BackgroundThere is considerable uncertainty in the disease rate estimation for aggregated area maps, especially for small population areas. As a consequence the delineation of local clustering is subject to substantial variation. Consider the most likely disease cluster produced by any given method, like SaTScan, for the detection and inference of spatial clusters in a map divided into areas; if this cluster is found to be statistically significant, what could be said of the external areas adjacent to the cluster? Do we have enough information to exclude them from a health program of prevention? Do all the areas inside the cluster have the same importance from a practitioner perspective?ResultsWe propose a method to measure the plausibility of each area being part of a possible localized anomaly in the map. In this work we assess the problem of finding error bounds for the delineation of spatial clusters in maps of areas with known populations and observed number of cases. A given map with the vector of real data (the number of observed cases for each area) shall be considered as just one of the possible realizations of the random variable vector with an unknown expected number of cases. The method is tested in numerical simulations and applied for three different real data maps for sharply and diffusely delineated clusters. The intensity bounds found by the method reflect the degree of geographic focus of the detected clusters.ConclusionsOur technique is able to delineate irregularly shaped and multiple clusters, making use of simple tools like the circular scan. Intensity bounds for the delineation of spatial clusters are obtained and indicate the plausibility of each area belonging to the real cluster. This tool employs simple mathematical concepts and interpreting the intensity function is very intuitive in terms of the importance of each area in delineating the possible anomalies of the map of rates. The Monte Carlo simulation requires an effort similar to the circular scan algorithm, and therefore it is quite fast. We hope that this tool should be useful in public health decision making of which areas should be prioritized.

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Irregularly shaped spatial disease clusters occur commonly in epidemiological studies, but their geographic delineation is poorly defined. Most current spatial scan software usually displays only one of the many possible cluster solutions with different shapes, from the most compact round cluster to the most irregularly shaped one, corresponding to varying degrees of penalization parameters imposed on the freedom of shape. Even when a fairly complete set of solutions is available, the choice of the most appropriate parameter setting is left to the practitioner, whose decision is often subjective. We propose quantitative criteria for choosing the best cluster solution, through multiobjective optimization, by finding the Pareto-set in the solution space. Two competing objectives are involved in the search: regularity of shape and scan statistic value. Instead of running sequentially a cluster-finding algorithm with varying degrees of penalization, the complete set of solutions is found in parallel, employing a genetic algorithm. The cluster significance concept is extended for this set in a natural and unbiased way, being employed as a decision criterion for choosing the optimal solution. The Gumbel distribution is used to approximate the empirical scan statistic distribution, speeding up the significance estimation. The multiobjective methodology is compared with the genetic mono-objective algorithm. The method is fast, with good power of detection. We discuss an application to breast cancer cluster detection. The introduction of the concept of Pareto-set in this problem, followed by the choice of the most significant solution, is shown to allow a rigorous statement about what is a "best solution," without the need of any arbitrary parameter.

The scan statistic is widely used in spatial cluster detection applications of inhomogeneous Poisson processes. However, real data may present substantial departure from the underlying Poisson process. One of the possible departures has to do with zero excess. Some studies point out that when applied to data with excess zeros, the spatial scan statistic may produce biased inferences. In this work, we develop a closed-form scan statistic for cluster detection of spatial zero-inflated count data. We apply our methodology to simulated and real data. Our simulations revealed that the Scan-Poisson statistic steadily deteriorates as the number of zeros increases, producing biased inferences. On the other hand, our proposed Scan-ZIP and Scan-ZIP+EM statistics are, most of the time, either superior or comparable to the Scan-Poisson statistic.

BackgroundIrregularly shaped spatial clusters are difficult to delineate. A cluster found by an algorithm often spreads through large portions of the map, impacting its geographical meaning. Penalized likelihood methods for Kulldorff's spatial scan statistics have been used to control the excessive freedom of the shape of clusters. Penalty functions based on cluster geometry and non-connectivity have been proposed recently. Another approach involves the use of a multi-objective algorithm to maximize two objectives: the spatial scan statistics and the geometric penalty function.Results & DiscussionWe present a novel scan statistic algorithm employing a function based on the graph topology to penalize the presence of under-populated disconnection nodes in candidate clusters, the disconnection nodes cohesion function. A disconnection node is defined as a region within a cluster, such that its removal disconnects the cluster. By applying this function, the most geographically meaningful clusters are sifted through the immense set of possible irregularly shaped candidate cluster solutions. To evaluate the statistical significance of solutions for multi-objective scans, a statistical approach based on the concept of attainment function is used. In this paper we compared different penalized likelihoods employing the geometric and non-connectivity regularity functions and the novel disconnection nodes cohesion function. We also build multi-objective scans using those three functions and compare them with the previous penalized likelihood scans. An application is presented using comprehensive state-wide data for Chagas' disease in puerperal women in Minas Gerais state, Brazil.ConclusionsWe show that, compared to the other single-objective algorithms, multi-objective scans present better performance, regarding power, sensitivity and positive predicted value. The multi-objective non-connectivity scan is faster and better suited for the detection of moderately irregularly shaped clusters. The multi-objective cohesion scan is most effective for the detection of highly irregularly shaped clusters.

The geographic delineation of irregularly shaped spatial clusters is an ill defined problem. Whenever the spatial scan statistic is used, some kind of penalty correction needs to be used to avoid clusters' excessive irregularity and consequent reduction of power of detection. Geometric compactness and non-connectivity regularity functions have been recently proposed as corrections. We present a novel internal cohesion regularity function based on the graph topology to penalize the presence of weak links in candidate clusters. Weak links are defined as relatively unpopulated regions within a cluster, such that their removal disconnects it. By applying this weak link cohesion function, the most geographically meaningful clusters are sifted through the immense set of possible irregularly shaped candidate cluster solutions. A multiobjective genetic algorithm (MGA) has been proposed recently to compute the Paretosets of clusters solutions, employing Kulldorff's spatial scan statistic and the geometric correction as objective functions. We propose novel MGAs to maximize the spatial scan, the cohesion function and the geometric function, or combinations of these functions. Numerical tests show that our proposed MGAs has high power to detect elongated clusters, and present good sensitivity and positive predictive value. The statistical significance of the clusters in the Pareto-set are estimated through Monte Carlo simulations. Our method distinguishes clearly those geographically inadequate clusters which are worse from both geometric and internal cohesion viewpoints. Besides, a certain degree of irregularity of shape is allowed provided that it does not impact internal cohesion. Our method has better power of detection for clusters satisfying those requirements. We propose a more robust definition of spatial cluster using these concepts.

This study aimed to associate Eating Competence (EC) with food consumption and health outcomes in the Brazilian adult population. Researchers developed a questionnaire to associate EC with sociodemographic information, health outcomes, and food consumption. Data on body weight and height was referred to by participants in the questionnaire, and body mass index (BMI) was calculated and classified. A question to evaluate the perception of body size was included. After constructing the questionnaire items, content validation and semantic evaluation were performed following the Delphi method with a group of judges composed of 26 health professionals. The judges evaluated the sociodemographic information, health outcomes, and food consumption items associated with the eating competence instrument (previously validated in Brazilian-Portuguese). The final version of the questionnaire was composed of 33 items. Our results confirmed good reliability, responsiveness, and internal consistency. A total of 1810 Brazilians answered the questionnaire. Most of the participants were female, up to 40 years old, with a high education level and high income. Most of the participants did not report diabetes or hypertension. The EC total score did not differ among males and females. Individuals up to 40 years old presented a lower total score. The increase in educational level and income also increased EC total score. Excess weight individuals showed lower EC compared to the normal weight/underweight. Individuals who consumed fruits and/or vegetables five or more days/week presented the best scores for total EC.

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