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Benmarhnia, T, Alexander S, Price K, Smargiassi A, King N, Kaufman JS.  2018.  The heterogeneity of vulnerability in public health: a heat wave action plan as a case study. Critical Public Health. 28:619-625.   10.1080/09581596.2017.1322176   AbstractWebsite

The concept of vulnerability is frequently used in public health policies to develop tailored interventions or dedicate proportionately more resources to certain sub-populations. However, once segments of the population are identified as vulnerable, they are rarely consulted regarding whether this label is acceptable before instituting interventions. Instead, it is implicitly assumed that the targeted individuals identify themselves as vulnerable and experience an unambiguous and consistent need for public health assistance. In this paper, using public health interventions during heat waves as a case study, we question such assumptions. A qualitative study was conducted in Montreal, Canada involving two focus groups among populations specifically targeted by the heat action plan as vulnerable: one composed of individuals diagnosed with schizophrenia, and one composed of individuals who have alcohol or drug addictions. Findings revealed significant heterogeneity in the definition and experience of vulnerability as it is used in the context of a heat action plan in Montreal. We found differences between the two focus groups in several areas including sources of information they had access to within the heat action plan measures and their perspectives regarding the appropriateness of specific measures in the heat action plan. We then observed differences within each of the focus groups in several areas including their social networks relationships. The concept of vulnerability is often used in public health policies. Yet, while this concept may be convenient for shaping policies to reduce inequalities in health, the heterogeneity of populations defined as vulnerable should not be underestimated.

Schinasi, LH, Benmarhnia T, De Roos AJ.  2018.  Modification of the association between high ambient temperature and health by urban microclimate indicators: A systematic review and meta-analysis. Environmental Research. 161:168-180.   10.1016/j.envres.2017.11.004   AbstractWebsite

Background: Landscape characteristics, including vegetation and impervious surfaces, influence urban micro climates and may lead to within-city differences in the adverse health effects of high ambient temperatures. Objective: Our objective was to quantitatively summarize the epidemiologic literature that assessed microclimate indicators as effect measure modifiers (EMM) of the association between ambient temperature and mortality or morbidity. Methods: We systematically identified papers and abstracted relative risk estimates for hot and cool micro climate indicator strata. We calculated the ratio of the relative risks (RRR) and 95% confidence intervals (95% CI) to assess differences in health effects across strata, and pooled the RRR estimates using random effects meta analyses. Results: Eleven papers were retained. In the pooled analyses, people living in hotter areas within cities (based on land surface temperature or modeled estimates of air temperature) had 6% higher risk of mortality/morbidity compared to those in cooler areas (95% CI: 1.03-1.09). Those living in less vegetated areas had 5% higher risk compared to those living in more vegetated areas (95% CI: 1.00-1.11). Discussion: There is epidemiologic evidence that those living in hotter, and less vegetated areas of cities have higher risk of morbidity or mortality from higher ambient temperature. Further research with improved assessment of landscape characteristics and investigation of the joint effects of physiologic adaptation and landscape will advance the current understanding. Conclusion: This review provides quantitative evidence that intra-urban differences in landscape characteristics and micro-urban heat islands contribute to within-city variability in the health effects of high ambient temperatures.

Benmarhnia, T, Kihal-Talantikite W, Ragettli MS, Deguen S.  2017.  Small-area spatiotemporal analysis of heatwave impacts on elderly mortality in Paris: A cluster analysis approach. Science of the Total Environment. 592:288-294.   10.1016/j.scitotenv.2017.03.102   AbstractWebsite

Background: Heat-waves have a substantial public health burden. Understanding spatial heterogeneity at a fine spatial scale in relation to heat and related mortality is central to target interventions towards vulnerable communities. Objectives: To determine the spatial variability of heat-wave-related mortality risk among elderly in Paris, France at the census block level. We also aimed to assess area-level social and environmental determinants of high mortality risk within Paris. Methods: We used daily mortality data from 2004 to 2009 among people aged >65 at the French census block level within Paris. We used two heat wave days' definitions that were compared to non-heat wave days. A Bernoulli cluster analysis method was applied to identify high risk clusters of mortality during heat waves. We performed random effects meta-regression analyses to investigate factors associated with the magnitude of the mortality risk. Results: The spatial approach revealed a spatial aggregation of death cases during heat wave days. We found that small scale chronic PM10 exposure was associated with a 0.02 (95% CI: 0.001; 0.045) increase of the risk of dying during a heat wave episode. We also found a positive association with the percentage of foreigners and the percentage of labor force, while the proportion of elderly people living in the neighborhoodwas negatively associated. We also found that green space density had a protective effect and inversely that the density of constructed feature increased the risk of dying during a heat wave episode. Conclusion: We showed that a spatial variation in terms of heat-related vulnerability exists within Paris and that it can be explained by some contextual factors. This study can be useful for designing interventions targeting more vulnerable areas and reduce the burden of heat waves. (C) 2017 Elsevier B.V. All rights reserved.

Benmarhnia, T, Oulhote Y, Petit C, Lapostolle A, Chauvin P, Zmirou-Navier D, Deguen S.  2014.  Chronic air pollution and social deprivation as modifiers of the association between high temperature and daily mortality. Environmental Health. 13   Artn 5310.1186/1476-069x-13-53   AbstractWebsite

Background: Heat and air pollution are both associated with increases in mortality. However, the interactive effect of temperature and air pollution on mortality remains unsettled. Similarly, the relationship between air pollution, air temperature, and social deprivation has never been explored.Methods: We used daily mortality data from 2004 to 2009, daily mean temperature variables and relative humidity, for Paris, France. Estimates of chronic exposure to air pollution and social deprivation at a small spatial scale were calculated and split into three strata. We developed a stratified Poisson regression models to assess daily temperature and mortality associations, and tested the heterogeneity of the regression coefficients of the different strata. Deaths due to ambient temperature were calculated from attributable fractions and mortality rates were estimated.Results: We found that chronic air pollution exposure and social deprivation are effect modifiers of the association between daily temperature and mortality. We found a potential interactive effect between social deprivation and chronic exposure with regards to air pollution in the mortality-temperature relationship.Conclusion: Our results may have implications in considering chronically polluted areas as vulnerable in heat action plans and in the long-term measures to reduce the burden of heat stress especially in the context of climate change.