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This paper investigates the impact of behavioural risk factors on non-communicable diseases mortality in Milan, focusing on their neighbourhood variation, with the scope to provide context-specific information to guide the development of effective health promotion interventions. Using administrative healthcare data, population attributable fractions were calculated based on information provided by the Global Burden of Disease project to estimate the number and proportion of deaths attributed to smoking, high body mass index, alcohol consumption, physical inactivity, and dietary risk. The findings revealed distinct territorial patterns of risk factors based on sex/gender, as territorial differences along the centre-periphery axis were observed in men but not in women. Smoking emerged as the primary risk factor for avoidable mortality, particularly in men whilst in females metabolic-related risk factors played a larger role. The proposed methodology provided valuable insights into the distribution of risky health behaviours at the neighbourhood level and underscored the need for context-specific interventions. Overall, the study emphasized the intertwined nature of territorial, socioeconomic, and gender dimensions in shaping health outcomes. It called for targeted interventions that address the specific risk profiles and challenges of each neighbourhood, promoting health equity and reducing the burden of non-communicable diseases. By understanding these complex dynamics, policymakers and public health professionals can develop effective strategies to improve population health and reduce health inequalities.

This article analyses the spatial distribution of foreigners living in the city of Milan, based on data from the civil registry and relying on theories and methods from the residential segregation literature, exploring the dimensions of evenness, exposure, concentration, centralisation and clustering, as well as analysing migrants’ over/under-representation in specific areas through maps of their location quotients. Despite the low degree of ethnic residential segregation detected, we highlight the presence of persistent dynamics that exclude ethnic minorities from the wealthiest areas of the city. The most relevant case is that of the Chinese, clustering in some peripheral areas north of the historic centre, where they have established an enclave economy, often making their residence coincide with their workplace and running commercial activities mostly directed towards their compatriots. The Egyptians, constituting the most numerous foreign group in the city, show a completely different settlement pattern, being more integrated into the social tissue and more scattered throughout the city. In the context of a city strongly polarised between a wealthy centre and progressively deprived peripheral belts, the only foreign groups with a marked presence in the city core are those traditionally employed in domestic work, which are however excluded from life in the public places in which they reside. Overall, the class dimension seems to prevail over the ethnic in shaping population settlement patterns within the city.

Background: In the context of the fourth wave of the COVID-19 pandemic in Italy, which occurred in correspondence with the outbreak of the Omicron variant, it became fundamental to assess differences in the risk of severe disease between the Omicron variant and the earlier SARS-CoV-2 variants that were still in circulation despite Omicron becoming prevalent. Methods: We collected data on 2,267 genotyped PCR-positive swab tests and assessed whether the presence of symptoms, risk of hospitalization, and recovery times were significantly different between Omicron and the earlier variants. Multivariable models adjusted for sex, age class, citizenship, comorbidities, and symptomatology allowed assessing the difference in outcomes between Omicron and the earlier variants according to vaccination status and timing of administration. Results: Compared to the earlier variants in the same period, Omicron was less symptomatic, resulted in fewer hospital admissions for those who were unvaccinated and for those who were already immunized after the booster dose, and was associated with quicker recovery, yet not in subjects with three vaccination doses. Conclusion: Despite being milder, Omicron's higher transmissibility and vaccine resistance should not lead to underrating its damage potential, especially with regard to hospital and health service saturation.

Background: This paper aims to assess the presence of gender differences in medication use and mortality in a cohort of patients affected exclusively by hypertension, in 193 municipalities in the Lombardy Region (Northern Italy), including Milan's metropolitan area. Methods: A retrospective cohort study was conducted (N = 232,507) querying administrative healthcare data and the Register of Causes of Death. Hypertensive patients (55.4% women; 44.6% men) in 2017 were identified; gender differences in medication use (treatment, 80% compliance) and deaths (from all causes and CVDs) were assessed at two-year follow-ups in logistic regression models adjusted for age class, census-based deprivation index, nationality, and pre-existing health conditions. Models stratified by age, deprivation index, and therapeutic compliance were also tested. Results: Overall, women had higher odds of being treated, but lower odds of therapeutic compliance, death from all causes, and death from CVDs. All the outcomes had clear sex differences across age classes, though not between different levels of deprivation. Comparing patients with medication adherence, women had lower odds of death from all causes than men (with a narrowing protective effect as age increased), while no gender differences emerged in non-compliant patients. Conclusions: Among hypertensive patients, gender differences in medication consumption and mortality have been found, but the extent to which these are attributable to a female socio-cultural disadvantage is questionable. The findings reached, with marked age-dependent effects in the outcomes investigated, suggest a prominent role for innate sex differences in biological susceptibility to the disease, whereby women would take advantage of the protective effects of their innate physiological characteristics, especially prior to the beginning of menopause.

Aims: Socio-economic inequalities originate from several channels, one of which is family origins, with clear effects on people’s health. This paper aims to evaluate the role played by social mobility in determining health inequalities, relying on Blau and Duncan’s status attainment model and focusing specifically on two moments of social reproduction of inequalities: one inter-generational, based on the transmission of resources from the family of origin, the other intra-generational, related to the capitalisation of economic resources to maximise well-being. Methods: Multi-group models of structural equations were used to examine the direct and indirect effects of parental cultural background, education and economic conditions of respondents on self-perceived health in 28 countries, relying on the European Social Survey (N=38,879). Results: Overall, the results confirmed the presence of an inter-generational transmission of social and health status. Different models of transmission of health inequalities emerged among the countries considered. Countries characterised by a social democratic welfare regime showed higher social mobility and fewer health inequalities, although in correspondence with a prominent role of economic factors in determining health conditions. On the other hand, in countries where social mobility is lower, health inequalities are more pronounced, yet driven by factors others than economics, such as socio-cultural origins. Conclusions: The presence of a higher economic-health gradient in social democratic countries – notwithstanding their egalitarian and universal welfare policies – provides support for the existence of a Nordic paradox in relation to health inequalities.

Background In February 2021, the spread of a new variant of SARS-CoV-2 in the Lombardy Region, Italy caused concerns about school-aged children as a source of contagion, leading local authorities to adopt an extraordinary school closure measure. This generated a debate about the usefulness of such an intervention in light of the trade-off between its related benefits and costs (e.g. delays in educational attainment, impact on children and families’ psycho-physical well-being). This article analyses the epidemiological impact of the school closure intervention in the Milan metropolitan area. Methods Data from the Agency for Health Protection of the Metropolitan City of Milan allowed analysing the trend of contagion in different age classes before and after the intervention, adopting an interrupted times series design, providing a quasi-experimental counterfactual scenario. Segmented Poisson regression models of daily incident cases were performed separately for the 3–11-year-old, the 12–19-year-old, and the 20+-year-old age groups, examining the change in the contagion curves after the intervention, adjusting for time-varying confounders. Kaplan-Meier survival curves and Cox regression were used to assess the equality of survival curves in the three age groups before and after the intervention. Results Net of time-varying confounders, the intervention produced a daily reduction of the risk of contagion by 4% in those aged 3–11 and 12–19 (IRR = 0.96) and by 3% in those aged 20 or more (IRR = 0.97). More importantly, there were differences in the temporal order of contagion decrease between the age groups, with the epidemic curve lowering first in the school-aged children directly affected by the intervention, and only subsequently in the adult population, which presumably indirectly benefitted from the reduction of contagion among children. Conclusion Though it was not possible to completely discern the effect of school closures from concurrent policy measures, a subs

Social inequalities in health are known to be influenced by the socioeconomic status of the territory in which people live. In the context of the ongoing coronavirus disease 2019 (COVID-19) pandemic, this study is aimed at assessing the role of 5 area-level indicators in shaping the risk of contagion in the provinces of Milan and Lodi (Lombardy, Italy), namely: educational disadvantage, unemployment, housing crowding, mobility, and population density. The study area includes the municipalities at the origin of the first Italian epidemic outbreak. Data on COVID-19 patients from the Integrated Datawarehouse for COVID Analysis in Milan were used and matched with aggregate-level data from the National Institute of Statistics Italy (Istat). Multilevel logistic regression models were used to estimate the association between the census block-level predictors and COVID-19 infection, independently of age, sex, country of birth, and preexisting health conditions. All the variables were significantly associated with the outcome, with different effects before and after the lockdown and according to the province of residence. This suggests a pattern of socioeconomic inequalities in the outbreak, which should be taken into account in the eventuality of future epidemics to contain their spread and its related disparities.

Background COVID-19 epidemic has paralleled with the so called infodemic, where countless pieces of information have been disseminated on putative risk factors for COVID-19. Among those, emerged the notion that people suffering from autoimmune diseases (AIDs) have a higher risk of SARS-CoV-2 infection. Methods The cohort included all COVID-19 cases residents in the Agency for Health Protection (AHP) of Milan that, from the beginning of the outbreak, developed a web-based platform that traced positive and negative cases as well as related contacts. AIDs subjects were defined ad having one the following autoimmune disease: rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, Sjogren disease, ankylosing spondylitis, myasthenia gravis, Hashimoto's disease, acquired autoimmune hemolytic anemia, and psoriatic arthritis. To investigate whether AID subjects are at increased risk of SARS-CoV-2 infection, and whether they have worse prognosis than AIDs-free subjects once infected, we performed a combined analysis of a test-negative design case-control study, a case-control with test-positive as cases, and one with test-negative as cases (CC-NEG). Results During the outbreak, the Milan AHP endured, up to April 27th 2020, 20,364 test-positive and 34,697 test-negative subjects. We found no association between AIDs and being positive to COVID-19, but a statistically significant association between AIDs and being negative to COVID-19 in the CC-NEG. If, as likely, test-negative subjects underwent testing because of respiratory infection symptoms, these results imply that autoimmune diseases may be a risk factor for respiratory infections in general (including COVID-19), but they are not a specific risk factor for COVID-19. Furthermore, when infected by SARS-CoV-2, AIDs subjects did not have a worse prognosis compared to non-AIDs subjects. Results highlighted a potential unbalance in the testing campaign, which may be correlated to the characteristics of the teste

Objective Low individual socioeconomic status (SES) is known to be associated with a higher risk of type 2 diabetes mellitus (T2DM), but the extent to which the local context in which people live may influence T2DM rates remains unclear. This study examines whether living in a low property value neighbourhood is associated with higher rates of T2DM independently of individual SES. Research Design and Methods Using cross-sectional data from the Maastricht Study (2010-2013) and geographical data from Statistics Netherlands, multilevel logistic regression was used to assess the association between neighbourhood property value and T2DM. Individual SES was based on education, occupation and income. Of the 2,056 participants (aged 40–75 years), 494 (24%) were diagnosed with T2DM. Results Individual SES was strongly associated with T2DM, but a significant proportion of the variance in T2DM was found at the neighbourhood level (VPC=9.2%; 95% CI=5.0% - 16%). Participants living in the poorest neighbourhoods had a 2.38 times higher odds ratio of T2DM compared to those living in the richest areas (95% CI=1.58 - 3.58), independently of individual SES. Conclusions Neighbourhood property value showed a significant association with T2DM, suggesting the usefulness of area-based programmes aimed at improving neighbourhood characteristics in order to tackle inequalities in T2DM.

La presente tesi di dottorato si propone di indagare lo stato delle disuguaglianze di salute nella città di Milano. Si parla di disuguaglianze di salute in presenza di differenze negli stati di salute delle persone all’interno di una popolazione, o tra gruppi di individui, quando queste sono attribuibili alle condizioni socioeconomiche delle persone, in virtù dell’iniqua distribuzione di risorse sociali, economiche, culturali e relazionali che consentono a ciascuno di raggiungere il proprio potenziale di salute. In aggiunta, il raggiungimento di uno stato di salute ottimale può essere influenzato anche dalle caratteristiche materiali e psicosociali del contesto di residenza, esponendo coloro che vivono in contesti svantaggiati a maggiori rischi per la loro. Muovendo dai presupposti teorici e concettuali della Fundamental Causes Theory e dall’approccio alla salute basato sui determinanti sociali questo lavoro si pone l’obiettivo di fornire una mappatura della distribuzione delle condizioni di salute all’interno del territorio milanese, contribuendo altresì al dibattito circa la presenza di neighbourhood effects sulla salute. Il lavoro svolto si basa sull’utilizzo di un approccio interdisciplinare, nel quale si fa ricorso a metodi e strumenti di tipo sociologico, epidemiologico, e geografico. Uno studio dettagliato della distribuzione sociale e territoriale di una patologia nei diversi quartieri della città è ad oggi assente, abbiamo dunque deciso di concentrarci sul Diabete Mellito di Tipo 2 alla luce della sua tipica associazione sia con le condizioni socioeconomiche individuali che con le caratteristiche dell’ambiente di vita. Facendo ricorso all’utilizzo inedito di dati amministrativi del sistema sanitario forniti dall’Unità di Epidemiologia dell’Agenzia di Tutela della Salute della Città Metropolitana di Milano, in combinazione con i dati provenienti dall’ultimo censimento della popolazione italiana, abbiamo condotto uno studio caso-controllo multilivello, This PhD dissertation is aimed at studying health inequalities in the Italian city of Milan. Health inequalities can be defined as differences in people’s health across the population and between population groups, which are attributable to individuals’ socioeconomic status as a consequence of the uneven distribution of social, economic, cultural, and relational resources that enable people to reach their health potential (Sarti et al., 2011). Moreover, people’s health may also be affected by psychosocial and physical characteristics of the local environment in which they live, so that those living in disadvantaged areas may be at a higher risk of being subjected to worse health conditions (Macintyre and Ellaway, 2000; 2003). Moving from the theoretical and conceptual foundations of the Fundamental Causes Theory (Link and Phelan 1995; Phelan et al., 2010) and the Social Determinants of Health approach ( Solar and Irwin, 2010; Wilkinson and Marmot, 2003) this work intends to provide both an accurate mapping of the distribution of health conditions within the Milanese territory – and its association with individual and contextual socioeconomic status – and to contribute to the debate on the presence of neighbourhood effects on health (Diez-Roux, 2004; Galster, 2012). We thus relied on an interdisciplinary approach, making use of tools and methods from sociology, epidemiology, and geography. A fine-grained study of disease distribution among the neighbourhoods of the city of Milan was missing, and we opted to focus on Type 2 Diabetes Mellitus in light of its typical association with both individual socioeconomic conditions (Agardh et al., 2011) and environmental characteristics (Den Braver et al., 2018). Relying on the unprecedented use of administrative healthcare data provided by the Epidemiology Unit of the Health Protection Agency of the Metropolitan City of Milan, linked with data from the most recent Italian census, we performed a multilevel case-control study, a

This article analyses the distribution of ethnic and social segregation in the city of Naples, based on data from the Statistical Office of the Municipality of Naples and the most recent Italian census. Comparing the results with previous literature on the subject, the analyses provide an overall description of the two kinds of urban segregation patterns, highlighting a process of slow but constant increase in the concentration of some ethnic groups in specific city neighbourhoods, as well as a clear distinction between a wealthy residential area and the rest of the city, which presents different degrees of socioeconomic deprivation.