International Journal of Health Geographics - Latest Articles

Geographical variation of unmet medical needs in Italy: a multivariate logistic regression analysis

Marina Cavalieri — 2013-05-12T00:00:00Z

Background: Unmet health needs should be, in theory, a minor issue in Italy where a publicly funded and universally accessible health system exists. This, however, does not seem to be the case. Moreover, in the last two decades responsibilities for health care have been progressively decentralized to regional governments, which have differently organized health service delivery within their territories. Regional decision-making has affected the use of health care services, further increasing the existing geographical disparities in the access to care across the country. This study aims at comparing self-perceived unmet needs across Italian regions and assessing how the reported reasons - grouped into the categories of availability, accessibility and acceptability -- vary geographically. Methods: Data from the 2006 Italian component of the European Union Statistics on Income and Living Conditions are employed to explore reasons and predictors of self-reported unmet medical needs among 45,175 Italian respondents aged 18 and over. Multivariate logistic regression models are used to determine adjusted rates for overall unmet medical needs and for each of the three categories of reasons. Results: Results show that, overall, 6.9% of the Italian population stated having experienced at least one unmet medical need during the last 12 months. The unadjusted rates vary markedly across regions, thus resulting in a clear-cut north--south divide (4.6% in the North-East vs. 10.6% in the South). Among those reporting unmet medical needs, the leading reason was problems of accessibility related to cost or transportation (45.5%), followed by acceptability (26.4%) and availability due to the presence of too long waiting lists (21.4%). In the South, more than one out of two individuals with an unmet need refrained from seeing a physician due to economic reasons. In the northern regions, working and family responsibilities contribute relatively more to the underutilization of medical services. Logistic regression results suggest that some population groups are more vulnerable than others to experiencing unmet health needs and to reporting some categories of reasons. Adjusting for the predictors resulted in very few changes in the rank order of macro-area rates. Conclusions: Policies to address unmet health care needs should adopt a multidimensional approach and be tailored so as to consider such geographical heterogeneities.

Associations of neighborhood characteristics with active park use: an observational study in two cities in the USA and Belgium

Delfien Van Dyck — 2013-05-07T00:00:00Z

Background: Public parks can be an important setting for physical activity promotion, but to increase park use and the activity levels of park users, the crucial attributes related to active park use need to be defined. Not only user characteristics and structural park attributes, but also characteristics of the surrounding neighborhood are important to examine. Furthermore, internationally comparable studies are needed, to find out if similar intervention strategies might be effective worldwide. The main aim of this study was to examine whether the overall number of park visitors and their activity levels depend on study site, neighborhood walkability and neighborhood income. Methods: Data were collected in 20 parks in Ghent, Belgium and San Diego, USA. Two trained observers systematically coded park characteristics using the Environmental Assessment of Public Recreation Spaces (EAPRS) tool, and park user characteristics using the System for Observing Play and recreation in Communities (SOPARC) tool. Multilevel multiple regression models were conducted in MLwiN 2.25. Results: In San Diego parks, activity levels of park visitors and number of vigorously active visitors were higher than in Ghent, while the number of visitors walking and the overall number of park visitors were lower. Neighborhood walkability was positively associated with the overall number of visitors, the number of visitors walking, number of sedentary visitors and mean activity levels of visitors. Neighborhood income was positively associated with the overall number of visitors, but negatively with the number of visitors being vigorously active. Conclusions: Neighborhood characteristics are important to explain park use. Neighborhood walkability-related attributes should be taken into account when promoting the use of existing parks or creating new parks. Because no strong differences were found between parks in high- and low-income neighborhoods, it seems that promoting park use might be a promising strategy to increase physical activity in low-income populations, known to be at higher risk for overweight and obesity.

A binary-based approach for detecting irregularly shaped clusters

Tai-Chi Wang — 2013-05-06T00:00:00Z

Background There are many applications for spatial cluster detection and more detectionmethods have been proposed in recent years. Most cluster detection methods areefficient in detecting circular (or circular-like) clusters, but the methods whichcan detect irregular-shaped clusters usually require a lot of computing time.Methods e propose a new spatial detection algorithm for lattice data.The proposed method can be separated into two stages:the first stage determines the significant cells with unusual occurrences (i.e., individual clustering)by applying the Choynowski's test,and the second stage determines if there are clusters based on the information of the first stageby a binomial approximate method.We first use computer simulation to evaluate the performance of the proposed methodand compare it with the scan statistics.Furthermore, we take the Taiwan Cancer data in 2000to illustrate the detection results of the scan statistics and the proposed method.Results The simulation results support using the proposed methodwhen the population sizes are large and the study regions are irregular.However, in general, the scan statistics still have better power in detecting clusters,especially when the population sizes are not large.For the analysis of cancer data,the scan statistics tend to spot more clusters,and the clusters' shapes are close to circular (or elliptic).On the other hand, the proposed methods only find one clusterand cannot detect small-sized clusters.Conclusions In brief, the proposed methods can detect both circular and non-circular clusters wellwhen the significant cells are correctly detected by the Choynowski's method.In addition,the binomial-based method can handle the problem of multiple testing andsave the computing time.On the other hand,both the circular and elliptical scan statistics have good power in detecting clusters,but tend to detect more clusters and have lower accuracy in detectingnon-circular clusters.

Defining neighborhood boundaries in studies of spatial dependence in child behavior problems

Margaret Caughy — 2013-05-03T00:00:00Z

Background: The purpose of this study was to extend the analysis of neighborhood effects on child behavioral outcomes in two ways: (1) by examining the geographic extent of the relationship between child behavior and neighborhood physical conditions independent of standard administrative boundaries such as census tracts or block groups and (2) by examining the relationship and geographic extent of geographic peers’ behavior and individual child behavior. Methods: The study neighborhood was a low income, ethnic minority neighborhood of approximately 20,000 residents in a large city in the southwestern United States. Observational data were collected for 11,552 parcels and 1,778 face blocks in the neighborhood over a five week period. Data on child behavior problems were collected from the parents of 261 school-age children (81% African American, 14% Latino) living in the neighborhood. Spatial analysis methods were used to examine the spatial dependence of child behavior problems in relation to physical conditions in the neighborhood for areas surrounding the child’s home ranging from a radius of 50 meters to a radius of 1000 meters. Likewise, the spatial dependence of child behavior problems in relation to the behavior problems of neighborhood peers was examined for areas ranging from a radius 255 meters to a radius of 600 meters around the child’s home. Finally, we examined the joint influence of neighborhood physical conditions and geographic peers. Results: Poor conditions of the physical environment of the neighborhood were related to more behavioral problems, and the geographic extent of the physical environment that mattered was an area with a radius between 400 and 800 meters surrounding the child’s home. In addition, the average level of behavior problems of neighborhood peers within 255 meters of the child’s home was also positively associated with child behavior problems. Furthermore, these effects were independent of one another. Conclusions: These findings demonstrate that using flexible geographies in the study of neighborhood effects can provide important insights into spatial influences on health outcomes. With regards to child behavioral outcomes, specifically, these findings support the importance of addressing the physical and social environment when planning community-level interventions to reduce child behavior problems.

A case-referent study: light at night and breast cancer risk in Georgia

Sarah Bauer — 2013-04-17T00:00:00Z

Background: Literature has identified detrimental health effects from the indiscriminate use of artificial nighttime light. We examined the co-distribution of light at night (LAN) and breast cancer (BC) incidence in Georgia, with the goal to contribute to the accumulating evidence that exposure to LAN increases risk of BC. Methods: Using Georgia Comprehensive Cancer Registry data (2000–2007), we conducted a case-referent study among 34,053 BC cases and 14,458 lung cancer referents. Individuals with lung cancer were used as referents to control for other cancer risk factors that may be associated with elevated LAN, such as air pollution, and since this cancer type was not previously associated with LAN or circadian rhythm disruption. DMSP-OLS Nighttime Light Time Series satellite images (1992–2007) were used to estimate LAN levels; low (0–20 watts per sterradian cm2), medium (21–41 watts per sterradian cm2), high (>41 watts per sterradian cm2). LAN levels were extracted for each year of exposure prior to case/referent diagnosis in ArcGIS. Results: Odds ratios (OR) and 95% confidence intervals (CI) were estimated using logistic regression models controlling for individual-level year of diagnosis, race, age at diagnosis, tumor grade, stage; and population-level determinants including metropolitan statistical area (MSA) status, births per 1,000 women aged 15–50, percentage of female smokers, MSA population mobility, and percentage of population over 16 in the labor force. We found that overall BC incidence was associated with high LAN exposure (OR = 1.12, 95% CI [1.04, 1.20]). When stratified by race, LAN exposure was associated with increased BC risk among whites (OR = 1.13, 95% CI [1.05, 1.22]), but not among blacks (OR = 1.02, 95% CI [0.82, 1.28]). Conclusions: Our results suggest positive associations between LAN and BC incidence, especially among whites. The consistency of our findings with previous studies suggests that there could be fundamental biological links between exposure to artificial LAN and increased BC incidence, although additional research using exposure metrics at the individual level is required to confirm or refute these findings.

Relative residential property value as a socioeconomic status indicator for health research

Neil Coffee — 2013-04-15T00:00:00Z

Background: Residential property is reported as the most valuable asset people will own and therefore provides the potential to be used as a socio-economic status (SES) measure. Location is generally recognised as the most important determinant of residential property value.Extending the well-established relationship between poor health and socio-economic disadvantage and the role of residential property in the overall wealth of individuals, this study tested the predictive value of the Relative Location Factor (RLF), a SES measure designed to reflect the relationship between location and residential property value, and six cardiometabolic disease risk factors, central obesity, hypertriglyceridemia, reduced high density lipoprotein (HDL), hypertension, impaired fasting glucose, and high low density lipoprotein (LDL). These risk factors were also summed and expressed as a cumulative cardiometabolic risk (CMR) score. Methods: RLF was calculated using a global hedonic regression model from residential property sales transaction data based upon several residential property characteristics, but deliberately blind to location, to predict the selling price of the property. The predicted selling price was divided by the actual selling price and the results interpolated across the study area and classified as tertiles. The measures used to calculate CMR were collected via clinic visits from a population-based cohort study. Models with individual risk factors and the cumulative cardiometabolic risk (CMR) score as dependent variables were respectively tested using log binomial and Poisson generalised linear models. Results: A statistically significant relationship was found between RLF, the cumulative CMR score and all but one of the risk factors. In all cases, participants in the most advantaged and intermediate group had a lower risk for cardio-metabolic diseases. For the CMR score the RR for the most advantaged was 19% lower (RR = 0.81; CI 0.76-0.86; p <0.0001) and the middle group was 9% lower (RR = 0.91; CI 0.86-0.95; p <0.0001) than the least advantaged group. Conclusions: This paper advances the understanding of the nexus between place, health and SES by providing an objective spatially informed SES measure for testing health outcomes and reported a robust association between RLF and several health measures.

A ubiquitous method for street scale spatial data collection and analysis in challenging urban environments: mapping health risks using spatial video in Petit-Goave, Haiti

Andrew Curtis — 2013-04-15T00:00:00Z

Background Fine-scale and longitudinal geospatial analysis of health risks in challenging urban areas is often limited by the lack of other spatial layers even if case data are available. Underlying population counts, residential context, and associated causative factors such as standing water or trash locations are often missing unless collected through logistically difficult, and often expensive, surveys. The lack of spatial context also hinders the interpretation of results and designing intervention strategies structured around analytical insights. This paper offers a ubiquitous spatial data collection approach using a spatial video that can be used to improve analysis and involve participatory collaborations. A case study will be used to illustrate this approach with three health risks mapped at the street scale for Petit-Goave, Haiti.Methods Spatial video was used to collect street and building scale information, including standing water, trash accumulation, presence of dogs, cohort specific population characteristics, and other cultural phenomena. These data were digitized into Google Earth and then coded and analyzed in a GIS using kernel density and spatial filtering approaches. The concentrations of these risks around area schools which are sometimes sources of diarrheal disease infection because of the high concentration of children and variable sanitary practices will show the utility of the method. In addition schools offer potential locations for cholera education interventions. Results: Previously unavailable fine scale health risk data vary in concentration across the town, with some schools being proximate to greater concentrations of the mapped risks. The spatial video is also used to validate coded data and location specific risks within these "hotspots".Conclusions Spatial video is a tool that can be used in any environment to improve local area health analysis and intervention. The process is rapid and can be repeated in study sites through time to track spatio-temporal dynamics of the communities. Its simplicity should also be used to encourage local participatory collaborations.

Utility of passive photography to objectively audit built environment features of active transport journeys: an observational study

Melody Oliver — 2013-04-10T00:00:00Z

Background: Active transport can contribute to physical activity accumulation and improved health in adults. The built environment is an established associate of active transport behaviours; however, assessment of environmental features encountered during journeys remains challenging. The purpose of this study was to examine the utility of wearable cameras to objectively audit and quantify environmental features along work-related walking and cycling routes. Methods: A convenience sample of employed adults was recruited in New Zealand, in June 2011. Participants wore a SenseCam for all journeys over three weekdays and completed travel diaries and demographic questionnaires. SenseCam images for work-related active transport journeys were coded for presence of environmental features hypothesised to be related to active transport. Differences in presence of features by transport mode and in participant-reported and SenseCam-derived journey duration were determined using two-sample tests of proportion and an independent samples t-test, respectively. Results: Fifteen adults participated in the study, yielding 1749 SenseCam images from 30 work-related active transport journeys for coding. Significant differences in presence of features were found between walking and cycling journeys. Almost a quarter of images were uncodeable due to being too dark to determine features. There was a non-significant tendency for respondents to under-report their journey duration. Conclusion: This study provides proof of concept for the use of the SenseCam to capture built environment data in real time that may be related to active transportation. Further work is required to test and refine coding methodologies across a range of settings, travel behaviours, and demographic groups.

Gaining a better understanding of respiratory health inequalities among cities: an ecological case study on elderly males in the larger French cities

Christina Aschan-Leygonie — 2013-04-10T00:00:00Z

Background: In recent years, there have been a growing number of studies on spatial inequalities in health covering a variety of scales, from small areas to metropolitan areas or regions, and for various health outcomes. However, few investigations have compared health status between cities with a view to gaining a better understanding of the relationships between such inequalities and the social, economic and physical characteristics. This paper focuses on disparities in respiratory health among the 55 largest French cities. The aim is to explore the relationships between inter-urban health patterns, city characteristics and regional context, and to determine how far a city's health status relates to the features observed on different geographical scales. Methods: We used health data describing hospitalizations for Chronic Obstructive Pulmonary Disease (COPD) as a proxy for respiratory health, and the total number of hospitalizations (overall) as a proxy for general health. This last indicator was used as a benchmark. A large set of indicators relating to socioeconomic, physical and amenity aspects of the cities (urban units) was also constructed. Data were analyzed using linear correlations and multiple linear regression models. Results: The results suggest that socioeconomic characteristics are major discriminators for inequalities in respiratory health status among urban units. Indeed, once combined to socioeconomic characteristics, only a climate indicator remained significant among the physical indicators. It appeared that the pollution indicators which were significantly correlated with COPD hospitalization rates loosed significance when associated to the socio-economic indicators in a multiple regression. The analysis showed that among the socio-economic indicators, an employment indicator derived at the regional scale, and two indicators reflecting the unequal intra-urban spatial distribution of population according to their education, were the most efficient to describe differences in the respiratory health status of urban units. Conclusion: In order to design effective urban policies, it is essential to gain a better understanding of the differences among cities in their entirety, rather than solely differences across small urban areas or individuals.

Exergames for health and fitness: the roles of GPS and geosocial apps

Maged Kamel Boulos — 2013-04-05T00:00:00Z

Large numbers of children and adolescents in Canada, UK and USA are not getting their recommended daily dose of moderate to vigorous physical activity, and are thus more prone to obesity and its ill health effects. Exergames (video games that require physical activity to play) are rapidly gaining user acceptance, and may have the potential to increase physical activity levels among young people. Mobile exergames for GPS (global positioning system)-enabled smartphones and mini-tablets take players outdoors, in the open air, unlike console exergames, e.g., Xbox 360 Kinect exergames, which limit players to playing indoors in front of a TV set. In this paper and its companion ‘Additional file 1’, we review different examples of GPS exergames and of gamified geosocial apps and gadgets (mobile, location-aware apps and devices with social and gamification features), and briefly discuss some of the issues surrounding their use. Further research is needed to document best practices in this area, quantify the exact health and fitness benefits of GPS exergames and apps (under different settings and scenarios), and find out what is needed to improve them and the best ways to promote their adoption by the public.