Atherosclerosis Research and Reference Center (CIRAH), Havana, Cuba.
MEDICC Rev. 2013 Apr;15(2):10-5. doi: 10.37757/MR2013V15.N2.3.
A population health profile is a cumulative product of socioenvironmental and political factors that create the contexts in which health problems arise, as well as opportunities and barriers to addressing them. Research on context has focused on demonstrating its effects, direct or indirect, on health indicators, but has made few incursions into assessing its role as a mediator of other factors. While individual risk factors for chronic diseases are well known, the same cannot be said for the complex of contextual factors operating at various levels and over the lifespan.
Estimate relative influences by contextual versus individual factors as determinants of diabetes type 2 and heart disease.
A cross-sectional study was carried out in populations served by 12 family doctor-and-nurse practices in Havana, in 840 families selected by simple random sampling, 70 per practice. Principal components analysis was used, as well as contextual logistic regression models with a nested model strategy, whose fit was meant to estimate the relative contributions of contextual compared to individual risk factors for diabetes and heart disease. Context was described and analyzed at two levels: that of the family or household and that of the catchment area served by a family doctor-and-nurse practice (geographically defined as a neighborhood).
For diabetes, the contextual effect of neighborhood was modified when household effect was removed; that is, the effect of neighborhood was indirect and mediated by household. Individual coefficients were practically invariant; the principal effect of household changed noticeably on removal of individual effects, while age maintained its effect without variation. For heart disease, the effect of neighborhood was slightly modified when household effect was controlled for. Individual coefficients showed little change. There was an important direct effect of household on risk of heart disease. Age and high blood pressure coefficients hardly varied.
We confirmed interactions between individual and contextual (neighborhood and household) factors, whose effects on individual health are not entirely mediated by individual factors. Research needs to pay more attention to context beyond its direct effect on individual risk factors.
人口健康状况是社会环境和政治因素的累积产物，这些因素创造了健康问题产生的背景，以及解决这些问题的机会和障碍。关于背景的研究侧重于展示其对健康指标的直接或间接影响，但很少涉及评估其作为其他因素中介的作用。虽然慢性病的个体危险因素众所周知，但对于在不同层面和整个生命周期发挥作用的复杂环境因素却知之甚少。
估计环境因素与个体因素作为 2 型糖尿病和心脏病决定因素的相对影响。
在哈瓦那的 12 个家庭医生和护士诊所服务的人群中进行了一项横断面研究，在 840 个家庭中进行了简单随机抽样，每个诊所 70 个家庭。采用主成分分析，以及具有嵌套模型策略的环境逻辑回归模型，其拟合旨在估计与个体危险因素相比，环境因素对糖尿病和心脏病的相对贡献。环境在两个层面上进行了描述和分析：家庭或家庭层面以及家庭医生和护士诊所服务的集水区（地理上定义为邻里）层面。
对于糖尿病，当去除家庭效应时，邻里的环境效应发生了变化；也就是说，邻里的影响是间接的，是由家庭介导的。个体系数实际上是不变的；家庭的主要影响在去除个体影响时明显发生变化，而年龄保持不变。对于心脏病，当控制家庭影响时，邻里的影响略有改变。个体系数变化不大。家庭对心脏病风险有重要的直接影响。年龄和高血压系数几乎没有变化。
我们证实了个体和环境（邻里和家庭）因素之间的相互作用，这些因素对个体健康的影响并非完全由个体因素介导。研究需要更多关注环境，而不仅仅是其对个体危险因素的直接影响。
