Percepção do ruído como incômodo, características sociodemográficas, de saúde e percepção da vizinhança em uma metrópole brasileira: Estudo Saúde em Beagá

Rev Bras Epidemiol rbepid Revista Brasileira de Epidemiologia Rev. bras. epidemiol. 1415-790X 1980-5497 Associação Brasileira de Saúde Coletiva RESUMO Objetivo: Analisar a associação entre o incômodo provocado pelo ruído com fatores individuais e sociodemográficos e a autopercepção de vizinhança em um centro urbano. Métodos: Os dados foram coletados por meio de um estudo transversal de base populacional, desenvolvido em dois dos nove distritos sanitários do município de Belo Horizonte, Minas Gerais, no período de 2008 a 2009. Participaram do estudo 3.934 indivíduos, de ambos os sexos, com 18 anos ou mais. A variável resposta foi a autopercepção do ruído, investigada pela pergunta: “Pensando na sua vizinhança o ruído/barulho incomoda você?”. As variáveis explicativas foram agrupadas nos seguintes domínios: sociodemográfico, determinantes sociais, autoavaliação de saúde e autorrelato de doenças. Resultados: Para as mulheres, a prevalência do incômodo ao ruído foi de 47%, e para os homens, foi de 39,8%. Para ambos os sexos, o incômodo ao ruído foi independentemente associado ao trânsito ruim e presença de música alta, discussões e festas até tarde. Conclusões: Diferenças entre os sexos foram observadas para associação entre o incômodo ao ruído, características sociodemográficas e morbidade autorreferida. O trânsito e os costumes sociais se configuraram como a principal fonte geradora de ruído nas regiões estudadas. INTRODUCTION Urbanization as a global phenomenon led to the restructuring of the nature of cities and, as a consequence, caused unfavorable health and well-being conditions1. Among the unfavorable environmental conditions associated with urbanization, noise is an invisible threat to the health of urban dwellers2. Noise consists of a combination of sounds coming from different sources such as: traffic of cars, buses, trains, and airplanes; industrial activities; leisure and sports activities, making it difficult to measure the isolated annoyance produced by each source. The soundscape of urban environments encompasses noise-generating and other sources that promote the disturbance of silence and can be observed in lifestyle, leisure, culture, and sports incorporated into people's daily lives3. In 2018, the World Health Organization updated its guidelines for Europe and classified health outcomes related to exposure to urban noise as critical and important. Among the critical outcomes, we can mention: cardiovascular diseases, annoyance, sleep disorders, cognitive impairment, hearing loss, and tinnitus. Important outcomes included adverse obstetric outcomes, quality of life, well-being, and mental health, as well as metabolic disorders3. Urban noise effects can be estimated objectively by measuring environmental sound pressure levels and subjectively by the annoyance it causes. Noise annoyance is one of the most studied metrics for surveying the impacts of exposure to urban noise2,4,5,6,7,8,9,10,11. It is a sensitive indicator of the adverse effects of noise exposure on quality of life and can be considered a marker of health outcomes associated with noise exposure12. Few studies have addressed the self-perception of noise in urban environments in Latin America. However, the size heterogeneity and fast-growing characteristics of Latin American cities make them relevant for investigating how urban environments influence health and environmental sustainability13. Analyzing the outcomes associated with self-perception of urban noise is therefore justified by the need for data to support public policies targeted at its control and the consequent reduction of its effects on health. The present study aims to analyze the association of noise annoyance with individual and sociodemographic factors and self-perception of the neighborhood in an urban center. METHODS This is a population-based cross-sectional study using data from the “BH Health Study” (BHS), developed by the Belo Horizonte Urban Health Observatory (OSUBH) of the Universidade Federal de Minas Gerais (UFMG), from 2008 to 2009, in two of the nine health districts of Belo Horizonte. The BHS is a household-based survey aimed to evaluate aspects of the population's habits and lifestyles, quality of life, and self-rated health. Details of the study design have been reported previously14. SAMPLE AND DATA COLLECTION INSTRUMENTS The study has a probabilistic, three-stage cluster sample design: first, the census tracts were selected, followed by the households and an adult individual (18 years and older) from each household. A total of 149 census tracts were selected. OSUBH researchers elaborated a questionnaire based on national and international epidemiological surveys, thus enabling the comparison with previously published studies. The questionnaire was answered in person, with an approximate duration of 40 minutes, comprising questions grouped into the following modules: home, sociodemographic characteristics, mobility, social determinants, health, habits, and behaviors14. The initial sample consisted of 4,048 individuals. Participants who reported hearing impairment, partial deafness, and total deafness or did not respond to the outcome were excluded, resulting in 114 exclusions. Thus, the final sample included 3,934 individuals. RESPONSE VARIABLE The response variable was the self-perception of noise, investigated by the question: “In your neighborhood, does the noise bother you?” (yes, no, I don't know, no answer). STRATIFICATION VARIABLE The World Health Organization recommends analyzing a population’s health information according to gender in addition to at least two other social determinants15. Also, studies have shown that noise perception and annoyance differ among men and women16,17. Therefore, in the current study, the stratification variable was gender. EXPLANATORY VARIABLES Individual-level explanatory variables were grouped into the following domains: sociodemographic, neighborhood perception, self-rated health, self-reported diseases, and sleep quality. The sociodemographic variables analyzed were: schooling, marital status, and family income. The neighborhood perception domain included the variables traffic and presence of noise-generating sources. Traffic perception was assessed by asking, “How do you rate the traffic in your neighborhood?”. The answers: “very good” and “good” were grouped as “good”, and the answers “bad” and “very bad” were grouped as “bad”. The presence of noise-generating sources related to habits and behaviors was evaluated by the question: “Are there people or places in your neighborhood where you usually hear loud music and conversations or late-night parties?”; “Is there gunfire noise in your vicinity?” (yes, no, I don't know, no answer). The current health condition was assessed by asking, “In general, how would you rate your health?” (very good or good, fair, poor or very poor). The presence of chronic diseases was investigated by the question, “Has a doctor or other healthcare professional ever said that you have any of the chronic diseases listed below: hypertension, depression, migraine, digestive disorder, mental disease?" (yes/no). Sleep quality was evaluated by asking, "In the last 30 days, have you slept poorly?" (yes, no, I don't know, no answer). Due to the small number of observations, the “I don't know” and “no answer” options, as well as missing data, were removed from the analysis in all questions. At the neighborhood level, the explanatory variable was the census tract of residence. The variables age and time living in the current residence were used with individual adjustment variables in the univariate and multivariate analyses. STATISTICAL ANALYSIS After a descriptive analysis, a univariate analysis adjusted for age and time living in the current residence was performed. Variables associated with self-perceived noise at a 20% level were candidates for the multivariate analysis, in the next step. The following categories were regarded as references according to the respective elected variables: 0 to 4 years of schooling; single marital status; family income lower than 2 minimum wages; good traffic; no loud music or late-night parties; no gunfire sound; good sleep quality; no work; very good or good self-rated health; no report of migraine, hypertension, mental disorders, digestive disorders, diabetes, and heart disease. Finally, multilevel multiple logistic regression analysis was performed, as follows18,19,20: analysis of variance with random effects for level 1 and level 2; model fit with level 1 variables (individual variables); adjustment of the complete model by adding the level 2 variable (census tract); comparison of models by the maximum likelihood method. The magnitude of the associations was estimated by odds ratios (OR) and their respective 95% confidence intervals, and the significance level was set at 5%. The median odds ratio (MOR) was calculated to express the neighborhood-level variability (census tract). Its estimation allows determining whether the probability of the individual reporting the event is related to contextual phenomena19. All analyses were performed with the Stata software, version 12, using the Generalized Linear Latent and Mixed Models (GLLAMM) and the Survey (svy) commands, considering the sample design. BHS was approved by the Research Ethics Committee of the Universidade Federal de Minas Gerais (protocol no. ETIC 253/06) and the Research Ethics Committee of the Municipal Health Department (opinion no. 073.2008). All participants signed the Informed Consent Form. RESULTS A total of 3,934 adults of both genders participated in this study, of whom 59.2% were women (mean age 44.8 years; standard deviation - SD = 16.7), and 40.8% were men (mean age 43.2 years; SD = 17.0). The prevalence of noise annoyance was 47% for women and 39.8% for men. Among men, 22.7% had 0 to 4 years of schooling, 21.9% had 5 to 8 years, 36.7% had 9 to 11 years, and 18.7% had 12 or more years. Regarding marital status, 31.8% were single, 59.9% were married, in a domestic partnership, or in a free union, 5.5% were separated or divorced, and 2.8% were widowed. As to family income, 19.4% earned less than 2 minimum wages, 47.9% earned 2 to 5 minimum wages, 19.2% earned 5 to 10 minimum wages, and 13.5% earned 10 minimum wages or more. With respect to work, 4% did not work, 72.6% worked, and 23.4% worked in the past but not anymore. Regarding the health vulnerability index (HVI), 18.8% lived in low-risk census tracts, 38.3% lived in moderate-risk census tracts, and 42.9% lived in high- or very high-risk census tracts. Concerning traffic, 71.1% considered traffic as good and 28.9% as bad. Presence of loud music, discussions, and late-night parties in the neighborhood was reported by 42.2% and was not reported by 57.8%. Gunfire sound was reported by 57% and was not reported by 43%. When asked about sleep, 27.1% of men declared poor sleep quality and 72.9% good sleep quality. Self-rated health was considered very good or good by 69.9% of male participants, migraine was reported by 7%, high blood pressure by 27.6%, depression by 8.1%, mental disorder by 2.3%, digestive disorder by 9.3%, diabetes by 7%, and heart disease by 5.9% (Table 1). Table 1. Descriptive analysis of self-reported health conditions (n = 3,934). Variable n % Men Women n % n % Self-rated health Very good and good 2,609 66.3 1,124 69.9 1,485 63.8 Fair 1,077 27.4 407 25.4 670 28.8 Poor or very poor 248 6.3 76 4.7 172 7.4 Migraine No 3,292 83.7 1,493 93.0 1,799 77.3 Yes 642 16.3 113 7.0 529 22.7 High blood pressure No 2,744 69.7 1,164 72.4 1,580 67.9 Yes 1,190 30.3 442 27.6 748 32.1 Depression No 3,276 83.3 1,475 91.9 1,801 77.3 Yes 658 16.7 130 8.1 528 22.7 Mental disorder No 3,799 96.6 1,568 97.7 2,231 95.8 Yes 135 3.4 37 2.3 98 4.2 Digestive disorder No 3,414 86.8 1,456 90.7 1,958 84.1 Yes 520 13.2 149 9.3 371 15.9 Diabetes, hyperglycemia No 3,627 92.2 1,493 93.0 2,134 91.6 Yes 307 7.8 112 7.0 195 8.4 Heart disease No 3,676 93.4 1,513 94.1 2,161 92.9 Yes 258 6.6 94 5.9 166 7.1 Among women, 28% had 0 to 4 years of schooling, 21.1% had 5 to 8 years, 34.2% had 9 to 11 years, and 16.7% had 12 or more years. Regarding marital status, 29% were single, 48.6% were married, in a domestic partnership, or in a free union, 10.2% were separated or divorced, and 12.2% were widowed. As to family income, 31.5% earned less than 2 minimum wages, 44.3% earned 2 to 5 minimum wages, 14.4% earned 5 to 10 minimum wages, and 9.8% earned 10 minimum wages or more. With respect to work, 13.7% did not work, 53.2% worked, and 33.1% worked in the past but not anymore. Regarding the health vulnerability index (HVI), 19.8% lived in low-risk census tracts, 38.4% lived in moderate-risk census tracts, and 41.8% lived in high- or very high-risk census tracts. Concerning traffic, 67% considered traffic as good and 33% as bad. Presence of loud music, discussions, and late-night parties in the neighborhood was reported by 43% and was not reported by 57%. Gunfire sound was reported by 59.8% and was not reported by 40.2%. When asked about sleep, 41.8% of women declared poor sleep quality and 58.2% good sleep quality. Self-rated health was considered very good or good by 63.8% of female participants, migraine was reported by 22.7%, high blood pressure by 32.1%, depression by 22.7%, mental disorder by 4.2%, digestive disorder by 15.9%, diabetes by 8.4%, and heart disease by 7.1% (Table 1). In the univariate analysis for men, significant associations (p ≤ 0.20) were found between noise annoyance and the following variables: schooling, marital status, bad traffic, presence of loud music, discussions, and late-night parties, gunfire sound, poor sleep, and self-reported digestive disorders. For women, significant associations (p ≤ 0.20) were identified between the perception of noise annoyance and the following variables: schooling, marital status, bad traffic, presence of loud music, discussions, and late-night parties, gunfire sound, poor sleep, fair self-rated health, and self-reported migraine, depression, mental disorder, and digestive disorder (Table 2). Table 2. Univariate and multilevel multivariate analysis of the association between noise annoyance and sociodemographic characteristics, social and health determinants, adjusted for age and time living in the current residence (n = 3,934)#. Variable Univariate Multivariate Men Women Men Women OR 95%CI OR 95%CI OR 95%CI OR 95%CI Years of schooling 0-4 1.00 - - 1.00 - - 5-8 1.08 0.70 - 1.68 1.27 0.89 - 1.82* 9-11 1.42 0.95 - 2.13* 1.41 0.97 - 2.05** 12 or more 1.83 1.04 - 3.23** 1.24 0.78 - 1.99 Marital status Single 1.00 - - 1.00 - - 1.00 - - 1.00 - - Married, domestic partnership, free union 1.77 1.19 - 2.64** 0.90 0.68 - 1.20 1.73 1.13 - 2.67** 1 0.72 - 1.4 Separated or divorced 1.85 0.89 - 3.86* 0.52 0.31 - 0.89** 1.88 0.86 - 4.11 0.55 0.31 - 0.98** Widowed 3.21 1.19 - 8.69** 0.70 0.42 - 1.18* 2.87 1.06 - 7.81** 0.79 0.46 - 1.37 Traffic Good 1.00 - - 1.00 - - 1.00 - - 1.00 - - Bad 1.96 1.45 - 2.67*** 1.96 1.46 - 2.62*** 1.71 1.22 - 2.38** 1.73 1.28 - 2.34*** Loud music, late-night parties No 1.00 - - 1.00 - - 1.00 - - 1.00 - - Yes 4.21 3.00 - 5.93*** 3.45 2.73 - 4.36*** 3.64 2.55 - 5.21*** 3.11 2.38 - 4.06*** Gunfire No 1.00 - - 1.00 - - 1 - - 1 - - Yes 2.16 1.49 - 3.12*** 1.77 1.33 - 2.36*** 1.81 1.26 - 2.6** 1.45 1.06 - 1.98** Poor sleep quality No 1.00 - - 1.00 - - - - - 1.00 - - Yes 1.86 1.28 - 2.71** 1.79 1.41 - 2.27*** - - - 1.66 1.31 - 2.11*** Self-rated health Very good and good 1.00 - - Fair 1.44 1.14 - 1.82** Poor or very poor 1.22 0.79 - 1.88 Migraine No 1.00 - - Yes 1.35 1.06 - 1.71** Depression No 1.00 - - Yes 1.37 1.03 - 1.82** Mental disorder No 1.00 - - Yes 1.90 1.17 - 3.08** Digestive disorder No 1.00 - - 1.00 - - - - - 1.00 - - Yes 1.38 0.87 - 2.20*** 1.68 1.21 - 2.32** - - - 1.52 1.1 - 2.11** #Reference categories: 0 to 4 years of schooling, single marital status, good traffic, no loud music, discussions, or late-night parties, no gunfire, good sleep quality, very good and good self-rated health, and no report of migraine, depression, mental disorder, or digestive disorder; 95%CI: 95% confidence interval; *p < 0.20; **p < 0.05; ***p < 0.001. The final multivariate analysis model for men indicated that noise annoyance was independently associated with being married, in a domestic partnership, or in a free union; being a widower; perceiving traffic as bad; and living in a neighborhood with loud music, discussions, and late-night parties or gunfire sounds. According to the analysis performed, the likelihood of perceiving noise as annoyance increased by 73% (OR = 1.73; 95%CI 1.13 - 2.67) among men who were married, in a domestic partnership, or in a free union and by 287% (OR = 2.87; 95%CI 1.06 - 7.81) among widowers when compared to single men. The likelihood of perceiving noise as annoyance was 71% higher (OR = 1.71; 95%CI 1.22 - 2.38) among those who considered traffic as bad compared to those who considered it as good. The presence of loud music, discussions, and late-night parties increased the chance of perceiving noise as annoyance by 364% (OR = 3.64; 95%CI 2.55 - 5.21). The perception of noise as annoyance was 81% higher (OR = 1.81; 95%CI 1.26 - 2.60) in the presence of gunfire sounds when compared to their absence (Table 2). The final multivariate analysis model for women indicated that noise annoyance was independently associated with being separated or divorced; perceiving traffic as bad; living in a neighborhood with loud music, discussions, and late-night parties or gunfire sounds; declaring poor sleep; and self-reporting digestive disorders. According to the analysis performed, the likelihood of perceiving noise as annoyance was 55% lower (OR = 0.55; 95%CI 0.31 - 0.98) among women who were separated or divorced when compared to single women. The likelihood of perceiving noise as annoyance was 73% higher (OR = 1.73; 95%CI 1.28 - 2.34) among those who considered traffic as bad compared to those who considered it as good. In the presence of loud music, discussions, and late-night parties, the chance of perceiving noise as annoyance increased by 311% (OR = 3.11; 95%CI 2.38 - 4.06). Also, noise annoyance was 45% higher (OR = 1.45; 95%CI 1.06 - 1.98) in the presence of gunfire sounds; 66% (OR = 1.66; 95%CI 1.31 - 2.11) greater when the sleep quality was poor; and 52% higher (OR = 1.52; 95%CI 1.10 - 2.11) when the participant self-reported digestive diseases (Table 2). MOR was 1.89 (0.45) for males and 1.71 (0.32) for females, indicating that the neighborhood contributed to the variance in noise perception. DISCUSSION The present study analyzed individual characteristics and environmental perceptions related to annoyance produced by noise, revealing that the variables bad traffic and presence of loud music, discussions, and late-night parties are independently associated with self-perceived noise annoyance. The prevalence of noise annoyance was higher among women than in men. This association was also detected in a study of the Finnish population, whose results showed a positive relationship between being a woman and having greater knowledge about the risks of urban noise, greater concern about environmental risks to their health and that of their family, and with a positive attitude towards environmental preservation5. In an investigation comparing noise annoyance among residents of vulnerable areas in Switzerland and South Africa, women were more sensitive and reported annoyance more often than men in both countries. For African women, noise annoyance decreased with the increase in schooling, whereas for Swiss women, noise annoyance increased with the increase in schooling16. Our study found no association between schooling and noise annoyance in women. A study conducted in the city of Porto (Portugal) evaluated the perception of soundscapes and noise annoyance in different environments, such as leisure spaces, home, and workplace, revealing that noise annoyance was reported more often in the workplace and at home11. Among both men and women, noise annoyance was independently associated with the perception of bad traffic and the presence of loud music, discussions, and late-night parties in the neighborhood. This association corroborates literature findings, which describe the main sources of noise in the urban environment as traffic, social habits and customs, and leisure activities5,6,8,10,21,22,23,24,25,26. In fact, transportation is the main source of noise in the urban environment. Therefore, improvements should be implemented in this context to reduce not only noise exposure but also pollutant emissions, since they are associated with undesirable health and well-being outcomes2,3,7,21,22,27. The use of alternative and public transport has been widely discussed and encouraged as a way to promote health and reduce noise and pollutants, representing a sustainability challenge in modern societies28. Annoyance caused by gunfire noise has not been reported in other studies, to the best of our knowledge. This association might have roots in urban violence, which is a reality in most Brazilian municipalities, especially in large cities, such as Belo Horizonte29. Defined as a well-being impairment due to exposure to urban noise, annoyance can be a trigger to stress and the genesis of pathophysiological mechanisms, leading to metabolic, cardiovascular3, psychological, and emotional changes, interfering in the performance of daily activities, and causing tiredness30,31. Despite being a subjective reaction, it is understood as an indicator of the psychological response to adverse environmental events, such as air and noise pollution10,32, and is considered one of the critical outcomes associated with exposure to urban noise3. Although not listed by the International Classification of Diseases as a disease, noise annoyance can preclude the attainment of a “state of complete physical, mental, and social well-being”, which is the World Health Organization's concept of health, since it can generate discomfort, as found in this study33. Among the health manifestations associated with exposure to environmental noise described in the literature, self-reported digestive disorders are connected with annoyance in women. Digestive changes are reported in individuals in stress situations33. Even though we found no association in the final model between noise annoyance and self-reported cardiovascular or even metabolic diseases, the univariate analysis showed relationships with self-reported migraine, mental disorders, and depression in women. Poor sleep quality caused by noise exposure is one of the critical outcomes of noise exposure in urban environments3. According to the World Health Organization, 1-1.6 million disability-adjusted life years are lost annually in Western Europe due to environmental noise, of which 903,000 are due to sleep disorders34. The current study identified an association between noise annoyance and poor sleep quality among women. This association has also been described in other investigations, which detected that noise annoyance is related to sleep disorders14,34,35. The MOR for male participants was 1.89, revealing that noise annoyance increased by 89% in this population if they moved from one census tract to another. For women, MOR was 1.71, demonstrating that noise annoyance increased by 71% if they moved from one census tract to another. These results indicate the importance of investigating which neighborhood characteristics of each of the sampled census tracts are associated with noise perception variability, as well as how individual health determinants may be directly related to the living environment. Although Belo Horizonte was one of the first planned cities in Brazil, its growth was disorganized, and the current urban design reveals important socioeconomic inequalities, with vulnerable areas interspersed with middle- and upper-class neighborhoods36. This study has several limitations. The main one is the lack of objective noise measures. On the other hand, since sound maps of the Belo Horizonte metropolitan region are not available, and no significant differences were observed in the last ten years concerning the demographic and epidemiological profile of the population, subjective evaluation of noise annoyance allows a valuable estimate of the potential effects of exposure to urban noise on health. Another limitation is the lack of information related to the work environment of the participating population. Noise perception is a complex phenomenon that suffers interference from various factors, such as years of work; stress rate; time spent at home during the day and night; windows in rooms and rooms that face the street; characteristics of day and night noise-generating sources37, which were not investigated in the present study but should be tested in future investigations on the subject in question. Despite the limitations described above, the strengths of this research remain, as, in addition to individual factors, we investigated the relationship of noise annoyance with the perceived living environment, socioeconomic status, and time living in the current residence, considering gender differences, using a population sample, and adopting a multilevel approach. As far as we know, no other study has data comparable to those presented herein for a Latin American metropolis, such as the city of Belo Horizonte. Also, the results highlighted the high prevalence of noise annoyance in one of the largest cities in Brazil. Considered one of the critical outcomes associated with noise exposure3, annoyance is at the physiological basis of health conditions responsible for the loss of thousands of disability-adjusted life years33. These results cannot be neglected; they indicate the need for public policies that can establish sound mapping in Brazil, so the effects of urban noise exposure on health and well-being can be investigated. ACKNOWLEDGMENTS The authors would like to thank the members and coordinators of the Belo Horizonte Observatory for Urban Health who participated in the BH Health Study and the Belo Horizonte Municipal Health Department for their support. REFERENCES 1 1. Grant M, Brown C, Caiaffa WT, Capon A, Corburn J, Coutts C, et al. Cities and health: an evolving global conversation. Cities Health 2017; 1(1): 1-9. https://doi.org/10.1080/23748834.2017.1316025 Grant M Brown C Caiaffa WT Capon A Corburn J Coutts C Cities and health: an evolving global conversation Cities Health 2017 1 1 1 9 https://doi.org/10.1080/23748834.2017.1316025 2 2. Basner M, Babisch W, Davis A, Brink M, Clark C, Janssen S, et al. Auditory and non-auditory effects of noise on health. Lancet 2014; 383(9925): 1325-32. https://doi.org/10.1016/S0140-6736(13)61613-X Basner M Babisch W Davis A Brink M Clark C Janssen S Auditory and non-auditory effects of noise on health Lancet 2014 383 9925 1325 1332 https://doi.org/10.1016/S0140-6736(13)61613-X 3 3. World Health Organization. Noise guidelines for the European Region. Geneva: World Health Organization; 2018. World Health Organization Noise guidelines for the European Region Geneva World Health Organization 2018 4 4. Popescu DI, Mohoela IF, Morariu-Glicor RM. Urban noise annoyance between 2001 and 2013-Study in a Romain City. Arch Acoust 2013; 38(2): 205-10. https://doi.org/10.2478/aoa-2013-0024 Popescu DI Mohoela IF Morariu-Glicor RM Urban noise annoyance between 2001 and 2013-Study in a Romain City Arch Acoust 2013 38 2 205 210 https://doi.org/10.2478/aoa-2013-0024 5 5. Okokon EO, Turunen AW, Ung-Lanki S, Vartiainen AK, Tiittanen P, Lanki T. Road-traffic noise: annoyance, risk perception, and noise sensitivity in the Finnish adult population. Int J Environ Res Public Health 2015; 12(6): 5712-34. https://doi.org/10.3390/ijerph120605712 Okokon EO Turunen AW Ung-Lanki S Vartiainen AK Tiittanen P Lanki T Road-traffic noise: annoyance, risk perception, and noise sensitivity in the Finnish adult population Int J Environ Res Public Health 2015 12 6 5712 5734 https://doi.org/10.3390/ijerph120605712 6 6. Jakovljević B, Belojević G, Paunović K, Stojanov V. Road traffic noise and sleep disturbances in an urban population: cross-sectional study. Croat Med J 2006; 47(1): 125-33. Jakovljević B Belojević G Paunović K Stojanov V Road traffic noise and sleep disturbances in an urban population: cross-sectional study Croat Med J 2006 47 1 125 133 7 7. Ndrepepa A, Twardella D. Relationship between noise annoyance from road traffic noise and cardiovascular diseases: a meta-analysis. Noise Health 2011; 13(52): 251-9. https://doi.org/10.4103/1463-1741.80163 Ndrepepa A Twardella D Relationship between noise annoyance from road traffic noise and cardiovascular diseases: a meta-analysis Noise Health 2011 13 52 251 259 https://doi.org/10.4103/1463-1741.80163 8 8. Moudon AV. Real noise from urban environment. How ambiente Community noise affects health and what can be done about it. Am J Prev Med 2009; 37(2): 167-71. https://doi.org/10.1016/j.amepre.2009.03.019 Moudon AV Real noise from urban environment. How ambiente Community noise affects health and what can be done about it Am J Prev Med 2009 37 2 167 171 https://doi.org/10.1016/j.amepre.2009.03.019 9 9. Urban J, Máca V. Linking traffic noise, noise annoyance and life satisfaction: a case study. Int J Environ Res Public Health 2013; 10(5): 1895-915. https://doi.org/10.3390/ijerph10051895 Urban J Máca V Linking traffic noise, noise annoyance and life satisfaction: a case study Int J Environ Res Public Health 2013 10 5 1895 1915 https://doi.org/10.3390/ijerph10051895 10 10. Belojević G, Jakovljević B, Aleksić O. Subjective reactions for traffic noise with regard to some personality traits. Environ Int 1997; 23(2): 221-6. https://doi.org/10.1016/S0160-4120(97)00008-1 Belojević G Jakovljević B Aleksić O Subjective reactions for traffic noise with regard to some personality traits Environ Int 1997 23 2 221 226 https://doi.org/10.1016/S0160-4120(97)00008-1 11 11. Vianna KMP, Cardoso MRA, Rodrigues RM. Noise pollution and annoyance: an urban soundscapes study. Noise Health 2015; 17(76): 125-33. https://doi.org/10.4103/1463-1741.155833 Vianna KMP Cardoso MRA Rodrigues RM Noise pollution and annoyance: an urban soundscapes study Noise Health 2015 17 76 125 133 https://doi.org/10.4103/1463-1741.155833 12 12. Miedema HME. Annoyance caused by environmental noise: elements for evidence-based noise policies. J Soc Issues 2007; 63(1): 41-57. https://doi.org/10.1111/j.1540-4560.2007.00495.x Miedema HME Annoyance caused by environmental noise: elements for evidence-based noise policies J Soc Issues 2007 63 1 41 57 https://doi.org/10.1111/j.1540-4560.2007.00495.x 13 13. Roux AVD, Slesinski SC, Alazraqui M, Caiaffa WT, Frenz P, Fuchs RJ, et al. A Novel International Partnership for Actionable Evidence on Urban Health in Latin America: LAC-Urban Health and SALURBAL. Global Challenges 2019; 3(4): 1800013. https://doi.org/10.1002/gch2.201800013 Roux AVD Slesinski SC Alazraqui M Caiaffa WT Frenz P Fuchs RJ A Novel International Partnership for Actionable Evidence on Urban Health in Latin America: LAC-Urban Health and SALURBAL Global Challenges 2019 3 4 1800013 1800013 https://doi.org/10.1002/gch2.201800013 14 14. Caiaffa WT, Proietti FA, Xavier CC, César CC, Sales ADF, Abreu MNS, et al. O Estudo Saúde em Beagá. In: Friche AAL, Xavier CC, Proietti FA, Caiaffa WT, editors. Saúde urbana em Belo Horizonte. Belo Horizonte: Editora UFMG; 2015. p. 39-72. Caiaffa WT Proietti FA Xavier CC César CC Sales ADF Abreu MNS O Estudo Saúde em Beagá Friche AAL Xavier CC Proietti FA Caiaffa WT Saúde urbana em Belo Horizonte Belo Horizonte Editora UFMG 2015 39 72 15 15. Commission on Social Determinants of Health. The social determinants of health: monitoring, research, and training. In: Commission on Social Determinants of Health, editor. Closing the gap in a generation: health equity through action on the social determinants of health. Geneva: World Health Organization ; 2008. p. 178-91. Commission on Social Determinants of Health The social determinants of health: monitoring, research, and training Commission on Social Determinants of Health Closing the gap in a generation: health equity through action on the social determinants of health Geneva World Health Organization 2008 178 191 16 16. Sieber C, Ragettli MS, Brink M, Olaniyan T, Baatjies R, Saucy A, et al. Comparison of sensitivity and annoyance to road traffic and community noise between a South African and a Swiss population sample. Environ Pollut 2018; 241: 1056-62. https://doi.org/10.1016/j.envpol.2018.06.007 Sieber C Ragettli MS Brink M Olaniyan T Baatjies R Saucy A Comparison of sensitivity and annoyance to road traffic and community noise between a South African and a Swiss population sample Environ Pollut 2018 241 1056 1062 https://doi.org/10.1016/j.envpol.2018.06.007 17 17. Beutel ME, Brähler E, Ernst M, Klein E, Reiner I, Wiltink J, et al. Noise annoyance predicts symptoms of depression, anxiety and sleep disturbance 5 years later. Findings from the Gutenberg Health Study. Eur J Public Health 2020; 30(3): 487-92. https://doi.org/10.1093/eurpub/ckaa015 Beutel ME Brähler E Ernst M Klein E Reiner I Wiltink J Noise annoyance predicts symptoms of depression, anxiety and sleep disturbance 5 years later. Findings from the Gutenberg Health Study Eur J Public Health 2020 30 3 487 492 https://doi.org/10.1093/eurpub/ckaa015 18 18. Maia JAR, Sousa MA, Fermino RC, Seabra A, Silva S, Silva RG, et al. Analysis and interpretation of physical activity levels in children: a tutorial based on hierarchical or multilevel modelling. Rev Bras Cineantropom Desempenho Hum 2007; 9(4): 424-35. Maia JAR Sousa MA Fermino RC Seabra A Silva S Silva RG Analysis and interpretation of physical activity levels in children: a tutorial based on hierarchical or multilevel modelling Rev Bras Cineantropom Desempenho Hum 2007 9 4 424 435 19 19. Merlo J, Chaix B, Ohlsson H, Beckman A, Johnell K, Hjerpe P, et al. A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena. J Epidemiol Community Health 2006; 60(4): 290-7. https://doi.org/10.1136/jech.2004.029454 Merlo J Chaix B Ohlsson H Beckman A Johnell K Hjerpe P A brief conceptual tutorial of multilevel analysis in social epidemiology: using measures of clustering in multilevel logistic regression to investigate contextual phenomena J Epidemiol Community Health 2006 60 4 290 297 https://doi.org/10.1136/jech.2004.029454 20 20. Merlo J, Chaix B, Yang M, Lynch J, Råstam L. A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon. J Epidemiol Community Health 2005; 59(6): 443-9. https://doi.org/10.1136/jech.2004.023473 Merlo J Chaix B Yang M Lynch J Råstam L A brief conceptual tutorial of multilevel analysis in social epidemiology: linking the statistical concept of clustering to the idea of contextual phenomenon J Epidemiol Community Health 2005 59 6 443 449 https://doi.org/10.1136/jech.2004.023473 21 21. Banerjee D, Das PP, Fouzdar A. Urban residential road traffic noise and hypertension: a cross-sectional study of adult population. J Urban Health 2014; 91(6): 1144-57. https://doi.org/10.1007/s11524-014-9916-1 Banerjee D Das PP Fouzdar A Urban residential road traffic noise and hypertension: a cross-sectional study of adult population J Urban Health 2014 91 6 1144 1157 https://doi.org/10.1007/s11524-014-9916-1 22 22. Babisch W. Updated exposure-response relationship between road traffic noise and coronary heart diseases: a meta-analysis. Noise Health 2014; 16(68): 1-9. https://doi.org/10.4103/1463-1741.127847 Babisch W Updated exposure-response relationship between road traffic noise and coronary heart diseases: a meta-analysis Noise Health 2014 16 68 1 9 https://doi.org/10.4103/1463-1741.127847 23 23. Clark C, Sbihi H, Tamburic L, Brauer M, Frank LD, Davies HW. Association of Long-Term Exposure to Transportation Noise and Traffic-Related Air Pollution with the Incidence of Diabetes: A Prospective Cohort Study. Environ Health Perspect 2017; 125(8): 087025. https://doi.org/10.1289/EHP1279 Clark C Sbihi H Tamburic L Brauer M Frank LD Davies HW Association of Long-Term Exposure to Transportation Noise and Traffic-Related Air Pollution with the Incidence of Diabetes: A Prospective Cohort Study Environ Health Perspect 2017 125 8 087025 087025 https://doi.org/10.1289/EHP1279 24 24. Sørensen M, Andersen ZJ, Nordsborg RB, Becker T, Tjønneland A, Overvad K, et al. Long-term exposure to road traffic noise and incident diabetes: a cohort study. Environ Health Perspect 2013; 121(2): 217-22. https://doi.org/10.1289/ehp.1205503 Sørensen M Andersen ZJ Nordsborg RB Becker T Tjønneland A Overvad K Long-term exposure to road traffic noise and incident diabetes: a cohort study Environ Health Perspect 2013 121 2 217 222 https://doi.org/10.1289/ehp.1205503 25 25. Sørensen M, Ketzel M, Overvad K, Tjønneland A, Raaschou-Nielsen O. Exposure to road traffic and railway noise and postmenopausal breast cancer: A cohort study. Int J Cancer 2014; 134(11): 2691-8. https://doi.org/10.1002/ijc.28592 Sørensen M Ketzel M Overvad K Tjønneland A Raaschou-Nielsen O Exposure to road traffic and railway noise and postmenopausal breast cancer: A cohort study Int J Cancer 2014 134 11 2691 2698 https://doi.org/10.1002/ijc.28592 26 26. Lacerda ABM, Magni C, Morata TC, Marques JM, Zannin PHT. Urban environment and perception to noise pollution. Ambient Soc 2005; 8(2): 85-98. https://doi.org/10.1590/S1414-753X2005000200005 Lacerda ABM Magni C Morata TC Marques JM Zannin PHT Urban environment and perception to noise pollution Ambient Soc 2005 8 2 85 98 https://doi.org/10.1590/S1414-753X2005000200005 27 27. Münzel T, Gori T, Babisch W, Basner M. Cardiovascular effects of environmental noise exposure. Eur Heart J 2014; 35(13): 829-36. https://doi.org/10.1093/eurheartj/ehu030 Münzel T Gori T Babisch W Basner M Cardiovascular effects of environmental noise exposure Eur Heart J 2014 35 13 829 836 https://doi.org/10.1093/eurheartj/ehu030 28 28. Giles-Corti B, Vernez-Moudon A, Reis R, Turrell G, Dannenberg AL, Badland H, et al. City planning and population health: a global challenge. Lancet 2016; 388(10062): 2912-24. https://doi.org/10.1016/S0140-6736(16)30066-6 Giles-Corti B Vernez-Moudon A Reis R Turrell G Dannenberg AL Badland H City planning and population health: a global challenge Lancet 2016 388 10062 2912 2924 https://doi.org/10.1016/S0140-6736(16)30066-6 29 29. Fórum Brasileiro de Segurança Pública. Anuário Brasileiro de Segurança Pública - Edição Especial 2018: análises dos estados e facções prisionais [Internet]. 2018 [cited on Nov 26, 2020]. Available at: Available at: https://forumseguranca.org.br/publicacoes_posts/anuario-brasileiro-de-seguranca-publica-edicao-especial-2018-analises-dos-estados-e-faccoes-prisionais/ Fórum Brasileiro de Segurança Pública Anuário Brasileiro de Segurança Pública - Edição Especial 2018: análises dos estados e facções prisionais [Internet] 2018 Nov 26, 2020 Available at: https://forumseguranca.org.br/publicacoes_posts/anuario-brasileiro-de-seguranca-publica-edicao-especial-2018-analises-dos-estados-e-faccoes-prisionais/ 30 30. Öhrström E, Skånberg A, Svensson H, Gidlöf-Gunnarsson A. Effects of road traffic noise and the benefit of access to quietness. J Sound Vibration 2006; 295(1-2): 40-59. https://doi.org/10.1016/j.jsv.2005.11.034 Öhrström E Skånberg A Svensson H Gidlöf-Gunnarsson A Effects of road traffic noise and the benefit of access to quietness J Sound Vibration 2006 295 1-2 40 59 https://doi.org/10.1016/j.jsv.2005.11.034 31 31. Riedel N, Köckler H, Scheiner J, Berger K. Objective exposure to road traffic noise, noise annoyance and self-related poor health-framing the relationship between noise and health as a matter of multiple stressors and resources in urban neighbourhoods. J Environ Plann Manage 2015; 58(2): 336-56. https://doi.org/10.1080/09640568.2013.859129 Riedel N Köckler H Scheiner J Berger K Objective exposure to road traffic noise, noise annoyance and self-related poor health-framing the relationship between noise and health as a matter of multiple stressors and resources in urban neighbourhoods J Environ Plann Manage 2015 58 2 336 356 https://doi.org/10.1080/09640568.2013.859129 32 32. Oiamo TH, Luginaah IN, Baxter J. Cumulative effects of noise and odour annoyances on environmental and health related quality of life. Soc Sci Med 2015; 146: 191-203. https://doi.org/10.1016/j.socscimed.2015.10.043 Oiamo TH Luginaah IN Baxter J Cumulative effects of noise and odour annoyances on environmental and health related quality of life Soc Sci Med 2015 146 191 203 https://doi.org/10.1016/j.socscimed.2015.10.043 33 33. World Health Organization. Burden of disease from environmental noise. Geneva: World Health Organization ; 2011. World Health Organization Burden of disease from environmental noise Geneva World Health Organization 2011 34 34. Eriksson C, Hilding A, Pyko A, Bluhm G, Pershagen G, Östenson CG. Long-term aircraft noise exposure and body mass index, waist circumference, and type 2 diabetes: a prospective study. Environ Health Perspect 2014; 122(7): 687-94. https://doi.org/10.1289/ehp.1307115 Eriksson C Hilding A Pyko A Bluhm G Pershagen G Östenson CG Long-term aircraft noise exposure and body mass index, waist circumference, and type 2 diabetes: a prospective study Environ Health Perspect 2014 122 7 687 694 https://doi.org/10.1289/ehp.1307115 35 35. Münzel T, Sørensen M, Gori T, Schmidt FP, Rao X, Brook J, et al. Environmental stressors and cardio-metabolic disease: part I-epidemiologic evidence supporting a role for noise and air pollution and effects of mitigation strategies. Eur Heart J 2017; 38(8): 550-6. https://doi.org/10.1093/eurheartj/ehw269 Münzel T Sørensen M Gori T Schmidt FP Rao X Brook J Environmental stressors and cardio-metabolic disease: part I-epidemiologic evidence supporting a role for noise and air pollution and effects of mitigation strategies Eur Heart J 2017 38 8 550 556 https://doi.org/10.1093/eurheartj/ehw269 36 36. Costa HSM, Peixoto MCD. Real-estate dynamics and environmental regulation: a discussion on the southern side of the Belo Horizonte Metropolitan Region. Rev Bras Estud Popul 2007; 24(2): 317-36. https://doi.org/10.1590/S0102-30982007000200009 Costa HSM Peixoto MCD Real-estate dynamics and environmental regulation: a discussion on the southern side of the Belo Horizonte Metropolitan Region Rev Bras Estud Popul 2007 24 2 317 336 https://doi.org/10.1590/S0102-30982007000200009 37 37. Jakovljevic B, Paunovic K, Belojevic G. Road traffic noise and factors influencing noise annoyance in an urban population. Envion Int 2009; 35(3): 552-6. https://doi.org/10.1016/j.envint.2008.10.001 Jakovljevic B Paunovic K Belojevic G Road traffic noise and factors influencing noise annoyance in an urban population Envion Int 2009 35 3 552 556 https://doi.org/10.1016/j.envint.2008.10.001 Financial support: National Health Fund of the Brazilian Ministry of Health, grant 25000.102984/2006-97; National Council for Scientific and Technological Development (CNPq), grants 475004/2006-0, 409688/2006-1, 432543/2016-3, and PQ 313377/2017-0; and Minas Gerais Research Foundation (FAPEMIG), grant APQ-00975-08.