Place effects on health: how can we conceptualise, operationalise and measure them?

Neighbourhood property value and type 2 diabetes mellitus in the Maastricht study: A multilevel study

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.

Constructing social identity through multiple "us and them": a grounded theory study of how contextual factors are manifested in the lives of residents of a vulnerable district in Brazil

The association between contextual factors and health inequalities is well documented, also in Brazil. However, questions about how contextual factors actually affect health and well-being persist. The aim of this qualitative study was to explore how contextual factors—i.e., social stratification and neighborhood opportunity structures—are manifested in the lives of the residents of a vulnerable district in Brazil. We used a Constructivist Grounded Theory approach based on 12 in-depth interviews. The core category constructing social identity through multiple “us and them” is supported by eight main categories that characterize different pairs of “us and them”, based on internal and external aspects of the social processes involved. Our findings strengthen and support the links between contextual factors and health inequalities, highlighting the relevance of downward social comparison, territorial segregation and stigmatization and erosion of social capital in the construction of social identities and the manifestation of social hierarchies and neighborhood structures in the Brazilian context. Ultimately, these create shame and stress but also pride and empowerment, which are recognized determinants of health inequities.

The role of regional health systems on the waiting time inequalities in health care services: Evidences from Italy

Inequalities in effective access to healthcare are present among countries and within the same country. Despite in Italy exist the principle of equity in access to health system, there are evidence of different access rates in the form of unequal waiting time within the country. Waiting times are an instruments to ration healthcare services dealing with resource scarsity. Theoretically, it is a fair tool because waiting times should depend only on health needs and not on the ability to pay. However, a growing literature has pointed out that belonging to a particular socioeconomic status leads to waiting times inequalities for healthcare services. Many countries have socioeconomic disparities among regions, and healthcare organizations need to take into account these differences. The increasing power of Regional Health Authorities in decentralized health systems, as in the case of Italy, has generated different organizational ways to provide health care, possibly leading to different access rates in the form of unequal waiting time within the country. This paper aims to understand if the administrative area (Regional Health Authorities) in charge of health services affects waiting times lowering or strengthening health care access inequalities. Using a series of logistic regression models, this work suggests the presence of two vectors: socioeconomic inequalities and regional inequalities. Health organizations need to implement different kinds of answers for each vectors of inequalities.

Religion, Health, Social Capital and Place: The Role of the Religious, Social Processes and the Beneficial and Detrimental Effects on the Health and Wellbeing of Inhabitants in Deprived Neighbourhoods in Malta

This paper emphasises the important role that place has in determining how religious social processes operate and impact on health and wellbeing. It draws upon evidence through qualitative in-depth interviews with families (both parents and children) living in two deprived neighbourhoods in Malta, a 'traditional' and a 'modern' one. It emerged that religious faith and practices can generate normative and resource-based social capital which can positively impact on health and wellbeing. However, some individuals found this social capital constraining and this had detrimental effects on their wellbeing. The context, composition, history and norms of the place emerge as highly important. This study emphasises that religious social processes operate in a highly complex manner, and 'adherents' and 'disaffiliates' are likely to enjoy positive or negative health and wellbeing according to where they live and according to important persons living in the neighbourhood such as the parish priest. This study contributes to the research gap between religion, social capital and health and the complex, social processes that operate at the local level of place.

Poor Health and Violent Crime Hot Spots: Mitigating the Undesirable Co-Occurrence Through Focused Place-Based Interventions

INTRODUCTION

The geographic overlap of violence and poor health is a major public health concern. To understand whether and how place-based interventions targeting micro-geographic places can reduce this undesirable co-occurrence, the study addresses 2 important questions. First, to what extent are deteriorated health conditions associated with living at violent crime hot spots? Second, through what mechanisms can focused place-based interventions break the association between living with violence and deteriorated health?

METHODS

This study used survey data from 2,724 respondents living on 328 street segments that were categorized as violent crime hot spots (181 segments with 1,532 respondents) versus non-hot spots (147 segments with 1,192 respondents) in 2013-2014 in Baltimore, Maryland. Propensity score analysis assessed whether individuals living at violent crime hot spots had lower general health perceptions than people living at non-hot spots. Marginal structural models estimated the proportion of total effects mediated by 3 theoretically informed intervening mechanisms. Analyses were conducted in 2019.

RESULTS

Respondents living at violent crime hot spots had a lower level of self-rated general health (b= -0.096, 95% CI= -0.176, -0.015) and higher levels of health limitations (b=0.068, 95% CI=0.027, 0.109) and problems (OR=2.026, 95% CI=1.225, 3.349) than those living at non-hot spots. Enhanced perceptions of safety, collective efficacy, and police legitimacy may break the association between living in places with extremely high levels of violence and deteriorated health.

CONCLUSIONS

Indicated or selective strategies are urgently needed to target micro-geographic locations with known increased risks, supplementing universal strategies applied to a broader community.

Risk of late cervical cancer screening in the Paris region according to social deprivation and medical densities in daily visited neighborhoods

Background

Social and physical characteristics of the daily visited neighborhoods have gained an extensive interest in analyzing socio-territorial inequalities in health and healthcare. The objective of the present paper is to estimate and discuss the role of individual and contextual factors on participation in preventive health-care activities (smear screening) in the Greater Paris area focusing on the characteristics of daily visited neighborhoods in terms of medical densities and social deprivation.

Methods

The study included 1817 women involved in the SIRS survey carried out in 2010. Participants could report three neighborhoods they regularly visit (residence, work/study, and the next most regularly visited). Two “cumulative exposure scores” have been computed from household income and medical densities (general practitioners and gynecologists) in these neighborhoods. Multilevel logistic regression models were used to measure association between late cervical screening (> 3 years) and characteristics of daily visited neighborhoods (residential, work or study, visit).

Results

One-quarter of the women reported that they had not had a smear test in the previous 3 years. Late smear test was found to be more frequent among younger and older women, among women being single, foreigners and among women having a low-level of education and a limited activity space. After adjustment on individual characteristics, a significant association between the cumulative exposure scores and the risk of a delayed smear test was found: women who were exposed to low social deprivation and to low medical densities in the neighborhoods they daily visit had a significantly higher risk of late cervical cancer screening than their counterparts.

Conclusions

For a better understanding of social and territorial inequalities in healthcare, there is a need for considering multiple daily visited neighborhoods. Cumulative exposure scores may be an innovative approach for analyzing contextual effects of daily visited neighborhoods rather than focusing on the sole residential neighborhood.

Children's perspectives on health-promoting living environments: The significance of social capital

This article discusses the usefulness of social capital as a conceptual tool to design neighbourhoods promoting children's health. The aim was to explore children's perspectives of health promoting environments, and we used a combination of photovoice and grounded theory. Children from two neighbourhoods in a Swedish municipality were invited to photograph and discuss places of importance for their well-being. They presented places facilitating togetherness, enjoyable activities and positive emotions, mostly found in their immediate environments: at home, at school and in their neighbourhoods, but the access to these places was unequally distributed between the areas. The results highlight a need for ensuring all children's access to health promoting places and to include children's views in policy and planning. Investments in the physical environment need to be combined with efforts to influence norms and collective efficacy to secure local ownership and use of these investments. We found that the concept of social capital is a relevant conceptual tool for understanding what constitutes health-promoting places from children's perspectives and contributes to a deeper understanding on how physical and social environments are interlinked.

Neighbourhood fast food exposure and consumption: the mediating role of neighbourhood social norms

Background

The association between the residential fast food environment and diet has gained growing attention. However, why the food environment affects food consumption is under-examined. This study aimed to investigate neighbourhood social norms with respect to fast food consumption as a potential mediating pathway between residential fast food outlet exposure and residents’ fast food consumption.

Methods

A correlational study was conducted in which a nationwide sample of 1038 respondents living across The Netherlands completed a survey. Respondents reported their fast food consumption (amount/week) as well as perceived descriptive and injunctive norms regarding fast food consumption in their neighbourhood. Fast food outlet exposure was measured by the average count of fast food outlets within a 400 m walking distance buffer around the zip-codes of the respondents, using a retail outlet database. Regression models were used to assess associations between residential fast food outlet exposure, fast food consumption, and social norm perceptions, and a bootstrapping procedure was used to test the indirect -mediation- effect. Separate analyses were performed for descriptive norms and injunctive norms.

Results

There was no overall or direct association between residential fast food outlet exposure and residents’ fast food consumption. However, fast food outlet exposure was positively associated with neighbourhood social norms (descriptive and injunctive) regarding fast food consumption, which in turn were positively associated with the odds of consuming fast food. Moreover, results of the bootstrapped analysis provided evidence of indirect effects of fast food outlet exposure on fast food consumption, via descriptive norms and injunctive norms.

Conclusions

In neighbourhoods with more fast food outlets, residents were more likely to perceive fast food consumption in the neighbourhood as more common and appropriate. In turn, stronger neighbourhood social norms were associated with higher fast food consumption. Acknowledging the correlational design, this study is the first that implies that neighbourhood social norms may be a mediating pathway in the relation between the residential fast food environment and fast food consumption. Future research may examine the role of neighbourhood social norms in other contexts and explore how the changing food environment may shift our consumption norms.

Socio-economic inequalities in life expectancy of older adults with and without multimorbidity: a record linkage study of 1.1 million people in England

Background

Age of onset of multimorbidity and its prevalence are well documented. However, its contribution to inequalities in life expectancy has yet to be quantified.

Methods

A cohort of 1.1 million English people aged 45 and older were followed up from 2001 to 2010. Multimorbidity was defined as having 2 or more of 30 major chronic diseases. Multi-state models were used to estimate years spent healthy and with multimorbidity, stratified by sex, smoking status and quintiles of small-area deprivation.

Results

Unequal rates of multimorbidity onset and subsequent survival contributed to higher life expectancy at age 65 for the least (Q1) compared with most (Q5) deprived: there was a 2-year gap in healthy life expectancy for men [Q1: 7.7 years (95% confidence interval: 6.4–8.5) vs Q5: 5.4 (4.4–6.0)] and a 3-year gap for women [Q1: 8.6 (7.5–9.4) vs Q5: 5.9 (4.8–6.4)]; a 1-year gap in life expectancy with multimorbidity for men [Q1: 10.4 (9.9–11.2) vs Q5: 9.1 (8.7–9.6)] but none for women [Q1: 11.6 (11.1–12.4) vs Q5: 11.5 (11.1–12.2)]. Inequalities were attenuated but not fully attributable to socio-economic differences in smoking prevalence: multimorbidity onset was latest for never smokers and subsequent survival was longer for never and ex smokers.

Conclusions

The association between social disadvantage and multimorbidity is complex. By quantifying socio-demographic and smoking-related contributions to multimorbidity onset and subsequent survival, we provide evidence for more equitable allocation of prevention and health-care resources to meet local needs.

How do perceived and objective measures of neighbourhood disadvantage vary over time? Results from a prospective-longitudinal study in the UK with implications for longitudinal research on neighbourhood effects on health

Background

Theories of health outcomes often hypothesize that living in more socially and economically disadvantaged neighbourhoods will lead to worse health. Multiple measures of neighbourhood disadvantage are available to researchers, which may serve as better or worse proxies for each other across time. To inform longitudinal study design and interpretation we investigated how perceived and objective measures of neighbourhood disadvantage vary over time and the factors underlying this variation.

Methods

Data were from 8,918 mothers with at least three time-points of neighbourhood data in the Avon Longitudinal Study of Parents and Children in the UK. We analyzed measures of objective (Indices of Multiple Deprivation) and perceived (neighbourhood quality, social cohesion, and stress) exposure to neighbourhood disadvantage at 10 time-points over 18 years. We used group-based trajectory modelling to determine the overlap in participants' trajectories on the different measures and evaluated the baseline factors associated with different perceived trajectories over time.

Results

There was evidence of heterogeneity in both perceived and objective measures of neighbourhood disadvantage over time (e.g., on the objective measure, 5% of participants moved to more deprived neighbourhoods, 11% moved to less deprived neighbourhoods, 20% consistently lived in deprived neighbourhoods, and 64% consistently lived in non-deprived neighbourhoods). Perceived social cohesion showed the weakest relationship with exposure to objective neighbourhood deprivation: most participants in each trajectory group of objective neighbourhood deprivation followed non-corresponding trajectories of perceived social cohesion (61–80%). Accounting for objective deprivation exposure, poorer socioeconomic and psychosocial indicators at baseline were associated with following more negative perceived neighbourhood trajectories (e.g., high neighbourhood stress) over time.

Conclusion

Trajectories of perceived and objective measures of neighbourhood disadvantage varied over time, with the extent of variation depending on the time point of measurement and individual-level social factors. Researchers should be mindful of this variation when choosing and determining the timing of measures of neighbourhood disadvantage in longitudinal studies and when inferring effect mechanisms.

The migration journey and mental health: Evidence from Venezuelan forced migration

•Using migration of Venezuelans to Peru as a case example, we surveyed migrants on mental health and migration factors at the Ecuador-Peru border.•Pre-migration: No factors associated with anxiety; choosing Peru for safety or expected respect for Venezuelans increased odds of depression.•Migration: Walking and education increased odds of anxiety; choosing Peru decreased odds of anxiety; being pregnant increased odds of depression.•Link between migration factors and mental health is concerning, as the associated distress may influence post-migration mental health.•More work is needed to understand the influence of the journey on the mental health outcomes of migrants over time.

Non-compensatory aggregation method to measure social and material deprivation in an urban area: relationship with premature mortality

Health inequalities exist between nations, regions, and even smaller units. In societies where social and economic structures change rapidly and continuously, analysis of health socioeconomic determinants plays a fundamental role to provide proper policy answers. This study aims to measure accurately two different conceptions of deprivation by developing two different indexes using non-compensatory among sub-indicators aggregation methods. The proposed indicators are compared with premature mortality to verify deprivation's effect on health status. The results show that materially deprived areas are not necessarily socially deprived and vice versa. Material deprivation has a positive statistical co-graduation with premature mortality, while social deprivation has no association with premature mortality.

Knowledge level of cancer symptoms and risk factors in the Gaza Strip: a cross-sectional study

BACKGROUND

In low-income settings, cancer is often diagnosed in advanced stages due to late presentation. Good public awareness of cancer signs and symptoms has a positive impact on the time patients take before they present to healthcare professionals. Therefore, this study examined public knowledge of cancer signs and symptoms as well as risk factors in Gaza.

METHODS

This was a cross-sectional study. Participants were recruited from adult visitors (≥18 years) to governmental hospitals covering all five governorates of Gaza, and adolescent students (15 to 17 years) from 10 high schools in corresponding locations. An Arabic version of the Cancer Awareness Measure (CAM) was completed in a face-to-face interview. It described demographic data and knowledge of: cancer prevalence, age-related risk, signs and symptoms as well as risk factors both in recall and recognition questions.

RESULTS

Of 3033 participants invited, 2886 completed the CAM (response rate = 95.2%). Adult mean age ± standard deviation was 33.7 ± 11.7 years and that of adolescents was 16.3 ± 0.8 years. Half of the participants (n = 1457, 50.5%) were adolescent (781 females; 53.6%) and 1429 (49.5%) were adult (702 females; 49.1%). About two thirds (n = 1885) thought about cancer as unrelated to age. Only 196 participants (6.8%) identified colorectal cancer as the most common cancer among men. Awareness of cancer signs/symptoms was poor to fair, where 'lump' was most commonly recognized (n = 2227, 77.2%) and 'change of bowel habit' the least (n = 670, 23.2%). Only 217 participants (7.5%) had a good level of recognizing risk factors with 'smoking' being the most identified and 'eating less than five portions of fruits and vegetables a day' the least. There was a higher likelihood for adults to identify most cancer signs/symptoms and risk factors than adolescents, except for recalling 'unexplained pain', 'persistent cough/hoarseness', 'non-healing ulcer', 'smoking', and 'eating less than five portions of fruits and vegetables a day'.

CONCLUSION

Public awareness of cancer signs/symptoms and risk factors needs to improve to facilitate early presentation and diagnosis in Gaza. Combining the delivery of public campaigns with tailored education to population groups, including the youth, may increase their knowledge and maintain its impact.

Social Relations, Community Engagement and Potentials: A Qualitative Study Exploring Resident Engagement in a Community-Based Health Promotion Intervention in a Deprived Social Housing Area

Emerging evidence points towards a lower quality of life, fragile social relations and suboptimal health behavior and status of residents living in social housing areas characterized by ethnic diversity and socioeconomic deprivation. Community-based health promotion interventions developed in collaboration with the target group and adjusted to the local context can affect the acceptance of and engagement in such interventions. However, few studies have investigated the potential of community-based interventions in deprived social housing areas. This study explores residents’ perspectives on engagement in a community-based health promotion intervention focusing on enhancing social relations. The study builds on qualitative methods including participant observations combined with pre- and post-intervention interviews with a selected group of residents (n = 9). Data were thematically analyzed with focuses on participation in an everyday life context, concepts of othering, and territorial stigmatization. Engagement in the intervention was motivated by the need to establish and enhance social relations, and to explore the world outside the housing area. However, barriers including cultural and language differences among residents, and competing contextual factors, challenged engagement. We conclude that participatory community-based interventions have a potential to enhance social relations in deprived social housing areas. However, adequate support and efforts to overcome the identified barriers are needed.

Community gender systems and a daughter's risk of female genital mutilation/cutting: Multilevel findings from Egypt

We tested a feminist social-ecological model to understand community influences on daughters' experience of female genital mutilation/cutting (FGMC) in Egypt, where over 90% of women ages 15-49 are cut. FGMC has potential adverse effects on demographic and health outcomes and has been defined as a human-rights violation. However, an integrated multilevel-level framework is lacking. We theorized that a more favorable community-level gender system, including stronger gender norms opposing FGMC and expanded extra-familial opportunities for women in the village or neighborhood, would be associated with a daughter's lower risk of FGMC and would strengthen the negative association of a mother's opposition to FGMC with her daughter's risk of cutting. Using a national sample of 14,171 mother-daughter dyads from the 2014 Egypt Demographic and Health Survey, we estimated multilevel discrete-time hazard models to test these relationships. Community gender norms opposing FGMC had significant direct, negative associations with the hazard that a daughter was cut, but women's opportunities outside the family did not. Maternal opposition to FGMC was negatively associated with cutting a daughter, and these associations were stronger where community opposition to FGMC and opportunities for women were greater. Results provided good support for a gender-systems framework of the multilevel influences on FGMC. Integrated, multilevel interventions that address gender norms about FGMC and structural opportunities for women in the community, as well as beliefs about the practice among the mothers of at-risk daughters, may be needed for sustainable declines in the practice.

Long-term Exposure to Neighborhood Deprivation and Intimate Partner Violence Among Women: A UK Birth Cohort Study

BACKGROUND

Intimate partner violence is the most common form of violence perpetrated against women. To our knowledge, the effect of neighborhood disadvantage on intimate partner violence against women has never been investigated prospectively outside the United States.

METHODS

We used data from the Avon Longitudinal Study of Parents and Children in the United Kingdom, which followed our target sample, 7,219 women, from birth and their mothers (from pregnancy). At age 21, 2,128 participants self-reported the frequency of experiencing physical, psychological, or sexual intimate partner violence since age 18. Participants' exposure to neighborhood-level deprivation and family-level socioeconomic characteristics (e.g., income) were measured at 10 time points from baseline (gestation) until children were 18 years old. We estimated the effect of cumulative exposure to greater neighborhood-level deprivation on the risk of experiencing intimate partner violence using marginal structural models with stabilized inverse probability weights, accounting for time-varying confounding by socioeconomic indicators and sample attrition.

RESULTS

A one-unit increase in cumulative exposure to more severe neighborhood deprivation was associated with a 62% increase in participants' frequency of experiencing intimate partner violence (95% confidence interval 11%, 237%) and 36% increase in their risk of experiencing any intimate partner violence (95% confidence interval 1%, 85%).

CONCLUSIONS

In our study, cumulative exposure to greater neighborhood deprivation over the first 18 years of life was associated with women's increased risk of experiencing intimate partner violence in early adulthood. Future studies should test this association across contexts, including underlying mechanisms, and evaluate preventive strategies that target structural disparities.

Robust estimation of the causal effect of time-varying neighborhood factors on health outcomes

The fundamental difficulty of establishing causal relationships between an exposure and an outcome in observational data involves disentangling causality from confounding factors. This problem underlies much of neighborhoods research, which abounds with studies that consider associations between neighborhood characteristics and health outcomes in longitudinal data. Such analyses are confounded by selection issues; individuals with above average health outcomes (or associated characteristics) may self-select into advantaged neighborhoods. Techniques commonly used to assess causal inferences in observational longitudinal data, such as inverse probability of treatment weighting (IPTW), may be inappropriate in neighborhoods data due to unique characteristics of such data. We advance the IPTW toolkit by introducing a procedure based on a multivariate kernel density function which is more appropriate for neighborhoods data. The proposed weighting method is applied in conjunction with a marginal structural model. Our empirical analyses use longitudinal data from the Health and Retirement Study; our exposure of interest is an index of neighborhood socioeconomic status (NSES), and we examine its influence on cognitive function. Our findings illustrate the importance of the choice of method for IPTW-the comparison weighting methods provide poor balance across the set of covariates (which is not the case for our preferred procedure) and yield misleading results when applied in the outcomes models. The utility of the multivariate kernel is also validated via simulation. In addition, our findings emphasize the importance of IPTW-controlling for covariates within a regression without IPTW indicates that NSES affects cognition, whereas IPTW-weighted models fail to show a statistically significant effect.

Multivariate spatiotemporal modeling of drug- and alcohol-poisoning deaths in New York City, 2009-2014

Drug- and alcohol-poisoning deaths remain current public health problems. Studies to date have typically focused on individual-level predictors of drug overdose deaths, and there remains a limited understanding of the spatiotemporal patterns and predictors of the joint outcomes. We use a hierarchical Bayesian spatiotemporal multivariate Poisson regression model on data from (N = 167) ZIP-codes between 2009 and 2014 in New York City to examine the spatiotemporal patterns of the joint occurrence of drug (opioids) and alcohol-poisoning deaths, and the covariates associated with each outcome. Results indicate that rates of both outcomes were highly positively correlated across ZIP-codes (cross-correlation: 0.57, 95% credible interval (CrI): 0.29, 0.77). ZIP-codes with a higher prevalence of heavy drinking had higher alcohol-poisoning deaths (relative risk (RR):1.63, 95% CrI: 1.26, 2.05) and drug-poisoning deaths (RR: 1.29, 95% CrI: 1.03, 1.59). These spatial patterns may guide public health planners to target specific areas to address these co-occurring epidemics.

Perceptions of public health and cross-sectoral collaboration in low SES neighbourhoods in Denmark

Cross-sectoral interventions in low socio-economic status (SES) neighbourhoods are an important contribution to reducing social inequities in health. This article investigates the health perceptions among professionals from public health, social and place-based initiatives, all working in low SES neighbourhoods in Denmark, and what implications these perceptions have on their work with health promotion and on collaboration between the initiatives. Empirically, we draw on 63 semi-structured interviews with frontline professionals across area-based initiatives (ABIs), social housing development plans (SHDPs) and municipal public health departments (PHDs). Our study shows that professionals across all sectors perceive it as important to work with a broad understanding of health to motivate and reach hard-to-reach groups in low SES neighbourhoods as opposed to a more narrow perspective on health and health promotion focussed on lifestyles and monitoring risks. The aims and practice of ABIs and SHDPs support work in line with a broad understanding of health, whereas frontline workers from the PHDs in practice more often end up applying a more narrow understanding of health. Consequently, real collaboration is infrequent and often confined to the coordination of activities. This limits the possibilities of implementing effective interventions in low SES neighbourhoods to reduce inequities in health. This article claims that there is a greater potential for synergy among different initiatives in low SES neighbourhoods if a broad understanding of health can be applied in practice across sectors.

Suicide and Types of Agriculture: A Time-Series Analysis in Japan

OBJECTIVE

In recent years, rural areas have reported higher suicide rates than urban areas worldwide. Although agricultural activity is a key characteristic of many rural areas, rurality may also have heterogeneous qualities based on the type of agriculture pursued. However, to date, no study has examined potential linkages between suicide rate and types of agriculture.

METHOD

In this study, we used 1983-2007 annual time-series data of the standardized mortality ratio (SMR) of suicide and product-specific agricultural outputs in Japanese municipalities to shed light on this phenomenon. We conducted a multilevel linear regression analysis, taking into account a hierarchical structure of the time-series data, limiting our analysis to municipalities where agricultural land use was high.

RESULTS

Our multilevel analysis showed that the animal husbandry output was positively associated with suicide SMR in both women and men, with a stronger relationship among women, whereas no association was observed in agricultural crop output. Temporal analysis showed that the association could be observed consistently throughout the period between 1983 and 2007.

CONCLUSIONS

This study raises the possibility that the industrial and cultural characteristics of communities that rely on animal husbandry may be associated with an increased risk of suicide.

Built Environments and Cardiometabolic Morbidity and Mortality in Remote Indigenous Communities in the Northern Territory, Australia

The health of Indigenous Australians is dramatically poorer than that of the non-Indigenous population. Amelioration of these differences has proven difficult. In part, this is attributable to a conceptualisation which approaches health disparities from the perspective of individual-level health behaviours, less so the environmental conditions that shape collective health behaviours. This ecological study investigated associations between the built environment and cardiometabolic mortality and morbidity in 123 remote Indigenous communities representing 104 Indigenous locations (ILOC) as defined by the Australian Bureau of Statistics. The presence of infrastructure and/or community buildings was used to create a cumulative exposure score (CES). Records of cardiometabolic-related deaths and health service interactions for the period 2010-2015 were sourced from government department records. A quasi-Poisson regression model was used to assess the associations between built environment "healthfulness" (CES, dichotomised) and cardiometabolic-related outcomes. Low relative to high CES was associated with greater rates of cardiometabolic-related morbidity for two of three morbidity measures (relative risk (RR) 2.41-2.54). Cardiometabolic-related mortality was markedly greater (RR 4.56, 95% confidence interval (CI), 1.74-11.93) for low-CES ILOCs. A lesser extent of "healthful" building types and infrastructure is associated with greater cardiometabolic-related morbidity and mortality in remote Indigenous locations. Attention to environments stands to improve remote Indigenous health.

A review of maternal prenatal exposures to environmental chemicals and psychosocial stressors-implications for research on perinatal outcomes in the ECHO program

Exposures to environmental chemicals and psychosocial stressors during pregnancy have been individually associated with adverse perinatal outcomes related to birthweight and gestational age, but are not often considered in combination. We review types of psychosocial stressors and instruments used to assess them and classes of environmental chemical exposures that are known to adversely impact perinatal outcomes, and identify studies relevant studies. We discuss the National Institutes of Health's Environmental influences on Child Health Outcomes (ECHO) program that has combined existing longitudinal cohorts that include more than 50,000 children across the U.S. We describe future opportunities for investigators to use this important new resource for addressing relevant and critical research questions to maternal health. Of the 84 cohorts in ECHO, 38 collected data on environmental chemicals and psychosocial stressors and perinatal outcomes. The diverse ECHO pregnancy cohorts provide capacity to compare regions with distinct place-based environmental and social stressors.

Neighbourhood community life and health: A systematic review of reviews

Neighbourhood community life has been widely recognized as an important determinant of population health. This systematic review of reviews provides an overview of the evidence for the ecological correlation between neighbourhood community life and population health. Nine databases were searched from 2008 to 2018 in order to identify systematic reviews of studies examining the association between neighbourhood community life and population health in urban neighbourhoods within the Organisation for Economic Co-operation and Development countries. Two reviewers completed selection and data extraction, then assessed the methodological quality of reviews using the Measurement Tool to Assess Systematic Reviews. We identified three high quality reviews and five of moderate quality. The reviews vary in quality of methodology, concepts, and measures. Most of the reviews examined the influence of social cohesion, social capital, and social interactions on health. Reviews found evidence supporting a consistently favourable correlation between social cohesion and physical activity, as well as a favourable trend in the relationship between social cohesion and healthy weight. They also found evidence of a favourable trend in the correlation between social capital and healthy weight. Reviews identified studies supporting a consistently favourable correlation between social interaction and depression. We identify evidence of a positive association between neighbourhood community life and several population health outcomes. Future research should define and conceptualize neighbourhood community life factors and health indicators to improve the comparison between studies and the process of evidence synthesis. This will also enable policy makers to take appropriate decisions.

Effects of gentrification on health status after Hurricane Katrina

Despite substantial debate about the impacts of gentrification on cities, neighborhoods, and their residents, there is limited evidence to demonstrate the implications of gentrification for health. We examine the impacts of gentrification on several health measures using a unique individual-level longitudinal data set. We employ data from the Resilience in Survivors of Hurricane Katrina (RISK) project, a study of low-income parents, predominantly non-Hispanic Black single mothers, who participated in a New Orleans-based study before and after Hurricane Katrina. After Katrina, all participants were displaced, at least temporarily, from New Orleans, and had little or no control over neighborhood placement immediately following the storm. This near-random displacement after Katrina created a natural experiment. We employ a quasi-experimental intent to treat design to assess the causal effects of gentrification on health in the RISK population. We do not find evidence of significant main effects of being displaced to a gentrified neighborhood on BMI, self-rated health, or psychological distress. The analysis employs a quasi-experimental design and has several additional unique features--homogeneous population, limited selection bias, and longitudinal data collection-- that improve our ability to draw causal conclusions about the relationship between gentrification and health. However, the unique context of displacement by natural disaster may limit the generalizability of our findings to other circumstances or residents experiencing gentrification.

Housing and Healthy Child Development: Known and Potential Impacts of Interventions

Housing is often described as an important determinant of health, but less commonly of child health. Despite acknowledgment of the importance of housing to health, however, there are relatively few studies of the effects of housing interventions on health, and again even fewer on child health. This article argues that a broad focus on healthy child development-as opposed to just physical health-coupled with a conceptual framework outlining specific attributes of housing with the potential to influence child health, should be adopted to guide a comprehensive approach to public health policy for healthy child development. Most housing interventions address direct pathways linking in-home hazard exposures to child health outcomes, with promising but mixed results. But few housing interventions address the broader aspects of healthy child development. This review addresses potential housing interventions that could impact the broader determinants of healthy child development and accompanying methodological challenges.

Social Mechanisms in Epidemiological Publications on Small-Area Health Inequalities-A Scoping Review

Background: Small-area social mechanisms-social processes involving the social environment around the place of residence-may be playing a role in the production of health inequalities. Understanding how small-area health inequalities (social environment affects health and consequently contribute to inequalities between areas) are generated and the role of social mechanisms in this process may help defining interventions to reduce inequalities. In mediation and pathway analyses, social mechanisms need to be treated as processes or factors. We aimed to identify which types of social mechanisms explaining the process leading from small-area characteristics to health inequalities have been considered and investigated in epidemiological publications and to establish how they have been operationalized. Methods: We performed a scoping review for social mechanisms in the context of small-area health inequalities in the database PubMed. Epidemiological publications identified were categorized according to the typology proposed by Galster (social networks, social contagion, collective socialization, social cohesion, competition, relative deprivation, and parental mediation). Furthermore, we assessed whether the mechanisms were operationalized at the micro or macro level and whether mechanisms were considered as processes or merely as exposure factors. Results: We retrieved 1,019 studies, 15 thereof were included in our analysis. Eight forms of operationalization were found in the category social networks and another nine in the category social cohesion. Other categories were hardly represented. Furthermore, all studies were cross sectional and did not consider mechanisms as processes. Except for one, all studies treated mechanisms merely as factors whose respective association to health outcomes was tested. Conclusion: In epidemiological publications, social mechanisms in studies on small-area effects on health inequalities are not operationalized as processes in which these mechanisms would play a role. Rather, the focus is on studying associations. To understand the production of health inequalities and the causal effect of social mechanisms on health, it is necessary to analyze mechanisms as processes. For this purpose, methods such as complex system modeling should be considered.

The legacy of the Home Owners' Loan Corporation and the political ecology of urban trees and air pollution in the United States

This study examines the persistent impacts of historical racebased discriminatory housing policies on contemporary urban environments in the United States. Specifically, we examine the relationships between Home Owners' Loan Corporation (HOLC) grades assigned to neighborhoods in the 1930s and the current distribution of tree canopy and level of exposure to air pollution hazards. Our results indicate a clear gradient in tree canopy by HOLC grade, with better neighborhood grades associated with significantly higher percentage of tree canopy coverage. The pattern also exists for airborne carcinogens and respiratory hazards, with worse neighborhood grades associated with significantly higher hazards exposure. Our findings indicate that early 20th century discriminatory housing policies exert a contemporary influence on patterns of green space exposure in American cities, with implications for health and health inequities. Our findings suggest that, in order to achieve equitable access to the benefits of urban greenspace, we must acknowledge these historical influences and consider policies and practices that directly counter these influences, for example, through targeted greenspace development in areas historically identified as unfit for investment.

Space and Place in Alcohol Research

PURPOSE OF REVIEW

To summarize the recent literature on social and physical environments and their links to alcohol use and identify empirical research strategies that will lead to a better understanding of alcohol use in contexts.

RECENT FINDINGS

Recent research has continued to describe the importance of neighborhood and regional contexts on alcohol use, while a smaller emerging scientific literature assesses the impacts of contexts on drinking.

SUMMARY

The dynamic, longitudinal, and multiscale processes by which social and physical structures affect social interactions and substance use have not yet been uncovered or quantified. In order to understand and quantify these processes, assessments of exposures (e.g., how individuals use space) and risks within specific locations are essential. Methods to better assess these exposures and risks include model-based survey approaches, ecological momentary assessment (EMA) and other forms of ecologically- and temporally-specific analyses, affiliation network analyses, simulation models, and qualitative/multi-methods studies.

Teacher Burnout and Contextual and Compositional Elements of School Environment

BACKGROUND

Teachers report higher levels of stress than most occupational groups. Burnout is a specific psychological condition that results from chronic job stress characterized by emotional exhaustion, low personal accomplishment, and depersonalization. This study considers associations between aspects of the school environment and teacher burnout.

METHODS

Exploratory analysis of baseline data from a cluster randomized controlled trial of 40 schools and 2278 teachers in the United Kingdom. Multilevel methods were used to consider the associations between different compositional and contextual aspects of the school environment and teacher burnout.

RESULTS

There was evidence for school effects on teacher burnout, evidenced by ICCs and likelihood ratio tests, supporting the association between school environment and teacher burnout. The factors most consistently associated with teacher burnout in our study were teachers' perceptions of the school's safety and support and student attitudes to learning.

CONCLUSIONS

The school environment does influence teacher burnout. More research is needed to develop and test causal pathways between the school environment and teacher burnout, and to understand ecological and individual predictors of teacher burnout and the interaction between the two.

Multilevel analysis in rural cancer control: A conceptual framework and methodological implications

Rural populations experience a myriad of cancer disparities ranging from lower screening rates to higher cancer mortality rates. These disparities are due in part to individual-level characteristics like age and insurance status, but the physical and social context of rural residence also plays a role. Our objective was two-fold: 1) to develop a multilevel conceptual framework describing how rural residence and relevant micro, macro, and supra-macro factors can be considered in evaluating disparities across the cancer control continuum and 2) to outline the unique considerations of multilevel statistical modeling in rural cancer research. We drew upon several formative frameworks that address the cancer control continuum, population-level disparities, access to health care services, and social inequities. Micro-level factors comprised individual-level characteristics that either predispose or enable individuals to utilize health care services or that may affect their cancer risk. Macro-level factors included social context (e.g. domains of social inequity) and physical context (e.g. access to care). Rural-urban status was considered a macro-level construct spanning both social and physical context, as "rural" is often characterized by sociodemographic characteristics and distance to health care services. Supra-macro-level factors included policies and systems (e.g. public health policies) that may affect cancer disparities. Our conceptual framework can guide researchers in conceptualizing multilevel statistical models to evaluate the independent contributions of rural-urban status on cancer while accounting for important micro, macro, and supra-macro factors. Statistically, potential collinearity of multilevel model predictive variables, model structure, and spatial dependence should also be considered.

Characteristics of place and the rural disadvantage in deaths from highly preventable causes

Extensive research has documented higher mortality in rural parts of the United States compared to urban areas. Much of this work focuses on aggregate rates, documenting a rural mortality penalty that has been increasing over the last three decades. Advances in place-based analyses suggest the importance of community resources for individual mortality but have largely focused on urban spaces. We advance knowledge on rural-urban mortality disparities by focusing on differences for highly preventable causes of death. Using unique geocoded mortality records from Washington state, we match individual-level attributes with area-level measures of socioeconomic conditions to examine whether characteristics of place elucidate the rural mortality penalty. We find that rural decedents have greater odds of dying from highly preventable causes compared to their urban counterparts. Place-based socioeconomic measures, meanwhile, independently associate with the odds of dying from highly preventable causes. However, we find no evidence that the relationship between socioeconomic conditions and highly preventable death varies across geographic contexts.

Intergenerational photovoice perspectives of place and health in public housing: Participatory coding, theming, and mapping in/of the "structure struggle"

This paper details an intergenerational photovoice project exploring spatial and perceptual differences of "place" and health among adult and youth public housing residents in a small urban rustbelt city in the Midwestern United States. It specifically highlights the value of fully participatory photovoice processes-participatory narrative-coding and digital web-based photo-mapping-in furthering conceptual and analytical understanding of "place" and health. Results indicate the critical import of accounting for non-residential locations (i.e. activity spaces), and the significance of engaging the generationally- and spatially-specific social and physical landscapes of residents' lived "place" to improve health opportunities within place-based strategies involving public housing.

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors - wealth, education, health insurance - contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.

Urban Regeneration Process: The Case of a Residential Complex in a Suburb of Rome, Italy

With the aim of promoting biological, social and psychological well-being, a multi-institutional and multidisciplinary action-research process was developed for the regeneration of a large residential complex in Rome, Italy. A methodology with a community-based approach was adopted in a context where spatial segregation is intertwined with health and social inequalities. Methods: Through qualitative-quantitative analysis involving the active participation of the local population and institutions in every stage, an integrated survey model was developed in order to create proper communication between the needs of the population and sustainable solutions. Results: the implemented process allowed for clear planning of actions and interventions that could be economically sustainable through the structuring and development of a local network. Conclusions: the process involving the participation of the population in the analysis of their own problems and difficulties, as well as in the development of possible interventions and actions to be proposed, appears to be the only adequate approach that allows for the definition of mutual objectives based on the real needs of the end users.

Spatial epidemiology of gestational age and birth weight in Switzerland: census-based linkage study

BACKGROUND

Gestational age and birth weight are strong predictors of infant morbidity and mortality. Understanding spatial variation can inform policies to reduce health inequalities. We examined small-area variation in gestational age and birth weight in Switzerland.

METHODS

All singleton live births recorded in the Swiss Live Birth Register 2011 to 2014 were eligible. We deterministically linked the Live Birth Register with census and survey data to create data sets including neonatal and pregnancy-related variables, parental characteristics and geographical variables. We produced maps of 705 areas and fitted linear mixed-effect models to assess to what extent spatial variation was explained by these variables.

RESULTS

We analysed all 315 177 eligible live births. Area-level averages of gestational age varied between 272 and 279 days, and between 3138 and 3467 g for birth weight. The fully adjusted models explained 31% and 87% of spatial variation of gestational age and birth weight, respectively. Language region accounted for most of the explained variation (23% in gestational age and 62% in birth weight), with shorter gestational age (-0.6 days and -0.9 days) and lower birth weight (-1.1% and -1.8%) in French-speaking and Italian-speaking areas, respectively, compared with German-speaking areas. Other variables explaining variation were, for gestational age, the level of urbanisation (10%) and parental nationality (3%). For birth weight, they were gestational age (27%), parental nationality (27%), civil status (10%) and altitude (10%). In a random sample of 81 968 live births with data on parental education, levels of education were only weakly associated with gestational age (-0.9 days for compulsory vs tertiary maternal education) or birth weight (-0.7% for compulsory vs tertiary maternal education).

CONCLUSIONS

In Switzerland, small area variation in birth weight is largely explained, and variation in gestational age partially explained, by geocultural, sociodemographic and pregnancy factors.

Mobility impairments and geographic variation in vulnerability to household food insecurity

Studies indicate an association between disability and higher rates of household food insecurity (HFI). Geographic variation in this relationship has not been explored despite the potential influence of economic and political contexts, including costs of living and disability social assistance. This study examines the association between mobility impairment and HFI within and across Canada considering the possible role of population composition, contextual, and collective influences. Using data from 217,094 adults from the 2007/08, 2009/10, 2013/14, and 2015/16 Canadian Community Health Survey, multivariate logistic regression models examined associations between mobility impairment and HFI controlling for socio-demographic factors and geography of residence (i.e., province, region, and urban/rural status). Subsequent analysis of 14,353 surveyed adults with mobility impairments was conducted to examine geographic and socio-demographic factors associated with HFI in this population. Adults with mobility impairments had elevated odds of HFI of 3.85 (95% CI: 3.49-4.24), when adjusting for age, sex, and geography of residence and 2.11 (95% CI: 1.89-2.35) adjusting for additional socio-demographic characteristics. Across Canada, mobility impaired adults experienced greater odds of HFI. Significantly lower odds of HFI were found for mobility impaired adults living in Newfoundland, Alberta, and Saskatchewan compared to Ontario when adjusting for age and sex, and in Quebec when controlling for additional socio-demographic factors. Socioeconomic factors and age accounted for most variation in HFI in this population, suggesting the importance of poverty reduction strategies that reduce vulnerability to HFI across the population.

Religion and Use of Institutional Child Delivery Services: Individual and Contextual Pathways in Mozambique

CONTEXT

Research on institutional child delivery in Sub-Saharan Africa typically focuses on availability and accessibility of health facilities. Cultural factors, including religion, that may facilitate or hinder the use of such services have not been well examined and remain poorly understood.

METHODS

The relationship between religious affiliation and delivery in a health facility was explored using data from a household survey of 1,297 women aged 18-50 and a census of 825 religious congregations, both conducted in a predominantly Christian district in Mozambique in 2008. Multilevel logistic regression analyses were conducted to predict the likelihood of recent institutional delivery according to both individual religious affiliation and the concentration of religious congregations of certain denominations in the community of residence.

RESULTS

Approximately 63% of deliveries occurred in a health facility. The odds of such deliveries were lower among women who belonged to Apostolic churches or had no religious affiliation than among members of Catholic or mainline Protestant churches, net of other factors (odds ratios, 0.5 and 0.6, respectively). In addition, regardless of a woman's religion, the odds that she had an institutional delivery increased by 9% for each additional Catholic or mainline Protestant congregation in her community of residence (1.1).

CONCLUSIONS

Organized religion is associated with critical health outcomes in Mozambique and, potentially, in other Sub-Saharan African contexts. Policymakers should consider designing programs and interventions that promote the use of institutional delivery services among members of religious groups characterized by low use of these services and in areas where such religious groups have a strong presence.

Can Asset-Based Community Development with Children and Youth Enhance the Level of Participation in Health Promotion Projects? A Qualitative Meta-Synthesis

The asset-based community development (ABCD) approach have been widely used to map local assets and to ensure participation of local communities in public health promotion strategies. Participatory practices, such as ABCD, have been applied to shift public health strategies towards addressing health inequities. In this meta-synthesis, we ask if, and how, ABCD enhance the level of participation for children, youth and schools. Three thousand eight hundred eight titles and abstracts were identified in ten databases and transferred to the online program Rayyan. Through a blinded process we excluded texts that did not meet the inclusion criteria. The twelve included texts on ABCD for children, youth and schools are of varying quality. The research on ABCD for children, youth and schools have not been cumulative. Nevertheless, the texts show that ABCD provides strategies that enhance the participation of children, youth, and schools, in health promotion projects. The projects were categorized according to Robert Hart's classical participation ladder, and we found that the projects with the highest level of adherence to ABCD principles also had the highest level of participation. The projects with high levels of participation were supported by adult facilitators that created learning environments where children and youth developed their participatory skills.

Association of Number of Indoor Tanning Salons With Neighborhoods With Higher Concentrations of Male-Male Partnered Households

IMPORTANCE

Both indoor tanning and skin cancer are more common among sexual-minority men, defined as gay and bisexual men, than among heterosexual men. Convenient access to indoor tanning salons may influence use patterns.

OBJECTIVE

To investigate whether indoor tanning salons are disproportionately located in areas with higher concentrations of gay men.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used geographic information systems to integrate census data and business location data obtained from ArcGIS and Google Maps for the 10 US cities with the largest lesbian, gay, bisexual, and transgender populations in 2010, ie, Los Angeles, California; Chicago, Illinois; San Francisco, California; Seattle, Washington; San Diego, California; Dallas, Texas; Phoenix, Arizona; Washington, DC; Portland, Oregon; and Denver, Colorado. The association of indoor tanning salon locations with proportions of gay men, using the concentration of male-male partnered households as a proxy measure for the latter, was examined. Data analysis was performed in October 2018.

EXPOSURES

Census tracts with at least 1%, 5%, or 10% male-male partnered households, adjusting for median household income, percentage young women, and percentage non-Hispanic white residents.

MAIN OUTCOMES AND MEASURES

Presence of 1 or more indoor tanning salons within census tracts.

RESULTS

Across the 10 cities and 4091 census tracts in this study, there were 482 823 unmarried partnered households, of which 35 164 (7.3%) were male-male. The median (interquartile range) percentage of male-male partnered households per census tract was 0% (0%-10.6%). Odds of indoor tanning salon presence in areas with at least 10% male-male households were more than twice those of areas with less than 10% male-male households (odds ratio, 2.17; 95% CI, 1.59-2.97). When sensitivity analyses using a 1-mile euclidian buffer around each tanning salon were conducted, this association remained significant (odds ratio, 2.48; 95% CI, 2.14-2.88). After adjusting for median household income, percentage young women, and percentage non-Hispanic white residents, the odds of an indoor tanning salon being within 1 mile of a census tract with at least 10% male-male households remained twice that of census tracts with less than 10% male-male households (odds ratio, 2.00; 95% CI, 1.71-2.35).

CONCLUSIONS AND RELEVANCE

In this study, indoor tanning salons were more likely to be located near neighborhoods with higher concentrations of male-male partnered households, possibly contributing to the disproportionate use of indoor tanning by sexual-minority men.

Geospatial modeling of microcephaly and zika virus spread patterns in Brazil

Microcephaly and Zika Virus infection (ZIKV) were declared Public Health Emergencies of International Concern by the World Health Organization in 2016. Brazil was considered the epicenter of the outbreak. However, the occurrence of both ZIKV and microcephaly in Brazil was not evenly distributed across the country. To better understand this phenomenon, we investigate regional characteristics at the municipal level that can be associated with the incidence of microcephaly, our response variable, and its relationship with ZIKV and other predictors. All epidemiological data in this study was provided by the Ministry of Health official database (DATASUS). Microcephaly was only confirmed after birth and the diagnostic was made regardless of the mother’s ZIKV status. Using exploratory spatial data analysis and spatial autoregressive Tobit models, our results show that microcephaly incidence is significantly, at 95% confidence level, related not only to ZIKV, but also to access to primary care, population size, gross national product, mobility and environmental attributes of the municipalities. There is also a significant spatial autocorrelation of the dependent variable. The results indicate that municipalities that show a high incidence of microcephaly tend to be clustered in space and that incidence of microcephaly varies considerably across regions when correlated only with ZIKV, i.e. that ZIKV alone cannot explain the differences in microcephaly across regions and their correlation is mediated by regional attributes.

The Association Between Neighborhood Socioeconomic Deprivation, Cardiorespiratory Fitness, and Physical Activity in US Youth

BACKGROUND

Growing evidence suggests that the broader neighborhood socioeconomic environment is independently associated with cardiometabolic health. However, few studies have examined this relationship among younger populations.

PURPOSE

The purpose of the study was to (1) investigate the association between neighborhood socioeconomic deprivation (SED) and cardiorespiratory fitness and (2) determine the extent to which physical activity mediates this relationship.

METHODS

Data from 312 youth (aged 12-15 y) were obtained from the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey. Cardiorespiratory fitness was measured using a standard submaximal treadmill test, and maximal oxygen consumption was estimated. Physical activity was self-reported time spent in moderate to vigorous activity. Neighborhood SED was measured by a composite index score at the census tract of residence. Logistic regression analyses examined relationships between neighborhood SED, physical activity, and cardiorespiratory fitness, adjusting for individual-level characteristics and the complex sampling design.

RESULTS

Neighborhood SED was not significantly associated with cardiorespiratory fitness or physical activity among youth in the study sample.

CONCLUSIONS

While not significant, cardiorespiratory fitness levels were observed to decrease as neighborhood SED increased. Future research is needed to better understand this relationship and to identify underlying mechanisms beyond fitness or physical activity that may drive the relationship between neighborhood SED and health.

Putting the "where" in HIV care: Unpacking narratives of antiretroviral therapy adherence among HIV-Positive men who have sex with men

This study explores the spatial constitution of adherence to antiretroviral therapy (ART) by recasting therapeutic landscapes (Gesler, 1992) and how it structures the exercise of expressive agency (Bowden, 2014). Engagement in antiretroviral therapy among HIV-positive men who have sex with men (MSM) is contextualized within the discursive-materiality of emplaced assemblages for HIV Care in the Philippines. Combining qualitative data from field visits and semi-structured interviews, three key spatial narratives were derived illustrating how adherence to ART unfolds in place: (a) an unwelcoming treatment hub, (b) an unsafe and safe home, and (c) a constraining workplace. The results illustrate the spatial, multilayered barriers to ART adherence proposing insights for the theorization of adherence as an emplaced process and the implications of using of place-based interventions in resource-limited countries beyond the discourse of free service and availability.

[Socioeconomic status and health insurance expenditures for children and adolescents with conduct disorder : An analysis of statutory health insurance data]

BACKGROUND

For various psychiatric and somatic disorders, there is evidence of an association between patients' socioeconomic status (SES), healthcare utilisation, and the resulting costs. In the field of child and adolescent psychiatric disorders, studies on this topic are lacking.

OBJECTIVES

To exploratively analyse the association of healthcare expenditures for children and adolescents with conduct disorder (including oppositional-defiant disorder) - one of the most prevalent child and adolescent psychiatric disorders - and SES.

MATERIALS AND METHODS

The analysis is based on routine data from the German statutory health insurance company AOK Nordost for the calendar year 2011, covering 6461 children and adolescents (age 5-18 years) with an ICD-10 diagnosis of conduct disorder. The insureds' SES was estimated indirectly, based on the social structure of the postcode area, using the German Index of Multiple Deprivation (Mecklenburg-Vorpommern, Brandenburg), and the Berliner Sozialindex I (Berlin), respectively. From the two indices, quintiles were derived. Based on these quintiles, average costs per case for the following cost types were analysed: inpatient healthcare, outpatient healthcare (general practitioners, paediatricians, child and adolescent psychiatrists, child and adolescent psychotherapists), and prescribed medication.

RESULTS

There was no significant functional association between SES and healthcare costs for any of the analysed cost types.

CONCLUSIONS

In contrast to findings in adults, this study on children and adolescents with conduct disorders did not reveal an association between SES and healthcare costs. Within this group of patients, social inequality does not seem to have a significant influence on healthcare utilisation in Germany.

The Impacts of Residential Location on the Risk of HIV Virologic Failure Among ART Users in Durban, South Africa

Using a case-control study of patients receiving antiretroviral treatment (ART) in 2010-2012 at McCord Hospital in Durban, South Africa, we sought to understand how residential locations impact patients' risk of virologic failure (VF). Using generalized estimating equations to fit logistic regression models, we estimated the associations of VF with socioeconomic status (SES) and geographic access to care. We then determined whether neighborhood-level poverty modifies the association between individual-level SES and VF. Automobile ownership for men and having non-spouse family members pay medical care for women remained independently associated with increased odds of VF for patients dwelling in moderately and severely poor neighborhoods. Closer geographic proximity to medical care was positively associated with VF among men, while higher neighborhood-level poverty was positively associated with VF among women. The programmatic implications of our findings include developing ART adherence interventions that address the role of gender in both the socioeconomic and geographical contexts.

"Clear action requires clear thinking": A systematic review of gentrification and health research in the United States

Gentrification is a process in which formerly declining, under-resourced, neighborhoods experience reinvestment and in-migration of increasingly affluent new residents, with understudied implications for individual health and health-protective community resources for low-income and minority residents. Increased attention on urban health inequities have propelled research on the relationship between gentrification and health. Yet, there are significant challenges inherent in the study of gentrification given its non-linear process occurring at multiple levels and via various mechanisms in a complex web of urban systems. How then have empirical studies addressed questions regarding the relationship between gentrification and health and wellness from a conceptual and methodological standpoint? Applying key search terms to PubMed and Web of Science, we identified 546 papers published in the United States. This review is guided by three foundational premises informing the inclusion and exclusion of articles. These include: 1. a clear definition of gentrification and explicit health outcome; 2. identification of a specific geographic context (United States) in which gentrification occurs, and 3. use of a social determinants of health framework to identify potential health outcomes of interest. 17 papers met our inclusion criteria. Through systematic content analysis using MaxQDA software, we evaluated the included studies using three critical frames: 1. conceptualization of gentrification; 2. mechanisms linking gentrification and health; and 3. spatio-temporal considerations. Based on this analysis, we identify the strengths and limitations of existing research, and offer three methodological approaches to strengthen the current literature on gentrification and health. We recommend that future studies: 1. explicitly identify the mechanisms and levels at which processes can occur and systems are organized; 2. incorporate space and time into the analytical strategy and 3. articulate an epistemological standpoint driven by their conceptualization of the exposure and identification of the relevant mechanism and outcome of interest.

A retrospective assessment of metropolitan religious adherence rate, individual and neighborhood social capital and their impact on women's health

Background

Social capital is a multilevel construct impacting health. Community level social capital, beyond the neighborhood, has received relatively less attention. Moreover, the measurement of community level social capital has tended to make use of aggregated individual data, rather than observable community characteristics.

Methods

Herein, metropolitan religious adherence, as an observable community-level measure of social capital, is used. We match it to city of residence for 2826 women in the Fragile Families Childhood Wellbeing Study (a cohort study) who have lived continuously in that city during a nine-year period. Using ordered logistic regression with clustered standard errors to account for area effects, we look at the relationship between metropolitan religious adherence and self-rated health, while controlling for lagged individual, neighborhood, and socioeconomic factors, as well as individual level religious attendance.

Results

Religious adherence at the community level is positive and statistically significant; every 1% increase in area religiosity corresponds to a 1.2% increase in the odds of good health.

Conclusions

These findings shed light on a possible pathway by which social capital may improve health, perhaps acting as a stress buffer or through spillover effects of reciprocity generated by exposure to religion.