Neighborhood characteristics as determinants of healthcare utilization - a theoretical model

Neighborhood Collective Efficacy: A Longitudinal Social Determinant of Access to Medical Care Among Recently Immigrated Latina Young Adults

The present longitudinal study examined changes in perceived access to health care among a recently immigrated cohort of Latina young adults who were assessed annually during their first 3 years in the United States. A parallel process growth model of perceived access to health care and neighborhood collective efficacy was examined, accounting for socioeconomic indicators and immigration status. Five hundred thirty Latina young adults (ages 18-23) participated at baseline assessment, and approximately 95% were retained over three annual assessment time points. Participants' mean level of perceived access to health care increased during their initial 3 years in the United States. Women who reported more of an increase in perceived access to health care tended to also indicate increased neighborhood collective efficacy relative to their peers during their first 3 years in the United States. Findings offer important information about the individual- and community-level factors that influence recently immigrated Latinas' health care access.

Geospatial Imprecision With Constraints for Precision Public Health: Algorithm Development and Validation

BACKGROUND

Location and environmental social determinants of health are increasingly important factors in both an individual's health and the monitoring of community-level public health issues.

OBJECTIVE

We aimed to measure the extent to which location obfuscation techniques, designed to protect an individual's privacy, can unintentionally shift geographical coordinates into neighborhoods with significantly different socioeconomic demographics, which limits the precision of findings for public health stakeholders.

METHODS

Point obfuscation techniques intentionally blur geographic coordinates to conceal the original location. The pinwheel obfuscation method is an existing technique in which a point is moved along a pinwheel-like path given a randomly chosen angle and a maximum radius; we evaluate the impact of this technique using 2 data sets by comparing the demographics of the original point and the resulting shifted point by cross-referencing data from the United States Census Bureau.

RESULTS

Using poverty measures showed that points from regions of low poverty may be shifted to regions of high poverty; similarly, points in regions with high poverty may be shifted into regions of low poverty. We varied the maximum allowable obfuscation radius; the mean difference in poverty rate before and after obfuscation ranged from 6.5% to 11.7%. Additionally, obfuscation inadvertently caused false hot spots for deaths by suicide in Cook County, Illinois.

CONCLUSIONS

Privacy concerns require patient locations to be imprecise to protect against risk of identification; precision public health requires accuracy. We propose a modified obfuscation technique that is constrained to generate a new point within a specified census-designated region to preserve both privacy and analytical accuracy by avoiding demographic shifts.

Measuring SARS-CoV-2 RNA concentrations in neighborhood wastewater

Longitudinal wastewater sampling during the COVID-19 pandemic was an important aspect of disease surveillance, adding to a more complete understanding of infection dynamics and providing important data for community public health monitoring and intervention planning. This was largely accomplished by testing SARS-CoV-2 RNA concentrations in samples from municipal wastewater treatment plants (WWTPs). We evaluated the utility of testing for virus levels upstream from WWTP within the residential neighborhoods that feed into the WWTP. We propose that monitoring virus dynamics across residential neighborhoods could reveal important public health-relevant information about community sub-group heterogeneity in virus concentrations. PRINCIPAL RESULTS: Virus concentration patterns display heterogeneity within neighborhoods and between neighborhoods over time. Sewage SARS-CoV-2 RNA concentrations as measured by RT-qPCR also corresponded closely to verified COVID-19 infection counts within individual neighborhoods. More importantly, our data suggest the loss of disease-relevant public health information when sampling occurs only at the level of WWTP instead of upstream in neighborhoods. Spikes in SARS-CoV-2 RNA concentrations in neighborhoods are often masked by dilution from other neighborhoods in the WWTP samples. MAJOR CONCLUSIONS: Wastewater-based epidemiology (WBE) employed at WWTP reliably detects SARS-CoV-2 in a city-sized population but provides less actionable public health information about neighborhoods experiencing greater viral infection and disease. Neighborhood sewershed sampling reveals important population-based information about local virus dynamics and improves opportunities for public health intervention. Longitudinally employed, neighborhood sewershed surveillance may provide a 3-6 day early warning of SARS-CoV-2 infection spikes and, importantly, highly specific information on subpopulations in a community particularly at higher risk at different points in time. Sampling in neighborhoods may thus provide timely and cost-saving information for targeted interventions within communities.

An evaluation of the impact of social and structural determinants of health on forgone care during the COVID-19 pandemic in Baltimore, Maryland

Evidence suggests that reductions in healthcare utilization, including forgone care, during the COVID-19 pandemic may be contributing towards excess morbidity and mortality. The objective of this study was to describe individual and community-level correlates of forgone care during the COVID-19 pandemic. We conducted a cross-sectional, secondary data analysis of participants (n = 2,003) who reported needing healthcare in two population-representative surveys conducted in Baltimore, MD in 2021 and 2021-2022. Abstracted data included the experience of forgone care, socio-demographic data, comorbidities, financial strain, and community of residence. Participant's community of residence were linked with data acquired from the Baltimore Neighborhood Indicators Alliance relevant to healthcare access and utilization, including walkability and internet access, among others. The data were analyzed using weighted random effects logistic regression. Individual-level factors found to be associated with increased odds for forgone care included individuals age 35-49 (compared to 18-34), female sex, experiencing housing insecurity during the pandemic, and the presence of functional limitations and mental illness. Black/African American individuals were found to have reduced odds of forgone care, compared to any other race. No community-level factors were significant in the multilevel analyses. Moving forward, it will be critical that health systems identify ways to address any barriers to care that populations might be experiencing, such as the use of mobile health services or telemedicine platforms. Additionally, public health emergency preparedness planning efforts must account for the unique needs of communities during future crises, to ensure that their health needs can continue to be met. Finally, additional research is needed to better understand how healthcare access and utilization practices have changed during versus before the pandemic.

Systematic review of individual-level, community-level, and healthcare system-level factors contributing to socioeconomic differences in healthcare utilisation in OECD countries with universal health coverage

OBJECTIVES

Countries with universal health coverage (UHC) strive for equal access for equal needs without users getting into financial distress. However, differences in healthcare utilisation (HCU) between socioeconomic groups have been reported in countries with UHC. This systematic review provides an overview individual-level, community-level, and system-level factors contributing to socioeconomic status-related differences in HCU (SES differences in HCU).

DESIGN

Systematic review following the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines. The review protocol was published in advance.

DATA SOURCES

Embase, PubMed, Web of Science, Scopus, Econlit, and PsycInfo were searched on 9 March 2021 and 9 November 2022.

ELIGIBILITY CRITERIA

Studies that quantified the contribution of one or more factors to SES difference in HCU in OECD countries with UHC.

DATA EXTRACTION AND SYNTHESIS

Studies were screened for eligibility by two independent reviewers. Data were extracted using a predeveloped data-extraction form. Risk of bias (ROB) was assessed using a tailored version of Hoy's ROB-tool. Findings were categorised according to level and a framework describing the pathway of HCU.

RESULTS

Of the 7172 articles screened, 314 were included in the review. 64% of the studies adjusted for differences in health needs between socioeconomic groups. The contribution of sex (53%), age (48%), financial situation (25%), and education (22%) to SES differences in HCU were studied most frequently. For most factors, mixed results were found regarding the direction of the contribution to SES differences in HCU.

CONCLUSIONS

SES differences in HCU extensively correlated to factors besides health needs, suggesting that equal access for equal needs is not consistently accomplished. The contribution of factors seemed highly context dependent as no unequivocal patterns were found of how they contributed to SES differences in HCU. Most studies examined the contribution of individual-level factors to SES differences in HCU, leaving the influence of healthcare system-level characteristics relatively unexplored.

Neighbourhood socioeconomic position, prenatal care and fulfilment of postpartum permanent contraception: Findings from a multisite cohort study

Introduction

Research suggests neighbourhood socioeconomic vulnerability is negatively associated with women's likelihood of receiving adequate prenatal care and achieving desired postpartum permanent contraception. Receiving adequate prenatal care is linked to a greater likelihood of achieving desired permanent contraception, and access to such care may be critical for women with Medicaid insurance given that the federally mandated Medicaid sterilization consent form must be signed at least 30 days before the procedure. We examined whether adequacy of prenatal care mediates the relationship between neighbourhood socioeconomic position and postpartum permanent contraception fulfilment, and examined moderation of relationships by insurance type.

Methods

This secondary analysis of a retrospective cohort study examined 3012 Medicaid or privately insured individuals whose contraceptive plan at postpartum discharge was permanent contraception. Path analysis estimated relationships between neighbourhood socioeconomic position (economic hardship and inequality, financial strength and educational attainment) and permanent contraception fulfilment by hospital discharge, directly and indirectly through adequacy of prenatal care. Multigroup testing examined moderation by insurance type.

Results

After adjusting for age, parity, weeks of gestation at delivery, mode of delivery, race, ethnicity, marital status and body mass index, having adequate prenatal care predicted achieving desired sterilization at discharge (β = 0.065, 95% confidence interval [CI]: 0.011, 0.117). Living in neighbourhoods with less economic hardship (indirect effect -0.007, 95% CI: -0.015, -0.001), less financial strength (indirect effect -0.016, 95% CI: -0.030, -0.002) and greater educational attainment (indirect effect 0.012, 95% CI: 0.002, 0.023) predicted adequate prenatal care, in turn predicting achievement of permanent contraception by discharge. Insurance status conditioned some of these relationships.

Conclusion

Contact with the healthcare system via prenatal care may be a mechanism by which neighbourhood socioeconomic disadvantage affects permanent contraception fulfilment, particularly for patients with Medicaid. To promote reproductive autonomy and healthcare equity, future inquiry and policy might closely examine how neighbourhood social and economic characteristics interact with Medicaid mandates.

Disease awareness and healthcare utilization in rural South Africa: a comparative analysis of HIV and diabetes in the HAALSI cohort

BACKGROUND

Studies from rural South Africa indicate that people living with HIV (PLHIV) may have better health outcomes than those without, potentially due to the frequent healthcare visits necessitated by infection. Here, we examined the association between HIV status and healthcare utilization, using diabetes as an illustrative comparator of another high-burden, healthcare-intensive disease.

METHODS

Our exposure of interest was awareness of positive disease status for both HIV and diabetes. We identified 742 individuals who were HIV-positive and aware of their status and 305 who had diabetes and were aware of their status. HIV-positive status was further grouped by viral suppression. For each disease, we estimated the association with (1) other comorbid, chronic conditions, (2) health facility visits, (3) household-level healthcare expenditure, and (4) per-visit healthcare expenditure. We used log-binomial regression models to estimate prevalence ratios for co-morbid chronic conditions. Linear regression models were used for all other outcomes.

RESULTS

Virally suppressed PLHIV had decreased prevalence of chronic conditions, increased public clinic visits [β = 0.59, 95% CI: 0.5, 0.7], and reduced per-visit private clinic spending [β = -60, 95% CI: -83, -6] compared to those without HIV. No differences were observed in hospitalizations and per-visit spending at hospitals and public clinics between virally suppressed PLHIV and non-PLHIV. Conversely, diabetic individuals had increased prevalence of chronic conditions, increased visits across facility types, increased household-level expenditures (β = 88 R, 95% CI: 29, 154), per-visit hospital spending (β = 54 R, 95% CI: 7, 155), and per-visit public clinic spending (β = 31 R, 95% CI: 2, 74) compared to those without diabetes.

CONCLUSIONS

Our results suggest that older adult PLHIV may visit public clinics more often than their HIV-negative counterparts but spend similarly on a per-visit basis. This provides preliminary evidence that the positive health outcomes observed among PLHIV in rural South Africa may be explained by different healthcare engagement patterns. Through our illustrative comparison between PLHIV and diabetics, we show that shifting disease burdens towards chronic and historically underfunded diseases, like diabetes, may be changing the landscape of health expenditure inequities.

Disparities in Successful Discharge to the Community Following Use of Medicare Home Health by Level of Neighborhood Socioeconomic Disadvantage

Considering the importance of social and structural support and resources in recovering health, where people reside could lead to differences in health outcome in Medicare home health care. We used the 2019 Outcome and Assessment Information Set and Area Deprivation Index to examine the association between neighborhood context and successful discharge to community among older Medicare home health care users. Based on the multivariable logistic regression (OR: 0.84; 95% CI, 0.83-0.85) and conditional logistic regression models stratified by home health agency (OR: 0.95; 95% CI, 0.94-0.95), patients living in the most disadvantaged neighborhoods were less likely to experience successful discharge to community than others. Furthermore, the predicted probability of successful discharge to community decreased as the percentage of patients from the most disadvantaged neighborhoods within a home health agency increased. Policymakers should consider using area-level interventions and supports to reduce disparities in Medicare home health care.

The Association of Neighborhood Characteristics and Frailty in Childhood Cancer Survivors: A Report from the St. Jude Lifetime Cohort Study

BACKGROUND

Childhood cancer survivors experience reduced physiologic reserve, or frailty, earlier and more frequently than peers. In other populations, frailty is impacted by one's neighborhood. This study's purpose was to evaluate associations between neighborhood characteristics and frailty in childhood cancer survivors.

METHODS

Participants in the St. Jude Lifetime Cohort Study with geocoded residential addresses were analyzed. Pre-frailty/Frailty was defined as having 1-2/≥3 of sarcopenia, muscle weakness, poor endurance, slow walking speed, and exhaustion from direct assessments. Neighborhood characteristics [e.g., access to exercise opportunities and healthy food, neighborhood socioeconomic status (nSES), and rurality/urbanicity] were determined using publicly available geospatial data. Nested multivariable logistic regression models identified associations between neighborhood characteristics and pre-frailty/frailty, adjusting for chronic health conditions, individual health behaviors and socio-demographics, and high-risk cancer treatment exposures.

RESULTS

For our cohort (N = 3,806, 46.79% female, 81.40% white, mean age 33.63±9.91 years), compared with non-frail survivors (n = 2,573; 67.6%), pre-frail (n = 900; 23.6%) and frail survivors (n = 333; 8.7%) were more likely to live in neighborhoods with decreased exercise opportunities (frail OR: 1.62, 1.26-2.09), reduced healthy food access (pre-frail OR: 1.28, 1.08-1.51; frail OR: 1.36, 1.06-1.75), and lower nSES (pre-frail OR: 1.31, 1.12-1.52; frail OR: 1.64, 1.30-2.07). Participants had 8% increased odds (95% confidence interval, 2%-14%) of being pre-frail/frail if they lived in "resource poor" neighborhoods as opposed to "resource rich" neighborhoods after adjusting for other pre-frailty/frailty risk factors.

CONCLUSIONS

The neighborhood a childhood cancer survivor resides in as an adult is associated with pre-frailty/frailty.

IMPACT

This study provides valuable information for creating interventions using neighborhood-level factors to mitigate frailty and improve health outcomes in survivors. See related commentary by Bhandari and Armenian, p. 997.

Community-level socioeconomic distress is associated with nutritional status in adults with sickle cell anemia

Sickle cell anemia (SCA) negatively impacts the ability to achieve educational and occupational goals increasing vulnerability to socioeconomic challenges. In a cross-sectional analysis of 332 SCA adults, we investigated whether the distressed community index (DCI) was associated with SCA-related complications and nutritional status. More patients with higher DCI had Medicaid insurance. A higher DCI was independently associated with tobacco use and lower body mass index, serum albumin, and vitamin D 25-OH levels after adjusting for insurance status but was not associated with SCA-related complications. Future studies investigating access to healthy foods may help improve health equity in patients with SCA.

Neighbourhood characteristics, lifestyle factors, and child development: Secondary analysis of the All our families cohort study

Background

Neighbourhood characteristics have been found to influence child development, but little is known about lifestyle factors that may moderate this relationship, which can provide modifiable targets for policies and programing. This study investigated the association between neighbourhood characteristics (e.g., deprivation, disorder) during pregnancy and child development at age 5 in relation to various lifestyle factors (e.g., physical activity, parent-child reading, community resource use) during early childhood.

Methods

A secondary analysis was conducted using multilevel modeling of data from the All Our Families cohort, recruited in Canada from 2008 to 2010. Participants self-reported on demographics during pregnancy, lifestyle factors at 3 years, and child development at 5 years using the Ages and Stages Questionnaire (ASQ-3). Neighbourhood deprivation was evaluated using the Vancouver Area Deprivation Index (VANDIX), while disorder was measured using police services' community crime reports.

Results

Geocoded information was available for 2,444 participants. After adjusting for covariates, multilevel modeling indicated a significant negative association between neighbourhood deprivation and overall child development (b = -.726, 95% CI: -1.344, -.120). Parent-child reading was found to be a significant moderator of the effect of neighbourhood disorder (b = .005, 95% CI: .001, .009). There were no statistically significant moderation effects for physical activity or community resource use.

Conclusion

Neighbourhood deprivation during pregnancy is associated with early child development. Parent-child reading may function as a protective factor in the presence of higher neighbourhood disorder. Overall, neighbourhood-level effects should be considered in policies and community programs that promote family and child well-being.

Community characteristics and the risk of non-communicable diseases in Ghana

Non-communicable Diseases (NCDs) are rising quickly in low- and middle- income countries. In Ghana, chronic diseases are major causes of morbidity and mortality, yet data and the evidence- base for awareness, detection, and management of NCDs are lacking. Using data from the 2014 Ghana Demographic and Health Survey (GDHS), the first national study with information on hypertension and other risk factors, we examine the correlates and community characteristics associated with the risk of hypertension, obesity, and anemia among women. We find that hypertension prevalence in Ghana was 16 percent and 17 percent were overweight/obese, while 41 percent had anemia of any form. On community characteristics, the level of poverty in a community was significantly associated with lower risks of all three NCDs, while the aggregate level of employment had higher risks. On individual characteristics, the wealth of a household, women's educational level and urban residence were significant predictors of NCDs. We interpret the findings within the literature on neighborhood characteristics, the social gradient of health and in the context of speeding up the attainment of the Sustainable Development Goals (SGDS) to reduce premature deaths by one-third by 2030.

Methodological Challenges in Spatial and Contextual Exposome-Health Studies

The concept of the exposome encompasses the totality of exposures from a variety of external and internal sources across an individual's life course. The wealth of existing spatial and contextual data makes it appealing to characterize individuals' external exposome to advance our understanding of environmental determinants of health. However, the spatial and contextual exposome is very different from other exposome factors measured at the individual-level as spatial and contextual exposome data are more heterogenous with unique correlation structures and various spatiotemporal scales. These distinctive characteristics lead to multiple unique methodological challenges across different stages of a study. This article provides a review of the existing resources, methods, and tools in the new and developing field for spatial and contextual exposome-health studies focusing on four areas: (1) data engineering, (2) spatiotemporal data linkage, (3) statistical methods for exposome-health association studies, and (4) machine- and deep-learning methods to use spatial and contextual exposome data for disease prediction. A critical analysis of the methodological challenges involved in each of these areas is performed to identify knowledge gaps and address future research needs.

Household and area determinants of emergency department attendance and hospitalisation in people with multimorbidity: a systematic review

OBJECTIVES

Multimorbidity is one of the greatest challenges facing healthcare internationally. Emergency department (ED) attendance and hospitalisation rates are higher in people with multimorbidity, but most research focuses on associations with individual characteristics, ignoring household or area mediators of service use.

DESIGN

Systematic review reported using the synthesis without meta-analysis framework.

DATA SOURCES

Twelve electronic databases (1 January 2000-21 September 2021): MEDLINE/OVID, Embase, Global Health, PsycINFO, ASSIA, CAB Abstracts, Science Citation Index Expanded/ISI Web of Science, Scopus, Cumulative Index to Nursing and Allied Health Literature, Sociological Abstracts, the Cochrane Library, and OpenGrey.

ELIGIBILITY CRITERIA

Adults aged ≥16 years, with multimorbidity. Exposure(s) were household and/or area determinants of health. Outcomes were ED attendance and/or hospitalisation. The literature search was limited to publications in English.

DATA EXTRACTION AND SYNTHESIS

Independent double screening of titles and abstracts to select relevant full-text studies. Methodological quality was assessed using an adaptation of the Newcastle-Ottawa Quality Assessment Scale tool. Given high study heterogeneity, narrative synthesis was performed.

RESULTS

After deduplication, 10 721 titles and abstracts were screened, and 142 full-text articles were reviewed, of which 10 were eligible for inclusion. In people with multimorbidity, household food insecurity was associated with hospitalisation (OR 1.58 (95% CI 1.06 to 2.36) in concordant multimorbidity). People with multimorbidity living in the most versus least deprived areas attended ED more frequently (8.9% (95% CI 8.6 to 9.1) in most versus 6.3% (95% CI 6.1 to 6.6) in least), had higher rates of hospitalisation (26% in most versus 22% in least), and higher probability of hospitalisation (6.4% (95% CI 5.8 to 7.2) in most versus 4.2% (95% CI 3.8 to 4.7) in least). There was non-conclusive evidence that household income is associated with ED attendance and hospitalisation. No statistically significant relationships were found between marital status, living with others with multimorbidity, or rurality with ED attendance or hospitalisation.

CONCLUSIONS

There is some evidence that household and area contexts mediate associations of multimorbidity with ED attendance and hospitalisation, but firm conclusions are constrained by the small number of studies published and study design heterogeneity. Further research is required on large population samples using robust analytical methods.

PROSPERO REGISTRATION NUMBER

CRD42021283515.

Patient characteristics and neighborhood attributes associated with hepatitis C screening and positivity in Philadelphia

Among patients of an urban primary care network in Philadelphia with a universal hepatitis C virus (HCV) screening policy for patients born during 1945-1965, we examined whether being unscreened and HCV positivity were associated with attributes of the census tracts where patients resided, which we considered as proxies for social health determinants. For patients with at least one clinic visit between 2014 and mid-2017, we linked demographic and HCV screening information from electronic health records with metrics that described the census tracts where patients resided. We used generalized estimating equations to estimate adjusted relative risk ratios (aRRs) for being unscreened and HCV positive. Overall, 28% of 6,906 patients were unscreened. Black race, male gender, and residence in census tracts with relatively high levels of violent crime, low levels of educational attainment and household incomes, and evidence of residential segregation by Hispanic ethnicity were associated with lower aRRs for being unscreened. Among screened patients, 9% were HCV positive. Factors associated with lower risks of being unscreened were, in general, associated with higher HCV positivity. Attributes of census tracts where patients reside are probably less apparent to clinicians than patients' gender or race but might reflect unmeasured patient characteristics that affected screening practices, along with preconceptions regarding the likelihood of HCV infection based on prior screening observations or implicit biases. Approaching complete detection of HCV-infected people would be hastened by focusing on residents of census tracts with attributes associated with higher infection levels or, if known, higher infection levels directly.

Social vulnerability, exposure to environmental risk factors, and accessibility of healthcare services: Evidence from 2,000+ informal settlements in Argentina

Globally, the question of how to improve the living standards of the inhabitants of informal settlements is a key political concern. These neighborhoods are characterized by economic vulnerability, social marginalization, and inaccessibility of basic services. The aim of this study is to provide evidence about the environmental risk factors faced by these populations in Argentina, and to identify whether their greater exposure to risk factors is associated with greater accessibility of healthcare services. We analyzed an original database that provides information about basic characteristics of the neighborhood, environmental risk factors (proximity to garbage dumps, industrial waste, and high-voltage towers), and accessibility of basic healthcare services on over 2000 informal settlements in Argentina. We calculated descriptive statistics and developed multivariate econometric models to estimate the probability of accessibility of healthcare services. On average, 31% of informal settlements were close to a garbage dump, 19% were close to a high-voltage tower, and 10% were close to industrial waste. In addition, 39% of these neighborhoods do not have a healthcare center nearby, 65% do not have an accessible hospital, and 39% are not consistently served by ambulances in the event of an emergency. The econometric estimates suggest that the accessibility of hospital healthcare service and to an ambulance service is positively associated with the age of the neighborhood, and whether the neighborhood is a slum, but there is no evidence of association with the exposure to environmental risk factors. In short, the populations living in informal settlements in Argentina are exposed to harmful environmental risk factors. Access to basic healthcare services is limited and does not reflect the elevated exposure to environmental risks. Health, environmental, and economic dimensions should be considered when designing and implementing public policies for vulnerable populations.

Residential Area Socioeconomic Deprivation is Associated with Physical Dependency and Polypharmacy in Community-Dwelling Older Adults: An Analysis of Health Administrative Data in Ireland

Introduction

Socioeconomic disadvantage is associated with multiple adverse health outcomes in ageing. Whether this negative impact persists in populations of more advanced age and dependency is less clear. We aimed to determine the association between residential area deprivation and pre-specified health characteristics among community-dwelling dependent older adults.

Methods

We conducted a cross-sectional analysis of data from 1591 community-dwelling adults aged 65 years and older of mean age 83.9 ± 7.1 years and in receipt of state home support in Ireland. The HP Pobal Deprivation Index was used to categorize residential areas by socioeconomic deprivation. Health variables analysed included physical dependency (Barthel Index), polypharmacy (≥5 medications), previous acute hospital admission, cognitive impairment, and mental health diagnoses. Associations between residential area deprivation and prespecified health outcomes were explored in multivariable logistic regression analysis.

Results

In socioeconomically disadvantaged areas, high physical dependency was twice that observed in affluent areas (16.2% vs 6.9%, p = 0.009). Similarly, acute hospitalization, as the trigger for increased dependency, was more common in deprived settings (41.6% v 29.1%, p < 0.001). Polypharmacy was common in this population (67.6%), but significantly higher in deprived vs affluent settings (74.7% v 64.5%, p = 0.030). The findings persisted in multivariable analyses when adjusted for age and gender. While all participants were accessing home support, those in deprived areas were on average 6.5 years younger than in affluent areas. Associations between residential deprivation and mental health conditions or cognitive impairment, however, were not observed in this study.

Conclusion

Community-dwelling older adults living in socioeconomically disadvantaged areas experienced greater polypharmacy, high physical dependency, hospitalization-associated dependency, and a 6.5-year earlier need for state home support than in affluent settings. The findings suggest that health inequality persists in populations of more advanced age and dependency and highlight a need for further research as well as community-based health and social care initiatives.

Prevalence and Factors Associated With Out-of-Pocket Pharmaceutical Expenditure Among Primary Healthcare Patients: Evidence From the Prover Project

OBJECTIVES

This study aimed to determine the prevalence and associated factors of out-of-pocket pharmaceutical expenditure (OOPPE) among primary healthcare patients.

METHODS

The study is part of the Prover Project, an exit survey conducted in 2017 in a large city (population 234 937) in Minas Gerais State, Brazil. A representative sample of patients (n = 1219) from pharmaceutical services based on primary healthcare was selected. Three components of OOPPE were assessed: the general prevalence, the types of medicines purchased (medicines for the treatment of chronic diseases, medicines for the treatment of acute diseases, or herbal medicines), and coverage by the National Health System. The factors associated with OOPPE were examined applying a modified Andersen's behavioral model of health services use. Data were analyzed using descriptive statistics and logistic regression.

RESULTS

The overall prevalence of OOPPE was 77%. Most patients who had OOPPE purchased medicines to treat chronic diseases (94%). In addition, these patients purchased medicines covered by public insurance but were out of stock (85%). OOPPE was associated with enabling factors, such as higher personal income (odds ratio [OR] 1.92; 95% confidence interval [CI] 1.02-3.62), holding health insurance (OR 1.40; 95% CI 1.01-1.95), and higher neighborhood trust (OR 1.34; 95% CI 1.01-1.79), and with need factors, that is, poorer perception of health (OR 1.63; 95% CI 1.20-2.21), multiple comorbidities (OR 1.70; 95% CI 1.18-2.46), and higher number of prescribed medicines (OR 2.84; 95% CI 1.90-4.26).

CONCLUSIONS

We found a high prevalence of OOPPE, identifying individuals more likely to incur these expenses. These findings are useful to inform policy makers from the healthcare system to plan and implement the needed interventions to protect primary care patients from this financial burden.

Assessing the relationship between adverse pregnancy outcomes and area-level deprivation in Wales 2014-2019: a national population-based cross-sectional study

OBJECTIVES

The aim of this study was to assess the relationship between deciles of area-level deprivation and seven adverse pregnancy outcomes in Wales.

DESIGN

Cross-sectional analysis.

SETTING

64 699 live births in Wales from 31 March 2014 to 16 September 2019.

PRIMARY OUTCOME VARIABLE

We examined each of the following seven adverse pregnancy outcomes: (1) small for gestational age (SGA); (2) large for gestational age; (3) preterm birth; (4) third-degree or fourth-degree perineal tear; (5) major postpartum haemorrhage (MPPH); (6) a lower Apgar score at 5 min and (7) emergency caesarean section.

RESULTS

There was no significant association between increasing aggregate measures of area-level deprivation and the adverse pregnancy outcomes we studied. Women living in an area with greater access to services are more likely to have a baby that is SGA (1.27, 95% CI 1.11 to 1.49), have a greater likelihood of a perineal tear (1.74, 95% CI 1.15 to 2.61), are significantly less likely to have MPPH (0.79, 95% CI 0.64 to 0.96), have a baby with an Apgar score of 0.26 higher (95% CI 0.22 to 0.29) and are significantly less likely to have an emergency caesarean section (0.81, 95% CI 0.73 to 0.88). Women living in areas with higher employment (0.26, 95% CI 0.19 to 0.36) and better health (0.26, 95% CI 0.19 to 0.35) were less likely to experience perineal tear.

CONCLUSIONS

There was no clear social-spatial gradient in area-level deprivation and adverse pregnancy outcomes. We found a stronger association for individual-level behavioural risk factors than area-level factors. These findings support the benefits that accessible and holistic person-centred care may bring through addressing individual behavioural risk factors. There is a need for improved data completeness and further individual-level data on risk factors such as employment and income to better understand the role which may be played by population-level policies and their pathways to affecting outcomes.

Factors Associated With Voluntary Refusal of Emergency Medical System Transport for Emergency Care in Detroit During the Early Phase of the COVID-19 Pandemic

IMPORTANCE

Emergency department (ED) and emergency medical services (EMS) volumes decreased during the COVID-19 pandemic, but the amount attributable to voluntary refusal vs effects of the pandemic and public health restrictions is unknown.

OBJECTIVE

To examine the factors associated with EMS refusal in relation to COVID-19 cases, public health interventions, EMS responses, and prehospital deaths.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study was conducted in Detroit, Michigan, from March 1 to June 30, 2020. Emergency medical services responses geocoded to Census tracts were analyzed by individuals' age, sex, date, and community resilience using the Centers for Disease Control and Prevention Social Vulnerability Index. Response counts were adjusted with Poisson regression, and odds of refusals and deaths were adjusted by logistic regression.

EXPOSURES

A COVID-19 outbreak characterized by a peak in local COVID-19 incidence and the strictest stay-at-home orders to date, followed by a nadir in incidence and broadly lifted restrictions.

MAIN OUTCOMES AND MEASURES

Multivariable-adjusted difference in 2020 vs 2019 responses by incidence rate and refusals or deaths by odds. The Social Vulnerability Index was used to capture community social determinants of health as a risk factor for death or refusal. The index contains 4 domain subscores; possible overall score is 0 to 15, with higher scores indicating greater vulnerability.

RESULTS

A total of 80 487 EMS responses with intended ED transport, 2059 prehospital deaths, and 16 064 refusals (62 636 completed EMS to ED transports) from 334 Census tracts were noted during the study period. Of the cohort analyzed, 38 621 were women (48%); mean (SD) age was 49.0 (21.4) years, and mean (SD) Social Vulnerability Index score was 9.6 (1.6). Tracts with the highest per-population EMS transport refusal rates were characterized by higher unemployment, minority race/ethnicity, single-parent households, poverty, disability, lack of vehicle access, and overall Social Vulnerability Index score (9.6 vs 9.0, P = .002). At peak COVID-19 incidence and maximal stay-at-home orders, there were higher total responses (adjusted incident rate ratio [aIRR], 1.07; 1.03-1.12), odds of deaths (adjusted odds ratio [aOR], 1.60; 95% CI, 1.20-2.12), and refusals (aOR, 2.33; 95% CI, 2.09-2.60) but fewer completed ED transports (aIRR, 0.82; 95% CI, 0.78-0.86). With public health restrictions lifted and the nadir of COVID-19 cases, responses (aIRR, 1.01; 0.97-1.05) and deaths (aOR, 1.07; 95% CI, 0.81-1.41) returned to 2019 baselines, but differences in refusals (aOR, 1.27; 95% CI, 1.14-1.41) and completed transports (aIRR, 0.95; 95% CI, 0.90-0.99) remained. Multivariable-adjusted 2020 refusal was associated with female sex (aOR, 2.71; 95% CI, 2.43-3.03 in 2020 at the peak; aOR 1.47; 95% CI, 1.32-1.64 at the nadir).

CONCLUSIONS AND RELEVANCE

In this cohort study, EMS transport refusals increased with the COVID-19 outbreak's peak and remained elevated despite receding public health restrictions, COVID-19 incidence, total EMS responses, and prehospital deaths. Voluntary refusal was associated with decreased EMS transports to EDs, disproportionately so among women and vulnerable communities.

Built Environment and HIV Linkage to Care in Rural South Africa

Background

We assessed built environment (residential density, landuse mix and aesthetics) and HIV linkage to care (LTC) among 1,681 (18–49 years-old) residents of 15 Mpumalanga villages, South Africa.

Methods

Multilevel models (linear-binomial) were used for the association between built environment, measured using NEWS for Africa, and LTC from a clinical database of 9 facilities (2015–2018). Additionally, we assessed effect-measure modification by universal test-and-treat policy (UTT).

Results

We observed, a significant association in the adjusted 3-month probability of LTC for residential density (risk difference (RD)%: 5.6, 95%CI: 1.2–10.1), however, no association for land-use mix (RD%: 2.4, 95%CI: −0.4, 5.2) and aesthetics (RD%: −1.2, 95%CI: −4.5–2.2). Among those diagnosed after UTT, residents of high land-use villages were more likely to link-to-care than those of low land-use villages at 12 months (RD%: 4.6, 95%CI: 1.1–8.1, p < 0.04), however, not at 3 months (RD%: 3.0, 95%CI: −2.1–8.0, p > 0.10).

Conclusion

Findings suggest, better built environment conditions (adequate infrastructure, proximity to services etc.) help facilitate LTC. Moreover, UTT appears to have a protective effect on LTC.

[Social inequality and mental health]

Social inequality refers to the inequitable distribution of social prosperity including the resource of health. The relationship between social inequality and mental health can be established by means of indicators of social inequality throughout all age groups in Germany. There are social gradients of mental health on the population level, i.e. the linear relationship between social classes or status and state of health. Fundamental determinants of health disparity are cultural, social, political, and geographical conditions, which interact with the genetic make-up and epigenetic processes. These determinants also influence the management of developmental tasks during the life course and are of utmost importance for the development of mental disorders. The maladaptation to chronic stress is at the core of health disparity. Interventions at the individual behavioral level should comprise the development of stress management and coping strategies.