Geographic life environments and coronary heart disease: a literature review, theoretical contributions, methodological updates, and a research agenda

The environmental correlates of overall and neighborhood based recreational walking (a cross-sectional analysis of the RECORD Study)

Background

Preliminary evidence suggests that recreational walking has different environmental determinants than utilitarian walking. However, previous studies are limited in their assessment of environmental exposures and recreational walking and in the applied modeling strategies. Accounting for individual sociodemographic profiles and weather over the walking assessment period, the study examined whether numerous street network-based neighborhood characteristics related to the sociodemographic, physical, service, social-interactional, and symbolic environments were associated with overall recreational walking and recreational walking in one’s residential neighborhood and could explain their spatial distribution.

Methods

Based on the RECORD Cohort Study (Paris region, France, n = 7105, 2007–2008 data), multilevel-spatial regression analyses were conducted to investigate environmental factors associated with recreational walking (evaluated by questionnaire at baseline). A risk score approach was applied to quantify the overall disparities in recreational walking that were predicted by the environmental determinants.

Results

Sixty-nine percent of the participants reported recreational walking over the past 7 days. Their mean reported recreational walking time was 3h31mn. After individual-level adjustment, a higher neighborhood education, a higher density of destinations, green and open spaces of quality, and the absence of exposure to air traffic were associated with higher odds of recreational walking and/or a higher recreational walking time in one’s residential neighborhood. As the overall disparities that were predicted by these environmental factors, the odds of reporting recreational walking and the odds of a higher recreational walking time in one’s neighborhood were, respectively, 1.59 [95% confidence interval (CI): 1.56, 1.62] times and 1.81 (95% CI: 1.73, 1.87) times higher in the most vs. the least supportive environments (based on the quartiles).

Conclusions

Providing green/open spaces of quality, building communities with services accessible from the residence, and addressing environmental nuisances such as those related to air traffic may foster recreational walking in one’s environment.

Trends in socioeconomic inequalities in ischemic heart disease mortality in small areas of nine Spanish cities from 1996 to 2007 using smoothed ANOVA

The aim of this study was to analyze the evolution of socioeconomic inequalities in mortality due to ischemic heart diseases (IHD) in the census tracts of nine Spanish cities between the periods 1996-2001 and 2002-2007. Among women, there are socioeconomic inequalities in IHD mortality in the first period which tended to remain stable or even increase in the second period in most of the cities. Among men, in general, no socioeconomic inequalities have been detected for this cause in either of the periods. These results highlight the importance of intra-urban inequalities in mortality due to IHD and their evolution over time.

Does neighborhood collective efficacy for families change over time? The Boston Neighborhood Survey

There is an increased interest in how neighborhood social processes, such as collective efficacy, may protect mental health. Yet little is known about how stable these neighborhood processes are over time, or how to change them to influence other downstream factors. We used a population-based, repeat cross-sectional study of adults (n=5135) to assess stability of collective efficacy for families in 38 Boston neighborhoods across 4 years (2006, 2008, 2010) (the Boston Neighborhood Survey). We test temporal stability of collective efficacy for families across and within neighborhoods using 2-level random effects linear regression, fixed effects linear regression, T-tests, and Wilcoxon rank tests. Across the different methods, neighborhood collective efficacy for families remained stable across 4 years, after adjustment for neighborhood composition. If neighborhood collective efficacy is measured within 4 years of the exposure period of interest, assuming temporal stability may be valid.

Gender differences in the association between socioeconomic status and subclinical atherosclerosis

OBJECTIVES

This study explored the pattern of associations between socioeconomic status (SES) and atherosclerosis progression (as indicated by carotid intima media thickness, CIMT) across gender.

DESIGN

Cross-sectional analysis of a sample of 5474 older persons (mean age 73 years) recruited between 1999 and 2001 in the 3C study (France). We fitted linear regression models including neighborhood SES, individual SES and cardiovascular risk factors.

RESULTS

CIMT was on average 24 µm higher in men (95% CI: 17 to 31). Neighborhood SES was inversely associated with CIMT in women only (highest versus lowest tertiles: -12.2 µm, 95%CI -22 to -2.4). This association persisted when individual SES and risk factors were accounted for. High individual education was associated with lower CIMT in men (-21.4 µm 95%CI -37.5 to -5.3) whereas high professional status was linked to lower CIMT among women (-15.7 µm 95%CI: -29.2 to -2.2). Adjustment for cardiovascular risk factors resulted in a slightly more pronounced reduction of the individual SES-CIMT association observed in men than in women.

CONCLUSION

In this sample, neighborhood and individual SES displayed different patterns of associations with subclinical atherosclerosis across gender. This suggests that the causal pathways leading to SES variations in atherosclerosis may differ among men and women.

Residential selection across the life course: adolescent contextual and individual determinants of neighborhood disadvantage in mid-adulthood

Background

Numerous cross-sectional studies have examined neighborhood effects on health. Residential selection in adulthood has been stressed as an important cause of selection bias but has received little empirical attention, particularly its determinants from the earlier life course. The present study aims to examine whether neighborhood, family, school, health behaviors and health in adolescence are related to socioeconomic disadvantage of one's neighborhood of residence in adulthood.

Methods

Based on the prospective Northern Swedish Cohort (analytical N = 971, 90.6% retention rate), information was collected at age 16 years concerning family circumstances, school adjustment, health behaviors and mental and physical health. Neighborhood register data was linked to the cohort and used to operationalize aggregated measures of neighborhood disadvantage (ND) at age 16 and 42. Data was analyzed with linear mixed models, with ND in adulthood regressed on adolescent predictors and neighborhood of residence in adolescence as the level-2 unit.

Results

Neighborhood disadvantage in adulthood was clustered by neighborhood of residence in adolescence (ICC = 8.6%). The clustering was completely explained by ND in adolescence. Of the adolescent predictors, ND (b = .14 (95% credible interval = .07–.22)), final school marks (b = −.18 (−.26–−.10)), socioeconomic disadvantage (b = .07 (.01–.14)), and, with borderline significance, school peer problems (b = .07 (−.00–.13)), were independently related to adulthood ND in the final adjusted model. In sex-stratified analyses, the most important predictors were school marks (b = −.21 (−.32–−.09)) in women, and neighborhood of residence (ICC = 15.5%) and ND (b = .20 (.09–.31)) in men.

Conclusions

These findings show that factors from adolescence – which also may impact on adult health – could influence the neighborhood context in which one will live in adulthood. This indicates that residential selection bias in neighborhood effects on health research may have its sources in early life.

Neighborhood problems and nocturnal blood pressure dipping

OBJECTIVE

Living in adverse neighborhood conditions has been linked with greater prevalence of cardiovascular disease (CVD). We aimed to learn whether perceived neighborhood problems are related to attenuated nocturnal blood pressure (BP) dipping, a risk factor for CVD morbidity.

METHOD

A sample of 133 adults (71 male, 62 female; 80 White, 53 Black) underwent 24-hr ambulatory blood pressure monitoring. The neighborhood problem scale (NPS) was used to assess neighborhood environmental stressors.

RESULTS

Nocturnal dipping in systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressure was reduced in individuals with higher NPS scores (p < .05). Hierarchical regression analyses revealed that neighborhood problems explained 4%-6% of the variance in SBP, DBP, and MAP dipping (p < .05) even after adjusting for several theoretical confounders such as social status, age, gender, race, body mass index (BMI), smoking, exercise, depression and discrimination.

CONCLUSION

Neighborhood problems may contribute to attenuated BP dipping beyond the effect of known risk factors.

Developing Behavioral Theory With the Systematic Integration of Community Social Capital Concepts

Health behavior theories state that social environments influence health behaviors, but theories of how this occurs are relatively underdeveloped. This article systematically surveys community social capital concepts in health behavior literature and proposes a conceptual framework that integrates these concepts into existing behavioral theory. Fifty-three studies tested associations between community social capital concepts and physical activity (38 studies), smoking (19 studies), and diet (2 studies). Trustworthiness of community members was consistently associated with more health-promoting and less disease-promoting behaviors in 19 studies. Neighborly reciprocity showed mixed results in 10 studies. Reporting a good sense of community was associated with more physical activity in only 5 of 16 studies. Neighborhood collective efficacy, which includes social cohesion and informal social control, was inconsistently associated with behaviors in 22 studies. Behavioral social norms were associated with smoking and physical activity in 2 of 6 studies, and neighborhood modeling of physical activity was associated with increased activity in 12 of 17 studies, with 1 opposing result. This review identifies several community social capital-related concepts that are, at times, associated with both health-promoting and disease-promoting behaviors and often have no associations. Theory explains these findings by describing the relationships and interactions among these concepts. Using these findings, this article proposes a conceptual framework that integrates community social capital concepts into existing behavioral theory. Iterative empirically based theory development is needed to address these concepts, which affect behaviors. These results can also inform theoretically based community-based and socially tailored interventions.

Spatial Polygamy and Contextual Exposures (SPACEs): Promoting Activity Space Approaches in Research on Place and Health

Exposure science has developed rapidly and there is an increasing call for greater precision in the measurement of individual exposures across space and time. Social science interest in an individual's environmental exposure, broadly conceived, has arguably been quite limited conceptually and methodologically. Indeed, we appear to lag behind our exposure science colleagues in our theories, data, and methods. In this paper we discuss a framework based on the concept of spatial polygamy to demonstrate the need to collect new forms of data on human spatial behavior and contextual exposures across time and space. Adopting new data and methods will be essential if we want to better understand social inequality in terms of exposure to health risks and access to health resources. We discuss the opportunities and challenges focusing on the potential seemingly offered by focusing on human mobility, and specifically the utilization of activity space concepts and data. A goal of the paper is to spatialize social and health science concepts and research practice vis-a-vis the complexity of exposure. The paper concludes with some recommendations for future research focusing on theoretical and conceptual development, promoting research on new types of places and human movement, the dynamic nature of contexts, and on training. "When we elect wittingly or unwittingly, to work within a level … we tend to discern or construct - whichever emphasis you prefer - only those kinds of systems whose elements are confined to that level."Otis Dudley Duncan (1961, p. 141)."…despite the new ranges created by improved transportation, local government units have tended to remain medieval in size."Torsten Hägerstrand (1970, p.18)"A detective investigating a crime needs both tools and understanding. If he has no fingerprint powder, he will fail to find fingerprints on most surfaces. If he does not understand where the criminal is likely to have put his fingers, he will not look in the right places. Equally, the analyst of data needs both tools and understanding."John Tukey (1977, p.1)"When we observe the environment, we necessarily do so on only a limited number of scales."Simon Levin (1992, p. 1945)There is a desperate need to develop methods with the same precision for an individual's environmental exposure as we have for an individual's genome … even a partial, targeted understanding of exposure can provide substantial advantages."Christopher Wild (2005, p.1848).

Home and work neighbourhood environments in relation to body mass index: the Multi-Ethnic Study of Atherosclerosis (MESA)

BACKGROUND

Little is known about the neighbourhood characteristics of workplaces, the extent to which they are independently and synergistically correlated with residential environments, and their impact on health.

METHODS

This study investigated cross-sectional relationships between home and workplace neighbourhood environments with body mass index (BMI) in 1503 working participants of the Multi-Ethnic Study of Atherosclerosis with mean age 59.6 (SD=7.4). Neighbourhood features were socioeconomic status (SES), social environment (aesthetic quality, safety and social cohesion) and physical environment (walking environment, recreational facilities and food stores) derived from census data, locational data on businesses and survey data. Paired t tests and correlations compared environments overall and by distance between locations. Cross-classified multilevel models estimated associations with BMI.

RESULTS

Home neighbourhoods had more favourable social environments while workplaces had more favourable SES and physical environments. Workplace and home measures were correlated (0.39-0.70), and differences between home and workplaces were larger as distance increased. Associations between BMI and neighbourhood SES and recreational facilities were stronger for home environment (p≤0.05) but did not significantly differ for healthy food, safety or social cohesion. Healthy food availability at home and work appeared to act synergistically (interaction p=0.01).

CONCLUSIONS

Consideration of workplace environment may enhance our understanding of how place affects BMI.

Characterising food environment exposure at home, at work, and along commuting journeys using data on adults in the UK

BACKGROUND

Socio-ecological models of behaviour suggest that dietary behaviours are potentially shaped by exposure to the food environment ('foodscape'). Research on associations between the foodscape and diet and health has largely focussed on foodscapes around the home, despite recognition that non-home environments are likely to be important in a more complete assessment of foodscape exposure. This paper characterises and describes foodscape exposure of different types, at home, at work, and along commuting routes for a sample of working adults in Cambridgeshire, UK.

METHODS

Home and work locations, and transport habits for 2,696 adults aged 29-60 were drawn from the Fenland Study, UK. Food outlet locations were obtained from local councils and classified by type - we focus on convenience stores, restaurants, supermarkets and takeaway food outlets. Density of and proximity to food outlets was characterised at home and work. Commuting routes were modelled based on the shortest street network distance between home and work, with exposure (counts of food outlets) that accounted for travel mode and frequency. We describe these three domains of food environment exposure using descriptive and inferential statistics.

RESULTS

For all types of food outlet, we found very different foodscapes around homes and workplaces (with overall outlet exposure at work 125% higher), as well as a potentially substantial exposure contribution from commuting routes. On average, work and commuting environments each contributed to foodscape exposure at least equally to residential neighbourhoods, which only accounted for roughly 30% of total exposure. Furthermore, for participants with highest overall exposure to takeaway food outlets, workplaces accounted for most of the exposure. Levels of relative exposure between home, work and commuting environments were poorly correlated.

CONCLUSIONS

Relying solely on residential neighbourhood characterisation greatly underestimated total foodscape exposure in this sample, with levels of home exposure unrelated to levels of away from home exposure. Such mis-estimation is likely to be expressed in analyses as attenuated parameter estimates, suggesting a minimal 'environmental' contribution to outcomes of interest. Future work should aim to assess exposure more completely through characterising environments beyond the residential neighbourhood, where behaviours related to food consumption are likely to occur.

Multivariate Bayesian spatial model of preterm birth and cardiovascular disease among Georgia women: Evidence for life course social determinants of health

BACKGROUND

There is epidemiologic evidence that women who experience preterm birth (PTB) are at elevated risk for cardiovascular disease (CVD) later in life. Each outcome independently has noted spatial and socioeconomic gradients; we test for spatial structure in the population correlation of the two.

METHODS

Exploratory spatial data analysis and multivariate Bayesian spatial models were fit to describe the spatial correlation of PTB with CVD among women in Georgia counties from 2002 to 2006.

RESULTS

Global Moran's I and local-indicators of spatial association statistics suggest significant co-occurrence of CVD and PTB. Bayesian posterior estimates for multivariate correlation of these outcomes range from r=0.11-0.34 for CVD and PTB. Significant spatial correlation persists with control for county covariates among whites but not blacks.

CONCLUSION

Modest evidence for spatial structure of the ecologic correlation of PTB and women's CVD is consistent with a lifecourse perspective on socially clustered determinants of health.

Changes in smoking, sports participation and overweight: does neighborhood prevalence matter?

We investigated whether the prevalence of health-related behaviors and overweight in neighborhoods is associated with changes in smoking, sports participation and overweight over 13 years of follow-up in Dutch adults residing in 86 neighborhoods of Eindhoven in 1991. We showed that living in neighborhoods with a high prevalence of non-smoking, no sports participation and overweight increased the odds of quitting smoking, quitting sports and becoming overweight. After adjustments for age, gender, education and neighborhood deprivation this association remained significant for becoming overweight. Neighborhood prevalence of health-related behaviors and overweight appears to be a currently neglected but relevant determinant of changes in health-related behaviors.

Future research directions for understanding neighborhood contributions to health disparities

This paper proposes several promising future directions for neighborhood research to address health inequalities. First, there is a need to apply a Geography of Opportunity framework to understand how vast spatial (neighborhood, regional) inequality translates into health inequality. Such a framework highlights inequality that unfolds across an entire region, as well as the continuing significance of race/ethnicity for producing disparities in health and in the social determinants of health. The Geography of Opportunity framework also points to some of the methodological limitations of current neighborhood-health studies, given the structure of neighborhood racial inequality in the US for estimating how important neighborhoods are for producing racial health disparities. Second, there is a need to incorporate life-course concepts, data, and methods, including to model residential histories, neighborhood temporal change and residential mobility, starting early in life. A life-course focus would help inform when in life neighborhoods matter most for health and health inequalities, as well as improve exposure assessment of residential contexts. Third, we must model mechanisms linking neighborhoods and health, including the role of individual and household socioeconomic status. Lastly, we need to more meaningfully integrate social determinants of health, including drawing on policy evaluations that aim to improve neighborhood environments or that aim to expand household neighborhood choice. Doing so would inform how specific modifiable neighborhood exposures stimulated by policy may influence health and health disparities.

Spatial accessibility to specific sport facilities and corresponding sport practice: the RECORD Study

BACKGROUND

Physical activity is considered as a major component of a healthy lifestyle. However, few studies have examined the relationships between the spatial accessibility to sport facilities and sport practice with a sufficient degree of specificity. The aim of this study was to investigate the associations between the spatial accessibility to specific types of sports facilities and the practice of the corresponding sports after carefully controlling for various individual socio-demographic characteristics and neighborhood socioeconomic variables.

METHODS

Data from the RECORD Study involving 7290 participants recruited in 2007-2008, aged 30-79 years, and residing in the Paris metropolitan area were analyzed. Four categories of sports were studied: team sports, racket sports, swimming and related activities, and fitness. Spatial accessibility to sport facilities was measured with two complementary approaches that both take into account the street network (distance to the nearest facility and count of facilities around the dwelling). Associations between the spatial accessibility to sport facilities and the practice of the corresponding sports were assessed using multilevel logistic regression after adjusting for individual and contextual characteristics.

RESULTS

High individual education and high household income were associated with the practice of racket sports, swimming or related activities, and fitness over the previous 7 days. The spatial accessibility to swimming pools was associated with swimming and related sports, even after adjustment for individual/contextual factors. The spatial accessibility to facilities was not related to the practice of other sports. High neighborhood income was associated with the practice of a racket sport and fitness.

CONCLUSIONS

Accessibility is a multi-dimensional concept that integrates educational, financial, and geographical aspects. Our work supports the evidence that strategies to increase participation in sport activities should improve the spatial and financial access to specific facilities, but also address educational disparities in sport practice.

Detecting activity locations from raw GPS data: a novel kernel-based algorithm

Background

Health studies and mHealth applications are increasingly resorting to tracking technologies such as Global Positioning Systems (GPS) to study the relation between mobility, exposures, and health. GPS tracking generates large sets of geographic data that need to be transformed to be useful for health research. This paper proposes a method to test the performance of activity place detection algorithms, and compares the performance of a novel kernel-based algorithm with a more traditional time-distance cluster detection method.

Methods

A set of 750 artificial GPS tracks containing three stops each were generated, with various levels of noise.. A total of 9,000 tracks were processed to measure the algorithms’ capacity to detect stop locations and estimate stop durations, with varying GPS noise and algorithm parameters.

Results

The proposed kernel-based algorithm outperformed the traditional algorithm on most criteria associated to activity place detection, and offered a stronger resilience to GPS noise, managing to detect up to 92.3% of actual stops, and estimating stop duration within 5% error margins at all tested noise levels.

Conclusions

Capacity to detect activity locations is an important feature in a context of increasing use of GPS devices in health and place research. While further testing with real-life tracks is recommended, testing algorithms’ performance with artificial track sets for which characteristics are controlled is useful. The proposed novel algorithm outperformed the traditional algorithm under these conditions.

GPS tracking in neighborhood and health studies: a step forward for environmental exposure assessment, a step backward for causal inference?

Recent studies have relied on GPS tracking to assess exposure to environmental characteristics over daily life schedules. Combining GPS and GIS allows for advances in environmental exposure assessment. However, biases related to selective daily mobility preclude assessment of environmental effects, to the extent that these studies may represent a step backward in terms of assessment of causal effects. A solution may be to integrate the Public health / Nutrition approach and the Transportation approach to GPS studies, so as to combine a GPS and accelerometer data collection with an electronic mobility survey. Correcting exposure measures and improving study designs with this approach may permit mitigating biases related to selective daily mobility.

Neighborhood Contexts, Health, and Behavior: Understanding the Role of Scale and Residential Sorting

Recent reviews in sociology, public health, and urban planning suggest small-scale geographic variations in urban environments are associated with an individual's health, behavior, and well-being. However, estimation of these ‘neighborhood effects' are complicated. One complicating factor is residential sorting: Individual characteristics such as race, age, and socioeconomic status are associated with behavior and health and these same individual-level factors are often geographically clustered within neighborhoods. This residential sorting leads to a correlation between individual and environmental determinants of behavior and health and poses problems for statistical inference. A second complicating factor is uncertainty about the geographic dimensions of a person's neighborhood. We explore these two potential confounders through a simulation experiment that generates synthetic cityscapes and synthetic behaviors for geolocated individuals. The simulation is used to develop a model of how residential sorting, urban structure, and the geographic definition of an individual's neighborhood affect our understanding of the association between the urban environment and behavior. We find that residential sorting does not systematically affect the magnitude of neighborhood effect estimates, however, the misrepresentation of the geographic dimensions of an individual's neighborhood leads to systematic bias in estimates of neighborhood effects. Unlike previous research on the modifiable areal unit problem we find a systematic relationship between the definition of geographic units of analysis and the magnitude of regression coefficients.

Neighborhood resources and social participation among older adults: results from the VoisiNuage study

OBJECTIVE

This article examined the associations between proximity to selected locations considered to be conducive to social participation, and social participation itself, in urban-dwelling seniors.

METHODS

A sample of 520 older adults residing in the Montreal area provided reports of social participation and information about health, sociodemographic characteristics, social networks, and perceptions about features of their residential environment. Information about the distance between their home and five locations deemed to be conducive to social participation were obtained from a geographic information system.

RESULTS

Analyses showed a significant association between proximity to selected locations and social participation while accounting for individual characteristics and perceptions of neighborhood features (β = 0.37; SE = 0.17; p < 0.05).

DISCUSSION

Findings were consistent with contributions highlighting the impact of the built environment on seniors' health-related behavior. Future work would benefit from the use of longitudinal designs and examinations of social participation through alternate channels.

The relationship between urban sprawl and coronary heart disease in women

Studies have reported relationships between urban sprawl, physical activity, and obesity, but - to date - no studies have considered the relationship between sprawl and coronary heart disease (CHD) endpoints. In this analysis, we use longitudinal data on post-menopausal women from the Women's Health Initiative (WHI) Clinical Trial to analyze the relationship between metropolitan statistical area (MSA)-level urban compactness (the opposite of sprawl) and CHD endpoints including death, any CHD event, and myocardial infarction. Models control for individual and neighborhood socio-demographic characteristics. Women who lived in more compact communities at baseline had a lower probability of experiencing a CHD event and CHD death or MI during the study follow-up period. One component of compactness, high residential density, had a particularly noteworthy effect on outcomes. Finally, exploratory analyses showed evidence that the effects of compactness were moderated by race and region.

Can the built environment reduce health inequalities? A study of neighbourhood socioeconomic disadvantage and walking for transport

Residents of socioeconomically disadvantaged neighbourhoods are more likely to walk for transport than their counterparts in advantaged neighbourhoods; however, the reasons for higher rates of transport walking in poorer neighbourhoods remain unclear. We investigated this issue using data from the HABITAT study of physical activity among 11,037 mid-aged residents of 200 neighbourhoods in Brisbane, Australia. Using a five-step mediation analysis and multilevel regression, we found that higher levels of walking for transport in disadvantaged neighbourhoods was associated with living in a built environment more conducive to walking (i.e. greater street connectivity and land use mix) and residents of these neighbourhoods having more limited access to a motor vehicle. The health benefits that accrue to residents of disadvantaged neighbourhoods as a result of their higher levels of walking for transport might help offset the negative effects of less healthy behaviours (e.g. smoking, poor diet), thus serving to contain or reduce neighbourhood inequalities in chronic disease.

Revisiting causal neighborhood effects on individual ischemic heart disease risk: a quasi-experimental multilevel analysis among Swedish siblings

Neighborhood socioeconomic disadvantage is associated to increased individual risk of ischemic heart disease (IHD). However, the value of this association for causal inference is uncertain. Moreover, neighborhoods are often defined by available administrative boundaries without evaluating in which degree these boundaries embrace a relevant socio-geographical context that condition individual differences in IHD risk. Therefore, we performed an analysis of variance, and also compared the associations obtained by conventional multilevel analyses and by quasi-experimental family-based design that provides stronger evidence for causal inference. Linking the Swedish Multi-Generation Register to several other national registers, we analyzed 184,931 families embracing 415,540 full brothers 45-64 years old in 2004, and residing in 8408 small-area market statistics (SAMS) considered as "neighborhoods" in our study. We investigated the association between low neighborhood income (categorized in groups by deciles) and IHD risk in the next four years. We distinguished between family mean and intrafamilial-centered low neighborhood income, which allowed us to investigate both unrelated individuals from different families and full brothers within families. We applied multilevel logistic regression techniques to obtain odds ratios (OR), variance partition coefficients (VPC) and 95% credible intervals (CI). In unrelated individuals a decile unit increase of low neighborhood income increased individual IHD risk (OR = 1.04, 95% CI: 1.03-1.07). In the intrafamilial analysis this association was reduced (OR = 1.02, 95% CI: 1.02-1.04). Low neighborhood income seems associated with IHD risk in middle-aged men. However, despite the family-based design, we cannot exclude residual confounding by genetic and non-shared environmental factors. Besides, the low neighborhood level VPC = 1.5% suggest that the SAMS are a rather inappropriate construct of the socio-geographic context that conditions individual variance in IHD risk. In contrast the high family level VPC = 20.1% confirms the relevance of the family context for understanding IHD risk.

Neighborhood socioeconomic status and coronary heart disease risk prediction in a nationally representative sample

OBJECTIVES

Test the association between coronary heart disease (CHD) risk scores and neighborhood socioeconomic status (NSES) in a US nationally-representative sample and describe whether the association varies by gender and race/ethnicity.

STUDY DESIGN

Cross-sectional study.

METHODS

We use Health and Nutrition Examination Survey (NHANES) data from 1999 to 2004 linked with Census tract data. Multivariable regression models and propensity score adjusted models are employed to test the association between NSES and 10-year risk of CHD based on the Framingham Risk Score (FRS), adjusting for individual-level characteristics.

RESULTS

An individual living in a neighborhood at the 75th percentile of NSES (high NSES) has, on average, a 10-year CHD risk that is 0.16 percentage points lower (95% Confidence Interval 0.16, 0.17) than a similar person residing in a neighborhood at the 25th percentile of NSES (low NSES). Race/ethnicity and gender were found to significantly modify the association between NSES and CHD risk: the association is larger in men than women and in whites than minorities. Propensity score models showed that findings on the main effects of NSES were robust to self-selection into neighborhoods. Similar results were observed between NSES and risk of cardiovascular disease events.

CONCLUSIONS

NSES is significantly associated with CHD risk, and the relationship varies by gender and race/ethnicity.

A typology of neighborhoods and blood pressure in the RECORD Cohort Study

BACKGROUND

Studies of associations between neighborhood environments and blood pressure (BP) have relied on imprecise characterizations of neighborhoods. This study examines associations between SBP and DBP and a neighborhood typology based on numerous residential environment characteristics.

METHODS

Data from the Residential Environment and Coronary Heart Disease Study involving 7290 participants recruited in 2007-2008, aged 30-79 years, and residing in the Paris metropolitan area were analyzed. Cluster analysis was applied to measures of the physical, services and social interactions aspects of neighborhoods. Six contrasting neighborhood types were identified and examined in relation to SBP and DBP using multivariable linear regression, adjusting for individual/neighborhood socioeconomic status and individual risk factors for hypertension.

RESULTS

The neighborhood typology included suburban to central urban neighborhood types with varying levels of adverse social conditions. SBP was 2-3 mmHg higher among participants residing in suburban neighborhood types and in the urban with low social standing neighborhood type, compared to residents of central urban with intermediate social standing neighborhoods (reference). The association between residing in urban low social standing neighborhoods and SBP remained after adjusting for individual/neighborhood socioeconomic status and individual risk factors for hypertension. Overall, an inverse association between DBP and level of urbanicity of the neighborhood was observed, even after adjustment for individual risk factors for hypertension.

CONCLUSIONS

Variations in BP were observed by levels of urbanicity and social conditions of residential neighborhoods, with different patterns for SBP and DBP. Population interventions to reduce hypertension targeted towards specific neighborhood types hold promise.

An interactive mapping tool to assess individual mobility patterns in neighborhood studies

As their most critical limitation, neighborhood and health studies published to date have not taken into account nonresidential activity places where individuals travel in their daily lives. However, identifying low-mobility populations residing in low-resource environments, assessing cumulative environmental exposures over multiple activity places, and identifying specific activity locations for targeting interventions are important for health promotion. Daily mobility has not been given due consideration in part because of a lack of tools to collect locational information on activity spaces. Thus, the first aim of the current article is to describe VERITAS (Visualization and Evaluation of Route Itineraries, Travel Destinations, and Activity Spaces), an interactive web mapping application that can geolocate individuals' activity places, routes between locations, and relevant areas such as experienced or perceived neighborhoods. The second aim is to formalize the theoretic grounds of a contextual expology as a subdiscipline to better assess the spatiotemporal configuration of environmental exposures. Based on activity place data, various indicators of individual patterns of movement in space (spatial behavior) are described. Successive steps are outlined for elaborating variables of multiplace environmental exposure (collection of raw locational information, selection/exclusion of locational data, defining an exposure area for measurement, and calculation). Travel and activity place network areas are discussed as a relevant construct for environmental exposure assessment. Finally, a note of caution is provided that these measures require careful handling to avoid increasing the magnitude of confounding (selective daily mobility bias).

Associations between resident perceptions of the local residential environment and metabolic syndrome

A substantial body of research has arisen concerning the relationships between objective residential area features, particularly area-level socioeconomic status and cardiometabolic outcomes. Little research has explored residents' perceptions of such features and how these might relate to cardiometabolic outcomes. Perceptions of environments are influenced by individual and societal factors, and may not correspond to objective reality. Understanding relations between environmental perceptions and health is important for the development of environment interventions. This study evaluated associations between perceptions of local built and social environmental attributes and metabolic syndrome, and tested whether walking behaviour mediated these associations. Individual-level data were drawn from a population-based biomedical cohort study of adults in Adelaide, South Australia (North West Adelaide Health Study). Participants' local-area perceptions were analysed in cross-sectional associations with metabolic syndrome using multilevel regression models (n = 1, 324). A nonparametric bootstrapping procedure evaluated whether walking mediated these associations. Metabolic syndrome was negatively associated with greater local land-use mix, positive aesthetics, and greater infrastructure for walking, and was positively associated with greater perceived crime and barriers to walking. Walking partially mediated associations between metabolic syndrome and perceived environmental features. Initiatives targeting residents' perceptions of local areas may enhance the utility of environmental interventions to improve population health.

Association between activity space exposure to food establishments and individual risk of overweight

OBJECTIVE

Environmental exposure to food sources may underpin area level differences in individual risk for overweight. Place of residence is generally used to assess neighbourhood exposure. Yet, because people are mobile, multiple exposures should be accounted for to assess the relation between food environments and overweight. Unfortunately, mobility data is often missing from health surveys. We hereby test the feasibility of linking travel survey data with food listings to derive food store exposure predictors of overweight among health survey participants.

METHODS

Food environment exposure measures accounting for non-residential activity places (activity spaces) were computed and modelled in Montreal and Quebec City, Canada, using travel surveys and food store listings. Models were then used to predict activity space food exposures for 5,578 participants of the Canadian Community Health Survey. These food exposure estimates, accounting for daily mobility, were used to model self-reported overweight in a multilevel framework. Median Odd Ratios were used to assess the proportion of between-neighborhood variance explained by such food exposure predictors.

RESULTS

Estimates of food environment exposure accounting for both residential and non-residential destinations were significantly and more strongly associated with overweight than residential-only measures of exposure for men. For women, residential exposures were more strongly associated with overweight than non-residential exposures. In Montreal, adjusted models showed men in the highest quartile of exposure to food stores were at lesser risk of being overweight considering exposure to restaurants (OR = 0.36 [0.21-0.62]), fast food outlets (0.48 [0.30-0.79]), or corner stores (0.52 [0.35-0.78]). Conversely, men experiencing the highest proportion of restaurants being fast-food outlets were at higher risk of being overweight (2.07 [1.25-3.42]). Women experiencing higher residential exposures were at lower risk of overweight.

CONCLUSION

Using residential neighbourhood food exposure measures may underestimate true exposure and observed associations. Using mobility data offers potential for deriving activity space exposure estimates in epidemiological models.

Making a Place for Space: Spatial Thinking in Social Science

New technologies and multilevel data sets that include geographic identifiers have heightened sociologists' interest in spatial analysis. I review several of the key concepts, measures, and methods that are brought into play in this work, and offer examples of their application in a variety of substantive fields. I argue that the most effective use of the new tools requires greater emphasis on spatial thinking. A device as simple as an illustrative map requires some understanding of how people respond to visual cues; models as complex as HLM with spatial lags require thoughtful measurement decisions and raise questions about what a spatial effect represents.

Multiple dimensions of residential environments, neighborhood experiences, and jogging behavior in the RECORD Study

OBJECTIVE

The purpose of this study was to examine the associations between a broad range of environmental characteristics and jogging behavior while taking into account different complementary outcomes to describe the behavior.

METHODS

Using the RECORD Cohort Study (7290 participants, 2007-2008, Paris region, France), multilevel models were used to investigate individual/neighborhood variables associated with the probability of jogging; the time spent jogging; and the location of the practice.

RESULTS

The presence and quality of green and open spaces was associated both with a greater probability of jogging [risk ratio (RR) for the first vs. the fourth quartile=1.22, 95% credible interval (CrI): 1.03-1.44] and with the practice of jogging within rather than outside the neighborhood (RR=1.29; 95% CrI: 1.10-1.53). Moreover, a high social cohesion and the presence of enjoyable places were associated with a higher probability of jogging (RR=1.15; 95% CrI: 1.00-1.31; RR=1.22; 95% CrI: 1.03-1.44) while the presence of parks or a lake increased the probability of jogging inside rather than outside the neighborhood (RR=1.29; 95% CrI: 1.10-1.53; RR=1.14; 95% CrI: 1.03-1.26).

CONCLUSIONS

Paying attention to physical and social environments, related neighborhood experiences, and attitudes toward health may be an effective approach to promote outdoor physical activity.

Using High-Resolution Population Data to Identify Neighborhoods and Establish Their Boundaries

Neighborhoods are about local territory, but what territory? This paper offers one approach to this question through a novel application of "local" spatial statistics. We conceptualize a neighborhood in terms of both space and social composition; it is a contiguous territory defined by a bundle of social attributes that distinguish it from surrounding areas. Our method does not impose either a specific social characteristic or a predetermined spatial scale to define a neighborhood. Rather we infer neighborhoods from detailed information about individual residents and their locations. The analysis is based on geocoded complete-count census data from the late 19(th) Century in four cities: Albany, NY, Buffalo, NY, Cincinnati, OH, and Newark, NJ. We find striking regularities (and some anomalies) in the spatial structure of the cities studied. Our approach illustrates the "spatialization" of an important social scientific concept.

Multicollinearity in associations between multiple environmental features and body weight and abdominal fat: using matching techniques to assess whether the associations are separable

Because of the strong correlations among neighborhoods' characteristics, it is not clear whether the associations of specific environmental exposures (e.g., densities of physical features and services) with obesity can be disentangled. Using data from the RECORD (Residential Environment and Coronary Heart Disease) Cohort Study (Paris, France, 2007-2008), the authors investigated whether neighborhood characteristics related to the sociodemographic, physical, service-related, and social-interactional environments were associated with body mass index and waist circumference. The authors developed an original neighborhood characteristic-matching technique (analyses within pairs of participants similarly exposed to an environmental variable) to assess whether or not these associations could be disentangled. After adjustment for individual/neighborhood socioeconomic variables, body mass index/waist circumference was negatively associated with characteristics of the physical/service environments reflecting higher densities (e.g., proportion of built surface, densities of shops selling fruits/vegetables, and restaurants). Multiple adjustment models and the neighborhood characteristic-matching technique were unable to identify which of these neighborhood variables were driving the associations because of high correlations between the environmental variables. Overall, beyond the socioeconomic environment, the physical and service environments may be associated with weight status, but it is difficult to disentangle the effects of strongly correlated environmental dimensions, even if they imply different causal mechanisms and interventions.

Obesogenic environments in youth: concepts and methods from a longitudinal national sample

To effectively prevent and reduce childhood obesity through healthy community design, it is essential to understand which neighborhood environment features influence weight gain in various age groups. However, most neighborhood environment research is cross-sectional, focuses on adults, and is often carried out in small, nongeneralizable geographic areas. Thus, there is a great need for longitudinal neighborhood environment research in diverse populations across the life cycle. This paper describes (1) insights and challenges of longitudinal neighborhood environment research and (2) advancements and remaining gaps in measurement and study design that examine individuals and neighborhoods within the context of the broader community. Literature-based research and findings from the Obesity and Neighborhood Environment Database (ONEdata), a unique longitudinal GIS that is spatially and temporally linked to data in the National Longitudinal Study of Adolescent Health (N=20,745), provide examples of current limitations in this area of research. Findings suggest a need for longitudinal methodologic advancements to better control for dynamic sources of bias, investigate and capture appropriate temporal frameworks, and address complex residential location processes within families. Development of improved neighborhood environment measures that capture relevant geographic areas within complex communities and investigation of differences across urbanicity and sociodemographic composition are needed. Further longitudinal research is needed to identify, refine, and evaluate national and local policies to most effectively reduce childhood obesity.

Time changes, so do people

When one discusses the dynamic changes in human health over time, one innately conceptualizes time from the three different, but related perspectives--age, period, and cohort. To determine their separate contributions to health outcomes, age-period-cohort analyses have been used for the past 80 years. This commentary aims to provide some insight into this analytical method by distinguishing the concept of time in terms of composition and context. To demonstrate, the author uses hypothetical nested data structures of age-period-cohort analyses in the two types of individual-level data, i.e., repeated cross-sectional survey and longitudinal data on the same individuals. The conceptual distinctions between composition and context have profound implications of hypothetical interventions in age-period-cohort analyses. Age is a compositional variable, and a hypothetical intervention to change age is at the individual level. By contrast, both period and cohort are contexts, and thus two distinct types of hypothetical interventions can be envisaged to examine their contextual effects. On a related issue, the author also discusses manipulability of time. Although time is a significant context in biomedical science, it is not the only context. In this commentary, context is proposed to be classified into three fundamental dimensions--relational, spatial, and temporal. Inattention to the contextual triad leads to a biased and precarious knowledge base for public health action, and the continuing flow of performance over time is an intrinsic component of improving our understanding of multilevel causal inference in the new era of eco-epidemiology.

The influence of neighbourhood disadvantage on smoking cessation and its contribution to inequalities in smoking status

INTRODUCTION AND AIMS

Individual smokers from disadvantaged backgrounds are less likely to quit, which contributes to widening inequalities in smoking. Residents of disadvantaged neighbourhoods are more likely to smoke, and neighbourhood inequalities in smoking may also be widening because of neighbourhood differences in rates of cessation. This study examined the association between neighbourhood disadvantage and smoking cessation and its relationship with neighbourhood inequalities in smoking.

DESIGN AND METHODS

A multilevel longitudinal study of mid-aged (40-67 years) residents (n = 6915) of Brisbane, Australia, who lived in the same neighbourhoods (n = 200) in 2007 and 2009. Neighbourhood inequalities in cessation and smoking were analysed using multilevel logistic regression and Markov chain Monte Carlo simulation.

RESULTS

After adjustment for individual-level socioeconomic factors, the probability of quitting smoking between 2007 and 2009 was lower for residents of disadvantaged neighbourhoods (9.0-12.8%) than their counterparts in more advantaged neighbourhoods (20.7-22.5%). These inequalities in cessation manifested in widening inequalities in smoking: in 2007 the between-neighbourhood variance in rates of smoking was 0.242 (P ≤ 0.001) and in 2009 it was 0.260 (P ≤ 0.001). In 2007, residents of the most disadvantaged neighbourhoods were 88% (OR 1.88, 95% credible intervals (CrI) 1.41-2.49) more likely to smoke than residents in the least disadvantaged neighbourhoods: the corresponding difference in 2009 was 98% (OR 1.98, 95% CrI 1.48-2.66).

CONCLUSION

Fundamentally, social and economic inequalities at the neighbourhood and individual levels cause smoking and cessation inequalities. Reducing these inequalities will require comprehensive, well-funded and targeted tobacco control efforts and equity-based policies that address the social and economic determinants of smoking.

Associations of supermarket characteristics with weight status and body fat: a multilevel analysis of individuals within supermarkets (RECORD study)

Purpose

Previous research on the influence of the food environment on weight status has often used impersonal measures of the food environment defined for residential neighborhoods, which ignore whether people actually use the food outlets near their residence. To assess whether supermarkets are relevant contexts for interventions, the present study explored between-residential neighborhood and between-supermarket variations in body mass index (BMI) and waist circumference (WC), and investigated associations between brands and characteristics of supermarkets and BMI or WC, after adjustment for individual and residential neighborhood characteristics.

Methods

Participants in the RECORD Cohort Study (Paris Region, France, 2007–2008) were surveyed on the supermarket (brand and exact location) where they conducted their food shopping. Overall, 7 131 participants shopped in 1 097 different supermarkets. Cross-classified multilevel linear models were estimated for BMI and WC.

Results

Just 11.4% of participants shopped for food primarily within their residential neighborhood. After accounting for participants' residential neighborhood, people shopping in the same supermarket had a more comparable BMI and WC than participants shopping in different supermarkets. After adjustment for individual and residential neighborhood characteristics, participants shopping in specific supermarket brands, in hard discount supermarkets (especially if they had a low education), and in supermarkets whose catchment area comprised low educated residents had a higher BMI/WC.

Conclusion

A public health strategy to reduce excess weight may be to intervene on specific supermarkets to change food purchasing behavior, as supermarkets are where dietary preferences are materialized into definite purchased foods.

Towns with extremely low mortality due to ischemic heart disease in Spain

BACKGROUND

The cause of coronary disease inframortality in Spain is unknown. The aim of this study is to identify Spanish towns with very low ischemic heart disease mortality, describe their health and social characteristics, and analyze the relationship with a series of contextual factors.

METHODS

We obtained the number of deaths registered for each of 8,122 Spanish towns in the periods 1989-1998 and 1999-2003. Expected deaths, standardized mortality ratio (SMR), smoothed Relative Risk (RR), and Posterior Probability (PP) of RR > 1 were calculated using Bayesian hierarchical models. Inframortality was defined as any town that displayed an RR below the 10th percentile, an SMR of under 1 for both sexes, and a PP of RR > 1 less than or equal to 0.002 for male and 0.005 for female mortality, during the two periods covered. All the remaining towns, except for those with high mortality classified as "tourist towns", were selected as controls. The association among socioeconomic, health, dietary, lifestyle and vascular risk factors was analyzed using sequential mixed logistic regression models, with province as the random-effects variable.

RESULTS

We identified 32 towns in which ischemic heart disease mortality was half the national rate and four times lower than the European Union rate, situated in lightly populated provinces spread across the northern half of Spain, and revealed a surprising pattern of geographic aggegation for 23 of the 32 towns. Variables related with inframortality were: a less aged population (OR 0.93, 95% CI 0.89-0.99); a contextual dietary pattern marked by a high fish content (OR 2.13, 95% CI 1.38-3.28) and wine consumption (OR 1.50, 95% CI 1.08-2.07); and a low prevalence of obesity (OR 0.47, 95% CI 0.22-1.01); and, in the case of towns of over 1000 inhabitants, a higher physician-population ratio (OR 3.80, 95% CI 1.17-12.3).

CONCLUSIONS

Results indicate that dietary and health care factors have an influence on inframortality. The geographical aggregation suggests that other factors with a spatial pattern, e.g., genetic or environmental might also be implicated. These results will have to be confirmed by studies in situ, with objective measurements at an individual level.

Are associations between neighborhood socioeconomic characteristics and body mass index or waist circumference based on model extrapolations?

BACKGROUND

We investigated whether neighborhood socioeconomic characteristics, measured within person-centered areas (ie, centered on individuals' residences) are associated with body mass index (BMI [kg/m²]) and waist circumference. We used propensity-score matching as a diagnostic and validation tool to examine whether socio-spatial segregation (and related structural confounding) allowed us to estimate neighborhood socioeconomic effects adjusted for individual socioeconomic characteristics without excessive model extrapolations.

METHODS

Using the RECORD (Residential Environment and CORonary heart Disease) Cohort Study, we conducted cross-sectional analyses of 7230 adults from the Paris region. We first estimated the relationships of 3 neighborhood socioeconomic indicators (education, income, real estate prices) with BMI and waist circumference using traditional multilevel regression models adjusted for individual covariates. Second, we examined whether these associations persisted when estimated among participants exchangeable based on their probability of living in low-socioeconomic-status neighborhoods (propensity-score matched samples).

RESULTS

After adjustment for covariates, BMI/waist circumference increased with decreasing neighborhood socioeconomic status, especially with neighborhood education measured within 500-m radius buffers around residences; associations were stronger for women. With propensity-score matching techniques, there was some overlap in the odds of exposure between exposed and unexposed populations. As a function of socio-spatial segregation and an indicator of whether the data support inferences, sample size decreased by 17%-59% from the initial to the propensity-score matched samples. Propensity-score matched models confirmed relationships obtained from models in the entire sample.

CONCLUSIONS

Overall, adjusted associations between neighborhood socioeconomic variables and BMI/waist circumference were empirically estimable in the French context, without excessive model extrapolations, despite the extent of socio-spatial segregation.

"Getting sicker quicker": does living in a more deprived neighbourhood mean your health deteriorates faster?

Data from the longitudinal West of Scotland Twenty-07 STUDY: Health in the Community was used to examine whether, over a 20 year period, the self-reported health of people living in deprived areas became poorer faster compared to those living in more affluent areas. Three cohorts (born in the early 1930s, 1950s and 1970s) are included, covering 60 years of the life span. Using multilevel growth curve models, a 40% probability of reporting poor health was predicted among residents of more deprived areas at an earlier age (66) compared to those living in more affluent areas (83). Wider area differences were seen for men than for women. Our findings indicate that attempts to reduce area differences in health should start young but also continue throughout the lifespan.

Spatial accessibility to physical activity facilities and to food outlets and overweight in French youth

Objective:

Some characteristics of the built environment have been associated with obesity in youth. Our aim was to determine whether individual and environmental socio-economic characteristics modulate the relation between youth overweight and spatial accessibility to physical activity (PA) facilities and to food outlets.

Design:

Cross-sectional study.

Subjects:

3293 students, aged 12±0.6 years, randomly selected from eastern France middle schools.

Measurements and methods:

Using geographical information systems (GIS), spatial accessibility to PA facilities (urban and nature) was assessed using the distance to PA facilities at the municipality level; spatial accessibility to food outlets (general food outlets, bakeries and fast-food outlets) was calculated at individual level using the student home address and the food outlets addresses. Relations of weight status with spatial accessibility to PA facilities and to food outlets were analysed using mixed logistic models, testing potential direct and interaction effects of individual and environmental socio-economic characteristics.

Results:

Individual socio-economic status modulated the relation between spatial accessibility to PA facilities and to general food outlets and overweight. The likelihood of being overweight was higher when spatial accessibility to urban PA facilities and to general food outlets was low, but in children of blue-collar-workers only. The odds ratio (OR) (95% confidence interval) for being overweight of blue-collar-workers children compared with non-blue-collar-workers children was 1.76 (1.25–2.49) when spatial accessibility to urban PA facilities was low. This OR was 1.86 (1.20–2.86) when spatial accessibility to general food outlets was low. There was no significant relationship of overweight with either nature PA facilities or other food outlets (bakeries and fast-food outlets).

Conclusion:

These results indicate that disparities in spatial accessibility to PA facilities and to general food outlets may amplify the risk of overweight in socio-economically disadvantaged youth. These data should be relevant for influencing health policies and urban planning at both a national and local level.

Improving the measurement of neighbourhood characteristics through systematic observation: inequalities in smoking as a case study

Systematic observation is increasingly used as a method to measure neighbourhood characteristics thought to influence health inequalities. This article reports on the theory-driven development of a new observation tool composed of reflective indicators of neighbourhood characteristics believed to influence inequalities in smoking. We also report the results of generalisability analyses conducted to estimate the reliability (inter-rater reliability and temporal stability) of the observation tool. We use the reliability results to reflect on the quality of the measures and on the theoretical anchors of the tool. We conclude by making recommendations to improve measures collected through systematic observation.

Local context influence, activity space, and foodscape exposure in two canadian metropolitan settings: is daily mobility exposure associated with overweight?

It has become increasingly common to attribute part of the obesity epidemic to changes in the environment. Identification of a clear and obvious role for contextual risk factors has not yet been demonstrated. The objectives of this study were to explain differences in local overweight risk in two different urban settings and to explore sex-specific associations with estimated mobility patterns. Overweight was modeled within a multilevel framework using built environmental and socioeconomic contextual indicators and individual-level estimates of activity space exposure to fast-food restaurants (or exposure to visited places). Significant variations in local levels in overweight risk were observed. Physical and socioeconomic contexts explained more area-level differences in overweight among men than among women and among inhabitants of Montreal than among inhabitants of Quebec City. Estimated activity space exposure to fast-food outlets was significantly associated with overweight for men in Montreal. Local-level analyses are required to improve our understanding of contextual influences on obesity, including multiple influences in people's daily geographies.

East-West gradient in cardio-vascular mortality in Austria: how much can we explain by following the pattern of risk factors?

Background

Various studies show major regional differences in the prevalence of cardio-vascular disease morbidity and mortality, both in Europe and within European countries. In Austria, these differences are documented by an East-West gradient with declining morbidity and mortality rates when moving from the East to the West of the country. It was the aim of this study to analyse if, and to what extent, socio-demographic and socio-economic determinants, social resources and health behaviour can contribute to the clarification of this East-West gradient by conducting secondary analyses of an existing Austrian health dataset.

Results

The data were analysed using bivariate analyses, as well as univariate and multivariate logistic regression models. These analyses revealed significant East-West gradients for various risk factors, as well as socio-demographic and socio-economic health determinants. There was a gradual decrease of hypertension, diabetes mellitus, obesity, and psycho-social discomfort in both sexes, with the highest prevalences in those Austrian regions with the highest cardio-vascular mortality and a stepwise decrease to the regions with the lowest cardio-vascular mortality. Controlling for educational level significantly raised the odds for diabetes, hypertension and obesity. In the results of the multivariate analyses, factors that significantly and independently predicted diabetes mellitus were geographic location, psycho-social discomfort, lack of physical exercise, and age in both sexes. For women these factors additionally included a low educational level, lack of social support, and being born abroad.

Conclusions

Our study shows a clear gradual decline of cardio-vascular mortality and some of its risk factors from East to West in Austria. Concerning these risk factors, the geographic region and psycho-social discomfort showed the greatest association with diabetes mellitus, hypertension, and obesity. Hence, they contribute to the explanation of the variance in spatial cardio-vascular disease mortality. Yet, a large proportion of this variance remains unexplained. It would be of great importance to public health and preventive measures to take a closer look at spatial differences in cardio-vascular disease morbidity and mortality to better tailor programmes to the regional environments and settings. Our results also call for a greater importance of preventative measures for psycho-social discomfort and increase of social support.

The modifiable areal unit problem (MAUP) in the relationship between exposure to NO2 and respiratory health

Background

Many Canadian population health studies, including those focusing on the relationship between exposure to air pollution and health, have operationalized neighbourhoods at the census tract scale. At the same time, the conceptualization of place at the local scale is one of the weakest theoretical aspects in health geography. The modifiable areal unit problem (MAUP) raises issues when census tracts are used as neighbourhood proxies, and no other alternate spatial structure is used for sensitivity analysis. In the literature, conclusions on the relationship between NO₂ and health outcomes are divided, and this situation may in part be due to the selection of an inappropriate spatial structure for analysis. Here, we undertake an analysis of NO₂ and respiratory health in Ottawa, Canada using three different spatial structures in order to elucidate the effects that the spatial unit of analysis can have on analytical results.

Results

Using three different spatial structures to examine and quantify the relationship between NO₂ and respiratory morbidity, we offer three main conclusions: 1) exploratory spatial analytical methods can serve as an indication of the potential effect of the MAUP; 2) OLS regression results differ significantly using different spatial representations, and this could be a contributing factor to the lack of consensus in studies that focus on the relation between NO₂ and respiratory health at the area-level; and 3) the use of three spatial representations confirms no measured effect of NO₂ exposure on respiratory health in Ottawa.

Conclusions

Area units used in population health studies should be delineated so as to represent the a priori scale of the expected scale interaction between neighbourhood processes and health. A thorough understanding of the role of the MAUP in the study of the relationship between NO₂ and respiratory health is necessary for research into disease pathways based on statistical models, and for decision-makers to assess the scale at which interventions will have maximum benefit. In general, more research on the role of spatial representation in health studies is needed.

Why socially deprived populations have a faster resting heart rate: impact of behaviour, life course anthropometry, and biology--the RECORD Cohort Study

Although studies have shown that resting heart rate (RHR) is predictive of cardiovascular morbidity/mortality, few studies focused on the epidemiology and social aetiology of RHR. Using the RECORD Cohort Study (7158 participants, 2007-2008, Paris region, France), we investigated individual/neighbourhood socioeconomic variables associated with resting heart rate, and assessed which of a number of psychological factors (depression and stress), behaviour (sport-related energy expenditure, medication use, and alcohol, coffee, and tobacco consumption), life course anthropometric factors (body mass index, waist circumference, and leg length as a marker of childhood environmental exposures), and biologic factors (alkaline phosphatase and gamma-glutamyltransferase) contributed to the socioeconomic disadvantage-RHR relationship. Combining individual/neighbourhood socioeconomic factors in a socioeconomic score, RHR increased with socioeconomic disadvantage: +0.9 [95% credible interval (CrI): +0.2, +1.6], +1.8 (95% CrI: +1.0, +2.5), and +3.6 (95% CrI: +2.9, +4.4) bpm for the 3 categories reflecting increasing disadvantage, compared with the lowest disadvantage category. Twenty-one percent of the socioeconomic disadvantage-RHR relationship was explained by sport practise variables, 9% by waist circumference, 7% by gamma-glutamyltransferase, 5% by alkaline phosphatase, and 3% by leg length. Future research should further clarify the mechanisms through which socioeconomic disadvantage influences resting heart rate, as a pathway to social disparities in cardiovascular morbidity/mortality.