ocorrência simultânea de tabagismo, uso abusivo de álcool, hábitos alimentares não saudáveis e inatividade física foi investigada. Modelos multiníveis testaram se a educação da vizinhança estava associada com cada fator de risco e com a co-ocorrência deles, ajustando-se por variáveis individuais. Resultados: Houve variância entregrupos (VPC) de 7,79, 7,11, 6,84 e 1,08% para inatividade física, uso problemático de álcool, hábitos alimentares não saudáveis e tabagismo, respectivamente. O VPC para a combinação dos quatro comportamentos foi de 14,2%. A educação da vizinhança explicou significativa proporção da variância da inatividade física e dos hábitos alimentares não saudáveis. Residentes de vizinhanças que tinham baixo nível educacional mostraram 2,40 (IC95% 1.58 - 3.66) vezes mais chance de hábitos alimentares não saudáveis e 1,78 (IC95% 1.19 - 2.67) vez mais chance de inatividade física. A probabilidade de indivíduos terem dois ou mais fatores de risco simultâneos foi maior entre residentes de vizinhanças com nível educacional mais baixo. Conclusão: Políticas públicas devem considerar características da vizinhança, incluindo a educação, quando tiverem como objetivo controlar os fatores de risco para doenças crônicas.

ABSTRACT: Introduction: This study aimed to investigate the association of four different risk factors for chronic diseases and accumulation of these health behaviors with area-level education, regardless of individual-level characteristics in Brazil. Methods: A population-based cross-sectional study was carried out in Southern Brazil including 1,720 adults in 2009/2010. The simultaneous occurrence of tobacco smoking, abusive drinking, unhealthy eating habits, and physical inactivity was investigated. Using multilevel models, we tested whether area-level education was associated with each risk factor and with the co-occurrence of them after controlling sociodemographic individual-level variables. Results: We observed a between-group variance of 7.79, 7.11, 6.84 and 1.08% for physical inactivity, problematic use of alcohol, unhealthy eating habits, and smoking, respectively. The between-group variance for the combination of four behaviors was 14.2%. Area-level education explained a significant proportion of the variance observed in physical inactivity and unhealthy eating habits. Residents of low educational level neighborhoods showed a 2.40 (95%CI 1.58 - 3.66) times higher chance of unhealthy eating and 1.78 (95%CI 1.19 - 2.67) times higher chance of physical inactivity. The likelihood of individuals with two or three/four risk factors was simultaneously higher among residents of low educational level neighborhoods. Conclusion: Public policies should consider the area-level characteristics, including education to control risk factors for chronic diseases.

ABSTRACT We analyzed data from the National School-based Health Survey (PeNSE) carried out in Brazil in 2015 (n = 102,072 adolescents) to estimate how much of the individual variance in the prevalence of health behaviors is attributable to the school level. Multilevel logistic regression models were calculated to estimate the variance partitional coefficient (VPC) of the use of drugs, intake of unhealthy food, leisure physical activity and weight-related behaviors. The between-schools variance was significant in all tested models. The highest VPCs were observed when the use of drugs was analyzed (15%-20% of the total variance of smoking and use of illegal drugs). Lower, but still significant, values were observed in the other outcomes. The school context plays an important role in the adolescents’ health and should be considered in the design of public policies and actions in public health.

ABSTRACT OBJECTIVE To test if the neighborhood socioeconomic status is associated with systolic blood pressure and hypertension in older adults. METHODS A cross-sectional population-based study with a sample of 1,705 older adults from Florianópolis, SC, Southern Brazil. The contextual variable used was the average years of schooling of the head of the household in census tracts. Participants were considered hypertensive when the systolic blood pressure was ≥ 140 mmHg, diastolic ≥ 90 mmHg, or both. Additionally, the use of antihypertensive medication was also considered. Data were analyzed by using multilevel models of logistic and linear regression. RESULTS The average age of the sample was 70.7 years and the average of systolic and diastolic blood pressure was 133.5 mmHg (SD = 20.5 mmHg) and 81.9 mmHg (SD = 12.5 mmHg), respectively. The systolic blood pressure was 4.46 mmHg (95%CI 1.00–7.92) higher and the chance of hypertension was 1.80 (95%CI 1.26–2.57) among those who lived in census tracts with lower level of schooling. When the use of antihypertensive medication was combined with blood pressure levels, none association was found between the outcome and the level of schooling of the census tract. CONCLUSIONS Analytical models more robust (such as multilevel analysis) in Brazil are still little used, with a small number of articles published. Neighborhood socioeconomic status is associated with systolic blood pressure and the chance of hypertension, regardless of individual characteristics.

ABSTRACT OBJECTIVE To test if the neighborhood socioeconomic status is associated with systolic blood pressure and hypertension in older adults. METHODS A cross-sectional population-based study with a sample of 1,705 older adults from Florianópolis, SC, Southern Brazil. The contextual variable used was the average years of schooling of the head of the household in census tracts. Participants were considered hypertensive when the systolic blood pressure was ≥ 140 mmHg, diastolic ≥ 90 mmHg, or both. Additionally, the use of antihypertensive medication was also considered. Data were analyzed by using multilevel models of logistic and linear regression. RESULTS The average age of the sample was 70.7 years and the average of systolic and diastolic blood pressure was 133.5 mmHg (SD = 20.5 mmHg) and 81.9 mmHg (SD = 12.5 mmHg), respectively. The systolic blood pressure was 4.46 mmHg (95%CI 1.00–7.92) higher and the chance of hypertension was 1.80 (95%CI 1.26–2.57) among those who lived in census tracts with lower level of schooling. When the use of antihypertensive medication was combined with blood pressure levels, none association was found between the outcome and the level of schooling of the census tract. CONCLUSIONS Analytical models more robust (such as multilevel analysis) in Brazil are still little used, with a small number of articles published. Neighborhood socioeconomic status is associated with systolic blood pressure and the chance of hypertension, regardless of individual characteristics.

OBJECTIVE: To assess the value of self-rated health assessments by examining the association between education and self-rated poor health. METHODS: We used the globally representative population-based sample from the 2002 World Health Survey, composed of 219 713 men and women aged 25 and over in 69 countries, to examine the association between education and self-rated poor health. In a binary regression model with a logit link function, we used self-rated poor health as the binary dependent variable, and age, sex and education as the independent variables. FINDINGS: Globally, there was an inverse association between years of schooling and self-rated poor health (odds ratio, OR: 0.929; 95% confidence interval, CI: 0.926-0.933). Compared with the individuals in the highest quintile of years of schooling, those in the lowest quintile were twice as likely to report poor health (OR: 2.292; 95% CI: 2.165-2.426). We found a dose-response relationship between quintiles of years of schooling and the ORs for reporting poor health.This association was consistent among men and women; low-, middle- and high-income countries; and regions. CONCLUSION: Our findings suggest that self-reports of health may be useful for epidemiological investigations within countries, even in low-income settings.

OBJETIVO: Determinar la utilidad de las autopuntuaciones de la salud estudiando la relación entre el nivel educativo y el nivel de salud declarado por las personas. MÉTODOS: Utilizamos la muestra poblacional representativa a nivel mundial de la Encuesta Mundial de Salud 2002, constituida por 219 713 hombres y mujeres de más de 25 años de 69 países, a fin de examinar la relación entre el nivel educativo y los problemas de salud autopuntuados por las personas. Aplicando un modelo de regresión binaria con una función de enlace logit, usamos la mala salud cuantificada por los propios interesados como variable dependiente binaria, y la edad, el sexo y la educación como variables independientes. RESULTADOS: Se observa a nivel mundial una relación inversa entre los años de escolarización y la autopuntuación de la mala salud (riesgo relativo aproximado, OR: 0,929; intervalo de confianza del 95%: 0,926-0,933). En comparación con las personas del quintil superior de años de escolarización, las situadas en el quintil inferior presentaban el doble de probabilidades de declararproblemas de salud (OR:2,292; IC95%: 2,165-2,426). Observamos una relación dosis-respuesta entre los quintiles de años de escolarización y los OR de declaración de mala salud, y esa relación se observó tanto en hombres como en mujeres; en países de ingresos bajos, medios y altos; y en todas las regiones. CONCLUSIÓN: Nuestros resultados parecen indicar que las autoevaluaciones de la salud pueden ser de utilidad para las investigaciones epidemiológicas en los países, incluso en los entornos de ingresos bajos.

OBJECTIF: Évaluer la valeur des auto-évaluations de l'état de santé en étudiant l'association entre niveau d'éducation et auto-déclaration d'un mauvais état de santé. MÉTHODES: Nous avons utilisé un échantillon représentatif de la population mondiale tiré de l'Enquête sur la santé dans le monde 2002 et composé de 219 713 hommes et femmes, âgés de 25 ans et plus et appartenant à plus de 69 pays, pour étudier l'association entre niveau d'éducation et auto-déclaration d'un mauvais état de santé. Dans un modèle de régression binaire faisant appel à une fonction de lien logit, nous avons utilisé l'auto- déclaration d'un mauvais état de santé comme variable binaire dépendante, et l'âge, le sexe et le niveau d'éducation comme variables indépendantes. RÉSULTATS: A l'échelle mondiale, nous avons relevé une association inverse entre le nombre d'années de scolarité et l'auto-déclaration d'un mauvais état de santé (Odds ratio, OR : 0,929 ; intervalle de confiance à 95 %, IC : 0,926-0,933). Par rapport aux individus du quintile totalisant le plus grand nombre d'années de scolarité, ceux appartenant au quintile de plus bas niveau d'éducation avaient une probabilité deux fois plus forte de se déclarer en mauvaise santé (OR : 2,292 ; IC à 95 % : 2,165-2,426). Nous avons observé une relation dose-réponse entre les quintiles d'années de scolarité et les Odds ratios correspondant à la déclaration d'une mauvaise santé. Cette association apparaissait de manière cohérente chez les hommes et les femmes, dans les pays à faible revenu comme dans ceux à revenu moyen et élevé et dans les différentes régions. CONCLUSION: Nos résultats laissent à penser que les auto- évaluations de l'état de santé peuvent être utiles aux investigations épidémiologiques dans les pays, y compris dans les pays à faible revenu.

Com o aumento da asma observado em nível mundial nas últimas três décadas, também ficou claro que se trata de uma doença social, conforme evidenciado por indicadores demográficos e socioeconômicos agrupados por áreas residenciais. Esta tendência não pode ser explicada apenas por paradigmas genéticos tradicionais ou influência física do ambiente, quando considerados isoladamente. Por isso passou-se a considerar a interação entre riscos ambientais físicos e psicológicos e os determinantes de risco moleculares e genéticos (i.e. enquadramento biomédico) no âmbito de um contexto socioambiental mais amplo, incluindo a posição socioeconômica como "causa das causas" (i.e. enquadramento ecológico). Estratégias de pesquisa transdisciplinares ou programas que acolhem esta complexidade por meio de uma estrutura conceitual comum integrando teorias, modelos, medidas e métodos analíticos específicos das diversas disciplinas à pesquisa atual da asma podem representar contribuições particularmente significantes a uma melhor compreensão de uma doença social. Este artigo em forma de relato de caso pretende dar uma visão geral de um estudo longitudinal usando vários níveis e métodos - o Asthma Coalition on Community, Environment and Social Stress (ACCESS) -, para mostrar as oportunidades e desafios de um estudo transdisciplinar investigando a expressão urbana da asma nos Estados Unidos.

As we have seen a global increase in asthma in the past three decades it has also become clear that it is a socially patterned disease, based on demographic and socioeconomic indicators clustered by areas of residence. This trend is not readily explained by traditional genetic paradigms or physical environmental exposures when considered alone. This has led to consideration of the interplay among physical and psychosocial environmental hazards and the molecular and genetic determinants of risk (i.e., biomedical framing) within the broader socioenvironmental context including socioeconomic position as an upstream "cause of the causes" (i.e., ecological framing). Transdisciplinary research strategies or programs that embrace this complexity through a shared conceptual framework that integrates diverse discipline-specific theories, models, measures, and analytical methods into ongoing asthma research may contribute most significantly toward furthering our understanding of socially patterned disease. This paper provides an overview of a multilevel, multimethod longitudinal study, the Asthma Coalition on Community, Environment and Social Stress (ACCESS), as a case study to exemplify both the opportunities and challenges of transdisciplinary research on urban asthma expression in the United States.

Com o aumento da asma observado em nível mundial nas últimas três décadas, também ficou claro que se trata de uma doença social, conforme evidenciado por indicadores demográficos e socioeconômicos agrupados por áreas residenciais. Esta tendência não pode ser explicada apenas por paradigmas genéticos tradicionais ou influência física do ambiente, quando considerados isoladamente. Por isso passou-se a considerar a interação entre riscos ambientais físicos e psicológicos e os determinantes de risco moleculares e genéticos (i.e. enquadramento biomédico) no âmbito de um contexto socioambiental mais amplo, incluindo a posição socioeconômica como "causa das causas" (i.e. enquadramento ecológico). Estratégias de pesquisa transdisciplinares ou programas que acolhem esta complexidade por meio de uma estrutura conceitual comum integrando teorias, modelos, medidas e métodos analíticos específicos das diversas disciplinas à pesquisa atual da asma podem representar contribuições particularmente significantes a uma melhor compreensão de uma doença social. Este artigo em forma de relato de caso pretende dar uma visão geral de um estudo longitudinal usando vários níveis e métodos - o Asthma Coalition on Community, Environment and Social Stress (ACCESS) -, para mostrar as oportunidades e desafios de um estudo transdisciplinar investigando a expressão urbana da asma nos Estados Unidos.

As we have seen a global increase in asthma in the past three decades it has also become clear that it is a socially patterned disease, based on demographic and socioeconomic indicators clustered by areas of residence. This trend is not readily explained by traditional genetic paradigms or physical environmental exposures when considered alone. This has led to consideration of the interplay among physical and psychosocial environmental hazards and the molecular and genetic determinants of risk (i.e., biomedical framing) within the broader socioenvironmental context including socioeconomic position as an upstream "cause of the causes" (i.e., ecological framing). Transdisciplinary research strategies or programs that embrace this complexity through a shared conceptual framework that integrates diverse discipline-specific theories, models, measures, and analytical methods into ongoing asthma research may contribute most significantly toward furthering our understanding of socially patterned disease. This paper provides an overview of a multilevel, multimethod longitudinal study, the Asthma Coalition on Community, Environment and Social Stress (ACCESS), as a case study to exemplify both the opportunities and challenges of transdisciplinary research on urban asthma expression in the United States.