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Benmarhnia, T, Bailey Z, Kaiser D, Auger N, King N, Kaufman JS.  2016.  A Difference-in-Differences Approach to Assess the Effect of a Heat Action Plan on Heat-Related Mortality, and Differences in Effectiveness According to Sex, Age, and Socioeconomic Status (Montreal, Quebec). Environmental Health Perspectives. 124:1694-1699.   10.1289/EHP203   AbstractWebsite

BACKGROUND: The impact of heat waves on mortality and health inequalities is well documented. Very few studies have assessed the effectiveness of heat action plans (HAPs) on health, and none has used quasi-experimental methods to estimate causal effects of such programs.OBJECTIVES: We developed a quasi-experimental method to estimate the causal effects associated with HAPs that allows the identification of heterogeneity across subpopulations, and to apply this method specifically to the case of the Montreal (Quebec, Canada) HAP.METHODS: A difference-in-differences approach was undertaken using Montreal death registry data for the summers of 2000-2007 to assess the effectiveness of the Montreal HAP, implemented in 2004, on mortality. To study equity in the effect of HAP implementation, we assessed whether the program effects were heterogeneous across sex (male vs. female), age (>= 65 years vs. < 65 years), and neighborhood education levels (first vs. third tertile). We conducted sensitivity analyses to assess the validity of the estimated causal effect of the HAP program.RESULTS: We found evidence that the HAP contributed to reducing mortality on hot days, and that the mortality reduction attributable to the program was greater for elderly people and people living in low-education neighborhoods.CONCLUSION: These findings show promise for programs aimed at reducing the impact of extreme temperatures and health inequities. We propose a new quasi-experimental approach that can be easily applied to evaluate the impact of any program or intervention triggered when daily thresholds are reached.

Heo, S, Nori-Sarma A, Lee K, Benmarhnia T, Dominici F, Bell ML.  2019.  The use of a quasi-experimental study on the mortality effect of a heat wave warning system in Korea. International Journal of Environmental Research and Public Health. 16   10.3390/ijerph16122245   AbstractWebsite

Many cities and countries have implemented heat wave warning systems to combat the health effects of extreme heat. Little is known about whether these systems actually reduce heat-related morbidity and mortality. We examined the effectiveness of heat wave alerts and health plans in reducing the mortality risk of heat waves in Korea by utilizing the discrepancy between the alerts and the monitored temperature. A difference-in-differences analysis combined with propensity score weighting was used. Mortality, weather monitoring, and heat wave alert announcement data were collected for 7 major cities during 2009-2014. Results showed evidence of risk reduction among people aged 19-64 without education (-0.144 deaths/1,000,000 people, 95% CI: -0.227, -0.061) and children aged 0-19 (-0.555 deaths/1,000,000 people, 95% CI: -0.993, -0.117). Decreased cardiovascular and respiratory mortality was found in several subgroups including single persons, widowed people, blue-collar workers, people with no education or the highest level of education (university or higher). No evidence was found for decreased all-cause mortality in the population (1.687 deaths/1,000,000 people per day; 95% CI: 1.118, 2.255). In conclusion, heat wave alerts may reduce mortality for several causes and subpopulations of age and socio-economic status. Further work needs to examine the pathways through which the alerts impact subpopulations differently.