How much of the difference in life expectancy between Scottish cities does deprivation explain?

The right to the unhealthy deprived city: An exploration into the impacts of state-led redevelopment projects on the determinants of mental health

Research shows mental health is impacted by poor-quality physical and social-environmental conditions. Subsequently state-led redevelopment/regeneration schemes focus on improving the physical environment, to provide better social-environmental conditions, addressing spatial and socioeconomic inequities thus improving residents' health. However, recent research suggests that redevelopment/regeneration schemes often trigger gentrification, resulting in new spatial and socioeconomic inequalities that may worsen health outcomes, including mental health, for long-term neighborhood residents. Using the right to the city and situating this within the framework of accumulation by dispossession and capitalist hegemony, this paper explores the potential mechanisms in which poor mental health outcomes may endure in neighborhoods despite the implementation of redevelopment/regeneration projects. To do so, we explored two neighborhoods in the city of Glasgow - North Glasgow and East End - and conducted a strong qualitative study based on 25 in-depth semi-structured interviews with key stakeholders. The results show that postindustrial vacant and derelict land spaces and socioeconomic deprivation in North and East Glasgow are potential mechanisms contributing to the poor mental health of its residents. Where redevelopment/regeneration projects prioritize economic goals, it is often at the expense of social(health) outcomes. Instead, economic investment instigates processes of gentrification, where long-term neighborhood residents are excluded from accessing collective urban life and its (health) benefits. Moreover, these residents are continually excluded from participation in decision-making and are unable to shape the urban environment. In summary, we found a number of potential mechanisms that may contribute to enduring poor mental health outcomes despite the existence of redevelopment/regeneration projects. Projects instead have negative consequences for the determinants of mental health, reinforcing existing inequalities, disempowering original long-term neighborhood residents and only providing the "right" to the unhealthy deprived city. We define this as the impossibility to benefit from material opportunities, public spaces, goods and services and the inability to shape city transformations.

How Should We Measure Social Deprivation in Orthopaedic Patients?

BACKGROUND

Social deprivation negatively affects a myriad of physical and behavioral health outcomes. Several measures of social deprivation exist, but it is unclear which measure is best suited to describe patients with orthopaedic conditions.

QUESTIONS/PURPOSES

(1) Which measure of social deprivation, defined as "limited access to society's resources due to poverty, discrimination, or other disadvantage," is most strongly and consistently correlated with patient-reported physical and behavioral health in patients with orthopaedic conditions? (2) Compared with the use of a single measure alone, how much more variability in patient-reported health does the simultaneous use of multiple social deprivation measures capture?

METHODS

Between 2015 and 2017, a total of 79,818 new patient evaluations occurred within the orthopaedic department of a single, large, urban, tertiary-care academic center. Over that period, standardized collection of patient-reported health measures (as described by the Patient-reported Outcomes Measurement Information System [PROMIS]) was implemented in a staged fashion throughout the department. We excluded the 25% (19,926) of patient encounters that did not have associated PROMIS measures reported, which left 75% (59,892) of patient encounters available for analysis in this cross-sectional study of existing medical records. Five markers of social deprivation were collected for each patient: national and state Area Deprivation Index, Medically Underserved Area Status, Rural-Urban Commuting Area code, and insurance classification (private, Medicare, Medicaid, or other). Patient-reported physical and behavioral health was measured via PROMIS computer adaptive test domains, which patients completed as part of standard care before being evaluated by a provider. Adults completed the PROMIS Physical Function version 1.2 or version 2.0, Pain Interference version 1.1, Anxiety version 1.0, and Depression version 1.0. Children ages 5 to 17 years completed the PROMIS Pediatric Mobility version 1.0 or version 2.0, Pain Interference version 1.0 or version 2.0, Upper Extremity version 1.0, and Peer Relationships version 1.0. Age-adjusted partial Pearson correlation coefficients were determined for each social deprivation measure and PROMIS domain. Coefficients of at least 0.1 were considered clinically meaningful for this purpose. Additionally, to determine the percentage of PROMIS score variability that could be attributed to each social deprivation measure, an age-adjusted hierarchical regression analysis was performed for each PROMIS domain, in which social deprivation measures were sequentially added as independent variables. The model coefficients of determination (r2) were compared as social deprivation measures were incrementally added. Improvement of the r2 by at least 10% was considered clinically meaningful.

RESULTS

Insurance classification was the social deprivation measure with the largest (absolute value) age-adjusted correlation coefficient for all adult and pediatric PROMIS physical and behavioral health domains (adults: correlation coefficient 0.40 to 0.43 [95% CI 0.39 to 0.44]; pediatrics: correlation coefficient 0.10 to 0.19 [95% CI 0.08 to 0.21]), followed by national Area Deprivation Index (adults: correlation coefficient 0.18 to 0.22 [95% CI 0.17 to 0.23]; pediatrics: correlation coefficient 0.08 to 0.15 [95% CI 0.06 to 0.17]), followed closely by state Area Deprivation Index. The Medically Underserved Area Status and Rural-Urban Commuting Area code each had correlation coefficients of 0.1 or larger for some PROMIS domains but neither had consistently stronger correlation coefficients than the other. Except for the PROMIS Pediatric Upper Extremity domain, consideration of insurance classification and the national Area Deprivation Index together explained more of the variation in age-adjusted PROMIS scores than the use of insurance classification alone (adults: r2 improvement 32% to 189% [95% CI 0.02 to 0.04]; pediatrics: r2 improvement 56% to 110% [95% CI 0.01 to 0.02]). The addition of the Medically Underserved Area Status, Rural-Urban Commuting Area code, and/or state Area Deprivation Index did not further improve the r2 for any of the PROMIS domains.

CONCLUSION

To capture the most variability due to social deprivation in orthopaedic patients' self-reported physical and behavioral health, insurance classification (categorized as private, Medicare, Medicaid, or other) and national Area Deprivation Index should be included in statistical analyses. If only one measure of social deprivation is preferred, insurance classification or national Area Deprivation Index are reasonable options. Insurance classification may be more readily available, but the national Area Deprivation Index stratifies patients across a wider distribution of values. When conducting clinical outcomes research with social deprivation as a relevant covariate, we encourage researchers to consider accounting for insurance classification and/or national Area Deprivation Index, both of which are freely available and can be obtained from data that are typically collected during routine clinical care.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Ten-year mortality and long-term visual acuity outcomes in patients with exudative age-related macular degeneration treated with intravitreal anti-vascular endothelial growth factor injections

PURPOSE

There are limited real-world data on long-term mortality and visual outcomes in patients treated with anti-vascular endothelial growth factor (VEGF) for exudative age-related macular degeneration (exudative AMD). We assessed 10-year mortality and clinical outcomes in exudative AMD patients treated with intravitreal therapy (IVT) anti-VEGF injections on a pro-re-nata (PRN) regime following a standard loading regime.

METHODS

Retrospective cohort study of the first 216 exudative AMD patients receiving IVT anti-VEGF for exudative AMD at a public tertiary referral hospital in Scotland. Main outcome measures were mortality, cause of death and best-corrected visual acuity (BCVA).

RESULTS

A total of 216 patients were included. Mean age at presentation was 79.1 years [standard deviation (SD) 6.9]. Mean follow-up duration was 6.6 years (SD 3.2) during which there was a mean 24.3 Early Treatment Diabetic Retinopathy Study (ETDRS) letter loss in BCVA (P < 0.0001). Patients received a mean of 2.2 (SD 1.8) injections per year of follow-up. Overall, 52.6% (113/216) died during the period studied. Observed annual mortality incidence risk was 6.5% (SD 3.1) and was found to be significantly lower (P = 0.0064) than the expected annual death incidence risk (9.6%, SD 1.5) based on age and sex standardised Scottish mortality risk. The most common causes of death were malignancies (21.3%) and infection (20.0%).

CONCLUSIONS

This study highlights the relatively good long-term prognosis in vision and mortality in exudative AMD treated with a PRN regime in the real world. Although the majority lost vision, the rate of decline was significantly slower than that which would have been experienced in the pre-anti-VEGF era and reassuringly standardised mortality risk was lower than the national average.

Life expectancy and mortality in 363 cities of Latin America

The concept of a so-called urban advantage in health ignores the possibility of heterogeneity in health outcomes across cities. Using a harmonized dataset from the SALURBAL project, we describe variability and predictors of life expectancy and proportionate mortality in 363 cities across nine Latin American countries. Life expectancy differed substantially across cities within the same country. Cause-specific mortality also varied across cities, with some causes of death (unintentional and violent injuries and deaths) showing large variation within countries, whereas other causes of death (communicable, maternal, neonatal and nutritional, cancer, cardiovascular disease and other noncommunicable diseases) varied substantially between countries. In multivariable mixed models, higher levels of education, water access and sanitation and less overcrowding were associated with longer life expectancy, a relatively lower proportion of communicable, maternal, neonatal and nutritional deaths and a higher proportion of deaths from cancer, cardiovascular disease and other noncommunicable diseases. These results highlight considerable heterogeneity in life expectancy and causes of death across cities of Latin America, revealing modifiable factors that could be amenable to urban policies aimed toward improving urban health in Latin America and more generally in other urban environments.

City-level analysis of data from the SALURBAL project shows vast heterogeneity in life expectancy across cities within the same country, in addition to substantive differences in causes of death among nine Latin American countries, revealing modifiable factors that could be leveraged by municipal-level policies aimed toward improving health in urban environments.

Perceived Neighbourhood Problems over Time and Associations with Adiposity

There is growing interest in understanding which aspects of the local environment influence obesity. Using data from the longitudinal West of Scotland Twenty-07 study (n = 2040) we examined associations between residents’ self-reported neighbourhood problems, measured over a 13-year period, and nurse-measured body weight and size (body mass index, waist circumference, waist–hip ratio) and percentage body fat. We also explored whether particular measures such as abdominal obesity, postulated as a marker for stress, were more strongly related to neighbourhood conditions. Using life course models adjusted for sex, cohort, household social class, and health behaviours, we found that the accumulation of perceived neighbourhood problems was associated with percentage body fat. In cross-sectional analyses, the strongest relationships were found for contemporaneous measures of neighbourhood conditions and adiposity. When analyses were conducted separately by gender, perceived neighbourhood stressors were strongly associated with central obesity measures (waist circumference, waist–hip ratio) among both men and women. Our findings indicate that chronic neighbourhood stressors are associated with obesity. Neighbourhood environments are modifiable, and efforts should be directed towards improving deleterious local environments to reduce the prevalence of obesity.

Obesity in Scotland: a persistent inequality

BACKGROUND

Obesity is a health problem in its own right and a risk factor for other conditions such as cardiovascular disease. The prevalence of overweight and obesity increased in Scotland between 1995 and 2008 with socio-economic inequalities persisting in adults over time and increasing in children. This paper explores changes in the underlying distribution of body mass index (BMI) which is less well understood.

METHODS

Using data from the Scottish Health Survey (SHeS) between 1995 and 2014 for adults aged 18-64 years, we calculated population distributions for BMI for the population overall, and for age, sex and deprivation strata. We used SHeS data for children aged 2-15 years between 1998 and 2014, in addition to data from the Child Health Systems Programme (CHSP) collected from primary one (P1) children in participating local authorities, to describe the overall trends and to compare trends in inequalities by deprivation strata.

RESULTS

Amongst adults, the BMI distribution shifted upwards, with a large proportion of the population gaining a small amount of weight between 1995 and 2008 before subsequently stabilising across the distribution. In men the prevalence of obesity showed a linear deprivation gradient in 1995 but over time obesity declined in the least deprived quintile while the remaining four quintiles converged (and stabilised). In contrast, a persistent and generally linear gradient is evident among women for most of the 1995-2014 period. For those aged 2-15 years, obesity increased between 1998 and 2014 for the most deprived 40% of children contrasted with stable trends for the least deprived. The surveillance data for P1 children in Scotland showed a persistent inequality between 2005/06 and 2014/15 though it was less clear if this is widening.

CONCLUSIONS

The BMI distribution for adults increased between 1995 and 2008 with a large proportion of the population gaining a small amount of weight before stabilising across the distribution. Inequalities in obesity persist for adults (with different underlying patterns evident for men and women), and may be widening for children. Actions to reduce the obesogenic environment, including structural changes not dependent on individual agency, are urgently needed if the long-term health, social and inequality consequences of obesity are to be reduced.