A Comprehensive Review on Social Inequalities and Pregnancy Outcome-Identification of Relevant Pathways and Mechanisms.

Scientific literature tends to support the idea that the pregnancy and health status of fetuses and newborns can be affected by maternal, parental, and contextual characteristics. In addition, a growing body of evidence reports that social determinants, measured at individual and/or aggregated level(s), play a crucial role in fetal and newborn health. Numerous studies have found social factors (including maternal age and education, marital status, pregnancy intention, and socioeconomic status) to be linked to poor birth outcomes. Several have also suggested that beyond individual and contextual social characteristics, living environment and conditions (or "neighborhood") emerge as important determinants in health inequalities, particularly for pregnant women. Using a comprehensive review, we present a conceptual framework based on the work of both the Commission on Social Determinants of Health and the World Health Organization (WHO), aimed at describing the various pathways through which social characteristics can affect both pregnancy and fetal health, with a focus on the structural social determinants (such as socioeconomic and political context) that influence social position, as well as on intermediary determinants. We also suggest that social position may influence more specific intermediary health determinants; individuals may, on the basis of their social position, experience differences in environmental exposure and vulnerability to health-compromising living conditions. Our model highlights the fact that adverse birth outcomes, which inevitably lead to health inequity, may, in turn, affect the individual social position. In order to address both the inequalities that begin in utero and the disparities observed at birth, it is important for interventions to target various unhealthy behaviors and psychosocial conditions in early pregnancy. Health policy must, then, support: (i) midwifery availability and accessibility and (ii) enhanced multidisciplinary support for deprived pregnant women.

Health Equity Impact Assessment Related to Air Pollution Reduction.

Despite considerable improvements in terms of prevention, management, and regulation, air pollution remains a leading environmental health issue worldwide [...].

Study protocol to explore the social effects of environmental exposure and lifestyle behaviours on pregnancy outcome: an overview of cohort of pregnant women study.

INTRODUCTION: A growing number of international studies have highlighted the adverse consequences of lived experience in the first thousand days of pregnancy and early life on the probability of stillbirth, child mortality, inadequate growth and healthy development during both childhood and adulthood. The lived experience of the fetus inside the womb and at the birth is strongly related to both maternal health during pregnancy and maternal exposure to a set of environmental factors known as 'exposome' characteristics, which include environmental exposure, health behaviours, living conditions, neighbourhood characteristics and socioeconomic profile. The aim of our project is to explore the relationships between exposome characteristics and the health status of pregnant women and their newborns. We are particularly interested in studying the relationships between the social inequality of adverse pregnancy outcomes and (1) short-term exposure to atmospheric pollution (MobiFem project) and (2) pregnancy lifestyle (EnviFem project). METHODS AND ANALYSIS: Ours is a prospective, observational and multisite cohort study of pregnant women, involving one teaching hospital across two sites in the Strasbourg metropolitan area.The research team at University Hospital of Strasbourg (HUS) Health collects data on outcomes and individual characteristics from pregnancy registries, clinical records data and questionnaires administered via email to study participants. Recruitment began in February 2021 and will be complete by December 2021. Participants are recruited from first trimester antenatal ultrasound examinations (conducted on weekdays across both sites); each woman meeting our inclusion criteria enters the cohort at the end of her first trimester. Study participants receive a total of three online questionnaires covering sociodemographic characteristics, travel behaviour patterns and lifestyle. Participants complete these questionnaires at recruitment, during the second and third trimester. The level of personal exposure to air pollution is characterised using a dynamic spatiotemporal trajectory model that describes the main daily movements of pregnant women and the time spent in each place frequented. Univariate, multilevel and Bayesian model will be used to investigate the relationships between exposome characteristics and the health status of pregnant women and their newborns. ETHICS AND DISSEMINATION: Our research was approved by the Commission de Protection des Personnes (CPP) Ile de France VI (Paris) on 9 December 2020 (File reference No. 20.09.15.41703 ID RCB: 2020-A02580-39 and No. 20 080-42137 IDRCB 2020-A02581-38). The Agence Nationale de Sécurité du Médicament was informed of it on 15 December 2020. Findings from the study will be disseminated through publications and international conferences and through presentation at meetings with local stakeholders, researchers and policy-makers. TRIAL REGISTRATION NUMBERS: NCT04705272, NCT04725734.

Exposome and Social Vulnerability: An Overview of the Literature Review.

Background-The exposome concept refers to the totality of exposures from internal and external sources, including chemical and biological agents from conception throughout the lifetime. Exposome is also made up of psychosocial components such as socio-economic status (SES), which will focus on in this review. Despite exposures to the same environmental nuisances, individuals and groups are impacted differently. According to the literature, health inequalities exist among different socioeconomic groups, and SES may influence the association between environmental nuisances and health outcomes. However, the variation of this interaction across ages has rarely been studied. There is a need to adopt a life course approach to understand the history of diseases better. Objective-The main objective of this review is to document how SES could modify the association between environmental nuisances and health outcomes, across different ages, as a first crucial step introducing the emerged concept of social exposome. Methods-The PubMed database was searched from January 2010 to August 2021 for systematic reviews published in English addressing the interaction between SES, environmental nuisances, and health outcomes. Socio-economic indicators considered include education, level of income, neighborhood environment. Environmental nuisances considered many environment nuisances, mainly air pollution and noise. Results-Among 242 literature reviews identified, 11 of them address the question of the effect modification. Overall, our work reveals that environmental nuisances were mostly associated with poorer health outcomes and that SES modified this association, increasing the health risk among the poorest. Very interestingly, our work reports the existence of this interaction across different ages, including pregnancy, childhood, and adulthood, and for various environmental nuisances. Conclusion-In conclusion, our work confirms that we are not all equal to face environmental nuisances. The poorest are more vulnerable to the health effect of environmental nuisances. Policy decisions and interventions should target this high-risk population as a priority. Further investigations are needed to formalize the concept of social exposome more precisely and then communicate about it.

[Societal inequalities and the urban exposome: Social origins for different exposures]. / Inégalités sociétales et exposome urbain - Des origines sociales pour des expositions différentes.

Today, many epidemiological studies have proved the adverse health consequences of environmental exposure. For instance, air pollution exposure is recognized to be related with respiratory and cardiovascular diseases as well as adverse pregnancy outcomes. Noise nuisances are also known to increase cardiovascular diseases and to disturb the sleeping quality. Inversely, the access and availability of various resources, as parks, green spaces, and playgrounds positively affect health, psychological and physical well-being, and favorable health behaviors. In this present literature review, we will focus on the urban dimension of exposome, defined by Robinson et al. as the accumulation of all urban settings favorable or unfavorable to health, from the time of life in utero [1].

TITLE: Inégalités sociétales et exposome urbain - Des origines sociales pour des expositions différentes. ABSTRACT: Les études épidémiologiques sont nombreuses aujourd'hui à révéler l'association entre des facteurs d'exposition environnementale et des problèmes de santé, aigus comme chroniques, survenant à différents stades de la vie. Citons, par exemple, l'exposition à la pollution de l'air associée à de nombreuses infections respiratoires, maladies cardiovasculaires et à certaines issues défavorables de la grossesse. L'exposition aux nuisances sonores est également reconnue comme pouvant augmenter le risque de maladies cardiovasculaires et perturber la qualité du sommeil. Inversement, l'accès à certaines ressources et leur disponibilité, comme les parcs, les aires de jeux, ou les espaces verts, sont associés à un meilleur état de santé, de bien-être physique et psychique et à des comportements favorables à la santé. Dans cette Synthèse, nous nous intéresserons plus particulièrement à l'exposome dit « urbain ¼, défini par Robinson et al. comme l'ensemble des éléments de l'environnement urbain favorables et défavorables à la santé, et ce, dès la vie in utero [1].

Measuring hospital spatial accessibility using the enhanced two-step floating catchment area method to assess the impact of spatial accessibility to hospital and non-hospital care on the length of hospital stay.

BACKGROUND: Optimal healthcare access improves the health status and decreases health inequalities. Many studies demonstrated the importance of spatial access to healthcare facilities in health outcomes, particularly using the enhanced two-step floating catchment area (E2SFCA) method. The study objectives were to build a hospital facility access indicator at a fine geographic scale, and then to assess the impact of spatial accessibility to inpatient hospital and non-hospital care services on the length of hospital stay (LOS). METHODS: Data concerning older adults (≥75 years) living in the Nord administrative region of France were used. Hospital spatial accessibility was computed with the E2SFCA method, and the LOS score was calculated from the French national hospital activity and patient discharge database. The relationship between LOS and spatial accessibility to inpatient hospital care and to three non-hospital care types (general practitioners, physiotherapists, and home-visiting nurses) was analyzed with linear regression models. RESULTS: The mean number (standard deviation) of beds per 10,000 inhabitants was 19.0 (10.69) in Medical, Surgical and Obstetrics (MCO) facilities and 5.58 (2.19) in Postoperative and Rehabilitation Care (SSR) facilities, highlighting important variations within the region. Accessibility to hospital services was higher in large urban areas, despite the dense population and higher demand. In 2014, the mean LOS scores were 0.26 for MCO and 0.85 for SSR, but their geographical repartition was non-homogeneous. The linear regression analysis revealed a strong negative and significant association between LOS and non-hospital care accessibility. CONCLUSIONS: This is the first study to measure spatial accessibility to inpatient hospital care in France using the E2SFCA method, and to investigate the relationship between healthcare utilization (LOS score) and spatial accessibility to inpatient hospital care facilities and three types of non-hospital care services. Our findings might help to make decisions about deploying additional beds and to identify the best locations for non-hospital care services. They might also contribute to improve access, and to ensure the best coordination and sustainability of inpatient and outpatient services, in order to better cover the population's healthcare needs. International studies using multiple consensual indicators of healthcare outcomes and accessibility and sophisticated modeling methods are needed.

Measuring Burden of Disease Attributable to Air Pollution Due to Preterm Birth Complications and Infant Death in Paris Using Disability-Adjusted Life Years (DALYs).

Several studies have found maternal exposure to particulate matter pollution was associated with adverse birth outcomes, including infant mortality and preterm birth. In this context, our study aims to quantify the air pollution burden of disease due to preterm birth complications and infant death in Paris, with particular attention to people living in the most deprived census blocks. Data on infant death and preterm birth was available from the birth and death certificates. The postal address of mother's newborn was converted in census block number. A socioeconomic deprivation index was built at the census block level. Average annual ambient concentrations of PM10 were modelled at census block level using the ESMERALDA atmospheric modelling system. The number of infant deaths attributed to PM10 exposure is expressed in years of life lost. We used a three-step compartmental model to appraise neurodevelopmental impairment among survivors of preterm birth. We estimated that 12.8 infant deaths per 100,000 live births may be attributable to PM10 exposure, and about one third of these infants lived in deprived census blocks. In addition, we found that approximately 4.8% of preterm births could be attributable to PM10 exposure, and approximately 1.9% of these infants died (corresponding to about 5.75 deaths per 100,000 live birth). Quantification of environmental hazard-related health impacts for children at local level is essential to prioritizing interventions. Our study suggests that additional effort is needed to reduce the risk of complications and deaths related to air pollution exposure, especially among preterm births. Because of widespread exposure to air pollution, significant health benefits could be achieved through regulatory interventions aimed at reducing exposure of the population as a whole, and particularly of the most vulnerable, such as children and pregnant women.

Gender differences in the association between socioeconomic status and hypertension in France: A cross-sectional analysis of the CONSTANCES cohort.

BACKGROUND: Hypertension prevalence increases when socioeconomic status decreases but gender differences in the relationship between socioeconomic status and hypertension have been less studied. This work aimed to explore the pattern of associations between three indicators of socioeconomic status at individual, household, and municipal levels with hypertension across genders in a large sample of French adults from the CONSTANCES cohort. METHODS: Using data at inclusion from 59 805 participants (52% women) aged 25-69 years and recruited between 2012 and 2015, multilevel log-Poisson regressions with robust variance estimates were used to assess the associations of Relative Index of Inequality in education, monthly income per consumption unit and residential deprivation with hypertension. Modifying effects of gender and age in those associations were tested. RESULTS: Hypertension prevalence was higher in men than in women. Steep socioeconomic gradients of hypertension were observed for the three socioeconomic indicators in both genders and from the youngest to the oldest age class. Socioeconomic inequalities, especially educational inequalities, were larger among women than men: Relative Index of Inequality for highest versus lowest education among the 25-34 years were 0.43 [95%-confidence interval = 0.28-0.67] in women and 0.70 [95%-confidence interval = 0.53-0.92] in men. With increasing age, socioeconomic gradients of hypertension eased in men and even more in women so that gender differences decreased. CONCLUSIONS: In this cross-sectional analysis of a large sample of adults, prevalence of hypertension was higher in men than in women. Moreover, socioeconomic status and especially education displayed a stronger association with hypertension prevalence in women compared to men. Reducing inequalities in hypertension may require gender-specific approaches.

Influence of Individual and Contextual Perceptions and of Multiple Neighborhoods on Depression.

The risk of depression is related to multiple various determinants. The consideration of multiple neighborhoods daily frequented by individuals has led to increased interest in analyzing socio-territorial inequalities in health. In this context, the main objective of this study was (i) to describe and analyze the spatial distribution of depression and (ii) to investigate the role of the perception of the different frequented spaces in the risk of depression in the overall population and in the population stratified by gender. Data were extracted from the 2010 SIRS (a French acronym for "health, inequalities and social ruptures") cohort survey. In addition to the classic individual characteristics, the participants reported their residential neighborhoods, their workplace neighborhoods and a third one: a daily frequented neighborhood. A new approach was developed to simultaneously consider the three reported neighborhoods to better quantify the level of neighborhood socioeconomic deprivation. Multiple simple and cross-classified multilevel logistic regression models were used to analyze the data. Depression was reported more frequently in low-income (OR = 1.89; CI = [1.07-3.35]) or middle-income (OR = 1.91; CI = [1.09-3.36]) neighborhoods and those with cumulative poverty (OR = 1.64; CI = [1.10-2.45]). In conclusion, a cumulative exposure score, such as the one presented here, may be an appropriate innovative approach to analyzing their effects in the investigation of socio-territorial inequalities in health.

Development of Serious Games (Equit'Game) to Address Health and Environmental Inequalities: Protocol for an App-Delivered Program to Perform a Territorial Diagnosis.

BACKGROUND: Territorial diagnosis is a prerequisite for local actions concerning public health and for the reduction of social, environmental, and health-related inequalities. To orient local programs or initiatives targeting health inequalities, policymakers need a simulation of territorial diagnosis tools. Yet, very few platforms have been developed for the purpose of guiding public authorities as they seek to reduce these social inequalities. OBJECTIVE: This study aimed to describe the design and methods of the development process of a territorial diagnosis tool based on a serious game named Equit'Game that puts learners at the heart of the territorial diagnosis process, asking them to review the current state of health, environmental state, and socioeconomic state of their territory. METHODS: The realistic situations employed in our serious game should encourage players, in a fun and playful manner, to (1) appropriate the data of their own territory, (2) apply their methodological knowledge in a practical way, (3) reflect on the most pertinent statistical or spatial tools for their situation, and (4) ultimately, to acquire new knowledge and skills in the use of territorial diagnosis tools with a spatial dynamic. Equit'Game was deployed over the course of a week's training and structured into 4 levels: level 1, Dataminer (identifying relevant information to respond to the question); level 2, Analyst (selecting the appropriate method of analysis); level 3, Atlas (mapping the data); and level 4, Cluster (extraction of statistical and spatial information). Equit'Game has also been designed as a sort of virtual campus, creating a fun learning environment in which each door represents a level. Users can access Equit'Game via a platform compatible with tablets, PCs, and mobile phones. RESULTS: In the first step, we tested our application interface designed especially for adults among a panel of local health professionals. The following are some of the most relevant points: font size and colors used, voice accompaniment in texts and messages guiding the user, clear and easy interfaces, and the change between successive game levels. In the second step, we used our application, Equit'Game, with postgraduate students from the School of Public Health (École des hautes études en santé publique). At the end of the game session, we conducted a satisfaction survey, including several items covering both the application interface and the execution of the game. CONCLUSIONS: Equit'Game was developed to help learners with the techniques of territorial diagnosis, with the aim of creating an innovative tool for public health capable of conveying educational messages and providing a structure for training. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/11786.

Geographical variations in the prevalence of hypertension in France: Cross-sectional analysis of the CONSTANCES cohort.

AIMS: While international variations in the prevalence of hypertension are well described, less is known about intra-national disparities and their determinants. We wanted to describe the variations in hypertension prevalence within France and to determine how much lifestyle and socioeconomic factors contributed to explain these regional variations. METHODS: Participants (62,247 French adults aged 18 to 69 years) were recruited in the 16 centres of the CONSTANCES study between 2012 and 2015. Hypertension was defined as blood pressure higher than 140/90 mmHg and/or taking antihypertensive medications. The contribution of lifestyle and socioeconomic factors to hypertension prevalence variations among centres was examined using sequential hierarchical logistic models. RESULTS: Hypertension prevalence was 37.3% (95% confidence interval (CI) = 36.6-38.0) in men and 23.2% (95% CI = 22.7-23.8) in women. Hypertension prevalence rates varied by almost two-fold among centres (1.9 in men, 1.6 in women) with the highest prevalence in the north and the east of France. Body mass index was strongly associated with hypertension in women (odds ratio (OR)1-unit increase = 1.11 (95% CI = 1.11-1.12)) and was the highest contributor to between-centre variations (27% in women), followed by socioeconomic characteristics (e.g. ORhigh versus low education = 0.85 (95% CI = 0.83-0.87), contributing to 14% of variations in women). Together, family history of hypertension, body mass index, education, occupation and residential area socioeconomic level explained about 30% and 40% of between-centre variations in men and women, respectively. CONCLUSION: Hypertension prevalence greatly varies among French regions and this is partly explained by known lifestyle and socioeconomic factors. Nevertheless, these variations and all the hypertension determinants have not been fully deciphered yet.

Premature Adult Death and Equity Impact of a Reduction of NO2, PM10, and PM2.5 Levels in Paris-A Health Impact Assessment Study Conducted at the Census Block Level.

Background: To support environmental policies aiming to tackle air pollution, quantitative health impact assessments (HIAs) stand out as one of the best decision-making tools. However, no risk assessment studies have quantified or mapped the health and equity impact of air pollution reduction at a small spatial scale. Objectives: We developed a small-area analysis of the impact of air pollution on "premature" death among an adult population over 30 years of age to quantify and map the health and equity impact related to a reduction of air pollution. Methods: All-cause mortality data of an adult population (>30 years) from January 2004 to December 2009 were geocoded at the residential census block level in Paris. Each census block was assigned socioeconomic deprivation levels and annual average ambient concentrations of NO2, PM10, and PM2.5. HIAs were used to estimate, at a small-area level, the number of "premature" deaths associated with a hypothetical reduction of NO2, PM10, and PM2.5 exposure. In total, considering global dose response function for the three pollutants and socioeconomic deprivation specific dose response function, nine HIAs were performed for NO2 and six and four HIAs for PM10 and PM2.5, respectively. Finally, a clustering approach was used to quantify how the number of "premature" deaths could vary according to deprivation level. Results: The number of deaths attributable to NO2, PM10, and PM2.5 exposure were equal to 4301, 3209, and 2662 deaths, respectively. The most deprived census blocks always appeared as one of the groups most impacted by air pollution. Our findings showed that "premature" deaths attributable to NO2 were not randomly distributed over the study area, with a cluster of excess "premature" deaths located in the northeastern area of Paris. Discussion: This study showed the importance of stratifying an environmental burden of disease study on the socioeconomic level, in order to take into consideration the modifier effect of socioeconomic status on the air pollution-mortality relationship. In addition, we demonstrated the value of spatial analysis to guide decision-making. This shows the need for tools to support priority-setting and to guide policymakers in their choice of environmental initiatives that would maximize health gains and reduce social inequalities in health.

Using a Clustering Approach to Investigate Socio-Environmental Inequality in Preterm Birth-A Study Conducted at Fine Spatial Scale in Paris (France).

Background & Objectives: Today, to support public policies aiming to tackle environmental and health inequality, identification and monitoring of the spatial pattern of adverse birth outcomes are crucial. Spatial identification of the more vulnerable population to air pollution may orient health interventions. In this context, the objective of this study is to investigate the geographical distribution of the risk of preterm birth (PTB, gestational age ≤36 weeks) at the census block level in in city of Paris, France. We also aimed to assess the implication of neighborhood characteristics including air pollution and socio-economic deprivation. Material & Methods: Newborn health data are available from the first birth certificate registered by the Maternal and Child Care department of Paris. All PTB from January 2008 to December 2011 were geocoded at the mother residential census block. Each census block was assigned a socioeconomic deprivation level and annual average ambient concentrations of NO2. A spatial clustering approach was used to investigate the spatial distribution of PTB. Results: Our results highlight that PTB is non-randomly spatially distributed, with a cluster of high risk in the northeastern area of Paris (RR = 1.15; p = 0.06). After adjustment for socio-economic deprivation and NO2 concentrations, this cluster becomes not statistically significant or shifts suggesting that these characteristics explain the spatial distribution of PTB; further, their combination shows an interaction in comparison with SES or NO2 levels alone. Conclusions: Our results may inform the decision makers about the areas where public health efforts should be strengthened to tackle the risk of PTB and to choose the most appropriate and specific community-oriented health interventions.

Does the edge effect impact on the measure of spatial accessibility to healthcare providers?

BACKGROUND: Spatial accessibility indices are increasingly applied when investigating inequalities in health. Although most studies are making mentions of potential errors caused by the edge effect, many acknowledge having neglected to consider this concern by establishing spatial analyses within a finite region, settling for hypothesizing that accessibility to facilities will be under-reported. Our study seeks to assess the effect of edge on the accuracy of defining healthcare provider access by comparing healthcare provider accessibility accounting or not for the edge effect, in a real-world application. METHODS: This study was carried out in the department of Nord, France. The statistical unit we use is the French census block known as 'IRIS' (Ilot Regroupé pour l'Information Statistique), defined by the National Institute of Statistics and Economic Studies. The geographical accessibility indicator used is the "Index of Spatial Accessibility" (ISA), based on the E2SFCA algorithm. We calculated ISA for the pregnant women population by selecting three types of healthcare providers: general practitioners, gynecologists and midwives. We compared ISA variation when accounting or not edge effect in urban and rural zones. The GIS method was then employed to determine global and local autocorrelation. Lastly, we compared the relationship between socioeconomic distress index and ISA, when accounting or not for the edge effect, to fully evaluate its impact. RESULTS: The results revealed that on average ISA when offer and demand beyond the boundary were included is slightly below ISA when not accounting for the edge effect, and we found that the IRIS value was more likely to deteriorate than improve. Moreover, edge effect impact can vary widely by health provider type. There is greater variability within the rural IRIS group than within the urban IRIS group. We found a positive correlation between socioeconomic distress variables and composite ISA. Spatial analysis results (such as Moran's spatial autocorrelation index and local indicators of spatial autocorrelation) are not really impacted. CONCLUSION: Our research has revealed minor accessibility variation when edge effect has been considered in a French context. No general statement can be set up because intensity of impact varies according to healthcare provider type, territorial organization and methodology used to measure the accessibility to healthcare. Additional researches are required in order to distinguish what findings are specific to a territory and others common to different countries. It constitute a promising direction to determine more precisely healthcare shortage areas and then to fight against social health inequalities.

Developing a data-driven spatial approach to assessment of neighbourhood influences on the spatial distribution of myocardial infarction.

BACKGROUND: There is a growing understanding of the role played by 'neighbourhood' in influencing health status. Various neighbourhood characteristics-such as socioeconomic environment, availability of amenities, and social cohesion, may be combined-and this could contribute to rising health inequalities. This study aims to combine a data-driven approach with clustering analysis techniques, to investigate neighbourhood characteristics that may explain the geographical distribution of the onset of myocardial infarction (MI) risk. METHODS: All MI events in patients aged 35-74 years occurring in the Strasbourg metropolitan area (SMA), from January 1, 2000 to December 31, 2007 were obtained from the Bas-Rhin coronary heart disease register. All cases were geocoded to the census block for the residential address. Each areal unit, characterized by contextual neighbourhood profile, included socioeconomic environment, availability of amenities (including leisure centres, libraries and parks, and transport) and psychosocial environment as well as specific annual rates standardized (per 100,000 inhabitants). A spatial scan statistic implemented in SaTScan was then used to identify statistically significant spatial clusters of high and low risk of MI. RESULT: MI incidence was non-randomly spatially distributed, with a cluster of high risk of MI in the northern part of the SMA [relative risk (RR) = 1.70, p = 0.001] and a cluster of low risk of MI located in the first and second periphery of SMA (RR 0.04, p value  =  0.001). Our findings suggest that the location of low MI risk is characterized by a high socioeconomic level and a low level of access to various amenities; conversely, the location of high MI risk is characterized by a high level of socioeconomic deprivation-despite the fact that inhabitants have good access to the local recreational and leisure infrastructure. CONCLUSION: Our data-driven approach highlights how the different contextual dimensions were inter-combined in the SMA. Our spatial approach allowed us to identify the neighbourhood characteristics of inhabitants living within a cluster of high versus low MI risk. Therefore, spatial data-driven analyses of routinely-collected data georeferenced by various sources may serve to guide policymakers in defining and promoting targeted actions at fine spatial level.

Small-area spatiotemporal analysis of heatwave impacts on elderly mortality in Paris: A cluster analysis approach.

BACKGROUND: Heat-waves have a substantial public health burden. Understanding spatial heterogeneity at a fine spatial scale in relation to heat and related mortality is central to target interventions towards vulnerable communities. OBJECTIVES: To determine the spatial variability of heat-wave-related mortality risk among elderly in Paris, France at the census block level. We also aimed to assess area-level social and environmental determinants of high mortality risk within Paris. METHODS: We used daily mortality data from 2004 to 2009 among people aged >65 at the French census block level within Paris. We used two heat wave days' definitions that were compared to non-heat wave days. A Bernoulli cluster analysis method was applied to identify high risk clusters of mortality during heat waves. We performed random effects meta-regression analyses to investigate factors associated with the magnitude of the mortality risk. RESULTS: The spatial approach revealed a spatial aggregation of death cases during heat wave days. We found that small scale chronic PM10 exposure was associated with a 0.02 (95% CI: 0.001; 0.045) increase of the risk of dying during a heat wave episode. We also found a positive association with the percentage of foreigners and the percentage of labor force, while the proportion of elderly people living in the neighborhood was negatively associated. We also found that green space density had a protective effect and inversely that the density of constructed feature increased the risk of dying during a heat wave episode. CONCLUSION: We showed that a spatial variation in terms of heat-related vulnerability exists within Paris and that it can be explained by some contextual factors. This study can be useful for designing interventions targeting more vulnerable areas and reduce the burden of heat waves.

The need for, and value of, a spatial scan statistical tool for tackling social health inequalities.

Today, one important challenge in developed countries is health inequalities. Research conducted in public health policy issues supply little evidence for effective interventions aiming to improve population health and to reduce health inequalities. There is a need for a powerful tool to support priority setting and guide policy makers in their choice of health interventions, and that maximizes social welfare. This paper proposes to divert a spatial tool based on Kulldorff's scan method to investigate social inequalities in health. This commentary argues that this spatial approach can be a useful tool to tackle social inequalities in health by guiding policy makers at three levels: (i) supporting priority setting and planning a targeted intervention; (ii) choosing actions or interventions which will be performed for the whole population, but with a scale and intensity proportionate to need; and (iii) assessing health equity of public interventions.

Assessment of the spatial accessibility to health professionals at French census block level.

BACKGROUND: The evaluation of geographical healthcare accessibility in residential areas provides crucial information to public policy. Traditional methods - such as Physician Population Ratios (PPR) or shortest travel time - offer only a one-dimensional view of accessibility. This paper developed an improved indicator: the Index of Spatial Accessibility (ISA) to measure geographical healthcare accessibility at the smallest available infra-urban level, that is, the Îlot Regroupé pour des Indicateurs Statistiques. METHODS: This study was carried out in the department of Nord, France. Healthcare professionals are geolocalized using postal addresses available on the French state health insurance website. ISA is derived from an Enhanced Two-Step Floating Catchment Area (E2FCA). We have constructed a catchment for each healthcare provider, by taking into account residential building centroids, car travel time as calculated by Google Maps and the edge effect. Principal Component Analyses (PCA) were used to build a composite ISA to describe the global accessibility of different kinds of health professionals. RESULTS: We applied our method to studying geographical healthcare accessibility for pregnant women, by selecting three types of healthcare provider: general practitioners, gynecologists and midwives. A total of 3587 healthcare providers are potentially able to provide care for inhabitants of the department of Nord. On average there are 92 general practitioners, 22 midwives and 21 gynecologists per 100,000 residents. The composite ISA for the three types of healthcare provider is 39 per 100,000 residents. A comparative analysis between ISA and physician-population ratios indicates that ISA represents a more even distribution whereas the physician-population ratios show an 'all-or-nothing' approach. CONCLUSION: ISA is a multidimensional and improved measure, which combines the volume of services relative to population size with the proximity of services relative to the population's location, available at the smallest feasible geographical scale. It could guide policy makers towards highlighting critical areas in need of more healthcare providers, and these areas should be earmarked for further knowledge-based policy making.

Use of geographic indicators of healthcare, environment and socioeconomic factors to characterize environmental health disparities.

BACKGROUND: An environmental health inequality is a major public health concern in Europe. However just few studies take into account a large set of characteristics to analyze this problematic. The aim of this study was to identify and describe how socioeconomic, health accessibility and exposure factors accumulate and interact in small areas in a French urban context, to assess environmental health inequalities related to infant and neonatal mortality. METHODS: Environmental indicators on deprivation index, proximity to high-traffic roads, green space, and healthcare accessibility were created using the Geographical Information System. Cases were collected from death certificates in the city hall of each municipality in the Nice metropolitan area. Using the parental addresses, cases were geocoded to their census block of residence. A classification using a Multiple Component Analysis following by a Hierarchical Clustering allow us to characterize the census blocks in terms of level of socioeconomic, environmental and accessibility to healthcare, which are very diverse definition by nature. Relation between infant and neonatal mortality rate and the three environmental patterns which categorize the census blocks after the classification was performed using a standard Poisson regression model for count data after checking the assumption of dispersion. RESULTS: Based on geographic indicators, three environmental patterns were identified. We found environmental inequalities and social health inequalities in Nice metropolitan area. Moreover these inequalities are counterbalance by the close proximity of deprived census blocks to healthcare facilities related to mother and newborn. So therefore we demonstrate no environmental health inequalities related to infant and neonatal mortality. CONCLUSION: Examination of patterns of social, environmental and in relation with healthcare access is useful to identify census blocks with needs and their effects on health. Similar analyzes could be implemented and considered in other cities or related to other birth outcomes.

City-Specific Spatiotemporal Infant and Neonatal Mortality Clusters: Links with Socioeconomic and Air Pollution Spatial Patterns in France.

Infant and neonatal mortality indicators are known to vary geographically, possibly as a result of socioeconomic and environmental inequalities. To better understand how these factors contribute to spatial and temporal patterns, we conducted a French ecological study comparing two time periods between 2002 and 2009 for three (purposefully distinct) Metropolitan Areas (MAs) and the city of Paris, using the French census block of parental residence as the geographic unit of analysis. We identified areas of excess risk and assessed the role of neighborhood deprivation and average nitrogen dioxide concentrations using generalized additive models to generate maps smoothed on longitude and latitude. Comparison of the two time periods indicated that statistically significant areas of elevated infant and neonatal mortality shifted northwards for the city of Paris, are present only in the earlier time period for Lille MA, only in the later time period for Lyon MA, and decrease over time for Marseille MA. These city-specific geographic patterns in neonatal and infant mortality are largely explained by socioeconomic and environmental inequalities. Spatial analysis can be a useful tool for understanding how risk factors contribute to disparities in health outcomes ranging from infant mortality to infectious disease-a leading cause of infant mortality.