Accuracy of city postal code coordinates as a proxy for location of residence

Proximity to Legal Cannabis Stores in Canada and Use of Cannabis Sources in the First Three Years of Legalization, 2019-2021

OBJECTIVE

The accessibility of legal cannabis in Canada may influence how consumers source their cannabis. The aims of this study were to examine (a) the distance between respondents' homes and legal retail stores, (b) the cannabis sources used in the past 12 months, and (c) the association between cannabis sources used and distance to legal retail stores.

METHOD

Data were analyzed from Canadian respondents participating in the International Cannabis Policy Study from 2019 to 2021. Respondents were 15,311 past-12-month cannabis consumers of legal age to purchase cannabis. Weighted logistic regression models examined cannabis sources used and their association with the Euclidean distance to the nearest legal store, province of residence, and year (n = 12,928).

RESULTS

Respondents lived closer to a legal retail store in 2021 (1.5 km) versus 2019 (6.8 km) as the number of retail stores increased. Respondents in 2020 and 2021 had higher odds of obtaining cannabis from legal sources (e.g., legal stores: 47.9% and 60.0% vs. 38.6%, respectively, adjusted odds ratio [AOR] range: 1.41-2.42) and lower odds of obtaining cannabis from illegal sources versus 2019 (e.g., dealers: 22.6% and 19.9% vs. 29.1%, respectively, AOR range: 0.65-0.54). Respondents who lived closest to legal stores had higher odds of sourcing from legal stores and lower odds of sourcing from legal websites or growing their own cannabis.

CONCLUSIONS

Legal cannabis stores are increasingly accessible to people living in Canada 3 years after legalization. Household proximity to a legal cannabis store was associated with sourcing cannabis from legal retail stores, but only among those who live very close (<3 km). Findings suggest that proximity to legal cannabis stores may aid uptake of the legal market, yet there may be diminishing returns after a certain point.

Urban Form Metrics for Promoting Walking: Street Layouts and Destinations

There is evidence that higher street connectivity and availability of destinations can support walking behavior. However, the availability of data and comparability between previous studies remain a challenge. Based on a large Canadian adult sample, this study examined the associations between street layout and walking behaviors and explored whether objectively measured destinations may mediate these relationships. This study used data from 12,378 adults from Alberta's Tomorrow Project (ATP), a prospective cohort study conducted in Alberta, Canada. Walking behaviors were obtained by questionnaires. Street layout and destination measures were calculated objectively. Covariate-adjusted multivariate linear models estimated the associations between the space syntax street integration and duration of transport and leisure walking. The mediation effects of the availability of destinations in these associations were tested by the structural equation modelling. Street integration was significantly positively associated with transportation walking (b=0.01, 95% CI 0.00, 0.01, p = 0.01) (indirect effect). The availability of destinations partially mediated this association. Using the natural movement theory in space syntax, our study provides insights into using street layouts as a primary measure to (re)design the built environment to support walking.

Urban design and cardio-metabolic risk factors

Accumulating evidence suggests that the built environment may be associated with cardiovascular disease via its influence on health behaviours. The aim of this study was to estimate the associations between traditional and novel neighbourhood built environment metrics and clinically assessed cardio-metabolic risk factors among a sample of adults in Canada. A total of 7171 participants from Albertas Tomorrow Project living in Alberta, Canada, were included. Cardio-metabolic risk factors were clinically measured. Two composite built environment metrics of traditional walkability and space syntax walkability were calculated. Among men, space syntax walkability was negatively associated with systolic and diastolic blood pressure (b = -0.87, 95% CI -1.43, -0.31 and b = -0.45, 95% CI -0.86, -0.04, respectively). Space syntax walkability was also associated with lower odds of overweight/obese among women and men (OR = 0.93, 95% CI 0.87, 0.99 and OR = 0.88, 95% CI 0.79, 0.97, respectively). No significant associations were observed between traditional walkability and cardio-metabolic outcomes. This study showed that the novel built environment metric based on the space syntax theory was associated with some cardio-metabolic risk factors.

Health promotion networks in two districts in Bavaria, Germany: an exploratory case study mapping networks with respect to thematic agenda and location

Introduction

Building networks is an essential part of health promotion. However, network analysis remains relatively unexplored in this field. This study introduces a new technique that maps thematic agendas and geographical locations of health promotion actors.

Methods

This case study used elements of quantitative and qualitative methods to analyse network data. We used empirical data from two networks in Bavaria, a federal state of Germany.

Results

We identified a total of 55 actors in the first network and 64 actors in the second. We categorized the thematic agenda of actors according to their main field of work: "healthy childhood development," "healthy middle age phase," "healthy ageing," "health equity in all phases of life." One network showed a significant surplus of actors that focus on "healthy ageing." We combined and analysed data from both networks collectively. Two districts with no health promotion actors within their geographical borders were identified. To put geographical gaps into context, data about deprivation and age was included.

Discussion

Results identified geographical areas with high need for support from health promotion actors. Through comparison of our results with existing literature, we derived potential network strategies for further successful networking. This study adds a new perspective to characterize health promotion networks by mapping them thematically and geographically. The concept can be used to give health promotion organisations relevant insight into network structures. This can improve decision-making processes concerning partnership strategy and finally lead to a positive health impact. Hence, our findings encourage further development of this technique and other networking methods in the field of health equity and health promotion.

Impact of Geographical Distance from Quaternary Treatment Center on Clinical Trial Participation, Intensive Induction Chemotherapy, and Outcomes in Patients with Newly Diagnosed Acute Myeloid Leukemia

INTRODUCTION

Care for patients with acute myeloid leukemia (AML) is centralized in the Ontario single-payer public healthcare system, with intensive induction chemotherapy and clinical trials only offered at specialized cancer centers with large catchment areas.

METHODS

We therefore conducted a retrospective single-center review of all AML patients assessed at a large specialized cancer center in Ontario, Canada.

RESULTS

Between 2012 and 2017, 1,310 patients were assessed by our center for upfront AML therapy. The median distance was 33.1 km, with 29% of patients living more than 50 km away from the center. There was no significant difference in probability of intensive induction chemotherapy or clinical trial by distance from center, both in univariate and multivariable analysis adjusting for age, sex, cytogenetics and molecular testing, and performance status. There was no significant difference in overall survival by distance from center on univariate and multivariable analysis.

CONCLUSION

In conclusion, geographic distance from treatment center does not appear to impact choice of upfront therapy, participation in clinical trials, or clinical outcomes in this study of newly diagnosed patients with AML treated in a single-payer environment.

Associations between neighborhood walkability and walking following residential relocation: Findings from Alberta's Tomorrow Project

Introduction

Cross-sectional studies consistently find that the neighborhood built environment (e.g., walkability) is associated with walking. However, findings from the few existing longitudinal residential relocation studies that have estimated associations between changes in neighborhood built characteristics and walking are equivocal. The study objective was to estimate whether changes in neighborhood walkability resulting from residential relocation were associated with leisure, transportation, and total walking levels among adults.

Methods

This study included longitudinal data from the "Alberta's Tomorrow Project"-a province-wide cohort study (Alberta, Canada). The analysis included data collected at two time points (i.e., baseline and follow-up) from 5,977 urban adults. The International Physical Activity Questionnaire (IPAQ) captured self-reported walking. We estimated neighborhood walkability, an index capturing intersection, destination, and population counts for the 400 m Euclidean buffer around participants' homes. Using household postal codes reported at baseline and follow-up, we categorized participants into three groups reflecting residential relocation ("non-movers:" n = 5,679; "movers to less walkability:" n = 164, and; "movers to more walkability:" n = 134). We used Inverse-Probability-Weighted Regression Adjustment to estimate differences [i.e., average treatment effects in the treated (ATET)] in weekly minutes of leisure, transportation, and total walking at follow-up between residential relocation groups, adjusting for baseline walking, sociodemographic characteristics, and walkability. The median time between baseline and follow-up was 2-years.

Results

The three residential relocation groups mainly included women (61.6-67.2%) and had a mean age of between 52.2 and 55.7 years. Compared to "non-movers" (reference group), weekly minutes of transportation walking at follow-up was significantly lower among adults who moved to less walkable neighborhoods (ATET: -41.34, 95 CI: -68.30, -14.39; p < 0.01). We found no other statistically significant differences in walking between the groups.

Discussion

Our findings suggest that relocating to less walkable neighborhoods could have detrimental effects on transportation walking to the extent of adversely affecting health. Public health strategies that counteract the negative impacts of low walkable neighborhoods and leverage the supportiveness of high walkable neighborhoods might promote more walking.

The effect of neighborhood walkability on changes in physical activity and sedentary behavior during a 12-week pedometer-facilitated intervention

BACKGROUND

Pedometer-facilitated interventions encourage physical activity via the accumulation of steps. Mixed evidence suggests that neighborhood walkability might influence the effectiveness of physical activity interventions, including pedometer-facilitated interventions. Our study investigated the moderating effect of neighborhood walkability on immediate (4-week) and short-term (12-week) changes in self-reported neighborhood-specific leisure and transportation walking, leisure-based moderate and vigorous-intensity physical activity, and leisure-based screen time during a pedometer-facilitated intervention (UWALK).

METHODS

This quasi-experiment undertaken in Calgary (Canada) compared behavior changes during the 12-week intervention between two neighborhood groups classified as 'walkable' or 'car dependent' based on Walk Score®. Of the 573 volunteers (adults in the contemplation and preparation stages of physical activity behavior change), 466 participated in UWALK. Surveys captured sociodemographic characteristics, perceived neighborhood walkability, neighborhood preferences, motivation, physical activity and screen-based leisure. Covariate-adjusted linear mixed models estimated the differences in physical activity and leisure screen time between the neighborhood walkability groups at baseline, 4-weeks, and 12-weeks.

RESULTS

UWALK participants included mostly females (83%) and had an average age of 49.2 years. Weekly minutes of walking for transport inside the neighborhood was higher (p < .001) among participants from walkable versus car dependent neighborhoods at baseline (42.5 vs. 21.1), 4-weeks (81.2 vs. 48.2), and 12-weeks (87.2 vs. 48.0). Regardless of neighborhood walkability, all physical activity outcomes were higher and leisure screen time lower at 4-weeks and 12-weeks compared with baseline. We found no significant neighborhood group by time interactions.

CONCLUSIONS

Pedometer-facilitated interventions may be effective for supporting short-term changes in physical activity and sedentary behavior even among adults residing in low walkable neighborhoods.

Cross-sectional and longitudinal associations between the built environment and walking: effect modification by socioeconomic status

BACKGROUND

Although socioeconomic status (SES) has been shown to modify associations between the neighborhood built environment and physical activity, contradictory results exist. Objectives of this cross-sectional and longitudinal analysis were to: 1) examine whether overall neighborhood walkability and specific built characteristics were associated with walking among adults at a single point in time and after they relocate neighborhoods, and 2) test for effect modification of these associations by SES.

METHODS

We linked longitudinal data from 703 adults who relocated urban neighborhoods between two waves of Alberta's Tomorrow Project (2008-2015) to neighborhood built environment data. We created a walkability index from measures of population counts, street connectivity, and destination diversity within 400 m of participants' homes. In cross-sectional analyses, we used generalized linear models to estimate associations between built characteristics and minutes walked per week at baseline. For the longitudinal analyses, we used fixed-effects linear regression models to estimate associations between changes in built characteristics and minutes walked per week. We also assessed if indicators of SES (individual education or household income) modified both sets of associations.

RESULTS

Most cross-sectional and longitudinal associations were small and statistically non-significant. Neighborhood population count (b = 0.03, 95% CI: 0.01, 0.07) and street connectivity (b = - 1.75, 95% CI: - 3.26, - 0.24) were cross-sectionally associated with walking duration among the overall sample. None of the longitudinal associations were statistically significant among the overall sample. There was limited evidence of effect modification by SES, however, we found negative cross-sectional associations between street connectivity and walking among adults with lower education and income, and a positive association between percent change in walkability and change in walking among lower educated adults.

CONCLUSIONS

Despite population count and street connectivity being associated with walking at baseline, changes in these built environment variables were not associated with changes in walking following residential relocation. Our findings also provide evidence, albeit weak, that changes in neighborhood walkability, resulting from residential relocation, might more strongly affect walking among low SES adults. Further longitudinal research is needed to examine built environment characteristics with walking for different purposes and to test for inequitable socioeconomic impacts.

Associations between neighborhood characteristics and dating violence: does spatial scale matter?

Background

Dating violence (DV) is a public health problem that could have serious repercussions for the health and well-being of a large number of adolescents. Several neighborhood characteristics could influence these behaviors, but knowledge on such influences is still limited. This study aims at (1) evaluating the associations between neighborhood characteristics and DV, and (2) assessing how spatial scale influences the estimations of the latter associations.

Methods

The Québec Health Survey of High School Students (2016–2017) was used to describe DV. Neighborhoods were operationalized with polygon-based network buffers of varying sizes (ranging from 250 to 1000 m). Multiple data sources were used to describe neighborhood characteristics: crime rate, alcohol outlet density (on-premises and off-premises), walkability, greenness, green spaces density, and youth organizations density. Gendered-stratified logistic regressions were used for assessing the association between neighborhood characteristics and DV.

Results

For boys, off-premises alcohol outlet density (500 m) is associated with an increase in perpetrating psychological DV. Crime rate (500 m) is positively associated with physical or sexual DV perpetration, and crime rate (250 m) is positively associated with physical or sexual DV victimization. Greenness (1000 m) has a protective effect on psychological DV victimization. For girls, walkability (500 m to 1000 m) is associated with a decrease in perpetrating and experiencing psychological DV, and walkability (250 m) is negatively associated with physical or sexual DV victimization.

Conclusions

Several neighborhood characteristics are likely to influence DV, and their effects depend on the form of DV, gender, and spatial scale. Public policies should develop neighborhood-level interventions by improving neighborhood living conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12942-022-00306-3.

Retail availability and legal purchases of dried flower in Canada post-legalization

OBJECTIVE

Retail availability of cannabis has the potential to influence demand for both legal and illegal cannabis. The aims of the study were to: 1) estimate the percentage of consumers who report purchasing dried flower legally; and 2) examine the association between purchasing dried flower legally and retail availability, where retail availability was represented as: a) Canadian province; b) 'objective' retail proximity; and c) self-reported retail proximity.

METHODS

Data come from Canadian respondents in Wave 2 of the International Cannabis Policy Study (ICPS) conducted one year after non-medical cannabis legalization in September-October 2019. Respondents were 18+ years in Alberta/Quebec and 19+ years elsewhere and had purchased any dried flower in the past year (n = 2506). Respondents were recruited through commercial online panels. Weighted binary logistic regression models examined likelihood of purchasing dried flower legally.

RESULTS

Overall, 47.7 % of past-year dried flower purchasers reported last purchasing dried flower legally, with variation across provinces (range = 40.5 %-81.2 %). Likelihood of purchasing dried flower legally was greater among those who lived closer to a legal retail store based on Euclidean distance (<3 km vs. > 10 km: AOR = 1.56, 95 % CI: 1.20,2.02), and who had shorter self-reported travel time to a retail store (<5 min. vs. > 15 min.: AOR = 2.24, 95 % CI: 1.56,3.21).

CONCLUSION

One year after legalization, retail availability was associated with last purchasing dried flower legally among past-year dried flower purchasers. To our knowledge, the current study is among the first to examine the legality of purchase source used for dried flower and retail availability of cannabis in Canada post-legalization.

A longitudinal residential relocation study of changes in street layout and physical activity

Few longitudinal residential relocation studies have explored associations between urban form and physical activity, and none has used the Space Syntax theory. Using a Canadian longitudinal dataset (n = 5944), we estimated: (1) differences in physical activity between non-movers, and those relocating to neighbourhoods with less or more integrated street layouts, and; (2) associations between changes in street layout integration exposure and differences in physical activity. Adjusting for covariates, we found relative to non-movers, those who moved to more integrated neighbourhoods undertook significantly (p < .05) more leisure walking (27.3 min/week), moderate-intensity (45.7 min/week), and moderate-to-vigorous intensity physical activity (54.4 min/week). Among movers, a one-unit increase in the relative change in street integration exposure ([Street integration at follow-up—street integration at baseline]/street integration at baseline) was associated with a 7.5 min/week increase in leisure walking. Our findings suggest that urban design policies that improve neighbourhood street integration might encourage more physical activity in adults.

Demographic, medical, social-cognitive, and environmental correlates of meeting independent and combined physical activity guidelines in kidney cancer survivors

PURPOSE

Guidelines for cancer survivors recommend both aerobic physical activity (PA) and strength training (ST). Few kidney cancer survivors (KCS) are meeting single-activity or combined guidelines; therefore, examining factors influencing PA participation is warranted. The purpose of this study is to examine demographic, medical, social-cognitive, and environmental correlates of meeting independent (i.e., aerobic-only, strength training (ST)-only) and combined guidelines (i.e., aerobic and ST) in KCS.

METHODS

KCS (N = 651) completed self-reported measures of PA and demographic, medical, social-cognitive, and perceived environmental factors. Built environment was assessed using the geographic information systems (GIS). Multinomial logistic regressions were conducted to determine the correlates of meeting the combined versus independent guidelines.

RESULTS

Compared with meeting neither guideline, meeting aerobic-only guidelines was associated with higher intentions (p < .01) and planning (p < .01); meeting ST-only guidelines was associated with higher intentions (p = .02) and planning (p < .01), lower perceived behavioral control (PBC) (p = .03), healthy weight (p = .01), and older age (p < .01); and meeting the combined guidelines were associated with higher intentions (p < .01), planning (p = .02), higher instrumental attitudes (p < .01), higher education (p = .04), better health (p < .01), and localized cancer (p = .05). Additionally, compared with neither guideline, meeting aerobic-only (p < .01) and combined (p < .01) guidelines was significantly associated with access to workout attire. Compared with neither guideline, meeting aerobic-only guidelines was associated with proximity to retail (p = .02).

CONCLUSION

PA participation correlates may vary based on the modality of interest. Interventions may differ depending on the modality promoted and whether KCS are already meeting single-modality guidelines.

Laboratory-Assessed Markers of Cardiometabolic Health and Associations with GIS-Based Measures of Active-Living Environments

Active-living-friendly environments have been linked to physical activity, but their relationships with specific markers of cardiometabolic health remain unclear. We estimated the associations between active-living environments and markers of cardiometabolic health, and explored the potential mediating role of physical activity in these associations. We used data collected on 2809 middle-aged adults who participated in the Canadian Health Measures Survey (2007⁻2009; 41.5 years, SD = 15.1). Environments were assessed using an index that combined GIS-derived measures of street connectivity, land use mix, and population density. Body mass index (BMI), systolic blood pressure (SBP), hemoglobin A1c, and cholesterol were assessed in a laboratory setting. Daily step counts and moderate-to-vigorous intensity physical activity (MVPA) were assessed for seven days using accelerometers. Associations were estimated using robust multivariable linear regressions adjusted for sociodemographic factors that were assessed via questionnaire. BMI was 0.79 kg/m² lower (95% confidence interval (CI) -1.31, -0.27) and SBP was 1.65 mmHg lower (95% CI -3.10, -0.20) in participants living in the most active-living-friendly environments compared to the least, independent of daily step counts or MVPA. A 35.4 min/week difference in MPVA (95% CI 24.2, 46.6) was observed between residents of neighborhoods in the highest compared to the lowest active-living-environment quartiles. Cycling to work rates were also the highest in participants living in the highest living-environment quartiles (e.g., Q4 vs. Q1: 10.4% vs. 4.9%). Although active-living environments are associated with lower BMI and SBP, and higher MVPA and cycling rates, neither daily step counts nor MVPA appear to account for environment⁻BMI/SBP relationships. This suggests that other factors not assessed in this study (e.g., food environment or unmeasured features of the social environment) may explain this relationship.

Neighbourhood built environment characteristics associated with different types of physical activity in Canadian adults

INTRODUCTION

The aim of this study was to estimate the associations between neighbourhood built environment characteristics and transportation walking (TW), recreational walking (RW), and moderate-intensity (MPA) and vigorous-intensity physical activity (VPA) in adults independent of sociodemographic characteristics and residential self-selection (i.e. the reasons related to physical activity associated with a person's choice of neighbourhood).

METHODS

In 2007 and 2008, 4423 Calgary adults completed land-based telephone interviews capturing physical activity, sociodemographic characteristics and reasons for residential self-selection. Using spatial data, we estimated population density, proportion of green space, path/cycleway length, business density, bus stop density, city-managed tree density, sidewalk length, park type mix and recreational destination mix within a 1.6 km street network distance from the participants' geolocated residential postal code. Generalized linear models estimated the associations between neighbourhood built environment characteristics and weekly neighbourhood-based physical activity participation (≥ 10 minutes/week; odds ratios [ORs]) and, among those who reported participation, duration of activity (unstandardized beta coefficients [B]).

RESULTS

The sample included more women (59.7%) than men (40.3%) and the mean (standard deviation) age was 47.1 (15.6) years. TW participation was associated with intersection (OR = 1.11; 95% CI: 1.03 to 1.20) and business (OR = 1.52; 1.29 to 1.78) density, and sidewalk length (OR = 1.19; 1.09 to 1.29), while TW minutes was associated with business (B = 19.24 minutes/week; 11.28 to 27.20) and tree (B = 6.51; 2.29 to 10.72 minutes/week) density, and recreational destination mix (B = -8.88 minutes/ week; -12.49 to -5.28). RW participation was associated with path/cycleway length (OR = 1.17; 1.05 to 1.31). MPA participation was associated with recreational destination mix (OR = 1.09; 1.01 to 1.17) and sidewalk length (OR = 1.10; 1.02 to 1.19); however, MPA minutes was negatively associated with population density (B = -8.65 minutes/ week; -15.32 to -1.98). VPA participation was associated with sidewalk length (OR = 1.11; 1.02 to 1.20), path/cycleway length (OR = 1.12; 1.02 to 1.24) and proportion of neighbourhood green space (OR = 0.89; 0.82 to 0.98). VPA minutes was associated with tree density (B = 7.28 minutes/week; 0.39 to 14.17).

CONCLUSION

Some neighbourhood built environment characteristics appear important for supporting physical activity participation while others may be more supportive of increasing physical activity duration. Modifications that increase the density of utilitarian destinations and the quantity of available sidewalks in established neighbourhoods could increase overall levels of neighbourhood-based physical activity.

Sharing post-AML consolidation supportive therapy with local centers reduces patient travel burden without compromising outcomes

Acute myeloid leukemia (AML) is frequently treated with induction and consolidation chemotherapy. Consolidation chemotherapy can be delivered on an ambulatory basis, requiring some patients to travel long distances for treatment at specialized centers. We developed a shared care model where patients receive consolidation chemotherapy at a quaternary center, but post-consolidation supportive care at local hospitals. To evaluate the impact of our model on patient travel and outcomes we conducted a retrospective analysis of AML and acute promyelocytic leukemia patients receiving consolidation over four years at our quaternary center. 73 patients received post-consolidation care locally, and 344 at the quaternary center. Gender, age and cytogenetic risk did not significantly differ between groups. Shared care patients saved mean round trip distance of 146.5km±99.6 and time of 96.7min±63.4 compared to travelling to quaternary center. There was no significant difference in overall survival between groups, and no increased hazard of death for shared care patients. 30, 60, and 90day survival from start of consolidation was 98.6%, 97.2%, and 95.9% for shared care and 98.8%, 97.1%, and 95.3% for quaternary center patients. Thus, a model utilizing regional partnerships for AML post-consolidation care reduces travel burden while maintaining safety.

Tobacco retail availability and risk of relapse among smokers who make a quit attempt: a population-based cohort study

INTRODUCTION

The availability of tobacco is thought to influence smoking behaviour, but there are few longitudinal studies examining if the location and number of tobacco outlets has a prospective impact on smoking cessation.

METHODS

The Ontario Tobacco Survey, a population-representative sample of Ontario adult smokers who were followed every 6 months for up to 3 years, was linked with tobacco outlet location data from the Ontario Ministry of Health. Proximity (distance), threshold (at least one outlet within 500 m) and density (number of outlets within 500 m) with respect to a smokers' home were calculated among urban and suburban current smokers (n=2414). Quit attempts and risk of relapse were assessed using logistic regression and survival analysis, adjusted for neighbourhood effects and individual characteristics.

RESULTS

Increased density of tobacco outlets was associated with decreased odds of making a quit attempt (OR: 0.54; 95% CI 0.35 to 0.85) in high-income neighbourhoods, but not in lower income ones. There was an increased risk of relapse among those who had at least one store within 500 m (HR: 1.41 (95% CI 1.06 to 1.88). Otherwise, there was no association of proximity with quit attempts or relapse.

CONCLUSIONS

The existence of a tobacco retail outlet within walking distance from home was associated with difficulty in succeeding in a quit attempt, while the increased density of stores was associated with decreased attempts in higher income neighbourhoods. The availability of tobacco may influence tobacco use through multiple mechanisms.

Spatial measurement errors in the field of spatial epidemiology

Background

Spatial epidemiology has been aided by advances in geographic information systems, remote sensing, global positioning systems and the development of new statistical methodologies specifically designed for such data. Given the growing popularity of these studies, we sought to review and analyze the types of spatial measurement errors commonly encountered during spatial epidemiological analysis of spatial data.

Methods

Google Scholar, Medline, and Scopus databases were searched using a broad set of terms for papers indexed by a term indicating location (space or geography or location or position) and measurement error (measurement error or measurement inaccuracy or misclassification or uncertainty): we reviewed all papers appearing before December 20, 2014. These papers and their citations were reviewed to identify the relevance to our review.

Results

We were able to define and classify spatial measurement errors into four groups: (1) pure spatial location measurement errors, including both non-instrumental errors (multiple addresses, geocoding errors, outcome aggregations, and covariate aggregation) and instrumental errors; (2) location-based outcome measurement error (purely outcome measurement errors and missing outcome measurements); (3) location-based covariate measurement errors (address proxies); and (4) Covariate-Outcome spatial misaligned measurement errors. We propose how these four classes of errors can be unified within an integrated theoretical model and possible solutions were discussed.

Conclusion

Spatial measurement errors are ubiquitous threat to the validity of spatial epidemiological studies. We propose a systematic framework for understanding the various mechanisms which generate spatial measurement errors and present practical examples of such errors.

Walkable home neighbourhood food environment and children's overweight and obesity: Proximity, density or price?

OBJECTIVES

To identify characteristics of the food environment associated with child overweight/obesity that could, if subjected to intervention, mitigate the risk of childhood overweight/obesity. We examined whether the proximity to or density of grocery and convenience stores or fast food restaurants, or the prices of healthy food options were more strongly associated with overweight/obesity risk in children.

METHODS

We collected geocoded data by residential addresses for 1,469 children aged 10-14 years and conducted a census of all food outlets in Saskatoon. The Nutrition Environment Measures Survey (NEMS)-Stores and the NEMS-Restaurants were used to measure availability, quality and relative price of healthy food items in stores and restaurants. Children's weight status was calculated on the basis of measured height and weight. Logistic regression was used to test the associations between overweight/obesity and food environment variables.

RESULTS

Within an 800 m walking distance from home, 76% of children did not have access to a grocery store; 58% and 32% had access to at least one convenience store or one fast-food restaurant respectively. A significantly lower odds of overweight/obesity was associated with lower price of healthy food items/options in grocery stores (odds ratio [OR] = 0.87, 95% confidence interval [CI] 0.77-0.99) and fast-food restaurants (OR = 0.97, 95% CI 0.95-0.99) within walking distance of home. Neither the distance to the closest food outlet nor the density of food outlets around children's homes was associated with odds of overweight/obesity.

CONCLUSIONS

Improving economic access to healthy food in food outlets or fast-food restaurants is one strategy to counter childhood overweight/ obesity.

Children's route choice during active transportation to school: difference between shortest and actual route

Background

The purpose of this study is to increase our understanding of environmental correlates that are associated with route choice during active transportation to school (ATS) by comparing characteristics of actual walking and cycling routes between home and school with the shortest possible route to school.

Methods

Children (n = 184; 86 boys, 98 girls; age range: 8–12 years) from seven schools in suburban municipalities in the Netherlands participated in the study. Actual walking and cycling routes to school were measured with a GPS-device that children wore during an entire school week. Measurements were conducted in the period April–June 2014. Route characteristics for both actual and shortest routes between home and school were determined for a buffer of 25 m from the routes and divided into four categories: Land use (residential, commercial, recreational, traffic areas), Aesthetics (presence of greenery/natural water ways along route), Traffic (safety measures such as traffic lights, zebra crossings, speed bumps) and Type of street (pedestrian, cycling, residential streets, arterial roads). Comparison of characteristics of shortest and actual routes was performed with conditional logistic regression models.

Results

Median distance of the actual walking routes was 390.1 m, whereas median distance of actual cycling routes was 673.9 m. Actual walking and cycling routes were not significantly longer than the shortest possible routes. Children mainly traveled through residential areas on their way to school (>80 % of the route). Traffic lights were found to be positively associated with route choice during ATS. Zebra crossings were less often present along the actual routes (walking: OR = 0.17, 95 % CI = 0.05–0.58; cycling: OR = 0.31, 95 % CI = 0.14–0.67), and streets with a high occurrence of accidents were less often used during cycling to school (OR = 0.57, 95 % CI = 0.43–0.76). Moreover, percentage of visible surface water along the actual route was higher compared to the shortest routes (walking: OR = 1.04, 95 % CI = 1.01–1.07; cycling: OR = 1.03, 95 % CI = 1.01–1.05).

Discussion

This study showed a novel approach to examine built environmental exposure during active transport to school. Most of the results of the study suggest that children avoid to walk or cycle along busy roads on their way to school.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-016-0373-y) contains supplementary material, which is available to authorized users.

Area Median Income and Metropolitan Versus Nonmetropolitan Location of Care for Acute Coronary Syndromes: A Complex Interaction of Social Determinants

Background

Metropolitan versus nonmetropolitan status and area median income may independently affect care for and outcomes of acute coronary syndromes. We sought to determine whether location of care modifies the association among area income, receipt of cardiac catheterization, and mortality following an acute coronary syndrome in a universal health care system.

Methods and Results

We studied a cohort of 14 012 acute coronary syndrome patients admitted to cardiology services between April 18, 2004, and December 31, 2011, in southern Alberta, Canada. We used multivariable logistic regression to determine the odds of cardiac catheterization within 1 day and 7 days of admission and the odds of 30‐day and 1‐year mortality according to area median household income quintile for patients presenting at metropolitan and nonmetropolitan hospitals. In models adjusting for area income, patients who presented at nonmetropolitan facilities had lower adjusted odds of receiving cardiac catheterization within 1 day of admission (odds ratio 0.22, 95% CI 0.11–0.46, P<0.001). Among nonmetropolitan patients, when examined by socioeconomic status, each incremental decrease in income quintile was associated with 10% lower adjusted odds of receiving cardiac catheterization within 7 days (P<0.001) and 24% higher adjusted odds of 30‐day mortality (P=0.008) but no significant difference for 1‐year mortality (P=0.12). There were no differences in adjusted mortality among metropolitan patients.

Conclusion

Within a universal health care system, the association among area income and receipt of cardiac catheterization and 30‐day mortality differed depending on the location of initial medical care for acute coronary syndromes. Care protocols are required to improve access to care and outcomes in patients from low‐income nonmetropolitan communities.

Neighbourhood walkability, daily steps and utilitarian walking in Canadian adults

OBJECTIVES

To estimate the associations of neighbourhood walkability (based on Geographic Information System (GIS)-derived measures of street connectivity, land use mix, and population density and the Walk Score) with self-reported utilitarian walking and accelerometer-assessed daily steps in Canadian adults.

DESIGN

A cross-sectional analysis of data collected as part of the Canadian Health Measures Survey (2007-2009).

SETTING

Home neighbourhoods (500 m polygonal street network buffers around the centroid of the participant's postal code) located in Atlantic Canada, Québec, Ontario, the Prairies and British Columbia.

PARTICIPANTS

5605 individuals participated in the survey. 3727 adults (≥18 years) completed a computer-assisted interview and attended a mobile clinic assessment. Analyses were based on those who had complete exposure, outcome and covariate data (n=2949).

MAIN EXPOSURE MEASURES

GIS-derived walkability (based on land use mix, street connectivity and population density); Walk Score.

MAIN OUTCOME MEASURES

Self-reported utilitarian walking; accelerometer-assessed daily steps.

RESULTS

No important relationship was observed between neighbourhood walkability and daily steps. Participants who reported more utilitarian walking, however, accumulated more steps (<1 h/week: 6613 steps/day, 95% CI 6251 to 6975; 1 to 5 h/week: 6768 steps/day, 95% CI 6420 to 7117; ≥6 h/week: 7391 steps/day, 95% CI 6972 to 7811). There was a positive graded association between walkability and odds of walking ≥1 h/week for utilitarian purposes (eg, Q4 vs Q1 of GIS-derived walkability: OR=1.66, 95% CI 1.31 to 2.11; Q3 vs Q1: OR=1.41, 95% CI 1.14 to 1.76; Q2 vs Q1: OR=1.13, 95% CI 0.91 to 1.39) independent of age, sex, body mass index, married/common law status, annual household income, having children in the household, immigrant status, mood disorder, perceived health, ever smoker and season.

CONCLUSIONS

Contrary to expectations, living in more walkable Canadian neighbourhoods was not associated with more total walking. Utilitarian walking and daily steps were, however, correlated and walkability demonstrated a positive graded relationship with utilitarian walking.

The safety of Canadian rural maternity services: a multi-jurisdictional cohort analysis

Background

Small Canadian rural maternity services are struggling to maintain core staffing and remain open. Existing evidence states that having to travel to access maternity services is associated with adverse outcomes. The goal of this study is to systematically examine rural maternal and newborn outcomes across three Canadian provinces.

Methods

We analyzed maternal newborn outcomes data through provincial perinatal registries in British Columbia, Alberta and Nova Scotia for deliveries that occurred between April 1st 2003 and March 31st 2008. All births were allocated to maternity service catchments based on the residence of the mothers. Individual catchments were stratified to service levels based on distance to access intrapartum maternity services or the model of maternity services available in the community. The amalgamation of analyses from each jurisdiction involved comparison of logistic regression effect estimates.

Results

The number of singleton births included in the study is 150,797. Perinatal mortality is highest in communities that are greater than 4 h from maternity services overall. Rates of prematurity at less than 37 weeks gestation are higher for rural women without local access to services. Caesarean section rates are highest in communities served by general surgical models.

Conclusion

Composite analysis of data from three Canadian provinces provides the strongest evidence to date demonstrating that we need to sustain small community maternity services with and without caesarean section capability.

The Neighbourhood Built Environment and Trajectories of Depression Symptom Episodes in Adults: A Latent Class Growth Analysis

Aim

To investigate the effect of the neighbourhood built environment on trajectories of depression symptom episodes in adults from the general Canadian population.

Research Design and Methods

We used 10 years of data collection (2000/01-2010/11) from the Canadian National Population Health Study (n = 7114). Episodes of depression symptoms were identified using the Composite International Diagnostic Interview Short-Form. We assessed the presence of local parks, healthy food stores, fast food restaurants, health services and cultural services using geospatial data. We used latent class growth modelling to identify different trajectories of depression symptom episodes in the sample and tested for the effect of neighbourhood variables on the trajectories over time.

Results

We uncovered three distinct trajectories of depression symptom episodes: low prevalence (76.2% of the sample), moderate prevalence (19.2%) and high prevalence of depression symptom episodes (2.8%). The presence of any neighbourhood service (healthy food store, fast-food restaurant, health service, except for cultural service) was significantly associated with a lower probability of a depression symptom episode for those following a trajectory of low prevalence of depression symptom episodes. The presence of a local park was also a significant protective factor in trajectory groups with both low and moderate prevalence of depression symptom episodes. Neighbourhood characteristics did not significantly affect the trajectory of high prevalence of depression symptom episodes.

Conclusions

For individuals following a trajectory of low and moderate prevalence of depression symptom episodes, the neighbourhood built environment was associated with a shift in the trajectory of depression symptom episodes. Future intervention studies are recommended to make policy recommendations.

Social-ecological correlates of physical activity in kidney cancer survivors

PURPOSE

Previous studies in cancer survivors have examined behavioral correlates of physical activity (PA), but no study to date has adopted a broader social-ecological framework in understanding PA. This study examined the associations among demographic, medical, social-cognitive, and environmental correlates of meeting PA guidelines among kidney cancer survivors (KCS).

METHODS

All 1985 KCS diagnosed between 1996 and 2010 identified through a Canadian provincial registry were mailed a survey that consisted of medical, demographic, and social-cognitive measures, as well as PA as measured by the Godin Leisure Time Exercise Questionnaire. Environmental constructs were also assessed for both self-report and objective measures using geographic information systems (GIS). A series of binary logistic regression analyses were conducted in this cross-sectional study.

RESULTS

Completed surveys with geographical information were received from 432 KCS with M age = 64.4 ± 11.1 years, 63.2 % male, and 82.2 % having localized kidney cancer. In the final multivariate model, meeting PA guidelines was associated with disease stage (OR = 0.25, p = .005), having drug therapy (OR = 3.98, p = .009), higher levels of instrumental attitudes (OR = 1.66, p = .053), higher levels of intention (OR = 1.72, p = .002), and the perceived presence of many retail shops in the neighborhood (OR = 1.37, p = .032).

CONCLUSIONS

Meeting PA guidelines in KCS were associated with various aspects of the social-ecological model.

IMPLICATIONS FOR CANCER SURVIVORS

Understanding the social-ecological correlates for PA can provide insight into future interventions designed to increase PA in KCS. Prime targets for PA promotion should consider treatment-related factors, promote the benefits of PA, and enhance positive perceptions of the built environment.

Undeveloped green space and free-time physical activity in 11 to 13-year-old children

BACKGROUND

Research on the association between the physical environment and physical activity in children has focused on built and developed features or total green space. The impact of natural, undeveloped green spaces is unknown. The objective of this study was to determine whether the presence of undeveloped green spaces in the home neighborhood are associated with physical activity in 11 to 13-year-olds.

METHODS

This was a cross-sectional study of grade 6 to 8 urban residing Canadian students who participated in the 2009/10 Health Behaviour in School-Aged Children survey. Children self-reported the frequency they participated in physical activity in their free-time outside of school hours. Geographic Information Systems (GIS) were used to assess the proportion of land area within 1 km of participants' homes that was devoted to publicly accessible meadows (i.e., field vegetated primarily by grass and other non-woody plants) and treed areas (i.e., field vegetated primarily by trees and shrubs). Ordinal logistic regression models were used to examine the relationships between the undeveloped green space areas and free-time physical activity. Several intrapersonal, family, and neighborhood environment factors were controlled for in these regression models.

RESULTS

The proportion of neighborhood land covered by meadows was not associated with the physical activity outcome (p > 0.6). However, the proportion of neighborhood land covered by treed areas was independently associated with the physical activity outcome (p = 0.02). For each additional 5% increase in the proportion of neighborhood land covered by treed areas there was a corresponding 5% increase (95% confidence interval: 1-10% increase) in the relative odds of increasing free-time physical activity outside of school hours.

CONCLUSIONS

The physical activity levels of 11 to 13-year-old children was associated with the amount of space in their home neighborhood devoted to treed areas.

Neighbourhood characteristics and 10-year risk of depression in Canadian adults with and without a chronic illness

The neighbourhood environment could play a role in the risk of depression in adults and those with a chronic illness. We investigated the effects of a range of neighbourhood characteristics on the 10-year risk of depression in a representative sample of 9026 Canadian adults and subsamples with a chronic condition. Characteristics of neighbourhoods were not significantly related to the risk of depression in the general sample and subsamples with a chronic condition. However, residing near a park was significantly associated with a lower risk of depression for people living in crowded households, and having a local health service nearby was protective for those living in materially deprived neighbourhoods. Living in a neighbourhood that was both socially advantaged and offered cultural services was also associated with lower risk of depression. Additional research is needed for smaller effect size detection. Future intervention research is warranted for health policy recommendations.

Crime and perceptions of safety in the home neighborhood are independently associated with physical activity among 11-15 year olds

OBJECTIVE

To determine whether perceptions of neighborhood safety and measures of neighborhood crime are independently associated within physical activity in youth.

METHODS

The study sample consisted of 14,125 youths in grades 6-10 (ages 11-15) who participated in the nationally representative cross-sectional 2009/10 Canadian Health Behaviour in School-Aged Children Survey. Participants responded to four questions about how safe their home neighborhood is and reported whether or not they accumulated at least 4h/week of physical activity in their free-time outside of school hours. Crimes against persons was assessed in 1 km radius buffers around participants' homes. Associations were assessed using logistic regression.

RESULTS

After controlling for crime and relevant confounders, the relative odds of being physically active outside of school was 0.52 (95% CI: 0.44-0.62) in youth whose perceptions of neighborhood safety were in the lowest quintile. After controlling for perceptions of safety and relevant confounders, the relative odds of being physically active outside of school was 0.75 (0.60-0.95) in youth from neighborhoods with crimes against persons scores in the highest quintile.

CONCLUSIONS

Within this large sample of 11-15 year olds, perceptions and objective measures of neighborhood safety and crime were independently associated with physical activity in free-time outside of school.

Geocoding large population-level administrative datasets at highly resolved spatial scales

Using geographic information systems to link administrative databases with demographic, social, and environmental data allows researchers to use spatial approaches to explore relationships between exposures and health. Traditionally, spatial analysis in public health has focused on the county, zip code, or tract level because of limitations to geocoding at highly resolved scales. Using 2005 birth and death data from North Carolina, we examine our ability to geocode population-level datasets at three spatial resolutions - zip code, street, and parcel. We achieve high geocoding rates at all three resolutions, with statewide street geocoding rates of 88.0% for births and 93.2% for deaths. We observe differences in geocoding rates across demographics and health outcomes, with lower geocoding rates in disadvantaged populations and the most dramatic differences occurring across the urban-rural spectrum. Our results suggest highly resolved spatial data architectures for population-level datasets are viable through geocoding individual street addresses. We recommend routinely geocoding administrative datasets to the highest spatial resolution feasible, allowing public health researchers to choose the spatial resolution used in analysis based on an understanding of the spatial dimensions of the health outcomes and exposures being investigated. Such research, however, must acknowledge how disparate geocoding success across subpopulations may affect findings.

The associations between objectively-determined and self-reported urban form characteristics and neighborhood-based walking in adults

Background

Self-reported and objectively-determined neighborhood built characteristics are associated with physical activity, yet little is known about their combined influence on walking. This study: 1) compared self-reported measures of the neighborhood built environment between objectively-determined low, medium, and high walkable neighborhoods; 2) estimated the relative associations between self-reported and objectively-determined neighborhood characteristics and walking and; 3) examined the extent to which the objectively-determined built environment moderates the association between self-reported measures of the neighborhood built environment and walking.

Methods

A random cross-section of 1875 Canadian adults completed a telephone-interview and postal questionnaire capturing neighborhood walkability, neighborhood-based walking, socio-demographic characteristics, walking attitudes, and residential self-selection. Walkability of each respondent’s neighborhood was objectively-determined (low [LW], medium [MW], and high walkable [HW]). Covariate-adjusted regression models estimated the associations between weekly participation and duration in transportation and recreational walking and self-reported and objectively-determined walkability.

Results

Compared with objectively-determined LW neighborhoods, respondents in HW neighborhoods positively perceived access to services, street connectivity, pedestrian infrastructure, and utilitarian and recreation destination mix, but negatively perceived motor vehicle traffic and crime related safety. Compared with residents of objectively-determined LW neighborhoods, residents of HW neighborhoods were more likely (p < .05) to participate in (odds ratio [OR] = 3.06), and spend more time, per week (193 min/wk) transportation walking. Perceived access to services, street connectivity, motor vehicle safety, and mix of recreational destinations were also significantly associated with transportation walking. With regard to interactions, HW x utilitarian destination mix was positively associated with participation, HW x physical barriers and MW x pedestrian infrastructure were positively associated with minutes, and HW x safety from crime was negatively associated with minutes, of transportation walking. Neither neighborhood type nor its interactions with perceived measures of walkability were associated with recreational walking, although perceived aesthetics was associated with participation (OR = 1.18, p < .05).

Conclusions

Objectively-determined and self-reported built characteristics are associated with neighborhood-based transportation walking. The objectively-determined built environment might moderate associations between perceptions of walkability and neighborhood-based transportation walking. Interventions that target perceptions in addition to modifications to the neighborhood built environment could result in increases in physical activity among adults.

Sex, socioeconomic status, access to cardiac catheterization, and outcomes for acute coronary syndromes in the context of universal healthcare coverage

BACKGROUND

Sex and neighborhood socioeconomic status (nSES) may independently affect the care and outcomes of acute coronary syndrome, partly through barriers in timely access to cardiac catheterization. We sought to determine whether sex modifies the association between nSES and the receipt of cardiac catheterization and mortality after an acute coronary syndrome in a universal healthcare system.

METHODS AND RESULTS

We studied 14 012 patients with acute coronary syndrome admitted to cardiology services between April 18, 2004, and December 31, 2011, in Southern Alberta, Canada. We used multivariable logistic regression to compare the odds of cardiac catheterization within 2 and 30 days of admission and the odds of 30-day and 1-year mortality for men and women by quintile of neighborhood median household income. Significant relationships between nSES and the receipt of cardiac catheterization and mortality after acute coronary syndrome were detected for women but not men. When examined by nSES, each incremental decrease in neighborhood income quintile for women was associated with a 6% lower odds of receiving cardiac catheterization within 30 days (P=0.01) and a 14% higher odds of 30-day mortality (P=0.03). For men, each decrease in neighborhood income quintile was associated with a 2% lower odds of receiving catheterization within 30 days (P=0.10) and a 5% higher odds of 30-day mortality (P=0.36).

CONCLUSIONS

Associations between nSES and receipt of cardiac catheterization and 30-day mortality were noted for women but not men in a universal healthcare system. Care protocols designed to improve equity of access to care and outcomes are required, especially for low-income women.

Subpopulation differences in the association between neighborhood urban form and neighborhood-based physical activity

This study investigated whether associations between the neighborhood built environment and neighborhood-based physical activity (PA) varied by sociodemographic and health-related characteristics. A random sample of adults (n=2006) completed telephone- and self-administered questionnaires. Questionnaires captured PA, sociodemographic, and health-related characteristics. Neighborhood-based PA (MET-minutes/week) was compared across low, medium, and high walkable neighborhoods for each sociodemographic (sex, age, dependents, education, income, motor vehicle access, and dog ownership) and health-status (general health and weight status) subpopulation. With few exceptions, subpopulations residing in high walkable neighborhoods undertook more (p<0.05) neighborhood-based PA than their counterparts in less walkable neighborhoods. Improving neighborhood walkability is a potentially effective population health intervention for increasing neighborhood-based PA.

Examination of how neighborhood definition influences measurements of youths' access to tobacco retailers: a methodological note on spatial misclassification

Measurements of neighborhood exposures likely vary depending on the definition of "neighborhood" selected. This study examined the extent to which neighborhood definition influences findings regarding spatial accessibility to tobacco retailers among youth. We defined spatial accessibility to tobacco retailers (i.e., tobacco retail density, closest tobacco retailer, and average distance to the closest 5 tobacco retailers) on the basis of circular and network buffers of 400 m and 800 m, census block groups, and census tracts by using residential addresses from the 2008 Boston Youth Survey Geospatial Dataset (n = 1,292). Friedman tests (to compare overall differences in neighborhood definitions) were applied. There were differences in measurements of youths' access to tobacco retailers according to the selected neighborhood definitions, and these were marked for the 2 spatial proximity measures (both P < 0.01 for all differences). For example, the median average distance to the closest 5 tobacco retailers was 381.50 m when using specific home addresses, 414.00 m when using census block groups, and 482.50 m when using census tracts, illustrating how neighborhood definition influences the measurement of spatial accessibility to tobacco retailers. These analyses suggest that, whenever possible, egocentric neighborhood definitions should be used. The use of larger administrative neighborhood definitions can bias exposure estimates for proximity measures.

Tobacco retail availability and smoking behaviours among patients seeking treatment at a nicotine dependence treatment clinic

Background

Availability of tobacco may be associated with increased smoking. Little is known about how proximity to a retail outlet is associated with smoking behaviours among smokers seeking treatment.

Methods

A cross sectional study was conducted using chart data was extracted for 734 new clients of a nicotine dependence clinic in Toronto, Canada who visited during the period April 2008 to June 2010. Using a tobacco retail licensing list, clients were coded as to whether there were 0, 1, or more than 1 retail outlet located 250 m from their postal code address. Conditional fixed effects regression analyses were used to assess the association between proximity and quit status, number of previous quit attempts, number of cigarettes per day, and time to first cigarette, controlling for demographic characteristics and neighbourhood.

Results

72% of patients lived within 250 m of a retail outlet. Those who had more than one outlet with 250 m of their address were less likely to be abstinent at the initial assessment (OR = 0.45; 95% CI: 0.23, 0.87; p = 0.014) and less likely to have a longer time to first cigarette (OR = 0.60; 95% CI: 0.45, 0.79), both before and after adjustment for covariates. Smokers who had at least one outlet within 250 m of their address smoked 3.4 cigarettes more per day than smokers without an outlet after controlling for neighbourhood and covariates. There was no significant association between proximity and lifetime number of quit attempts.

Conclusions

Proximity to a tobacco retail outlet was associated with smoking behaviours among a heavily addicted, treatment seeking population. Environmental factors may have a substantial impact on the ability of smokers to quit smoking.

Determinants of place of death: a population-based retrospective cohort study

Background

As Canada’s population ages, the location of end of life care (whether at home, extended care facility or hospital) may change depending on the location of death. We carried out a study to identify determinants of the place of death.

Methods

Data on deaths in British Columbia between 2004 and 2008 were obtained from the Vital Statistics Agency. Place of death was categorized into home, extended care facility, hospital or other. Logistic regression analyses were used to estimate the effects of age, sex, marital status, residence, place of birth and cause of death on place of death using adjusted odds ratios and 95% confidence intervals (95% CI).

Results

Of the 153,111 deaths in the study, 16.5% occurred at home, 29.0% in extended care, 51.0% in hospital and 3.5% occurred elsewhere. Male deaths were less likely to occur in extended care as compared with female deaths (odds ratio 0.73, 95% CI 0.71–0.75). Age (odds ratio 3.31, 95% CI 3.19–3.45 for those for ≥90 vs 70–79 years), marital status (odds ratio 1.42, 95% CI 1.38–1.47 widowed vs married), residence (odds ratio 0.80, 95% CI 0.76–0.83 rural vs Vancouver), place of birth (odds ratio 0.80, 95% CI 0.75–0.86 China vs Canada) and cause of death (odds ratio 3.91, 95% CI 3.69–4.13 dementia vs cancer) were also associated with death in extended care.

Conclusions

Information on determinants of place of death can inform public health policy regarding care at the end of life and make resource allocation more efficient.

Obesogenic neighbourhoods: the impact of neighbourhood restaurants and convenience stores on adolescents' food consumption behaviours

OBJECTIVE

To examine the relationship between the neighbourhood food environment and dietary intake among adolescents.

DESIGN

Cross-sectional design using: (i) a geographic information system to assess characteristics of the neighbourhood food environment and neighbourhood socio-economic status; (ii) the modified Healthy Eating Index (HEI) to assess participants' overall diet quality; and (iii) generalized linear models to examine associations between HEI and home and school food environmental correlates.

SETTING

Mid-sized Canadian city in Ontario, Canada. Participants Grade 7 and 8 students (n 810) at twenty-one elementary schools.

RESULTS

Students living in neighbourhoods with a lower diversity of land-use types, compared with their higher diversity counterparts, had higher HEI scores (P < 0.05). Students with more than 1 km between their home and the nearest convenience store had higher HEI scores than those living within 1 km (P < 0.01). Students attending schools with a distance further than 1 km from the nearest convenience store (P < 0.01) and fast-food outlet (P < 0.05) had higher HEI scores than those within 1 km. Those attending schools with three or more fast-food outlets within 1 km had lower HEI scores than those attending schools with no fast-food outlet in the school surroundings (P < 0.05).

CONCLUSIONS

Close proximity to convenience stores in adolescents' home environments is associated with low HEI scores. Within adolescents' school environments, close proximity to convenience and fast-food outlets and a high density of fast-food outlets are associated with low HEI scores.

Multi-level examination of correlates of active transportation to school among youth living within 1 mile of their school

Background

Active transportation to school is a method by which youth can build physical activity into their daily routines. We examined correlates of active transportation to school at both individual- (characteristics of the individual and family) and area- (school and neighborhood) levels amongst youth living within 1 mile (1.6 km) of their school.

Methods

Using the 2009/10 Canadian Health Behaviour in School-Aged Children (HBSC) survey, we selected records of students (n = 3 997) from 161 schools that resided in an urban setting and lived within 1 mile from their school. Student records were compiled from: (1) individual-level HBSC student questionnaires; (2) area-level administrator (school) questionnaires; and (3) area-level geographic information system data sources. The outcome, active transportation to school, was determined via a questionnaire item describing the method of transportation that individual students normally use to get to school. Analyses focused on factors at multiple levels that potentially contribute to student decisions to engage in active transportation. Multi-level logistic regression analyses were employed.

Results

Approximately 18% of the variance in active transportation was accounted for at the area-level. Several individual and family characteristics were associated with engagement in active transportation to school including female gender (RR vs. males = 0.86, 95% CI: 0.80-0.91), having ≥2 cars in the household (RR vs. no cars = 0.87, 0.74-0.97), and family socioeconomic status (RR for ‘not well off’ vs. ‘very well off’ = 1.14, 1.01-1.26). Neighborhood characteristics most strongly related to active transportation were: the length of roads in the 1 km buffer (RR in quartile 4 vs. quartile 1 = 1.23, 1.00-1.42), the amount of litter in the neighborhood (RR for ‘major problem’ vs. ‘no problem’ = 1.47, 1.16-1.57), and relatively hot climates (RR in quartile 4 vs. quartile 1 = 1.33 CI, 1.05-1.53).

Conclusion

Engagement in active transportation to school was related to multiple factors at multiple levels. We identified gender, perception of residential neighborhood safety, the percentage of streets with sidewalks, and the total length of roads as the most important correlates of active transportation to school.

Linking childhood obesity to the built environment: a multi-level analysis of home and school neighbourhood factors associated with body mass index

OBJECTIVES

This study examines environmental factors associated with BMI (body mass index) levels among adolescents with the aim of identifying potential interventions for reducing childhood obesity.

METHODS

Students (n=1,048) aged 10-14 years at 28 schools in London, ON, completed a survey providing information on age, sex, height, weight, home address, etc., which was used to construct age-sex adjusted BMI z-scores. The presence of recreation opportunities, fast-food outlets and convenience stores was assessed using four areal units around each participant's home and school neighbourhood: "circular buffers" encompassing territory within a straight-line distance of 500 m and 1000 m; and "network buffers" of 500 m and 1000 m measured along the street network. School neighbourhoods were also assessed using school-specific "walksheds". Multilevel structural equation modeling techniques were employed to simultaneously test the effects of school-environment (Level 2) and home-environment (Level 1) predictors on BMI z-scores.

RESULTS

Most participants (71%) had a normal BMI, 16.9% were overweight, 7.6% were obese, and 4.6% were considered underweight. Multilevel analyses indicated that built environment characteristics around children's homes and schools had a modest but significant effect on their BMI. The presence of public recreation opportunities within a 500 m network distance of home was associated with lower BMI z-scores (p<0.05), and fast-food outlets within the school walkshed was associated with higher BMI z-scores (p<0.05).

CONCLUSION

Interventions and policies that improve children's access to publicly provided recreation opportunities near home and that mitigate the concentration of fast-food outlets close to schools may be key to promoting healthy lifestyles and reducing childhood obesity.

Linking childhood obesity to the built environment: a multi-level analysis of home and school neighbourhood factors associated with body mass index

OBJECTIVES

This study examines environmental factors associated with BMI (body mass index) levels among adolescents with the aim of identifying potential interventions for reducing childhood obesity.

METHODS

Students (n=1,048) aged 10-14 years at 28 schools in London, ON, completed a survey providing information on age, sex, height, weight, home address, etc., which was used to construct age-sex adjusted BMI z-scores. The presence of recreation opportunities, fast-food outlets and convenience stores was assessed using four areal units around each participant's home and school neighbourhood: "circular buffers" encompassing territory within a straight-line distance of 500 m and 1000 m; and "network buffers" of 500 m and 1000 m measured along the street network. School neighbourhoods were also assessed using school-specific "walksheds". Multilevel structural equation modeling techniques were employed to simultaneously test the effects of school-environment (Level 2) and home-environment (Level 1) predictors on BMI z-scores.

RESULTS

Most participants (71%) had a normal BMI, 16.9% were overweight, 7.6% were obese, and 4.6% were considered underweight. Multilevel analyses indicated that built environment characteristics around children's homes and schools had a modest but significant effect on their BMI. The presence of public recreation opportunities within a 500 m network distance of home was associated with lower BMI z-scores (p&lt;0.05), and fast-food outlets within the school walkshed was associated with higher BMI z-scores (p&lt;0.05).

CONCLUSION

Interventions and policies that improve children's access to publicly provided recreation opportunities near home and that mitigate the concentration of fast-food outlets close to schools may be key to promoting healthy lifestyles and reducing childhood obesity.

Risk factors for loss to follow-up among children and young adults with congenital heart disease

OBJECTIVE

To identify risk factors for loss to cardiology follow-up among children and young adults with congenital heart disease.

METHODS

We used a matched case-control design. Cases were born before January, 2001 with moderate or complex congenital heart disease and were previously followed up in the paediatric or adult cardiology clinic, but not seen for 3 years or longer. Controls had been seen within 3 years. Controls were matched 3:1 to cases by year of birth and congenital heart disease lesion. Medical records were reviewed for potential risk factors for loss to follow-up. A subset of cases and controls participated in recorded telephone interviews.

RESULTS

A total of 74 cases (66% male) were compared with 222 controls (61% male). A history of missed cardiology appointments was predictive of loss to follow-up for 3 years or longer (odds ratio 13.0, 95% confidence interval 3.3-51.7). Variables protective from loss to follow-up were higher family income (odds ratio 0.87 per $10,000 increase, 0.77-0.98), cardiac catheterisation within 5 years (odds ratio 0.2, 95% confidence interval 0.1-0.6), and chart documentation of the need for cardiology follow-up (odds ratio 0.4, 95% confidence interval 0.2-0.8). Cases lacked awareness of the importance of follow-up and identified primary care physicians as their primary source of information about the heart, rather than cardiologists. Unlike cases, controls had methods to remember appointments.

CONCLUSIONS

A history of one or more missed cardiology appointments predicted loss to follow-up for 3 or more years, as did lack of awareness of the need for follow-up. Higher family income, recent catheterisations, and medical record documentation of the need for follow-up were protective.

The relationship between cluster-analysis derived walkability and local recreational and transportation walking among Canadian adults

We investigated the association between objectively-assessed neighborhood walkability and local walking among adults. Two independent random cross-sectional samples of Calgary (Canada) residents were recruited. Neighborhood-based walking, attitude towards walking, neighborhood self-selection, and socio-demographic characteristics were captured. Built environmental attributes underwent a two-staged cluster analysis which identified three neighborhood types (HW: high walkable; MW: medium walkable; LW: low walkable). Adjusting for all other characteristics, MW (OR 1.40, p < 0.05) and HW (OR 1.34, approached p < 0.05) neighborhood residents were more likely than LW neighborhood residents to participate in neighborhood-based transportation walking. HW neighborhood residents spent 30-min/wk more on neighborhood-based transportation walking than both LW and MW neighborhood residents. MW neighborhood residents spent 14-min/wk more on neighborhood-based recreational walking than LW neighborhood residents. Neighborhoods with a highly connected pedestrian network, large mix of businesses, high population density, high access to sidewalks and pathways, and many bus stops support local walking.

The influence of local food environments on adolescents' food purchasing behaviors

This study examined the relationship between the neighborhood food environment and the food purchasing behaviors among adolescents. Grade 7 and 8 students (n = 810) at 21 elementary schools in London, Ontario, Canada completed a questionnaire assessing their food purchasing behaviors. Parents of participants also completed a brief questionnaire providing residential address and demographic information. A Geographic Information System (GIS) was used to assess students' home and school neighborhood food environment and land use characteristics. Logistic regression analysis was conducted to assess the influence of the home neighborhood food environment on students' food purchasing behaviors, while two-level Hierarchical Non-Linear Regression Models were used to examine the effects of school neighborhood food environment factors on students' food purchasing behaviors. The study showed that approximately 65% of participants reported self-purchasing foods from fast-food outlets or convenience stores. Close proximity (i.e., less than 1 km) to the nearest fast-food outlet or convenience store in the home neighborhood increased the likelihood of food purchasing from these food establishments at least once per week by adolescents (p < 0.05). High fast-food outlet density in both home and school neighborhoods was associated with increased fast-food purchasing by adolescents (i.e., at least once per week; p < 0.05). In conclusion, macro-level regulations and policies are required to amend the health-detracting neighborhood food environment surrounding children and youth's home and school.

Investigating impacts of positional error on potential health care accessibility

Accessibility to health services at the local or community level is an effective approach to measuring health care delivery in various constituencies in Canada and the United States. GIS and spatial methods play an important role in measuring potential access to health services. The Three-Step Floating Catchment Area (3SFCA) method is a GIS based procedure developed to calculate potential (spatial) accessibility as a ratio of primary health care (PHC) providers to the surrounding population in urban settings. This method uses PHC provider locations in textual/address format supplied by local, regional, or national health authorities. An automated geocoding procedure is normally used to convert such addresses to a pair of geographic coordinates. The accuracy of geocoding depends on the type of reference data and the amount of value-added effort applied. This research investigates the success and accuracy of six geocoding methods as well as how geocoding error affects the 3SFCA method. ArcGIS software is used for geocoding and spatial accessibility estimation. Results will focus on two implications of geocoding: (1) the success and accuracy of different automated and value-added geocoding; and (2) the implications of these geocoding methods for GIS-based methods that generalise results based on location data.

Temporal and geographic shifts in urban and nonurban cocaine-related fatal overdoses in British Columbia, Canada

PURPOSE

Illicit drug overdose is a leading cause of premature mortality. We sought to examine fatal overdose trends from 2001 to 2005 in urban and nonurban areas of British Columbia, Canada.

METHODS

We conducted a review of all provincial coroner files in which drug overdose was the cause of death between January 1, 2001, and December 31, 2005. We compared cocaine and non-cocaine-related overdoses and examined temporal changes in cocaine-related mortality rates in urban and nonurban areas. Multilevel mixed effects models were used to determine the independent risk factors for cocaine-related death. Spatial analyses were conducted to identify clusters of these cases.

RESULTS

During the study period, 904 illicit drug overdoses were recorded, including 369 (40.8%) in nonurban areas and 532 (58.9%) related to cocaine consumption. In a multilevel model, we observed a significant interaction (p = .010) between population density and year, indicating a considerable and differential increase in the likelihood of cocaine-related deaths in nonurban areas. Cocaine-related deaths were clustered in the southeast region of the province.

CONCLUSIONS

Cocaine-related overdoses in nonurban areas should be a public health concern. Evidence-based interventions to reduce the risks associated with cocaine consumption and reach drug users in nonurban settings are needed.

[Potential accessibility to mental health services in Montreal: a geographical information system approach]

BACKGROUND

The inequitable spatial distribution of health resources is a major public health problem because it exacerbates the spatial disparities of access and use of health services. However, efforts to quantify the problem and its consequences on public health have been hampered by a lack of adequate measures and methods. This study explores the spatial potential accessibility to mental health services in a heterogeneous urban environment and evaluates inequities in access to services in deprived areas.

METHODS

The study examines the spatial accessibility to mental health services in the Island of Montreal. All mental health services were geocoded from the six-digital postal code using the software ArcGIS 9.3. Accessibility was assessed through the two step floating catchment area method using the shortest route through a road network more often called reticular distance. This method takes into account the whole population, which is considered as the potential demand.

RESULTS

In general, accessibility to mental health services seems high in Montreal. It can be seen that at a distance of 1 km, nearly 90% of the territory is accessible. However, we also note that accessibility scores greatly diminish with distance. At 1 km, there are about 10.05 services for 10,000 persons and at 3 km, there is only 1.12 services for 10,000 persons. Over 50% of non-accessible areas are concentrated in the first quartile of deprivation and less than 10% are found in the fourth quartile, indicating good accessibility in severely deprived areas.

CONCLUSION

Accessibility to health services will always be the dominant issue debate in developing and undeveloped countries over the next decade. It is therefore urgent to develop technical and methodological tools to study and anticipate areas that may face services' shortage.

Regional surveillance of social and geographic inequalities in smoking: the case of Montréal, Canada

Surveillance of social inequalities in health is a platform for action. We examined the trends in smoking behaviours (current and ever smoking, quit ratios) according to education and place of residence and we quantified the observed inequalities. Data were from repeated cross-sectional surveys (2003-2009) of Montreal (Canada) residents ≥15 years (n=12,053). Trends in smoking behaviours according to education were measured with logistic and log-binomial regressions. Spatial distribution of smoking behaviours across local areas was assessed with Morans' Index. Observed inequalities were quantified with prevalence ratio and difference, population attributable risk, and slope index of inequality. Results showed that ever smoking rose among low-educated individuals. Among their high-educated fellow-citizens, current smoking decreased and quit ratios increased. Adverse smoking behaviours (current and ever smoking) were clustered in south-central areas. We conclude that smoking inequalities in Montreal are growing. We thus encourage a closer monitoring of smoking social differentials.

The effects of publishing emergency department wait time on patient utilization patterns in a community with two emergency department sites: a retrospective, quasi-experiment design

BACKGROUND

Providing emergency department (ED) wait time information to the public has been suggested as a mechanism to reduce lengthy ED wait times (by enabling patients to select the ED site with shorter wait time), but the effects of such a program have not been evaluated. We evaluated the effects of such a program in a community with two ED sites.

METHODS

Descriptive statistics for wait times of the two sites before and after the publication of wait time information were used to evaluate the effects of the publication of wait time information on wait times. Multivariate logistical regression was used to test whether or not individual patients used published wait time to decide which site to visit.

RESULTS

We found that the rates of wait times exceeding 4 h, and the 95th percentile of wait times in the two sites decreased after the publication of wait time information, even though the average wait times experienced a slight increase. We also found that after controlling for other factors, the site with shorter wait time had a higher likelihood of being selected after the publication of wait time information, but there was no such relationship before the publication.

CONCLUSIONS

These findings were consistent with the hypothesis that the publication of wait time information leads to patients selecting the site with shorter wait time. While publishing ED wait time information did not improve average wait time, it reduced the rates of lengthy wait times.