Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study.

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (ß = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (ß = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

Comparison of ten policy options to equitably reduce children's exposure to unhealthy food marketing.

OBJECTIVE: Reducing children's exposure to unhealthy food marketing is crucial to combat childhood obesity. We aimed to estimate the reduction of children's exposure to food marketing under different policy scenarios and assess exposure differences by socio-economic status. DESIGN: Data on children's exposure to unhealthy food marketing were compiled from a previous cross-sectional study in which children (n 168) wore wearable cameras and Global Positioning System (GPS) units for 4 consecutive days. For each exposure, we identified the setting, the marketing medium and food/beverage product category. We analysed the percentage reduction in food marketing exposure for ten policy scenarios and by socio-economic deprivation: (1) no product packaging, (2) no merchandise marketing, (3) no sugary drink marketing, (4) no confectionary marketing in schools, (5) no sugary drink marketing in schools, (6) no marketing in public spaces, (7) no marketing within 400 m of schools, (8) no marketing within 400 m of recreation venues, (9) no marketing within 400 m of bus stops and (10) no marketing within 400 m of major roads. SETTING: Wellington region of New Zealand. PARTICIPANTS: 168 children aged 11-14 years. RESULTS: Exposure to food marketing varied by setting, marketing medium and product category. Among the ten policy scenarios, the largest reductions were for plain packaging (60·3 %), no sugary drink marketing (28·8 %) and no marketing in public spaces (22·2 %). There were no differences by socio-economic deprivation. CONCLUSIONS: The results suggest that plain packaging would result in the greatest decrease in children's exposure to food marketing. However, given that children are regularly exposed to unhealthy food marketing in multiple settings through a range of marketing mediums, comprehensive bans are needed to protect children's health.

A synthesis of health benefits of natural sounds and their distribution in national parks.

Parks are important places to listen to natural sounds and avoid human-related noise, an increasingly rare combination. We first explore whether and to what degree natural sounds influence health outcomes using a systematic literature review and meta-analysis. We identified 36 publications examining the health benefits of natural sound. Meta-analyses of 18 of these publications revealed aggregate evidence for decreased stress and annoyance (g = -0.60, 95% CI = -0.97, -0.23) and improved health and positive affective outcomes (g = 1.63, 95% CI = 0.09, 3.16). Examples of beneficial outcomes include decreased pain, lower stress, improved mood, and enhanced cognitive performance. Given this evidence, and to facilitate incorporating public health in US national park soundscape management, we then examined the distribution of natural sounds in relation to anthropogenic sound at 221 sites across 68 parks. National park soundscapes with little anthropogenic sound and abundant natural sounds occurred at 11.3% of the sites. Parks with high visitation and urban park sites had more anthropogenic sound, yet natural sounds associated with health benefits also were frequent. These included animal sounds (audible for a mean of 59.3% of the time, SD: 23.8) and sounds from wind and water (mean: 19.2%, SD: 14.8). Urban and other parks that are extensively visited offer important opportunities to experience natural sounds and are significant targets for soundscape conservation to bolster health for visitors. Our results assert that natural sounds provide important ecosystem services, and parks can bolster public health by highlighting and conserving natural soundscapes.

Identifying the 'active ingredients' of socioeconomic disadvantage for youth outcomes in middle childhood.

BACKGROUND: Youth experiencing socioeconomic deprivation may be exposed to disadvantage in multiple contexts (e.g., neighborhood, family, and school). To date, however, we know little about the underlying structure of socioeconomic disadvantage, including whether the 'active ingredients' driving its robust effects are specific to one context (e.g., neighborhood) or whether the various contexts increment one another as predictors of youth outcomes. METHODS: The present study addressed this gap by examining the underlying structure of socioeconomic disadvantage across neighborhoods, families, and schools, as well as whether the various forms of disadvantage jointly predicted youth psychopathology and cognitive performance. Participants were 1,030 school-aged twin pairs from a subsample of the Michigan State University Twin Registry enriched for neighborhood disadvantage. RESULTS: Two correlated factors underlay the indicators of disadvantage. Proximal disadvantage comprised familial indicators, whereas contextual disadvantage represented deprivation in the broader school and neighborhood contexts. Results from exhaustive modeling analyses indicated that proximal and contextual disadvantage incremented one another as predictors of childhood externalizing problems, disordered eating, and reading difficulties, but not internalizing symptoms. CONCLUSIONS: Disadvantage within the family and disadvantage in the broader context, respectively, appear to represent distinct constructs with additive influence, carrying unique implications for multiple behavioral outcomes during middle childhood.

Associations between neighborhood built, social, or toxicant conditions and child externalizing behaviors in the Detroit metro area: a cross-sectional study of the neighborhood 'exposome'.

BACKGROUND: The specific 'active ingredients' through which neighborhood disadvantage increases risk for child psychopathology remains unclear, in large part because research to date has nearly always focused on poverty to the exclusion of other neighborhood domains. The objective of this study was to evaluate whether currently assessed neighborhood built, social, or toxicant conditions were associated with child externalizing psychopathology outcomes separately, and in a combined model, using data from the Detroit-metro county area. METHODS: We conducted principal components analyses for built, social, or toxicant conditions. Next, we fitted separate multiple regression models for each of the child externalizing psychopathology measures (oppositional defiant and conduct problems) as a function of built, social, or toxicant components. RESULTS: We found that built features (more non-profits, churches, and alcohol outlets, and less agriculture and vacant properties) were associated with conduct problems, while toxicant conditions (high percent industrial, toxins released and number of pre-1978 structures) were associated with oppositional defiance problems. There was no significant association between greenspace or social conditions and child externalizing outcomes. When examined simultaneously, only the significant independent association between built conditions and conduct problems remained. CONCLUSIONS: Built, social, and toxicant neighborhood conditions are not interchangeable aspects of a given neighborhood. What's more, built features are uniquely associated with child externalizing outcomes independently of other neighborhood characteristics. Future research should consider how changes in the built conditions of the neighborhood (e.g., development, decay) serve to shape child externalizing behaviors, with a focus on identifying potentially actionable elements.

Feelings of safety during daytime walking: associations with mental health, physical activity and cardiometabolic health in high vacancy, low-income neighborhoods in Detroit, Michigan.

INTRODUCTION: Individuals living in low-income neighborhoods have disproportionately high rates of obesity, Type-2 diabetes, and cardiometabolic conditions. Perceived safety in one's neighborhood may influence stress and physical activity, with cascading effects on cardiometabolic health. METHODS: In this study, we examined relationships among feelings of safety while walking during the day and mental health [perceived stress (PSS), depression score], moderate-to-vigorous physical activity (PA), Body Mass Index (BMI), and hemoglobin A1C (A1C) in low-income, high-vacancy neighborhoods in Detroit, Michigan. We recruited 69 adults who wore accelerometers for one week and completed a survey on demographics, mental health, and neighborhood perceptions. Anthropometrics were collected and A1C was measured using A1CNow test strips. We compiled spatial data on vacant buildings and lots across the city. We fitted conventional and multilevel regression models to predict each outcome, using perceived safety during daytime walking as the independent variable of interest and individual or both individual and neighborhood-level covariates (e.g., number of vacant lots). Last, we examined trends in neighborhood features according to perceived safety. RESULTS: In this predominantly African American sample (91%), 47% felt unsafe during daytime walking. Feelings of perceived safety significantly predicted PSS (ß = - 2.34, p = 0.017), depression scores (ß = - 4.22, p = 0.006), and BMI (ß = - 2.87, p = 0.01), after full adjustment. For PA, we detected a significant association for sex only. For A1C we detected significant associations with blighted lots near the home. Those feeling unsafe lived in neighborhoods with higher park area and number of blighted lots. CONCLUSION: Future research is needed to assess a critical pathway through which neighborhood features, including vacant or poor-quality green spaces, may affect obesity-via stress reduction and concomitant effects on cardiometabolic health.

Do neighborhood social processes moderate the etiology of youth conduct problems?

BACKGROUND: Prior work has robustly suggested that social processes in the neighborhood (i.e. informal social control, social cohesion, norms) influence child conduct problems (CP) and related outcomes, but has yet to consider how these community-level influences interact with individual-level genetic risk for CP. The current study sought to do just this, evaluating neighborhood-level social processes as etiologic moderators of child CP for the first time. METHODS: We made use of two nested samples of child and adolescent twins within the Michigan State University Twin Registry (MSUTR): 5649 families who participated in in the Michigan Twins Project (MTP) and 1013 families who participated in the Twin Study of Behavioral and Emotional Development (TBED-C). The neighborhood social processes of informal social control, social cohesion, and norms were assessed using neighborhood sampling techniques, in which residents of each twin family's neighborhood reported on the social processes in their neighborhood. Standard biometric GxE analyses evaluated the extent to which they moderated the etiology of CP. RESULTS: The 'no moderation' model provided the best fit to the data in nearly all cases, arguing against neighborhood social processes as etiologic moderators of youth CP. CONCLUSIONS: The neighborhood social processes evaluated here do not appear to exert their effects on child CP via etiologic moderation. The documented links between neighborhood social processes and child CP are thus likely to reflect a different etiologic process. Possibilities include environmental main effects of neighborhood social processes on child CP, or genotype-environment correlations.

Study of active neighborhoods in Detroit (StAND): study protocol for a natural experiment evaluating the health benefits of ecological restoration of parks.

BACKGROUND: Individuals living in deprived inner cities have disproportionately high rates of cancers, Type 2 diabetes and obesity, which have stress- and physical inactivity-related etiologies. This study aims to quantify effects of ecological park restoration on physical activity, stress and cardio-metabolic health outcomes. METHODS: The Study of Active Neighborhoods in Detroit is a quasi-experimental, longitudinal panel natural experiment with two conditions (restored park intervention (INT) and control (CNT)) and annual measurements at baseline and 3-years post-restoration. Individuals (sampled within 500 m of an INT/CNT park) serve as the unit of analysis. Restoration (n = 4 parks) involves replacing non-native plants and turf with native plants; creating trails; posting signage; and leading community stewardship events. The CNT condition (n = 5) is an unmaintained park, matched to INT based on specified neighborhood conditions. Recruitment involves several avenues, with a retention goal of 450 participants. Park measures include plant/avian diversity; usage of the park (SOPARC); signs of care; auditory environment recordings; and visual greenness using 360 imagery. Health outcomes include device-based physical activity behavior (primary outcome); salivary cortisol (secondary outcome); and several downstream health outcomes. Exposure to the INT will be assessed through visual contact time and time spent in the park using GPS data. Changes in health outcomes between years and INT versus CNT will be tested using generalized linear (mixed) models. DISCUSSION: Our study will examine whether restored urban greenspaces increase physical activity and lower stress, with public health planning implications, where small changes in neighborhood greenspaces may have large health benefits in low-income neighborhoods. STUDY REGISTRATION: Registration: OSF Preregistration registered March 31, 2020. Accessible from https://osf.io/surx7.

Space-time analysis of unhealthy food advertising: New Zealand children's exposure and health policy options.

Reducing children's exposure to unhealthy food advertising is an accepted strategy to end childhood obesity. This study aimed to (i) measure children's space-time exposures to unhealthy food advertising in public outdoor spaces, using GPS and wearable cameras; and (ii) test effectiveness of banning options. We compiled data (collected July 2014-June 2015) on 138 12-year-old children in Wellington, New Zealand, using wearable cameras and GPS devices worn over 4 days. In 2017-18, we linked 59 150 images taken in public outdoor spaces to GPS data. Of these, 1631 contained unhealthy food advertising exposures, defined as ≥50% of an advertisement observed in each image. We examined spatial patterns using kernel density mapping and graphed space-time trends. We interpolated a kriged exposure rate across Wellington to estimate exposure reductions for potential bans. Children were exposed to 7.4 (95% CI 7.0-7.8) unhealthy food advertisements/hour spent in outdoor public spaces. Exposures occurred in shopping centres, residential areas and sports facilities, commonly involving fast food, sugary drinks and ice cream. Peak exposure times were weekend afternoons/evenings and weekdays before/after school. In Wellington, we estimated that banning such advertising within 400 m of playgrounds would yield a 33% reduction in exposure, followed by in residential areas (27%), within 400 m of schools (25%), and 50% for a ban combining all above. This work documents the extent of children's exposure to unhealthy food advertising and the potential impact of bans. Given the ubiquity of advertising in public spaces, this New Zealand research offers innovative methods and findings likely relevant in other jurisdictions.

It really does take a village: The role of neighbors in the etiology of nonaggressive rule-breaking behavior.

Although there is growing recognition that disadvantaged contexts attenuate genetic influences on youth misbehavior, it is not yet clear how this dampening occurs. The current study made use of a "geographic contagion" model to isolate specific contexts contributing to this effect, with a focus on nonaggressive rule-breaking behaviors (RB) in the families' neighbors. Our sample included 847 families residing in or near modestly-to-severely disadvantaged neighborhoods who participated in the Michigan State University Twin Registry. Neighborhood sampling techniques were used to recruit neighbors residing within 5km of a given family (the mean number of neighbors assessed per family was 13.09; range, 1-47). Analyses revealed clear evidence of genotype-environment interactions by neighbor RB, such that sibling-level shared environmental influences on child RB increased with increasing neighbor self-reports of their own RB, whereas genetic influences decreased. Moreover, this moderation appeared to be driven by geographic proximity to neighbors. Sensitivity analyses further indicated that this effect was specifically accounted for by higher levels of neighbor joblessness, rather than elements of neighbor RB that would contribute to neighborhood blight or crime. Such findings provocatively suggest that future genotype-environment interactions studies should integrate the dynamic networks of social contagion theory.

Spatial equity and realised access to healthcare - a geospatial analysis of general practitioner enrolments in Waikato, New Zealand.

INTRODUCTION: Geographic measures of accessibility can quantify inequitable distributions of health care. Although closest distance measures are often used in Aotearoa New Zealand these may not reflect patient use of health care. This research examines patterns of patient enrolment in general practitioner (GP) services from a geospatial perspective. METHODS: Patient enrolment records (n=137 596) from one primary health organisation were examined and geographic information systems used to determine whether patients enrolled with their closest GP service. A binomial logistic regression was performed to examine factors associated with the bypass of GP services closer to patients' homes. RESULTS: Overall 68.1% of patients in the sample bypassed the GP service closest to their home, while rates of GP bypass varied across the Waikato region and between rural and urban areas. A binary logistic regression analysis revealed that rurality of patient residence, patient ethnicity, patient age, area-level socioeconomic deprivation, sex, distance to the closest GP clinic, clinic after-hours availability, Māori service provider status, GP and nurse full time equivalent hours, and clinic fees were statistically significant predictors of increased closest-GP bypass. While residents of major urban areas had high rates of GP bypass, this was followed by patients living in rural areas - patients living more than 20 km from the closest GP service had exceptionally high rates of GP bypass. CONCLUSION: This study suggests that most patients in the Waikato region do not enrol with the GP service closest to their home and it outlines several factors, including rurality of residence, associated with the GP bypass. Closest distance accessibility measures may be inappropriate in mixed urban-rural settings, and researchers should consider other approaches to quantifying spatial equity. Health services should also be designed to better reflect the realities of the populations they serve.

Quantifying the Nature and Extent of Children's Real-time Exposure to Alcohol Marketing in Their Everyday Lives Using Wearable Cameras: Children's Exposure via a Range of Media in a Range of Key Places.

AIMS: Children's exposure to alcohol marketing is typically measured using self-report data, television viewing data or street marketing audits, which are subject to bias and often do not provide quantifiable measures of daily exposure. This article describes an innovative methodology to capture the world in which children live using wearable cameras. SHORT SUMMARY: Children wearing wearable cameras were exposed 4.5 times per day to alcohol marketing in multiple places and via a range of marketing media. The results reinforce calls for legislative restrictions and a global response to alcohol marketing in order to protect children and reduce alcohol-related harm. METHODS: Children aged 11-13 years (n = 167) wore cameras that automatically captured images approximately every 7 s for a 4-day period between June 2014 and July 2015. Content analysis of images (n = 700,000) was manually undertaken to assess children's exposure to alcohol marketing. RESULTS: On average, children were exposed to alcohol marketing 4.5 (95% CI: 3.3, 6.0) times per day, excluding within off-licence retailers, on screens and product packaging. Children were exposed at home (47%), on-licence alcohol retailers (19%), off-licence shop fronts (16%) and sporting venues (12%), and via sports sponsorship (31%) and shop front signage (31%) and merchandise (25%). The highest exposure rates were found among Maori (5.4 times higher than New Zealand European) and Pacific (3.0 times higher than New Zealand European), and boys (2.0 times higher than girls). CONCLUSIONS: These findings highlight the urgent need to implement strict legislative restrictions on all forms of alcohol marketing to fulfil the World Health Organization Global Alcohol Strategy.

Retraction Note: Inequities in coverage of smokefree space policies within the United States.

The authors have retracted this article [1] because of an error with the data extraction process.

Inequities in coverage of smokefree outdoor space policies within the United States: school grounds and playgrounds.

BACKGROUND: Previous studies have found extensive geographic and demographic differences in tobacco use. These differences have been found to be reduced by effective public policies, including banning smoking in public spaces. Smokefree outdoor spaces reduce secondhand smoke exposure and de-normalize smoking. METHODS: After previously publishing a study of smokefree indoor and outdoor space policies, it was brought to the authors' attention that the dataset used in analyses was incomplete (Lowrie et al., BMC Public Health 17:456, 2017). The current manuscript is a corrected version. Here, we include analyses for outdoor space policies. We evaluated regional and demographic differences in the proportion of the population (both adult and child) covered by smokefree outdoor space policies for school grounds and playgrounds enacted in the United States prior to 2014. RESULTS: Children had a low level of protection in playgrounds and schools (8% covered nationwide in both settings). Significant differences in coverage were found by ethnicity, region, income, and education (p < 0.001). The odds of having a smokefree playgrounds policy was lower for jurisdictions with higher proportions of poor households, households with no high school diploma, whites and the Alaska/Hawaii region. Increased ethnic heterogeneity was found to be a significant predictor of increased odds of having a smokefree playgrounds policy, meaning that diversity is protective, with differential effect by region (p < 0.001) - which may relate to urbanicity. CONCLUSIONS: Disparities in smokefree outdoor space policies have potential to exacerbate existing health inequities. A national increase in smokefree outdoor space policies to protect children in playgrounds and schools is a crucial intervention to reduce such inequities.

Framework for examining the spatial equity and sustainability of general practitioner services.

OBJECTIVE: To propose a framework for examining both the spatial equity and sustainability of GP services. DESIGN: A conceptual discussion based on a systematic literature review of spatial equity definitions and methods. SETTING: Improving the spatial equity of health services is a key step in achieving health equity. Health systems should contribute to achieving health equity and maintain equitable services into the future. The GP services are a key component of primary health care, which often aims to promote health equity. Despite the importance of spatially equitable and sustainable GP services, a framework for analysis has not yet been established. MAIN OUTCOME MEASURE: Examples of how the proposed framework could be implemented are provided from the New Zealand health care context. RESULT: The framework entails three steps: (i) defining spatial equity and sustainability; (ii) estimating current and future distributions of health services and needs; and (iii) quantifying spatial equity and sustainability. In step (i), a needs-based distribution is the most common definition of spatial equity, while sustainability is the ability to provide ongoing equitable access. Step (ii) depends on current and future estimates of access and need within a well-defined geographical area. In step (iii), spatial equity and sustainability should be quantified through measures, such as the Gini coefficient. Current and future levels of spatial equity should then be compared to assess the sustainability of equitable GP services. CONCLUSION: This article outlines a novel conceptual framework for examining the spatial equitability and sustainability of GP services.

Inequities in coverage of smokefree space policies within the United States.

BACKGROUND: Previous studies have found extensive geographic and demographic differences in tobacco use. These differences have been found to be reduced by effective public policies, including banning smoking in public spaces. Smokefree indoor and outdoor spaces reduce secondhand smoke exposure and denormalize smoking. METHODS: We evaluated regional and demographic differences in the proportion of the population covered by smokefree policies enacted in the United States prior to 2014, for both adults and children. RESULTS: Significant differences in coverage were found by ethnicity, region, income, and education (p < 0.001). Smokefree policy coverage was lower for jurisdictions with higher proportions of poor households, households with no high school diploma and the Southeast region. Increased ethnic heterogeneity was found to be a significant predictor of coverage in indoor "public spaces generally", meaning that diversity is protective, with differential effect by region (p = 0.004) - which may relate to urbanicity. Children had a low level of protection in playgrounds and schools (~10% covered nationwide) - these spaces were found to be covered at lower rates than indoor spaces. CONCLUSIONS: Disparities in smokefree space policies have potential to exacerbate existing health inequities. A national increase in smokefree policies to protect children in playgrounds and schools is a crucial intervention to reduce such inequities.

Correction: Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand.

[This corrects the article DOI: 10.1371/journal.pmed.1001856.].

Tobacco retail outlet restrictions: health and cost impacts from multistate life-table modelling in a national population.

BACKGROUND: Since there is some evidence that the density and distribution of tobacco retail outlets may influence smoking behaviours, we aimed to estimate the impacts of 4 tobacco outlet reduction interventions in a country with a smoke-free goal: New Zealand (NZ). METHODS: A multistate life-table model of 16 tobacco-related diseases, using national data by sex, age and ethnicity, was used to estimate quality-adjusted life years (QALYs) gained and net costs over the remainder of the 2011 NZ population's lifetime. The outlet reduction interventions assumed that increased travel costs can be operationalised as equivalent to price increases in tobacco. RESULTS: All 4 modelled interventions led to reductions of >89% of current tobacco outlets after the 10-year phase-in process. The most effective intervention limited sales to half of liquor stores (and nowhere else) at 129 000 QALYs gained over the lifetime of the population (95% UI: 74 100 to 212 000, undiscounted). The per capita QALY gains were up to 5 times greater for Maori (indigenous population) compared to non-Maori. All interventions were cost-saving to the health system, with the largest saving for the liquor store only intervention: US$1.23 billion (95% UI: $0.70 to $2.00 billion, undiscounted). CONCLUSIONS: These tobacco outlet reductions reduced smoking prevalence, achieved health gains and saved health system costs. Effects would be larger if outlet reductions have additional spill-over effects (eg, smoking denormalisation). While these interventions were not as effective as tobacco tax increases (using the same model), these and other strategies could be combined to maximise health gain and to maximise cost-savings to the health system.

Comparison of methods to estimate water access: a pilot study of a GPS-based approach in low resource settings.

BACKGROUND: Most water access studies involve self-reported measures such as time spent or simple spatial measures such as Euclidean distance from home to source. GPS-based measures of access are often considered actual access and have shown little correlation with self-reported measures. One main obstacle to widespread use of GPS-based measurement of access to water has been technological limitations (e.g., battery life). As such, GPS-based measures have been limited by time and in sample size. METHODS: The aim of this pilot study was to develop and test a novel GPS unit, (≤4-week battery life, waterproof) to measure access to water. The GPS-based method was pilot-tested to estimate number of trips per day, time spent and distance traveled to source for all water collected over a 3-day period in five households in south-western Uganda. This method was then compared to self-reported measures and commonly used spatial measures of access for the same households. RESULTS: Time spent collecting water was significantly overestimated using a self-reported measure, compared to GPS-based (p < 0.05). In contrast, both the GIS Euclidean distances to nearest and actual primary source significantly underestimated distances traveled, compared to the GPS-based measurement of actual travel paths to water source (p < 0.05). Households did not consistently collect water from the source nearest their home. Comparisons between the GPS-based measure and self-reported meters traveled were not made, as respondents did not feel that they could accurately estimate distance. However, there was complete agreement between self-reported primary source and GPS-based. CONCLUSIONS: Reliance on cross-sectional self-reported or simple GIS measures leads to misclassification in water access measurement. This new method offers reductions in such errors and may aid in understanding dynamic measures of access to water for health studies.

Health, Health Inequality, and Cost Impacts of Annual Increases in Tobacco Tax: Multistate Life Table Modeling in New Zealand.

BACKGROUND: Countries are increasingly considering how to reduce or even end tobacco consumption, and raising tobacco taxes is a potential strategy to achieve these goals. We estimated the impacts on health, health inequalities, and health system costs of ongoing tobacco tax increases (10% annually from 2011 to 2031, compared to no tax increases from 2011 ["business as usual," BAU]), in a country (New Zealand) with large ethnic inequalities in smoking-related and noncommunicable disease (NCD) burden. METHODS AND FINDINGS: We modeled 16 tobacco-related diseases in parallel, using rich national data by sex, age, and ethnicity, to estimate undiscounted quality-adjusted life-years (QALYs) gained and net health system costs over the remaining life of the 2011 population (n = 4.4 million). A total of 260,000 (95% uncertainty interval [UI]: 155,000-419,000) QALYs were gained among the 2011 cohort exposed to annual tobacco tax increases, compared to BAU, and cost savings were US$2,550 million (95% UI: US$1,480 to US$4,000). QALY gains and cost savings took 50 y to peak, owing to such factors as the price sensitivity of youth and young adult smokers. The QALY gains per capita were 3.7 times greater for Maori (indigenous population) compared to non-Maori because of higher background smoking prevalence and price sensitivity in Maori. Health inequalities measured by differences in 45+ y-old standardized mortality rates between Maori and non-Maori were projected to be 2.31% (95% UI: 1.49% to 3.41%) less in 2041 with ongoing tax rises, compared to BAU. Percentage reductions in inequalities in 2041 were maximal for 45-64-y-old women (3.01%). As with all such modeling, there were limitations pertaining to the model structure and input parameters. CONCLUSIONS: Ongoing tobacco tax increases deliver sizeable health gains and health sector cost savings and are likely to reduce health inequalities. However, if policy makers are to achieve more rapid reductions in the NCD burden and health inequalities, they will also need to complement tobacco tax increases with additional tobacco control interventions focused on cessation.