Neighbourhoods and potential access to health care: The role of spatial and aspatial factors

Low neighborhood socioeconomic status is associated with poor outcomes in young adults with colorectal cancer

BACKGROUND

The incidence of early-onset colorectal cancer has increased markedly over the past decade. Although established for older adults, there are limited data on socioeconomic and racial disparities in screening, treatment, and outcomes in this distinct group.

METHODS

Adults with primary colorectal cancer diagnosed at age <50 were identified from the Surveillance, Epidemiology, and End Results database. The exposure of interest was neighborhood socioeconomic status based on the Yost Index, a census-tract level composite score of neighborhood economic health. Univariate analysis was performed with χ2 analyses. Logistic regression models were created to evaluate the association of neighborhood socioeconomic status (Yost Index quintile) with metastasis at presentation and surgical intervention. Kaplan-Meier and Cox proportional hazards models were created.

RESULTS

In total, 45,660 early-onset colorectal cancer patients were identified; 16.8% (7,679) were in the lowest quintile of neighborhood socioeconomic status. Patients with the lowest neighborhood socioeconomic status were 1.13 times (95% confidence interval 1.06-1.21) more likely to present with metastases and had lower survival (hazard ratio 1.45, 95% confidence interval 1.37-1.53) compared to those with the highest neighborhood socioeconomic status. Non-Hispanic Black patients were more likely to present with metastatic disease (odds ratio 1.11, 95% confidence interval 1.05-1.19), less likely to undergo surgery for localized or regional disease (odds ratio 0.48, 95% confidence interval 0.43-0.53), and had lower survival (hazard ratio 1.21, 95% confidence interval 1.15-1.27) than non-Hispanic White patients.

CONCLUSION

Socioeconomic and racial disparities in early-onset colorectal cancer span diagnosis, treatment, and survival. As the disease burden of early-age onset colorectal cancer increases, interventions to boost early diagnosis and access to surgery are necessary to improve survival among minorities and patients with low neighborhood socioeconomic status.

"We do not go outside, though We want to": Unequal Access to Public Transport and Transport-Related Social Exclusion of Older Adults in Dhaka, Bangladesh

This study investigated key physical and social barriers to accessing public transport in Dhaka, Bangladesh, and how the unequal accessibility of transport leads to the social exclusion of older adults. Employing a transport disadvantage perspective and drawing on visual surveys and in-depth interviews, the study explores the context and lived experiences of older adults using public transport in their everyday lives. Difficulty in accessing buses due to overcrowding and congestion, struggling to get on rickshaws due to height, avoiding CNG (an autorickshaw) and cabs due to high fares, disliking Laguna (a small four-wheeler human haulier for carrying passengers) for compact seating arrangements, undesirable behavior, and social attitudes discourage older adults from participating in social activities and produce a feeling of social isolation and exclusion. Hence, more inclusive transport policies are essential in low- and middle-income countries to reduce transport-related social exclusion and improve the well-being of older adults.

Ethnic networks in neighborhoods affect mental health: Evidence from a quasi-random assignment of applicants in the public social housing system

This paper examines the impact of residence-based ethnic networks on mental health; such networks are defined as the concentration of residents from the same country of origin in a neighborhood. To estimate the effect, we utilize administrative registry data, together with data on quasi-random assignment of apartments to non-Western households with housing needs to various neighborhoods. After controlling for individual characteristics, time-invariant neighborhood characteristics, and general practitioners (GP) fixed effects, we find that a 1-percentage-point increase in the concentration of residence-based co-ethnics (RBCEs) increases the probability of being treated with psychiatric medications by 0.7-percentage point over a 5-year period after the assignment. With 19% of the population being treated with psychiatric medications the year before assignment, the result translates into an effect size of 3.7%. The results indicate that relatively high concentrations of co-ethnics treated with psychiatric medications increase the probability of being treated with psychiatric medications. The positive impact on treatment with psychiatric medication reflects an increase in the demand for these drugs when moving into a neighborhood with neighbors of the same ethnicity. If new residents are in good mental health condition when moving, these results suggest that moving into a neighborhood with a high co-ethic concentration worsens mental health status. However, as the population in this study is a vulnerable group an increase in treatment with psychiatric medications likely reflects that untreated mental health problems are treated, and the mental health status improved. The group of non-Western immigrants in this study differs significantly from the population in general, thus, results may not be generalized to all non-Western immigrants.

A French classification to describe medical deserts: a multi-professional approach based on the first contact with the healthcare system

BACKGROUND

Increasing inequalities in accessibility to primary care has generated medical deserts. Identifying them is key to target the geographic areas where action is needed. An extensive definition of primary care has been promoted by the World Health Organization: a first level of contact with the health system, which involves the co-presence of different categories of health professionals alongside the general practitioner for the diagnosis and treatment of patients. Previous analyses have focused mainly on a single type of provider while this study proposes an integrated approach including various ones to define medical deserts in primary care.

METHOD

Our empirical approach focuses on the first point of contact with the health system: general practitioners, proximity primary care providers (nurses, physiotherapists, pharmacies, laboratories, and radiologists), and emergency services. A multiple analysis approach was performed, to classify French municipalities using the information on the evolution and needs of health care accessibility, combining a principal component analysis and a hierarchical ascending classification.

RESULTS

Two clusters of medical deserts were identified with low accessibility to all healthcare professionals, socio-economic disadvantages, and a decrease in care supply. In other clusters, accessibility difficulties only concern a part of the health supply considered, which raises concern for the efficiency of primary care for optimal healthcare pathways. Even for clusters with better accessibility, issues were identified, such as a decrease and high needs of health care supply, revealing potential future difficulties.

CONCLUSION

This work proposes a multi-professional and multi-dimensional approach to medical deserts based mainly on an extensive definition of primary care that shows the relevance of the co-presence of various healthcare professionals. The classification also makes it possible to identify areas with future problems of accessibility and its potential consequences. This framework could be easily applied to other countries according to their available data and their health systems' specificities.

How to Achieve a Healthy City: a Scoping Review with Ten City Examples

This scoping review of the literature explores the following question: what systematic measures are needed to achieve a healthy city? The World Health Organization (WHO) suggests 11 characteristics of a healthy city. Measures contributing to these characteristics are extracted and classified into 29 themes. Implementation of some of these measures is illustrated by examples from Freiburg, Greater Vancouver, Singapore, Seattle, New York City, London, Nantes, Exeter, Copenhagen, and Washington, DC. The identified measures and examples indicate that a healthy city is a system of healthy sectors. A discussion section suggests healthy directions for nine sectors in a healthy city. These sectors include transportation, housing, schools, city planning, local government, environmental management, retail, heritage, and healthcare. Future work is advised to put more focus on characteristic 5 (i.e., the meeting of basic needs for all the city's people) and characteristic 10 (i.e., public health and sick care services accessible to all) of a healthy city.

Health justice and economic segregation in climate risks: Tracing vulnerability and readiness progress

Climate vulnerability can make urban space unhealthy and accentuate existing health (in)justice and (economic) segregation. Drawing on the vulnerability-readiness nexus and measuring health justice (i.e., health poverty, health distribution, and health access) and economic segregation (through indices), we strive to investigate the plausible pathways of the two constructs at the heat risks. Our work, focusing on metropolitan cities in South Korea, addresses the role of heat vulnerability and readiness nexus regarding health justice and economic segregation through correlational analysis and a time-trend comparative approach between 2011 and 2015 (as five year-long effects). Our results show that potential positive links exist between health poverty as a component of health justice and economic segregation. Moreover, climate readiness, as opposed to vulnerability, plays a crucial role in reducing economic segregation in the context of health justice and heat risks.

A comparative study for accessing primary healthcare between planning assessment and actual utilization for older adults: a case from Dalian City, China

Introduction

As China has rapidly evolved into an aging society, the Chinese government has developed a community-oriented primary healthcare system to vigorously expedite the transfer of primary health care (PHC) from higher-level hospitals to community health centers (CHCs). However, current planning standards for CHCs have not considered the heterogeneity of older adults in supply-demand services, such that the areas with severe aging may comprise of underestimated levels of accessibility.

Methods

This study focuses on the gap in PHC access between planning assessment and actual utilization for older adults. We conducted an empirical study in the city area of Dalian based on the check-in and survey data from CHCs during the COVID-19 pandemic. A comparison model was built to calculate matching probability using a modified Gaussian Two-Step Floating Catchment Area (G2SFCA) method.

Results

As indicated by the results, the communities in the primary healthcare shortage area (PHCSA) increased 6.8% by considering the heterogeneity of older adults; these communities with underserved PHC were ignored by the current planning assessment. Based on the comparison of actual and theoretical accessibility for older adults, we found that the average matching probability was about 76.6%, which means approximately a quarter of older adults have been misestimated the accessibility of PHC.

Discussion

Further analysis for the older adults with mismatched accessibility showed two causes of the gap, one is the lack of connection between the spatial distribution of facilities and the allocation of service supply, and the other is the subjective cross-catchment visit to CHCs for older adults.

Change in Geographic Accessibility to Dental Clinics Affects Access to Care

Access to dental clinics is a feature of the neighborhood service environment that may influence oral health care utilization. However, residential selection poses a challenge to causal inference. By studying the involuntary relocation of survivors of the 2011 Great East Japan Earthquake and Tsunami (GEJE), we examined the association between changes in geographic distance to dental clinics and dental visits. Longitudinal data from a cohort of older residents in Iwanuma City directly impacted by the GEJE were analyzed in this study. The baseline survey was conducted in 2010, 7 mo before the occurrence of GEJE, and a follow-up was conducted in 2016. Using Poisson regression models, we estimated the incidence rate ratios (IRR) and 95% confidence intervals (CIs) for the uptake of denture use (as a proxy for dental visits) according to changes in distance from the nearest dental clinic to their house. Age at baseline, housing damage by the disaster, deteriorating economic conditions, and worsened physical activity were used as confounders. Among the 1,098 participants who had not worn dentures before the GEJE, 495 were men (45.1%), with a mean ± SD age at baseline of 74.0 ± 6.9 y. During the 6-year follow-up, 372 (33.9%) participants initiated denture use. Compared to those who experienced a large increase in distance to dental clinics (>370.0-6,299.1 m), a large decrease in distance to dental clinics (>429.0-5,382.6 m) was associated with a marginally significantly higher initiation of denture use among disaster survivors (IRR = 1.28; 95% CI, 0.99-1.66). The experience of major housing damage was independently associated with higher initiation of denture use (IRR = 1.77; 95% CI, 1.47-2.14). Improved geographic access to dental clinics may increase dental visits of disaster survivors. Further studies in non-disaster-affected areas are needed to generalize these findings.

Evaluation of accessibility and equity to hospitals by public transport: evidence from six largest cities of Ohio

INTRODUCTION

In the United States, health care has long been viewed as a 'right,' and residents of the state of Ohio are no exception. The Ohio Department of Health ensures that this right exists for all residents of Ohio. Socio-spatial characteristics, however, can have an impact on access to health care, particularly among vulnerable groups. This article seeks to measure the spatial accessibility to healthcare services by public transport in the six largest cities of Ohio based on population and to compare the accessibility of healthcare to vulnerable demographic groups. To the authors' knowledge, this is the first study to analyze the accessibility and equity of hospitals by public transit across different cities in Ohio, allowing the identification of common patterns, difficulties, and knowledge gaps.

METHODOLOGY

Using a two-step floating catchment area technique, the spatial accessibility to general medical and surgical hospitals through public transportation was estimated, considering both service-to-population ratios and travel time to these health services. The average accessibility of all census tracts and the average accessibility of the 20% of most susceptible census tracts were determined for each city. Using Spearman's rank correlation coefficient between accessibility and vulnerability, an indicator was then devised to evaluate vertical equity.

FINDINGS

Within cities (except Cleveland), people of vulnerable census tracts have less access to hospitals via public transportation. These cities (Columbus, Cincinnati, Toledo, Akron, and Dayton) fail in terms of vertical equity and average accessibility. According to this, vulnerable census tracts in these cities have the lowest accessibility levels.

CONCLUSION

This study emphasizes the issues connected with the suburbanization of poverty in Ohio's large cities and the need to provide adequate public transportation to reach hospitals on the periphery. In addition, this study shed light on the need for additional empirical research to inform the implementation of guidelines for healthcare accessibility in Ohio. Researchers, planners, and policymakers who want to make healthcare more accessible for everyone should take note of the findings in this study.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

The Commodification of Health Services: an Alternative for the Marginalized Population of Mexico City

The Doctor's Office Adjacent to Pharmacies (DAP) model has grown exponentially in Mexico. Its proliferation is due to two factors. The first is the high cost of medical consultations in private hospitals, and the second is that public health services are insufficient. To gauge the importance this model has acquired, it is necessary to analyze the pattern of distribution and operation of this type of doctors' offices and determine whether they are responding to the unmet demand of a population that is socio-territorially marginalized from health infrastructure. A database was created with updated, geo-referenced information on the precise location of DAP throughout Mexico City and its metropolitan area. Information was obtained on the location, condition and type of franchise, and the infrastructure of each establishment. The analysis found that the distribution pattern of DAP satisfies an unmet need in areas with the highest demand for health services. This situation occurs particularly in areas inhabited by the most marginalized population.

NB housing study protocol: investigating the relationship between subsidized housing, mental health, physical health and healthcare use in New Brunswick, Canada

BACKGROUND

Income and housing are pervasive social determinants of health. Subsidized housing is a prominent affordability mechanism in Canada; however, waitlists are lengthy. Subsidized rents should provide greater access to residual income, which may theoretically improve health outcomes. However, little is known about the health of tenants who wait for and receive subsidized housing. This is especially problematic for New Brunswick, a Canadian province with low population density, whose inhabitants experience income inequality, social exclusion, and challenges with healthcare access.  METHODS: This study will use a longitudinal, prospective matched cohort design. All 4,750 households on New Brunswick's subsidized housing wait list will be approached to participate. The survey measures various demographic, social and health indicators at six-month intervals for up to 18 months as they wait for subsidized housing. Those who receive housing will join an intervention group and receive surveys for an additional 18 months post-move date. With consent, participants will have their data linked to a provincial administrative database of medical records.  DISCUSSION: Knowledge of housing and health is sparse in Canada. This study will provide stakeholders with a wealth of health information on a population that is historically under-researched and underserved.

Prehospital Time Interval for Urban and Rural Emergency Medical Services: A Systematic Literature Review

The aim of this study was to discuss the differences in pre-hospital time intervals between rural and urban communities regarding emergency medical services (EMS). A systematic search was conducted through various relevant databases, together with a manual search to find relevant articles that compared rural and urban communities in terms of response time, on-scene time, and transport time. A total of 37 articles were ultimately included in this review. The sample sizes of the included studies was also remarkably variable, ranging between 137 and 239,464,121. Twenty-nine (78.4%) reported a difference in response time between rural and urban areas. Among these studies, the reported response times for patients were remarkably variable. However, most of them (number (n) = 27, 93.1%) indicate that response times are significantly longer in rural areas than in urban areas. Regarding transport time, 14 studies (37.8%) compared this outcome between rural and urban populations. All of these studies indicate the superiority of EMS in urban over rural communities. In another context, 10 studies (27%) reported on-scene time. Most of these studies (n = 8, 80%) reported that the mean on-scene time for their populations is significantly longer in rural areas than in urban areas. On the other hand, two studies (5.4%) reported that on-scene time is similar in urban and rural communities. Finally, only eight studies (21.6%) reported pre-hospital times for rural and urban populations. All studies reported a significantly shorter pre-hospital time in urban communities compared to rural communities. Conclusions: Even with the recently added data, short pre-hospital time intervals are still superior in urban over rural communities.

Proximity of Water Wells to Public Water Testing Facilities in Alberta Using Drive Times

Approximately 10% of Albertans rely on well water for domestic purposes. The responsibility of water testing and stewardship is left to private well owners. Few well water owners conduct routine testing of their well water supplies. Drive times to public water testing facilities may be an important factor limiting a well owner's ability to conduct routine water testing. The objective of this study is to describe the proximity of water wells, using drive times, to public water testing facilities and describe the availability of facilities based on hours of operation. Using network analysis, we determined the proportion of a sample of wells within 3 estimated drive times of public water testing facilities. 5872 wells were included in the sample. One hundred and seven water testing facilities were mapped within the province. Of the 5872 wells mapped, 89% were located within 30 minutes of a water testing facility, 15% were located within 0 to 10 minutes of a water testing facility, 48% were located between 10 and 20 minutes of a water testing facility and 37% were located within 20 to 30 minutes of a water testing facility. Further analysis revealed that access to water testing facilities may be influenced by the hours of operation of the facilities.

Spatial modeling of vaccine deserts as barriers to controlling SARS-CoV-2

BACKGROUND

COVID-19 vaccine distribution is at risk of further propagating the inequities of COVID-19, which in the United States (US) has disproportionately impacted the elderly, people of color, and the medically vulnerable. We sought to measure if the disparities seen in the geographic distribution of other COVID-19 healthcare resources were also present during the initial rollout of the COVID-19 vaccine.

METHODS

Using a comprehensive COVID-19 vaccine database (VaccineFinder), we built an empirically parameterized spatial model of access to essential resources that incorporated vaccine supply, time-willing-to-travel for vaccination, and previous vaccination across the US. We then identified vaccine deserts-US Census tracts with localized, geographic barriers to vaccine-associated herd immunity. We link our model results with Census data and two high-resolution surveys to understand the distribution and determinates of spatially accessibility to the COVID-19 vaccine.

RESULTS

We find that in early 2021, vaccine deserts were home to over 30 million people, >10% of the US population. Vaccine deserts were concentrated in rural locations and communities with a higher percentage of medically vulnerable populations. We also find that in locations of similar urbanicity, early vaccination distribution disadvantaged neighborhoods with more people of color and older aged residents.

CONCLUSION

Given sufficient vaccine supply, data-driven vaccine distribution to vaccine deserts may improve immunization rates and help control COVID-19.

Medicaid Expansion and Change in Federally Qualified Health Center Accessibility From 2008 to 2016

BACKGROUND

The Affordable Care Act expanded health coverage for low-income residents through Medicaid expansion and increased funding for Health Center Program New Access Points from 2009 to 2015, improving federally qualified health center (FQHC) accessibility. The extent to which these provisions progressed synergistically as intended when states could opt out of Medicaid expansion is unknown.

OBJECTIVE

To compare change in FQHC accessibility among census tracts in Medicaid expansion and nonexpansion states.

RESEARCH DESIGN

Tract-level FQHC accessibility scores for 2008 and 2016 were estimated applying the 2-step floating catchment area method to American Community Survey and Health Resources and Services Administration data. Multivariable linear regression compared changes in FQHC accessibility between tracts in Medicaid expansion and nonexpansion states, adjusting for sociodemographic and health system factors and accounting for state-level clustering.

SUBJECTS

In total, 7058 census tracts across 10 states.

RESULTS

FQHC accessibility increased comparably among tracts in Medicaid expansion and nonexpansion states (coef: 0.3; 95% CI: -0.3, 0.8; P -value: 0.36). FQHC accessibility increased more in tracts with higher poverty and uninsured rates, and those with lower proportions of non-English speakers and Black or African American residents.

CONCLUSION

Similar gains in FQHC accessibility across Medicaid expansion and nonexpansion states indicate improvements progressed independently from Medicaid expansion, rather than synergistically as expected. Accessibility increases appeared consistent with HRSA's goal to improve access for individuals experiencing economic barriers to health care but not for those experiencing cultural or language barriers to health care.

Challenging terrains: socio-spatial analysis of Primary Health Care Access Disparities in West Virginia

Existing measures of health care access were inadequate for guiding policy decisions in West Virginia, as they identified the entire state as having limited access. To address this, we compiled a comprehensive database of primary health care providers and facilities in the state, developed a modified E2SFCA tool to measure spatial access in the context of West Virginia's rural and mountainous nature, and integrated this with an index of socio-economic barriers to access. The integrated index revealed that the rural areas, especially in the southern part of the state, have especially limited access to primary health care. 1. Introduction. An emerging public health issue which has been exacerbated by the COVID-19 pandemic, is that of healthcare deserts, which are places where basic affordable health care is not accessible for residents. This problem has become worse in rural areas as rural hospitals close. In these areas, including West Virginia, scattered populations suffer from limited access to primary healthcare services. Uneven geographic and socio-economic barriers to accessing primary health care are major contributing factors to these health disparities. West Virginia's unique rural and mountainous settlement patterns, aging population, and economic crisis over the past two decades have resulted in unequal access to the primary healthcare services for its residents. The rural nature of the state makes it difficult to maintain medical facilities accessible to much of the population, especially as rural hospitals have been closing, such as the one in Williamson, WV (Jarvie, 2020). The mountainous terrain slows down travel across winding roads, lengthening travel times to the nearest hospital, while an aging population has increased health care needs. Lastly, an economic crisis and higher poverty rate makes West Virginians less able to pay for health care. As a result, West Virginians are confronting a health crisis. According to a recent report by the West Virginia Health Statistics Center (2019), West Virginians rank first in the country for heart attacks, have the second-highest obesity rate and prevalence of mental health problems in the country, along with the fourth-highest rate of diabetes and fifth-highest rate of cancer. An issue faced by West Virginia's policymakers is the limitations of tools for identifying and assessing healthcare deserts, as they are poorly suited for the unique challenges in West Virginia. Academic research has not analyzed comprehensive primary healthcare accessibility in WV, although previous studies have focused on Appalachia (e.g., Behringer & Friedell 2006; Smith & Holloman, 2011; Elnicki et al., 1995; Donohoe et al., 2015, 2016a, 2016b), and others focus on access to more specialized services (Valvi et al., 2019; Donohoe, 2016a). Existing approaches to identify the healthcare deprived areas, such as Health Professional Shortage Areas (HPSA), are not suitable for guiding West Virginia policies, because every one of the 55 counties within the state has several HPSAs, which makes prioritizing resources difficult. The lack of easily accessible, comprehensive, and up-to-date physician and healthcare facility database creates additional difficulties. Physician license datasets were found to often include inconsistent, misleading, and out-of-date information. The last limitation of the HPSA designation is that it is based on zip code areas and census tracts, which are not ideal as zip code areas lack spatial context and much covariate data, while rural census tracts are too large to capture spatial variation of access. In this context, the WV HealthLink project was begun with joint effort with WV Rural Health Initiative (RHI) to fill gaps in research and support decision making for primary healthcare access in West Virginia. The goals of the projects are: (1) to help West Virginia's three medical schools provide specialized professional training in rural healthcare; (2) to address health disparities by investing in clinical projects in underserved areas; and (3) to retain health professionals in WV. In 2018, to support these goals, HealthLink was invited by the RHI's leadership to analyze disparities in primary health care access in West Virginia and develop tools for rural healthcare decision-making. These goals also create a comprehensive and up-to-date physician and facility database, new analysis tools, and new visualization tools for decision support. The goals of this paper are to assess the spatial and social accessibility of primary health care in West Virginia, and to understand spatial and social determinants that shape this access. To achieve these goals, this paper completes the following objectives: (1) define primary healthcare and access; (2) build an extensive and up-to-date primary healthcare database; (3) develop an assessment framework for WV; and (4) visualize the results for policy makers and practitioners. The structure of this paper is as follows. First, we describe three methodological problems encountered as we define primary health care access. Second, we present the methods used to resolve these problems, and conclude by presenting our modified enhanced two-step floating catchment area (E2FCA hereafter) approach and its results for WV. Our foci in this modification were improving the accuracy of the analysis regarding measuring distance, considering distance decay effect, and more precisely representing the location of supply and demand.

Geographic inequalities in paediatric emergency department visits in Ontario and Alberta: a multilevel analysis of 2.5 million visits

Background

Research on intra- and inter-regional variations in emergency department (ED) visits among children can provide a better understanding of the patterns of ED utilization and further insight into how contextual features of the urban environment may be associated with these health events. Our objectives were to assess intra-urban and inter-urban variation in paediatric emergency department (PED) visits in census metropolitan areas (CMAs) in Ontario and Alberta, Canada and explore if contextual factors related to material and social deprivation, proximity to healthcare facilities, and supply of family physicians explain this variation.

Methods

A retrospective, population-based analysis of data on PED visits recorded between April 1, 2015 and March 31, 2017 was conducted. Random intercept multilevel regression models were constructed to quantify the intra- (between forward sortation areas [FSAs]) and inter- (between CMAs) variations in the rates of PED visits.

Results

In total, 2,537,442 PED visits were included in the study. The overall crude FSA-level rate of PED visits was 415.4 per 1,000 children population. Across CMAs, the crude rate of PED visits was highest in Thunder Bay, Ontario (771.6) and lowest in Windsor, Ontario (237.2). There was evidence of substantial intra- and inter-urban variation in the rates of PED visits. More socially deprived FSAs, FSAs with decreased proximity to healthcare facilities, and CMAs with a higher rate of family physicians per 1,000 children population had higher rates of PED visits.

Conclusions

The variation in rates of PED visits across CMAs and FSAs cannot be fully accounted for by age and sex distributions, material and social deprivation, proximity to healthcare facilities, or supply of family physicians. There is a need to explore additional contextual factors to better understand why some metropolitan areas have higher rates of PED visits.

Environmental barriers matter from the early stages of functional decline among older adults in France

Background

The adaptation of living environments can preserve functional independence among older people. A few studies have suggested that this would only benefit the most impaired. But conceptual models theorize that environmental pressure gradually increases with functional decline.

Objectives

We examined (1) how far different environmental barriers increased difficulties and favoured resort to assistance; (2) at what stage in functional decline environmental barriers begin to matter.

Methods

We used the French cross-sectional survey CARE (2015), including 7,451 participants (60+) with at least one severe functional limitation (FL). Multinomial logistic regressions models were used to compare predicted probabilities for outdoor activities of daily living (OADL) difficulties (no OADL difficulties; difficulties but without assistance; use of assistance) among individuals with and without environmental barriers (self-reported or objective), in relation to the number of FLs.

Results

Poor-quality pedestrian areas and lack of places to rest were associated with a higher probability of experiencing OADL difficulties, whatever the number of FLs; the association increased with the number of FLs. Up to 6 FLs, individuals with these barriers were more likely to report difficulties without resorting to assistance, with a decreasing association. Living in cities/towns with high diversity of food outlets was associated with a lower probability of reporting assistance, whatever the number of FLs, but with a decreasing association.

Discussion

Overall, the results suggest that environmental barriers increasingly contribute to OADL difficulties with the number of FLs. Conclusions differed as to whether they tended to favour resort to assistance, but there was a clear association with food outlets, which decreased with impairment severity. The adaptation of living environments could reduce difficulties in performing activities from the early stages of decline to the most severe impairment. However, the most deteriorated functional impairments seem to generate resort to assistance whatever the quality of the environment.

Evaluation of Park Accessibility Based on Improved Gaussian Two-Step Floating Catchment Area Method: A Case Study of Xi’an City

Park accessibility plays a critical role in evaluating the quality of park construction. However, the conventional accessibility model ignores non-spatial factors, so it is crucial to use more complex methods for evaluating park accessibility. This study aims to establish an improved Gaussian-based two-step floating catchment area method (iG2SFCA) based on Point of Interest (POI), population data and Baidu map, to measure the park accessibility of various travel modes (walking, riding and driving modes) in 5-min, 15-min and 30-min scenarios, and location quotient is used to assess spatial equity of parks. The results show that: (1) There are clear disparities between park supply and population demand at the street level. (2) iG2SFCA evaluates the level and attractiveness of the park comprehensively. It is more sensitive to identifying accessibility, which can lead to a more realistic assessment of Park accessibility. (3) Under the three modes of transportation, the accessible area of the park increases with time, and the accessibility difference between residential areas is the smallest under the 30-min scenario. Overall, accessibility of park is relatively high; however, there is an obvious tendency for the accessibility level to decrease from the park as the center. The areas with poor accessibility appear in the north and southeast of the research area. (4) There are regional variances in the spatial equity of parks within Xi’an 3 City, and the park configuration needs to be optimized. These findings can provide theoretical support for further optimizing the layout of park in Xi’an in order to improve the spatial equity of urban parks.

Perspectives of structurally marginalised patients attending contextually tailored and integrated care practices in Canada: a focused ethnography study

OBJECTIVES

To better understand the experience of patients attending community-based primary healthcare practices (CBPHCPs) aimed at improving equity and access to primary care for underserved patients, which have been implemented locally in several countries, including Canada. There are currently little data on how, or to what extent, they mitigate patients' experience of social inequalities in care and improve their access to health. This study explored the impacts of the sociospatial characteristics of these practices on patients' care experience.

DESIGN AND METHODS

Qualitative, multisite, focused ethnographic study based on in-situ observations and interviews, incorporating inductive and deductive analysis, and using the concept of sense of place.

SETTING

Three CBPHCPs located in deprived urban areas in two provinces of Canada.

PARTICIPANTS

28 structurally marginalised persons (17 women) attending the clinics, ranging in age from 18 to 79 years, and 16 managers, clinicians and practitioners working in these clinics.

RESULTS

Data underscored the importance of clinic proximity and accessibility in facilitating patients' navigation of the health system. Patients appreciated the clinics' positive sociospatial characteristics. Non-judgmental environments and informal spaces fostered patients' empowerment and social interaction among themselves and with peer navigators and healthcare professionals. The experience of supportive continuity of care had a positive impact on patients' sense of well-being and, for many, a positive ripple effect and long-term impact on their social integration.

CONCLUSION

These results have important implications for policy given the current context, in which governments are challenged to support primary healthcare that addresses the social determinants of health to achieve greater equity. We conclude that scaling up contextually tailored care and deploying humanistic innovative organisational practices into mainstream care will help narrow the equity gap and reduce current prevalent social inequalities in the health system.

A multicriteria decision analysis framework to measure equitable healthcare access during COVID-19

The ongoing novel coronavirus (COVID-19) pandemic has highlighted the need for individuals to have easy access to healthcare facilities for treatment as well as vaccinations. The surge in COVID-19 hospitalizations during 2020 also underscored the fact that accessibility to nearby hospitals for testing, treatment and vaccination sites is crucial for patients with fever or respiratory symptoms. Although necessary, quantifying healthcare access is challenging as it depends on a complex interaction between underlying socioeconomic and physical factors. In this case study, we deployed a Multi Criteria Decision Analysis (MCDA) approach to uncover the barriers and their effect on healthcare access. Using a least cost path (LCP) analysis we quantified the costs associated with healthcare access from each census block group in the Los Angeles metropolitan area (LA Metro) to the nearest hospital. Social vulnerability reported by the Centers for Disease Control and Prevention (CDC), the daily number of COVID-19 cases from the Los Angeles open data portal and built environment characteristics (slope of the street, car ownership, population density distribution, walkability, traffic collision density, and speed limit) were used to quantify overall accessibility index for the entire study area. Our results showed that the census block groups with a social vulnerability index above 0.75 (high vulnerability) had low accessibility owing to the higher cost of access to nearby hospitals. These areas were also coincident with the hotspots for COVID-19 cases and deaths which highlighted the inequitable exposure of socially disadvantaged populations to COVID-19 infections and how the pandemic impacts were exacerbated by the synergistic effect of socioeconomic status and built environment characteristics of the locations where the disadvantaged populations resided. The framework proposed herein could be adapted to geo-target testing/vaccination sites and improve accessibility to healthcare facilities in general and more specifically among the socially vulnerable populations residing in urban areas to reduce their overall health risks during future pandemic outbreaks.

Siting of Healthcare Care Facilities Based on the Purpose of Their Operation, Demographic Changes, Environmental Characteristics, and the Impact on Public Health

A contemporary approach to the spatial design of healthcare care facilities faces numerous challenges at the crossroads of multidisciplinary topics of architecture and urbanism, healthcare, security, and organisational sciences. Due to the unique combination of uses, users and architectural expression, they are defined as urban nodes. With their inclusion, architects facilitate a better placing of healthcare facilities, indirectly improving human health. The purpose of the article is to seek guidelines for the siting of healthcare facilities to provide suitable and equal healthcare to different social structures, and for the optimal and fair spatial distribution of healthcare services. The descriptive method was used to review literature on the siting of healthcare facilities based on the purpose of their operation, demographic changes, environmental characteristics, and the impact on public health. This method was selected as it facilitates data acquisition from various sources and a comprehensive understanding of the topic discussed. The results of the research show how important the impact of the healthcare care facilities siting on human health and the wider social significance of the topic discussed is. The findings may provide guidelines and proposals for future spatial decisions.

Socio-spatial disparities in access to emergency health care-A Scandinavian case study

Having timely access to emergency health care (EHC) depends largely on where you live. In this Scandinavian case study, we investigate how accessibility to EHC varies spatially in order to reveal potential socio-spatial disparities in access. Distinct measures of EHC accessibility were calculated for southern Sweden in a network analysis using a Geographical Information System (GIS) based on data from 2018. An ANOVA test was carried out to investigate how accessibility vary for different measures between urban and rural areas, and negative binominal regression modelling was then carried out to assess potential disparities in accessibility between socioeconomic and demographic groups. Areas with high shares of older adults show poor access to EHC, especially those in the most remote, rural areas. However, rurality alone does not preclude poor access to EHC. Education, income and proximity to ambulance stations were also associated with EHC accessibility, but not always in expected ways. Despite indications of a well-functioning EHC, with most areas served within one hour, socio-spatial disparities in access to EHC were detected both between places and population groups.

Investigating Health Context: Using Geospatial Big Data Ecosystem (Preprint)

Background

Objective

Methods

Results

Conclusions

Contextual factors underpinning geographical inequalities in disability-free life expectancy in 100 French départements

The objectives were to estimate disability-free life expectancy (DFLE) and life expectancy with disability (DLE) by gender for the 100 French départements (administrative geographical subdivisions) and to investigate associations with socioeconomic factors, supply of healthcare and services for older persons. DFLE and DLE at age 60 are estimated using the Sullivan method and based on the GALI indicator provided by the French cross-sectional survey Vie Quotidienne et Santé 2014. In 2014, DFLE for men and women aged 60 was 14.3 years and 15.6 years, respectively. Variations across départements were considerable (5.4 years for men, 6.7 years for women). Multivariate random effects meta-regression models indicated a negative association for men between DFLE and some of the socioeconomic contextual indicators (ratio of manual workers to higher-level occupations and unemployment rate); the level of in-home nursing services (HNS) was negatively associated with DFLE and density of nurses positively associated with DLE. Among women, ratio of manual workers to higher-level occupations, unemployment rate, proportion of the population living in large urban areas, density of nurses, and level of HNS were negatively associated with DFLE; density of physiotherapy supply was associated positively with DFLE and negatively with DLE. Our results suggest that geographical inequalities in health expectancies are significantly correlated with socioeconomic status and with healthcare supply, support for older persons, and urban environments, particularly among women. These results underline the importance of monitoring these indicators and disparities at infra-national-level, and of investigating their relations with local context, particularly the supply of healthcare and services.

A model for measuring healthcare accessibility using the behavior of demand: a conditional logit model-based floating catchment area method

BACKGROUND

Estimating realistic access to health services is essential for designing support policies for healthcare delivery systems. Many studies have proposed a metric to calculate accessibility. However, patients' realistic willingness to use a hospital was not explicitly considered. This study aims to derive a new type of potential accessibility that incorporates a patient's realistic preference in selecting a hospital.

METHODS

This study proposes a floating catchment area (FCA)-type metric combined with a discrete choice model. Specifically, a new FCA-type metric (clmFCA) was proposed using a conditional logit model. Such a model estimates patients' realistic willingness to use health services. The proposed metric was then applied to calculate the accessibility of obstetric care services in Korea.

RESULTS

The clmFCA takes advantage of patients' realistic preferences. Specifically, it can represent each patient's heterogeneous characteristics regarding hospital choice. Such characteristics include bypassing behavior, which could not be considered using prior FCA metrics. Empirical analysis reveals that the clmFCA avoids the misestimation of accessibility to health services to an extent.

CONCLUSIONS

The clmFCA offers a new framework that more realistically estimates patients' accessibility to health services. This is achieved by accurately estimating the potential demand for a service. The proposed method's effectiveness was verified through a case study using nationwide data.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Neighborhood Environment and Child Health in Immigrant Families: Using Nationally Representative Individual, Family, and Community Datasets

PURPOSE

This study aimed to examine neighborhood effects on the physical and socioemotional health of children from immigrant families, after controlling for parents' demographic characteristics, socioeconomic status, acculturation, and health care issues.

DESIGN

Pooled cross-sectional data were merged with community profiles.

SETTING

The United States in 2013, 2014, and 2015.

PARTICIPANTS

10,399 children from immigrant families in the 2013-2015 National Health Interview Surveys and the U.S. Census Data.

MEASURES

Both objective and subjective measures of neighborhood environments were assessed, including neighborhood physical disorder, socioeconomic status, demographic composition, community resources, and social trust.

ANALYSIS

Descriptive statistics, logistic regression models.

RESULTS

About half of the sampled children were male (51%); 68% were white; 56% were of Hispanic; and 34% were school-aged. Three neighborhood factors-neighborhood trust, area-level poverty rate, and the presence of primary care physician-were identified as significant predictors for child health outcomes. Foreign-born population, green space, and food desert were not significant. At the individual level, parents' racial and ethnic minority status, non-marital status, and healthcare issues were found to be risk factors. Families' financial resources and parental education were identified as protective factors of socioemotional health.

CONCLUSION

Intervention approaches to build on neighborhood trust may have broad potential to improve child outcomes. Programs focusing on immigrant families with children in high poverty neighborhoods should be a high priority.

Boundary organising in healthcare: theoretical perspectives, empirical insights and future prospects

Purpose

The purpose of this paper is to introduce a special issue on boundary organising in healthcare bringing together a selection of six leading papers accepted for presentation at the 12th Organisational Behaviour in Health Care (OBHC 2020) Conference.

Design/methodology/approach

In this introductory paper, the guest editors position the special issue papers in relation to the theoretical literature on boundaries and boundary organising and highlight how these contributions advance our understanding of boundary phenomena in healthcare.

Findings

Three strands of thinking – practice-based, systems theory and place-based approaches – are briefly described, followed by an analytical summary of the six papers included in the special issue. The papers illustrate how the dynamic processes of boundary organising, stemming from the dual nature of boundaries and boundary objects, can be constrained and enabled by the complexity of broader multi-layered boundary landscapes, in which local clinical and managerial practices are embedded.

Originality/value

The authors set the scene for the papers included in the special issue, summarise their contributions and implications, and suggest directions for future research.

Research implications/limitations

The authors call for interdisciplinary and multi-theoretical investigations of boundary phenomena in health organisation and management, with a particular attention to (1) the interplay between multiple types of boundaries, actors and objects operating in complex multi-layered boundary systems; (2) diversity of the backgrounds, experiences and preferences of patients and services users and (3) the role of artificial intelligence and other non-human actors in boundary organising.

Practical implications

Developing strategies of reflection, mitigation, justification and relational work is crucial for the success of boundary organising initiatives.

Beyond the map: evidencing the spatial dimension of health inequalities

Background

Spatial inequalities in health result from different exposures to health risk factors according to the features of geographical contexts, in terms of physical environment, social deprivation, and health care accessibility. Using a common geographical referential, which combines indices measuring these contextual features, could improve the comparability of studies and the understanding of the spatial dimension of health inequalities.

Methods

We developed the Geographical Classification for Health studies (GeoClasH) to distinguish French municipalities according to their ability to influence health outcomes. Ten contextual scores measuring physical and social environment as well as spatial accessibility of health care have been computed and combined to classify French municipalities through a K-means clustering. Age-standardized mortality rates according to the clusters of this classification have been calculated to assess its effectiveness.

Results

Significant lower mortality rates compared to the mainland France population were found in the Wealthy Metropolitan Areas (SMR = 0.868, 95% CI 0.863–0.873) and in the Residential Outskirts (SMR = 0.971, 95% CI 0.964–0.978), while significant excess mortality were found for Precarious Population Districts (SMR = 1.037, 95% CI 1.035–1.039), Agricultural and Industrial Plains (SMR = 1.066, 95% CI 1.063–1.070) and Rural Margins (SMR = 1.042, 95% CI 1.037–1.047).

Conclusions

Our results evidence the comprehensive contribution of the geographical context in the constitution of health inequalities. To our knowledge, GeoClasH is the first nationwide classification that combines social, environmental and health care access scores at the municipality scale. It can therefore be used as a proxy to assess the geographical context of the individuals in public health studies.

Home-Based Locational Accessibility to Essential Urban Services: The Case of Wake County, North Carolina, USA

Accessibility is an important concept in urban studies and planning, especially on issues related to sustainable transportation planning and urban spatial structure. This paper develops an optimization model to examine the accessibility from single family homes to major urban facilities for services or amenities using geographical information systems. The home-based accessibility to facilities is based upon the point to point direct distance from sampled homes to sampled facilities. Descriptive statistics about the accessibility, such as min/max, mean/median, and standard deviation/variance were computed. Variations of accessibility for a range of categories by home price and year built were also examined. Multivariate linear regression models examining the housing value with respect to home-facility accessibility by facility types were implemented. The results show that desirable urban facilities, which are also more frequently used for livability, enjoy better accessibility than undesirable urban facilities. The home-based accessibility’s positive or negative associations with home price along with year built and/or residential lot size exist for most facilities in general, and by confirming to the literature, the home-facility accessibility in particular does strongly impact home values as evidenced by fair to excellent R2 values. Accordingly, this research provides evidence-based recommendations for sustainable urban mobility and urban planning.

Disparities in Geographical Access to Hospitals in Portugal

Geographical accessibility to health care services is widely accepted as relevant to improve population health. However, measuring it is very complex, mainly when applied at administrative levels that go beyond the small-area level. This is the case in Portugal, where the municipality is the administrative level that is most appropriate for implementing policies to improve the access to those services. The aim of this paper is to assess whether inequalities in terms of access to a hospital in Portugal have improved over the last 20 years. A population-weighted driving time was applied using the census tract population, the roads network, the reference hospitals’ catchment area and the municipality boundaries. The results show that municipalities are 25 min away from the hospital—3 min less than in 1991—and that there is an association with premature mortality, elderly population and population density. However, disparities between municipalities are still huge. Municipalities with higher rates of older populations, isolated communities or those located closer to the border with Spain face harder challenges and require greater attention from local administration. Since municipalities now have responsibilities for health, it is important they implement interventions at the local level to tackle disparities impacting access to healthcare.

Geographic availability to optometry services across Canada: mapping distribution, need and self-reported use

BACKGROUND

This research investigates the distribution of optometrists in Canada relative to population health needs and self-reported use of vision services.

METHODS

Optometrist locations were gathered from provincial regulatory bodies. Optometrist-to-population ratios (i.e. the number of providers per 10,000 people at the health region level) were then calculated. Utilization of vision care services was extracted from the Canadian Community Health Survey (CCHS) 2013-2014 question regarding self-reported contacts with optometrists or ophthalmologists. Data from the 2016 Statistics Canada census were used to create three population 'need' subgroups (65 years and over; low-income; and people aged 15 and over with less than a high school diploma). Cross-classification mapping compared optometrist distribution to self-reported use of vision care services in relation to need. Each variable was converted into three classes (i.e., low, moderate, and high) using a standard deviation (SD) classification scheme where ±0.5SD from the mean was considered as a cut-off. Three classes: low (< - 0.5SD), moderate (- 0.5 to 0.5SD), and high (> 0.5SD) were used for demonstrating distribution of each variable across health regions.

RESULTS

A total of 5959 optometrists across ten Canadian provinces were included in this analysis. The nationwide distribution of optometrists is variable across Canada; they are predominantly concentrated in urban areas. The national mean ratio of optometrists was 1.70 optometrists per 10,000 people (range = 0.13 to 2.92). Out of 109 health regions (HRs), 26 were classified as low ratios, 51 HRs were classified as moderate ratios, and 32 HRs were high ratios. Thirty-five HRs were classified as low utilization, 39 HRs were classified as moderate, and 32 HRs as high utilization. HRs with a low optometrist ratio relative to eye care utilization and a high proportion of key sociodemographic characteristics (e.g. older age, low income) are located throughout Canada and identified with maps indicating areas of likely greater need for optometry services.

CONCLUSION

This research provides a nationwide overview of vision care provided by optometrists identifying gaps in geographic availability relative to "supply" and "need" factors. This examination of variation in accessibility to optometric services will be useful to inform workforce planning and policies.

Role of Area-Level Access to Primary Care on the Geographic Variation of Cardiometabolic Risk Factor Distribution: A Multilevel Analysis of the Adult Residents in the Illawarra-Shoalhaven Region of NSW, Australia

BACKGROUND

Access to primary care is important for the identification, control and management of cardiometabolic risk factors (CMRFs). This study investigated whether differences in geographic access to primary care explained area-level variation in CMRFs.

METHODS

Multilevel logistic regression models were used to derive the association between area-level access to primary care and seven discrete CMRFs after adjusting for individual and area-level co-variates. Two-step floating catchment area method was used to calculate the geographic access to primary care for the small areas within the study region.

RESULTS

Geographic access to primary care was inversely associated with low high density lipoprotein (OR 0.94, CI 0.91-0.96) and obesity (OR 0.91, CI 0.88-0.93), after adjusting for age, sex and area-level disadvantage. The intra-cluster correlation coefficient (ICCs) of all the fully adjusted models ranged between 0.4-1.8%, indicating low general contextual effects of the areas on CMRF distribution. The area-level variation in CMRFs explained by primary care access was ≤10.5%.

CONCLUSION

The findings of the study support proportionate universal interventions for the prevention and control of CMRFs, rather than any area specific interventions based on their primary care access, as the contextual influence of areas on all the analysed CMRFs were found to be minimal. The findings also call for future research that includes other aspects of primary care access, such as road-network access, financial affordability and individual-level acceptance of the services in order to gain an overall picture of the area-level contributing role of primary care on CMRFs in the study region.

Association between the regional variation in premature mortality and immigration in Ontario, Canada

Objectives

Health region differences in immigration patterns and premature mortality rates exist in Ontario, Canada. This study used linked population-based databases to describe the regional proportion of immigrants in the context of provincial health region variation in premature mortality.

Methods

We analyzed all adult premature deaths in Ontario from 1992 to 2012 using linked population files, Canadian census, and death registry databases. Geographic boundaries were analyzed according to 14 health service regions, known as Local Health Integration Networks (LHINs). We assessed the role of immigrant status and regional proportion of immigrants in the context of these health region variations and assessed the contribution using sex-specific multilevel negative binomial models, accounting for age, individual- and area-level immigration, and area-level material deprivation.

Results

We observed significant premature mortality variation among health service regions in Ontario between 1992 and 2012. Average annual rates ranged across LHINs from 3.03 to 6.40 per 1000 among males and 2.04 to 3.98 per 1000 among females. The median rate ratio (RR) decreased for men from 1.14 (95% CI 1.06, 1.19) to 1.07 (95% CI 1.00, 1.11) after adjusting for year, age, area-based material deprivation, and individual- and area-level immigration, and among females reduced from 1.13 (95% CI 1.05, 1.18) to 1.04 (95% CI 1.00, 1.05). These adjustments explained 84.1% and 94.4% of the LHIN-level variation in males and females respectively. Reduced premature mortality rates were associated with immigrants compared with those for long-term residents in the fully adjusted models for both males 0.43 (95% CI 0.42, 0.44) and females 0.45 (0.44, 0.46).

Conclusion

The findings demonstrate that health region differences in premature mortality in Ontario are in part explained by individual-level effects associated with the health advantage of immigrants, as well as contextual area-level effects that are associated with regional differences in the immigrant population. These factors should be considered in addition to health system factors when looking at health region variation in premature deaths.

Electronic supplementary material

The online version of this article (10.17269/s41997-020-00330-5) contains supplementary material, which is available to authorized users.

A systematic review of the geospatial barriers to antiretroviral initiation, adherence and viral suppression among people living with HIV

Background With the emergence of antiretroviral therapy (ART), Treatment as Prevention (TasP) has become the cornerstone of both HIV clinical care and HIV prevention. However, despite the efficacy of treatment-based programs and policies, structural barriers to ART initiation, adherence and viral suppression have the potential to reduce TasP effectiveness. These barriers have been studied using Geographic Information Systems (GIS). While previous reviews have examined the use of GIS for HIV testing - an essential antecedent to clinical care - to date, no reviews have summarised the research with respect to other ART-related outcomes.

METHODS

Therefore, the present review leveraged the PubMed database to identify studies that leveraged GIS to examine the barriers to ART initiation, adherence and viral suppression, with the overall goal of understanding how GIS has been used (and might continue to be used) to better study TasP outcomes. Joanna Briggs Institute criteria were used for the critical appraisal of included studies.

RESULTS

In total, 33 relevant studies were identified, excluding those not utilising explicit GIS methodology or not examining TasP-related outcomes.

CONCLUSIONS

Findings highlight geospatial variation in ART success and inequitable distribution of HIV care in racially segregated, economically disadvantaged, and, by some accounts, increasingly rural areas - particularly in the United States. Furthermore, this review highlights the utility and current limitations of using GIS to monitor health outcomes related to ART and the need for careful planning of resources with respect to the geospatial movement and location of people living with HIV (PLWH).

Geodemographic Disparities in Availability of Comprehensive Intimate Partner Violence Screening Services in Miami-Dade County, Florida

This study examined geodemographic factors associated with availability of comprehensive intimate partner violence (IPV) screening services in Miami-Dade County, Florida. We geocoded 2014 survey data from 278 health facilities and created a population-normalized density surface of IPV screening comprehensiveness. We used correlation analysis and spatial regression techniques to evaluate census tract-level predictors of the mean normalized comprehensiveness score (NCS) for 505 census tracts in Miami-Dade. The population-adjusted density surface of IPV screening comprehensiveness revealed geographic disparities in the availability of screening services. Using a spatial lag regression model, we observed that race and ethnicity are associated with mean NCS by census tract after controlling for age, median gross rent, and receipt of Social Security benefits. The percentage of White non-Hispanic residents was positively associated with NCS, Black non-Hispanic was negatively associated with NCS, while Hispanic-the majority ethnicity in Miami-Dade-was not associated with NCS. This exploratory study may be the first to put IPV screening comprehensiveness on the map, and provides a starting point for addressing urban disparities in the availability of IPV screening services that are shaped by race, ethnicity, zoning, and socioeconomic status.

Spatial Accessibility and Social Inclusion: The Impact of Portugal's Last Health Reform

Health policies seek to promote access to health care and should provide appropriate geographical accessibility to each demographical functional group. The dispersal demand of health-care services and the provision for such services at fixed locations contribute to the growth of inequality in their access. Therefore, the optimal distribution of health facilities over the space/area can lead to accessibility improvements and to the mitigation of the social exclusion of the groups considered most vulnerable. Requiring for such, the use of planning practices joined with accessibility measures. However, the capacities of Geographic Information Systems in determining and evaluating spatial accessibility in health system planning have not yet been fully exploited. This paper focuses on health-care services planning based on accessibility measures grounded on the network analysis. The case study hinges on mainland Portugal. Different scenarios were developed to measure and compare impact on the population's accessibility. It distinguishes itself from other studies of accessibility measures by integrating network data in a spatial accessibility measure: the enhanced two-step floating catchment area. The convenient location for health-care facilities can increase the accessibility standards of the population and consequently reduce the economic and social costs incurred. Recently, the Portuguese government implemented a reform that aimed to improve, namely, the access and equity in meeting with the most urgent patients. It envisaged, in terms of equity, the allocation of 89 emergency network points that ensured more than 90% of the population be within 30 min from any one point in the network. Consequently, several emergency services were closed, namely, in rural areas. This reform highlighted the need to improve the quality of the emergency care, accessibility to each care facility, and equity in their access. Hence, accessibility measures become an efficient decision-making tool, despite its absence in effective practice planning. According to an application of this type of measure, it was possible to verify which levels of accessibility were decreased, including the most disadvantaged people, with a larger time of dislocation of 12 min between 2001 and 2011.

Generating statistics from health facility data: the state of routine health information systems in Eastern and Southern Africa

Health facility data are a critical source of local and continuous health statistics. Countries have introduced web-based information systems that facilitate data management, analysis, use and visualisation of health facility data. Working with teams of Ministry of Health and country public health institutions analysts from 14 countries in Eastern and Southern Africa, we explored data quality using national-level and subnational-level (mostly district) data for the period 2013-2017. The focus was on endline analysis where reported health facility and other data are compiled, assessed and adjusted for data quality, primarily to inform planning and assessments of progress and performance. The analyses showed that although completeness of reporting was generally high, there were persistent data quality issues that were common across the 14 countries, especially at the subnational level. These included the presence of extreme outliers, lack of consistency of the reported data over time and between indicators (such as vaccination and antenatal care), and challenges related to projected target populations, which are used as denominators in the computation of coverage statistics. Continuous efforts to improve recording and reporting of events by health facilities, systematic examination and reporting of data quality issues, feedback and communication mechanisms between programme managers, care providers and data officers, and transparent corrections and adjustments will be critical to improve the quality of health statistics generated from health facility data.

Change in geographic access to community health centers after Health Center Program expansion

OBJECTIVE

To examine geographic access to community health centers (CHC accessibility) before and after Health Center Program expansion in three Southern states.

DATA SOURCES

Community health center data were from the Health Resources and Services Administration (1967-2016). Population estimates and sociodemographic characteristics were from the American Community Survey (2006-2015).

STUDY DESIGN

We used the two-step floating catchment area method to calculate CHC accessibility for census tracts in 2008 and 2016. We mapped census tract-level variation and used spatial regression to assess to what extent indicators of potential CHC need were associated with change in accessibility from 2008 to 2016.

PRINCIPAL FINDINGS

Community health center accessibility increased by 192 percent overall, and the proportion of tracts with no accessibility decreased by 65 percent. Indicators of potential need were not associated with greater gains in CHC accessibility from 2008 to 2016, but census tracts with less accessibility at baseline saw larger accessibility increases.

CONCLUSIONS

Community health center accessibility substantially increased from 2008 to 2016, but increases did not differentially impact groups with greater potential need. This approach for measuring CHC accessibility offers significant improvement in granularity over traditional CHC accessibility measures.

Socio-spatial heterogeneity in participation in mass dog rabies vaccination campaigns, Arequipa, Peru

To control and prevent rabies in Latin America, mass dog vaccination campaigns (MDVC) are implemented mainly through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination free of charge. Dog rabies is still endemic in some Latin-American countries and high overall dog vaccination coverage and even distribution of vaccinated dogs are desired attributes of MDVC to halt rabies virus transmission. In Arequipa, Peru, we conducted a door-to-door post-campaign survey on >6,000 houses to assess the placement of vaccination points on these two attributes. We found that the odds of participating in the campaign decreased by 16% for every 100 m from the owner’s house to the nearest vaccination point (p = 0.041) after controlling for potential covariates. We found social determinants associated with participating in the MDVC: for each child under 5 in the household, the odds of participating in the MDVC decreased by 13% (p = 0.032), and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8% (p<0.001), after controlling for distance and other covariates. We also found significant spatial clustering of unvaccinated dogs over 500 m from the vaccination points, which created pockets of unvaccinated dogs that may sustain rabies virus transmission. Understanding the barriers to dog owners’ participation in community-based dog-vaccination programs will be crucial to implementing effective zoonotic disease preventive activities. Spatial and social elements of urbanization play an important role in coverage of MDVC and should be considered during their planning and evaluation.

In Peru and other dog rabies-affected countries, mass dog vaccination campaigns (MDVC) are implemented primarily through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination. To stop rabies virus transmission, a high and even dog vaccination coverage is desired. In Arequipa, Peru, following a MDVC, we conducted a door-to-door survey of >6,000 houses to assess how the placement of vaccination points affected coverage of the campaign. When comparing dog owners with similar characteristics, we found that the odds of participating in the MDVC was reduced by 16% for every 100 m distance from the nearest vaccination point. Some social conditions were also associated with participating in the MDVC: for each child under 5 in the household, odds of participating in the MDVC decreased by 13%, and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8%. Distance to the vaccination point and variation in social conditions across the city play important roles in achieving coverage of MDVC and should be considered during campaign planning and evaluation.

Advancing health equity and access using telemedicine: a geospatial assessment

INTRODUCTION

Health disparity affects both urban and rural residents, with evidence showing that rural residents have significantly lower health status than urban residents. Health equity is the commitment to reducing disparities in health and in its determinants, including social determinants.

OBJECTIVE

This article evaluates the reach and context of a virtual urgent care (VUC) program on health equity and accessibility with a focus on the rural underserved population.

MATERIALS AND METHODS

We studied a total of 5343 patient activation records and 2195 unique encounters collected from a VUC during the first 4 quarters of operation. Zip codes served as the analysis unit and geospatial analysis and informatics quantified the results.

RESULTS

The reach and context were assessed using a mean accumulated score based on 11 health equity and accessibility determinants calculated for each zip code. Results were compared among VUC users, North Carolina (NC), rural NC, and urban NC averages.

CONCLUSIONS

The study concluded that patients facing inequities from rural areas were enabled better healthcare access by utilizing the VUC. Through geospatial analysis, recommendations are outlined to help improve healthcare access to rural underserved populations.

Using Geographic Information Systems to investigate variations in accessibility to 'extended hours' primary healthcare provision

There are ongoing policy concerns surrounding the difficulty in obtaining timely appointments to primary healthcare services and the potential impact on, for example, attendance at accident and emergency services and potential health outcomes. Using the case study of potential access to primary healthcare services in Wales, Geographic Information System (GIS)-based tools that permit a consideration of population-to-provider ratios over space are used to examine variations in geographical accessibility to general practitioner (GP) surgeries offering appointment times outside of 'core' operating hours. Correlation analysis is used to explore the association of accessibility scores with potential demand for such services using UK Population Census data. Unlike the situation in England, there is a tendency for accessibility to those surgeries offering 'extended' hours of appointment times to be better for more deprived census areas in Wales. However, accessibility to surgeries offering appointments in the evening was associated with lower levels of working age population classed as 'economically active'; that is, those who could be targeted beneficiaries of policies geared towards 'extended' appointment hours provision. Such models have the potential to identify spatial mismatches of different facets of primary healthcare, such as 'extended' hours provision available at GP surgeries, and are worthy of further investigation, especially in relation to policies targeted at particular demographic groups.

Fear, Boldness, and Familiarity: The Therapeutic Landscapes of Undocumented Latina Immigrants in Atlanta, Georgia

Drawing from 56 semi-structured interviews, this article details how undocumented Latina immigrants living in Atlanta, Georgia, in 2013 cultivated health and well-being in an insecure environment. In addition to the myriad challenges that immigrants face in accessing health care in their new communities, undocumented immigrants living in Atlanta at that time faced the legal barrier presented by Georgia’s new “show me your papers” law, which imbued public space with the risk of deportation for those who are undocumented. This law complicated health care access by making the trip to the doctor’s office risky. Immigrants’ health care decisions were thus shaped by the “geography of fear” that permeated their new communities. This fear presented itself not only in public space but also in clinics and hospitals, where many immigrants feared – and sometimes received – bad treatment. Despite the obstacles fear and immigrant policing presented, many of the women I interviewed showed boldness in their health care decisions, staking their claim to medical attention where they saw fit. Additionally, many maintained transnational networks and continued with familiar health practices from home. Combined, these strategies worked to create complex and shifting “therapeutic landscapes” in an environment permeated by insecurity and fear.

The Spatial Equity of Nursing Homes in Changchun: A Multi-Trip Modes Analysis

Based on network analysis, different trip modes were integrated into an improved potential model, and the geography of the spatial equity of nursing homes in Changchun is explored in 5-min, 10-min and 15-min scenarios, respectively. Results show that: (1) trip modes have significant influence on spatial equity and that the geography of spatial equity varied with trip modes; (2) the spatial equity value in Changchun is overall kept to a very low level. Most areas in urban fringes and urban core areas belong to underserved areas, and the capacity of nursing home, travel cost and the number of seniors, are the main influencing factors; (3) the geography of spatial equity in different scenarios show a very similar ring structure; namely, the spatial equity value within the urban core and at the most urban periphery is lower than that in intermediate areas. The hot spot analysis showed that the southwest urban fringes and east of the urban core are hot spot areas, while the urban core itself has cold spot areas.

Insights from Self-Organizing Maps for Predicting Accessibility Demand for Healthcare Infrastructure

As urban populations grow worldwide, it becomes increasingly important to critically analyse accessibility—the ease with which residents can reach key places or opportunities. The combination of ‘big data’ and advances in computational techniques such as machine learning (ML) could be a boon for urban accessibility studies, yet their application in this field remains limited. In this study, we provided detailed predictions of healthcare accessibility across a rapidly growing city and related them to socio-economic factors using a combination of classical and modern data analysis methods. Using the City of Surrey (Canada) as a case study, we clustered high-resolution income data for 2016 and 2022 using principal component analysis (PCA) and a powerful ML clustering tool, the self-organising map (SOM). We then combined this with door-to-door travel times to hospitals and clinics, calculated using a simple open-source tool. Focusing our analysis on senior populations (65+ years), we found that higher income clusters are projected to become more prevalent across Surrey over our study period. Low income clusters have on average better accessibility to healthcare facilities than high income clusters in both 2016 and 2022. Population growth will be the biggest accessibility challenge in neighbourhoods with good existing access to healthcare, whereas income change (both positive and negative) will be most challenging in poorly connected neighbourhoods. A dual accessibility problem may arise in Surrey: first, large senior populations will reside in areas with access to numerous and close-by, clinics, putting pressure on existing facilities for specialised services. Second, lower-income seniors will increasingly reside in areas poorly connected to healthcare services, which may impact accessibility equity. We demonstrate that combining PCA and SOM clustering techniques results in novel insights for predicting accessibility at the neighbourhood level. This allows for robust planning policy recommendations to be drawn from large multivariate datasets.

Older Immigrants’ Access to Primary Health Care in Canada: A Scoping Review

Le vieillissement et l’immigration ont significativement transformé la composition démographique au Canada, et les immigrants y représentent une proportion croissante de la population adulte plus âgée. L’accès adéquat aux services de santé est essentiel au bien-être et à l’inclusion sociale de cette population. Cet examen de la portée porte sur les connaissances actuelles concernant l’accès des immigrants d’âge avancé aux médecins omnipraticiens et à leur consultation, considérant que ces médecins jouent un rôle central dans la prestation de soins de première ligne, dans les soins préventifs et les soins de santé mentale. Le modèle en 5 étapes d’Arksey et O’Malley a été utilisé pour effectuer des recherches dans une grande variété de bases de données pour des articles publiés en anglais dans des revues avec comité de pairs concernant ce sujet dans le contexte canadien. Un total de 31 articles répondant aux critères d’inclusion ont été examinés en détail. Ces articles ont été classés en fonction de l’information disponible sur leurs auteurs, la population à l’étude, la méthodologie, le domaine de la santé et les obstacles mentionnés. Trois thèmes principaux ont émergé de cet examen de portée : l’accès et l’utilisation des soins de première ligne, la promotion de la santé et le dépistage du cancer, ainsi que l’utilisation des services de santé mentale. Les immigrants d’âge avancé font face à des obstacles en termes d’accès aux soins et ceux-ci seraient liés à la littératie en santé, à la langue, à la culture, aux croyances en matière de santé, aux inégalités spatiales et à des circonstances structurelles. L’examen de la portée présente de manière détaillée l’accès aux soins des personnes âgées immigrantes au Canada, et permet de dériver des implications sur les politiques qui permettraient de répondre à leurs besoins qui sont non comblés dans le domaine de la santé.