Safe nurse staffing standards in hospitals saves lives and lowers costs

UNIVERSITY OF PENNSYLVANIA SCHOOL OF NURSING

Research News

 

IMAGE: LINDA H. AIKEN, PHD, RN, PROFESSOR AND FOUNDING DIRECTOR OF THE CENTER FOR HEALTH OUTCOMES AND POLICY RESEARCH AT THE UNIVERSITY OF PENNSYLVANIA SCHOOL OF NURSING. view more 

CREDIT: PENN NURSING

Philadelphia and Santiago -A new study published in The Lancet Global Health showed that establishing safe nurse staffing standards in hospitals in Chile could save lives, prevent readmissions, shorten hospital stays, and reduce costs.

The study, by the Center for Health Outcomes and Policy Research (CHOPR) at the University of Pennsylvania School of Nursing, and the Universidad de los Andes - Chile School of Nursing, found very large variations in patient to nurse staffing across 40 hospitals located throughout Chile. Nurse staffing was significantly better in private compared to public hospitals. Differences in nurse staffing across public hospitals were found to be associated with avoidable deaths and higher than necessary costs, "Nursing has been overlooked in Chile as a solution to healthcare quality and access problems; this study shows investments in improving hospital nurse staffing would result in higher quality of care and greater productivity which could improve access to public hospitals," said lead-author Linda H. Aiken, PhD, RN, Professor and Founding Director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

The researchers collected extensive data from 1652 nurses practicing in 40 Chilean complex general acute hospitals and analyzed outcomes for more than 761,948 patients. They found that:

• Nurse staffing in Chilean hospitals is much worse than international standards. On average, nurses in hospitals in Chile care for 14 patients each compared to 5 patients each in the US and Australia where legislation sets safe nurse staffing standards. Variation in nurse staffing is great across Chilean public complex hospitals with patient to nurse ratios as high as 24 patients per nurse.
• Variation in hospital nurse staffing results in avoidable deaths. Patients in hospitals where nurses were responsible for 18 patients each had 41 percent higher risk of death compared to patients in hospitals where nurses cared for 8 patients each.
• Better hospital nurse staffing would reduce costs of care enough to fund additional needed nurses. Researchers estimated that in poorly nurse staffed hospitals the average length of stay was significantly longer and more patients had to be readmitted after discharge because of complications. Improving nurse staffing to 10 patients per nurse could save over $29 million USD a year from avoided hospital days which would more than pay for the costs of employing the 1,118 additional nurses needed
• Study revealed that the availability of hospital beds was adversely affected by poor nurse staffing. Research revealed that if Chilean public hospitals staffed at levels where nurses cared for no more than 10 patients each, more than 100,000 days of inpatient care could be avoided annually from shorter stays and reduced readmissions which would contribute to reducing hospital admission waiting lists.
• Chile has a sufficiency large supply of nurses to staff hospitals at much improved levels. Chile has an excellent nurse education system which graduates more than 6,000 nurses a year all with bachelor's degrees.

"The findings from this study suggest that Chile has the resources and the means to improve nurse staffing in public hospitals to enhance access to high quality hospital care in the country," said Marta Simonetti, PhD, RN, the lead researcher at Universidad de los Andes - Chile,

The state of Queensland in Australia recently successfully implemented safe hospital nurse staffing standards that research shows saved lives and money and which could serve as a model for consideration in Chile.

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The study was carried out by the Universidad de los Andes - Chile School of Nursing and Clínica Universidad de los Andes in partnership with the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing and the Population Research Center at the University of Pennsylvania.

Spanish translation: https://www.uandes.cl/wp-content/uploads/2021/06/LGH-press-release-spanish-.pdf

About the University of Pennsylvania School of Nursing

The University of Pennsylvania School of Nursing is one of the world's leading schools of nursing. For the sixth year in a row, it is ranked the #1 nursing school in the world by QS University and is consistently ranked highly in the U.S. News & World Report annual list of best graduate schools. Penn Nursing is ranked # 1 in funding from the National Institutes of Health. Penn Nursing prepares nurse scientists and nurse leaders to meet the health needs of a global society through innovation in research, education, and practice. Follow Penn Nursing on: Facebook, Twitter, LinkedIn, & Instagram.

About the Universidad de los Andes - Chile School of Nursing and Clínica Universidad de los Andes.

The Universidad de los Andes School of Nursing has been ranked among the top five nursing schools in Chile. It is the first private nursing school to achieve national accreditation for the longest possible period. For almost 30 years, it has been preparing highly qualified nurses to meet the care needs of the population. Clínica Universidad de los Andes is the university teaching hospital. In its short history, of only seven years, it has rapidly gained reputation for its quality and safety standards and its patient-centered model of care.

Follow the Universidad de los Andres School of Nursing on: Facebook & Instagram.

Follow Clínica Universidad de los Andes on: Facebook, Twitter, LinkedIn & Instagram.

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion

Kirsten M. J. Thompson, MPH¹; Hugh J. W. Sturrock, PhD²; Diana Greene Foster, PhD³; et alUshma D. Upadhyay, PhD, MPH³

Author Affiliations Article Information

JAMA Netw Open. 2021;4(7):e2115530. doi:10.1001/jamanetworkopen.2021.15530

Original Investigation 

Obstetrics and Gynecology

July 6, 2021

Key Points

Question  Is there an association between median travel distance to an abortion facility and abortion rate?

Findings  In this cross-sectional geographic analysis of US counties, increases in median travel distance to the nearest abortion care facility were associated with significant reductions in median abortion rate (21.1 per 1000 female residents of reproductive age for <5 miles; 3.9 per 1000 female residents of reproductive age for ≥120 miles). Reductions in travel distances were associated with significant increases in the median abortion rate (telemedicine simulation, 10.2 per 1000 female residents of reproductive age).

Meaning  In this study, the abortion rates declined as travel distance to an abortion care facility increased, and modeling suggests the need for abortion care can be only partially met through service delivery innovations.

Abstract

Importance  Travel distance to abortion services varies widely in the US. Some evidence shows travel distance affects use of abortion care, but there is no national analysis of how abortion rate changes with travel distance.

Objective  To examine the association between travel distance to the nearest abortion care facility and the abortion rate and to model the effect of reduced travel distance.

Design, Setting, and Participants  This cross-sectional geographic analysis used 2015 data on abortions by county of residence from 1948 counties in 27 states. Abortion rates were modeled using a spatial Poisson model adjusted for age, race/ethnicity, marital status, educational attainment, household poverty, nativity, and state abortion policies. Abortion rates for 3107 counties in the 48 contiguous states that were home to 62.5 million female residents of reproductive age (15-44 years) and changes under travel distance scenarios, including integration into primary care (<30 miles) and availability of telemedicine care (<5 miles), were estimated. Data were collected from April 2018 to October 2019 and analyzed from December 2019 to July 2020.

Exposures  Median travel distance by car to the nearest abortion facility.

Main Outcomes and Measures  US county abortion rate per 1000 female residents of reproductive age.

Results  Among the 1948 counties included in the analysis, greater travel distances were associated with lower abortion rates in a dose-response manner. Compared with a median travel distance of less than 5 miles (median rate, 21.1 [range, 1.2-63.6] per 1000 female residents of reproductive age), distances of 5 to 15 miles (median rate, 12.2 [range, 0.5-23.4] per 1000 female residents of reproductive age; adjusted coefficient, −0.05 [95% CI, −0.07 to −0.03]) and 120 miles or more (median rate, 3.9 [range, 0-12.9] per 1000 female residents of reproductive age; coefficient, −0.73 [95% CI, −0.80 to −0.65]) were associated with lower rates. In a model of 3107 counties with 62.5 million female residents of reproductive age, 696 760 abortions were estimated (mean rate, 11.1 [range, 1.0-45.5] per 1000 female residents of reproductive age). If abortion were integrated into primary care, an additional 18 190 abortions (mean rate, 11.4 [range, 1.1-45.5] per 1000 female residents of reproductive age) were estimated. If telemedicine were widely available, an additional 70 920 abortions were estimated (mean rate, 12.3 [range, 1.4-45.5] per 1000 female residents of reproductive age).

Conclusions and Relevance  These findings suggest that greater travel distances to abortion services are associated with lower abortion rates. The results indicate which geographic areas have insufficient access to abortion care. Modeling suggests that integrating abortion into primary care or making medication abortion care available by telemedicine may decrease unmet need.

Introduction

In the US, increasing travel distance or travel time to a health care clinician is associated with less use of preventive care and poorer health outcomes for women, including reduced use of mammography,^1,2 later stage at diagnosis of breast cancer,^3,4 and reduced use of risk-appropriate colonoscopy.⁵ County-level analyses of pregnancy-related outcomes have shown spatial relationships in rates of prenatal care use,⁶ and the closure of rural hospitals not adjacent to urban areas was associated with increased preterm births in the following year.⁷

Abortion is a common reproductive health care service, with 1 in 4 US women obtaining this care during their lifetime.⁸ However, many states have implemented policies restricting abortion care clinicians and facilities (hereinafter referred to as abortion providers).⁹ Studies of these policies have documented clinic closures and women unable to obtain abortion care, with disproportionate effects on low-income women and non-White women.^10,11 Increased travel for an abortion is associated with delays in care, increased costs, and stress.^10,12 Even when women are able to obtain abortion care, greater travel distance has been associated with decreased odds of returning to the abortion facility for follow-up care and increased odds of visiting an emergency department.¹³

Research in a variety of settings has indicated that the farther a woman lives from an abortion care facility, the less likely she is to obtain that care. These studies used distance or travel time to an abortion provider as a measure of potential rather than realized access.¹⁴ Regional research has focused on California, Texas, New York, and Wisconsin^11,15-18; national analyses have focused on disparities in access.^19-21 One longitudinal, econometric study in 18 states²² found an association between travel distance and abortion rate but did not generate interpretable abortion rates.

We conducted a national analysis to test the hypothesis that greater travel distance to the nearest abortion facility is associated with lower abortion rates and to provide estimated abortion rates under actual conditions and alternate assumptions of abortion access. We extend the literature by estimating changes in abortion rate under 2 travel distance scenarios: less than 30 miles (48 km), a common definition of network adequacy for primary care,²³ and less than 5 miles (8 km), a simulation of medication abortion by telemedicine

READ ON...

Association of Travel Distance to Nearest Abortion Facility With Rates of Abortion | Health Disparities | JAMA Network Open | JAMA Network

 

Sexual reproduction without mating

RUHR-UNIVERSITY BOCHUM

Research News

Hannah Enders and Dr. Florian Hennicke describe the precise anatomy of these structures of the poplar mushroom in the Journal of Fungi of 19 May 2021.

An edible wild mushroom

One of the organisms attacked by the fungus Cyclocybe parasitica is the Tawa tree (Beilschmiedia tawa), which is relevant to the timber industry in New Zealand. Cyclocybe parasitica is widespread in the Pacific region and has long been known to the Maori, the indigenous people of New Zealand, under the name "Tawaka" as an edible wild mushroom.

Biology student Hannah Elders, supervised by Florian Hennicke at the Department of Evolution of Plants and Fungi, studied the sexual behaviour of the Tawaka fungus. The two researchers were able to show that the Pacific Tawaka, like its European relative, the Sword-belt Mushroom (Cyclocybe aegerita), which is also edible, is able to develop a complex structure reserved for the sexual reproduction of two partner individuals, the so-called fruiting body, on its own. The specialist term for this is monokaryotic fruiting in the narrow sense.

Sister strains can form different monokaryotic fruiting structures on their own

Elders and Hennicke not only identified a competent strain of this fungus that can produce almost fully developed fruiting bodies. They also characterised sister strains that were capable of producing precursors of these fruiting bodies to varying degrees, one precursor of which, the so-called stromatic type, was previously only known from bracket fungi. Furthermore, tissue sectioning techniques and microscopy succeeded in revealing the exact anatomical differences between the complex multicellular structures of these sister strains.

"The results of the work are also interesting in terms of reproductive biology, as it examines a question of fungal research that has been unsolved for decades in a new context: the question of whether wild Sword-belt Mushroom populations whose main reproductive strategy is based on monokaryotic fruiting in the narrow sense occur in nature", says Florian Hennicke. They also discuss the question of how this type of reproduction would provide agarics with greater ecological fitness, i.e. by recombining genetic information despite the absence of a mating partner. Greater ecological fitness conferred in this way may, for example, allow the fungi to become established in a previously unsuitable habitat, as is normally possible with reproduction with a male and a female mate.

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Disclaimer: AAAS and EurekAlert! are not responsible for 

Comparison of Spending on Common Generic Drugs by Medicare vs Costco Members

 Research Letter

July 6, 202

Erin Trish, PhD^1,2; Laura Gascue, MS¹; Rocio Ribero, PhD¹; et alKaren Van Nuys, PhD^1,3; Geoffrey Joyce, PhD^1,2

Author Affiliations Article Information

JAMA Intern Med. Published online July 6, 2021. doi:10.1001/jamainternmed.2021.3366

Efforts to control drug prices have highlighted the role of the pharmaceutical supply chain. Rather than driving efficiencies, this complex web of highly concentrated intermediaries with proprietary contracts may instead raise prices.¹

Much attention has focused on brand name drugs, although recent reports show that intermediaries can capture significant profits in the generic market as well.² With 88% of Medicare Part D prescriptions dispensed for generic medications in 2018,³ excess profits retained by intermediaries in the generic supply chain could be substantial. This analysis compared the amount Medicare pays for common generic prescriptions in Part D with prices available to patients without insurance at Costco.

Methods

This cross-sectional study identified the 200 most common generic products prescribed in 2017 Medicare Part D claims, by drug name, strength, and dosage form and matched them to their member prices, including all fees and taxes, at Costco pharmacies nationwide. A membership warehouse chain with 80 million US members, Costco has more than 500 US stores and a mail-order business, making these prices available to virtually any US resident with a prescription, without insurance.

Using the “days supplied” variable in Medicare claims, we eliminated 16 products that were not commonly prescribed in 30-day or 90-day quantities, resulting in a final sample of 184 products. The University of Southern California Institutional Review Board determined that the study met the criteria for coded private information or biological specimens and thus was exempt from informed consent requirements.

Using Medicare claims data, we calculated the total spending, including beneficiary out-of-pocket (OOP) payments and payments from all other sources, for all 30-day and 90-day claims for these products in 2017 and 2018. We labeled the difference between the “counterfactual” cost of these prescriptions if purchased at the member price available at the time and the total amount spent as “overspending” under Medicare. Data analysis was performed using SAS Enterprise Guide software, version 7.15 (SAS Institute Inc).

Results

Across more than 1.4 billion Medicare Part D claims for 184 products, the mean (SD) total prices were $12.02 ($18.47) and $24.32 ($41.07) for 30-day and 90-day prescription fills, respectively. Medicare overspent by 13.2% in 2017 and 20.6% in 2018 compared with Costco member prices for these prescriptions (Table 1). Total overspending increased from $1.7 billion in 2017 to $2.6 billion in 2018.

In 2018, overspending was much lower on 30-day prescription fills (7.3%) than 90-day fills (29.4%) (Table 1), which accounted for 69.7% of the total days supplied for these 184 products. Medicare overspent relative to the Costco member price on 43.2% of all 30-day and 90-day prescription fills for these products, with overspending more common on 90-day fills (52.9%) (Table 2). The member price fell below the patient’s OOP payment on 11.0% of prescription fills, and below $20 on 82.4% of fills. In all, 98.8% of these prescription fills had a member price below $50 (Table 2). Results for 2017 were similar.

Discussion

Among 2018 stand-alone Part D plans, median cost sharing was $1 for preferred generic medications and $6 for nonpreferred generic medications.⁴ Furthermore, approximately 30% of beneficiaries received low-income subsidies and paid little to no cost sharing.⁴ These low OOP costs mask the fact that Medicare overpaid on 43.2% of prescriptions for the most common generic medicines that year. In comparison, Costco’s streamlined distribution system could have saved $2.6 billion on these 184 drugs. With generic medications accounting for 22% of Part D spending,³ eliminating generic overspending could significantly reduce beneficiary premiums and federal spending.

This analysis was limited to generic drugs, because generic manufacturers do not pay (unobserved) rebates to pharmacy benefit managers or plans.⁵ Brand name drugs may exhibit different patterns. We did not incorporate Costco’s annual membership fee into member prices. However, membership fees account for only 2.2% of Costco’s annual revenues,⁶ so it is unlikely that such fees are materially subsidizing product prices.

While Medicare coverage of generic drugs likely improves patient adherence and reduces other health care utilization, our analysis highlighted the inefficiencies that the current system introduces through its complex and opaque system of intermediaries, which Costco largely bypasses.

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Article Information

Accepted for Publication: May 12, 2021.

Published Online: July 6, 2021. doi:10.1001/jamainternmed.2021.3366

Corresponding Author: Erin Trish, PhD, USC Schaeffer Center for Health Policy and Economics, 635 Downey Way, VPD 412D, Los Angeles, CA 90089-3333 (etrish@healthpolicy.usc.edu).

Author Contributions: Ms Gascue had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Trish, Gascue, Van Nuys, Joyce.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Joyce.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Trish, Gascue, Ribero, Joyce.

Obtained funding: Van Nuys, Joyce.

Administrative, technical, or material support: Joyce.

Supervision: Trish, Van Nuys, Joyce.

Conflict of Interest Disclosures: The Leonard D. Schaeffer Center for Health Policy & Economics is supported by a wide variety of public and private entities and donors, including health insurers and pharmaceutical manufacturers. More information on the Center's funding sources is available at https://healthpolicy.usc.edu/wp-content/uploads/2021/03/Schaeffer-Center-2020-Annual-Report.pdf. Dr Trish reported receiving grant support from Arnold Ventures and the Commonwealth Fund and personal fees from the Blue Cross Blue Shield Association, Cedars Sinai Health System, Cornerstone Research, Multiplan, Premera, and Varian Medical Systems, outside the submitted work.

Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the Leonard D. Schaeffer Center for Health Policy & Economics.

References

1.

Sood  N, Shih  T, Van Nuys  K, Goldman  DP. The flow of money through the pharmaceutical distribution system. Leonard D. Schaeffer Center for Health Policy & Economics. June 6, 2017. Accessed June 2, 2021. https://healthpolicy.usc.edu/research/flow-of-money-through-the-pharmaceutical-distribution-system/

2.

Yost  D. Ohio’s Medicaid Managed Care Pharmacy Services Auditor of State Report. Ohio Pharmacists Association. August 16, 2018. Accessed June 2, 2021. https://audits.ohioauditor.gov/Reports/AuditReports/2018/Medicaid_Pharmacy_Services_2018_Franklin.pdf

3.

Boards of Trustees, Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. 2019 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Centers for Medicare & Medicaid Services. April 22, 2019. Accessed June 2, 2021. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2019.pdf

4.

Cubanski  J, Damico  A, Neuman  T. Medicare Part D in 2018: The Latest on Enrollment, Premiums, and Cost Sharing. Kaiser Family Foundation. May 17, 2018. Accessed June 2, 2021. https://www.kff.org/medicare/issue-brief/medicare-part-d-in-2018-the-latest-on-enrollment-premiums-and-cost-sharing/

5.

Introduction to the Generic Drug Supply Chain and Key Considerations for Policymakers. Association for Accessible Medicines. October 13, 2017. Accessed June 2, 2021. https://accessiblemeds.org/sites/default/files/2017-10/AAM-Generic-Brand-Drug-Supply-Chain-Brief.pdf

6.

2019 Annual Report: Costco Wholesale. December 10, 2019. Accessed June 2, 2021. https://investor.costco.com/static-files/05c62fe6-6c09-4e16-8d8b-5e456e5a0f7e

 

Long-term urban emissions data show a decrease in high-income countries

IOP PUBLISHING

Research News

A new study shows how urbanisation has influenced anthropogenic CO2 and air pollutant emissions across all world regions, by making use of the latest developments in the Emissions Database for Global Atmospheric Research (EDGAR, https://edgar.jrc.ec.europa.eu/) developed by the Joint Research Centre of the European Commission. The results show that by 2015 urban centres were the source of a third of global anthropogenic greenhouse gases, and the majority of air pollutant emissions.

The authors, from institutions in France and Italy, used the EDGAR database to provide a country-to-global view of the evolution of sector-specific air pollutant and greenhouse gas emissions from urban centres and other geographical entities for different types of human settlement over the past five decades. Their results are published on July 6 in the IOP Publishing journal Environmental Research Letters.

Between 1975 and 2015, the global population increased by 80%; the global urban population almost doubled, while the global rural population increased by only 40%. The urban population increased for all continents. The fastest urban population growth occurred in developing and emerging regions. By 2015, almost half of the global population lived in urban centres, while the largest urban centres with more than 1 million inhabitants (representing only 5% of the global surface) had 22% of the world's population living in them.

From a sustainability perspective, the capacity to identify the nature, location, and source of emissions is particularly important, to be able to tailor emission reduction policies and evaluate population exposure properly.

The consolidated version 5 of EDGAR represents the state of the art within the emission inventory communities, characterising current and historic emissions of air pollutants and greenhouse gases at the global, regional, and country level. EDGAR provides spatio-temporal homogenous consistent greenhouse gas and air pollutant emissions data at the global scale between 1970 and 2015. EDGAR spatially distributes anthropogenic emissions over a global grid map with a spatial resolution of 0.1 degree (about 10 km), enabling the investigation of where emissions happen, and supporting the development of place-based mitigation measures from global to local level.

The results show that urban centres make a large contribution to global air pollutant and CO2 emissions. Expanding the definition of urban areas to include suburbs, roughly 50% of the global emissions take place in around 1% of the global surface. When all urban areas and not only urban centres are included, around 70-80% of global emissions are included. These are mostly driven by combustion sources. Given that these emissions are spatially concentrated, they can benefit from geographically focused mitigation actions. The only exception is NH3, where rural areas account for more than 50% of global emissions, mainly associated with agricultural activities. Emissions in urban centres have increased strongly in emerging economies in the past five decades, but decreased in high-income economies; CO, SO2 and PM10 emissions in industrialised countries decreased, due to higher energy efficiency and the implementation of new technologies and abatement measures. For megacities, emissions in high-income countries have been reduced by the implementation of effective mitigation actions, de-industrialisation, and the growth of the service economy. Finally, per-capita urban CO2 emissions show spatial differences at the global level, among different countries and cities; high-income countries have decoupled their emissions from economic growth.

While climate change is a global issue, air quality is related to the more local problem of reducing urban population exposure to harmful pollutants, to decrease the impact on human health and ecosystems. Local actions are therefore needed for both climate and air pollution reasons. From this point of view, city-level actions can be effective in reducing PM2.5 population exposure; for European cities, a 30% PM2.5 reduction can be achieved with urban actions in at least half of the considered cities.

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 SOCIAL ECOLOGY

Study is first to show that air pollutants increase risk of painful periods for women

FRONTIERS

Research News

Dysmenorrhea, that is, frequent severe and painful cramps during menstruation from abnormal contractions of the uterus, is the most common of all gynecological disorders. It affects between 16-91% of girls and women of reproductive age, of whom 2%-29% have symptoms severe enough to restrict their daily activity. Now, for the first time, researchers from China Medical University Hospital in Taiwan have shown that long-term exposure to air pollutants such as nitrogen and carbon oxides and fine particulate matter greatly raises the risk of developing dysmenorrhea. Based on long-term data on air quality and public health from national databases, they show that the risk to develop dysmenorrhea over a period of 13 years (2000-2013) was up to 33 times higher among Taiwanese women and girls who lived in areas with the highest levels of air pollutants compared to their peers exposed to lower levels of pollutants. These results were recently published in the open access journal Frontiers in Public Health.

A common debilitating disorder with no known cure

Dysmenorrhea can be due to hormonal imbalances or to underlying gynecological conditions such as endometriosis, pelvic inflammatory disease, ectopic pregnancy, or tumors in the pelvic cavity. Symptoms are often life-long: they include cramps and pain in the lower abdomen, pain in the lower back and legs, nausea and vomiting, diarrhea, fainting, weakness, fatigue, and headaches. In addition to reducing quality of life, dysmenorrhea also has a major socioeconomic impact, as females with dysmenorrhea may be temporarily unable to work, attend school, or engage in leisure activities. Dysmenorrhea has no known cure, but its symptoms may be managed with anti-inflammatory drugs and hormonal contraceptives.

"Research has already shown that women who smoke or drink alcohol during their periods, or who are overweight, or have their first period very young, run a greater risk of dysmenorrhea. Women who have never been pregnant are likewise known to be at greater risk. But here we demonstrate for the first time another important risk factor for developing dysmenorrhea: air quality, in particular long-term exposure to pollution. We don't yet know the underlying mechanism, but emotional stress in women exposed to air pollutants, or higher average levels of the hormone-like prostaglandins in their body, might be part of the answer," says one of the authors, Prof Chung Y. Hsu at the College of Medicine, China Medical University, Taichung, Taiwan.

The authors, led by Prof Chia-Hung Kao, the Director of the department of nuclear medicine and the Center for Positron Emission Tomography (PET) at China Medical University, studied de-identified health measures from a total of 296,078 women and girls (approximately 1.3% of the total population) between 16-55 years old. These data came from Taiwan's Longitudinal Health Insurance Database starting 2000 (LHID 2000), a representative subsample from Taiwan's nation-wide health insurance database.

The study sample exclusively included women and girls without any recorded history of dysmenorrhea before 2000. The authors looked for a long-term association between the risk of dysmenorrhea and air quality, in particular the mean exposure over the years to air pollutants - nitrogen oxide (NOx), nitric oxide (NO), nitrogen dioxide (NO2), carbon monoxide (CO), and particles smaller than 2.5 μm in diameter ('PM2.5') - obtained from the 'Taiwan Air Quality Monitoring Database' (TAQMD) of the Environmental Protection Agency.

Air pollutants are an important new risk factor

They found that from 2000- to 2013, 4.2% of women and girls in the studied sample were diagnosed with dysmenorrhea for the first time. As was expected from previous studies, younger women, women of lower incomes, and living in more urbanized areas tended to have a higher risk of developing dysmenorrhea over the study period. But importantly, the 'hazard ratio' (that is, the age- and year-specific risk) of developing dysmenorrhea increased by 16.7 to 33.1 fold for women and girls from the 25% of areas with the highest yearly exposure to air pollutants, compared to those from the 25% of areas with the lowest exposure. NOx, NO, NO2, CO, and PM2.5 levels each contributed separately to the increased risk, but the greatest individual effect was from long-term exposure to high PM2.5.

"Our results study demonstrate the major impact of the quality of air on human health in general, here specifically on the risk of dysmenorrhea in women and girls. This is a clear illustration of the need to for actions by governmental agencies and citizens to reduce air pollution, in order to improve human health," concludes Prof Hsu.

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 SOCIAL ECOLOGY

Schools in Barcelona create a map of the city's air pollution thanks to citizen science

UNIVERSITY OF BARCELONA

Research News

IMAGE: THE OBTAINED DATA BY SCHOOL GROUPS IS AVAILABLE PUBLICLY IN AN INTERACTIVE MAP. view more 

CREDIT: PERELLÓ, J. ET AL. (2021)

A study led by University of Barcelona researchers and carried out together with more than 1,650 students and their family members from 18 educational centres in Barcelona shows that citizen science is a valid approach able for doing high quality science, and in this case, able to provide nitrogen dioxide values with an unprecedented resolution and to assess the impact of the pollution in the health of their inhabitants.

The journal Science of the Total Environment has published the results of a study carried out by the research group OpenSystems of the University of Barcelona, the Barcelona Institute for Global Health (ISGlobal), promoted by La Caixa Foundation and the 4Sfera company, that shows the key role of citizen science in the relationship between the assessment of the exposure to air pollution and the collective action for the improvement of air quality.

The publication describes the xAire project, which involved the organization of collective data gathering in Barcelona regarding the concentration of nitrogen dioxide, a pollutant related to the motorized vehicles. This concentration was measured during a 1-month period between February and March 2018 thanks to the families with children aged between 7 and 18, from 18 public primary schools in the different districts of the city.

The results provide unprecedented information on the pollution of the air in the city with a notable precision. The location of the measuring spots was decided autonomously among the students and their families following the same scientific process. "xAire has not only shown the problems surrounding the schools and the neighbourhoods but it has also provided arguments to the families and schools to ask for improvements in their environment according to the data they gathered", notes Professor Josep Perelló, leader of the study and member of the Institute of Complex Systems of the UB (UBICS).

Air pollution in Barcelona, a serious and underestimated problem

The results of the research show a wide and representative distribution of nitrogen dioxide concentration levels of the city regarding population density. The study analysed very high levels, with an annual average of 49 μg/m3, above the thresholds of the European directive and the WHO, which are 40 μg/m3. More than 5% of the samples double the threshold value of 40 μg/m3, thus confirming that air quality is a serious problem in Barcelona. The measured levels also show large differences between districts and within the same district, depending on the street. The average values obtained in Ciutat Vella, Sants / Montjuïc, Les Corts and Horta / Guinardó by xAire are particularly worrying, as they are higher than those of the nearest official stations.

Improvements in a model of the pollution impact on health

The obtained data have also made it possible to obtain a more up-to-date and accurate estimation of the models for estimating the impact of NO2 on health used by the scientific community. Specifically, the study has estimated that 1,084 new cases of childhood asthma are attributable to NO2 each year in Barcelona, an equal figure to 48% of the total annual cases. According to Mark Nieuwenhuijsen, head of Urban Planning, Environment and Health Initiative of ISGlobal, "if we reduce NO2 levels, especially around schools, we could significantly reduce cases of childhood asthma".

A coordinated effort to measure pollution in 725 areas of the city

xAire was born with the aim to expand the detail and representativeness of the city's levels of pollution, provided by the city's seven official stations. The effort with more than 1,600 involved people has resulted in measurements of nitrogen dioxide in 725 locations. The number of obtained samples exceeds previous campaigns conducted by professional scientists, who gathered the concentration of nitrogen dioxide in a maximum of 200 locations simultaneously.

The xAire project returned the data to each school group and these are available publicly on an interactive map. The results were discussed in the schools mainly considering the WHO and EU limit values. The discussions showed a clear understanding of the follow-up data and the scientific research process.

Boys and girls aged between seven and eight were able to perfectly explain the scientific protocol and the meaning of the data in the InfoK of the Super 3 Channel, during the Science Congress, organized by the Barcelona Education Consortium and in front of the city mayor Ada Colau (Escola El Sagrer). The same schools provided the data to City Council officials along with a set of proposals based on scientific evidence, at an event held in Saló de Cent. The proposed measures range from the promotion of public transport in the neighbourhood and pedestrian routes to the need to cover part of the ronda de Dalt (Dolors Monserdà, Sarrià) or to accelerate the reform of Avinguda Meridiana (El Sagrer).

Large-scale citizen science campaigns on air quality should not be seen simply as a public awareness activity and an education program. "In this intense participatory component, citizens can be actors in research and not just recipients of a message. This approach to citizen science adds sophistication and diversity to the scientific research process, as it requires multidisciplinary professional scientists and the participation of non-academic organizations", says Isabelle Bonhoure, researcher at the OpenSystems Group of the UB.

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