Residential Environment and Health: A Review of Methodological and Conceptual Issues.

Geographic patterns of poor health and mortality risk are found in most countries. Important health effects at the neighborhood level are mortality, general health, illness and disabilities, mental health, and healthcare utilization. Awareness of the influence of social class on health has been growing during the last decades. Studies show that individuals with lower socioeconomic status (SES) have a shorter life expectancy than do their 'well-off' counterparts. Yet SES-related health inequalities cannot be fully explained by individual characteristics, and environmental qualities should be taken into account. Many aspects of local areas that might be related to health or access to opportunities to live healthily are systematically poorer in socially disadvantaged areas. Such factors have the potential to explain health differences between deprived and prosperous neighborhoods. Investigating health differences at the neighborhood level implies conceptual as well as methodological issues pertaining to selection, accumulation, multiple level measurement, objective features versus perceptions, and time dynamic aspects. This article reviews such issues and evaluates several exemplary theoretical approaches from the fields of public health and environmental health in their ability to overcome such problems.

Does selective migration bias the health impact assessment of urban regeneration programmes in cross-sectional studies? Findings from a Dutch case study.

We examined if the assessment of the health impact of a national Dutch regeneration programme depends on using either a repeated cross-sectional or longitudinal study design. This is important as only the latter design can incorporate migration patterns. For both designs, we compared trends in medication use between target and control districts. We found differences in medication use trends to be modest under the longitudinal design, and not demonstrable under the repeated cross-sectional design. The observed differences were hardly influenced by migration patterns. We conclude that in the Netherlands migration patterns had little effect on the health impact assessment of this national urban regeneration programme, so either the cross-sectional or longitudinal evaluation study design will do.

Does the Health Impact of Exposure to Neighbourhood Green Space Differ between Population Groups? An Explorative Study in Four European Cities.

It has been suggested that certain residents, such as those with a low socioeconomic status, the elderly, and women, may benefit more from the presence of neighbourhood green space than others. We tested this hypothesis for age, gender, educational level, and employment status in four European cities. Data were collected in Barcelona (Spain; n = 1002), Kaunas (Lithuania; n = 989), Doetinchem (The Netherlands; n = 847), and Stoke-on-Trent (UK; n = 933) as part of the EU-funded PHENOTYPE project. Surveys were used to measure mental and general health, individual characteristics, and perceived neighbourhood green space. Additionally, we used audit data about neighbourhood green space. In Barcelona, there were positive associations between neighbourhood green space and general health among low-educated residents. In the other cities and for the other population groups, there was little evidence that the association between health and neighbourhood green space differed between population groups. Overall, our study does not support the assumption that the elderly, women, and residents who are not employed full-time benefit more from neighbourhood green space than others. Only in the highly urbanised city of Barcelona did the low-educated group benefit from neighbourhood green spaces. Perhaps neighbourhood green spaces are more important for the health of low-educated residents in particularly highly urbanised areas.

Is it better to invest in place or people to maximize population health? Evaluation of the general health impact of urban regeneration in Dutch deprived neighbourhoods.

AIM: To study the general health impact of urban regeneration programmes in deprived Dutch districts. We compared initiatives that focused on the improvement of place with initiatives that mainly invested in people. METHOD: A quasi-experimental design compared the trend in good perceived general health in the target districts with comparison districts. Generalized general mixed models assessed the rate of change in prevalence of good health per half year during a prolonged period before and after the start of the interventions. RESULTS: Neither the target districts that invested mainly in place nor the ones with interventions focused on people showed trends in general health different than comparison districts (p>0.05). However, only districts with interventions focused on place showed no deterioration in general health during the intervention period. The trend change in these districts differed significantly from the change in the districts that invested mainly in people (p<0.05). CONCLUSION: Urban regeneration programmes that focus on place may be effective in promoting general health.

The impact of greenery on physical activity and mental health of adolescent and adult residents of deprived neighborhoods: A longitudinal study.

The aim of the study is to assess the impact of perceived and objective changes in greenery on physical activity and mental health of adolescents and adults living in severely deprived neighborhoods in the Netherlands. Longitudinal data regarding changes in greenery, walking, cycling, and depressive symptoms (CES-D), were gathered for 401 adolescents and 454 adults, using questionnaires and interviews with local district managers. Multivariate linear regression models examined the association between greenery and outcome variables, correcting for demographic and socioeconomic covariates and season. Overall, the results showed small and non-significant associations, with two exceptions. Objective improvements in greenery were associated with smaller decline in adolescents' leisure time cycling, and improvements in perceived greenery were related to a decrease in adults' depressive symptoms. In addition, there were several subgroup effects. In conclusion, changes in greenery did not yield consistent positive results among residents of severely deprived neighborhoods. However, there are some indications regarding positive effects of greenery in certain subgroups.

Impact of a Dutch urban regeneration programme on mental health trends: a quasi-experimental study.

BACKGROUND: This paper aims to assess the mental health impact of an urban regeneration programme implemented from 2008 onwards in the 40 most deprived districts in the Netherlands. Interventions varied from improvements in the built environment to activities promoting social cohesion. METHODS: We accessed repeated cross-sectional data from the annual Health Interview Survey, for the period 2004-2011 among adults (n target districts=1445, n rest of the Netherlands=44 795). We used multilevel logistic regression models to compare the development of mental health in the target districts with the rest of the Netherlands and with comparably deprived districts. Results were presented as 'slope estimates' with corresponding 95% CIs. Finally, we analysed the trends by gender and by the intensity of the programme. RESULTS: The trend change in mental health between the intervention and preintervention period was approximately the same in the target districts as in broadly comparably deprived control districts (Δ slope 0.06 (-0.08 to 0.20)). However, among women, a tendency was found towards more positive trend changes in the target districts compared with control districts (Δ slope 0.17 (-0.01 to 0.34)). Those districts that implemented an intensive programme experienced an improvement in mental health, while residents of the comparably deprived control districts experienced a deterioration, resulting in a statistically significantly more positive trend change between the preintervention and intervention period in those target districts (Δ slope 0.19 (0.01 to 0.38)). CONCLUSIONS: Implementing an urban regeneration programme with a wide range of intensive interventions may be effective in promoting good mental health. Further research is required to examine which mix of interventions is needed for the programme to be effective.

The interplay between neighbourhood characteristics: The health impact of changes in social cohesion, disorder and unsafety feelings.

This study examined how the health of Dutch residents in 2012 was influenced by changes in neighbourhood social cohesion, disorder, and unsafety feelings between 2009 and 2011. Multilevel regression analyses on repeated cross-sectional survey data included 43,635 respondents living in 2100 areas. Deteriorating social cohesion and unsafety feelings were negatively associated with general health, while improvement in social cohesion was associated with better general health of the population. When the interplay of neighbourhood features was considered, deteriorating neighbourhood safety appeared decisive for health, i.e. improving social cohesion did not mitigate the health effect of deteriorating neighbourhood safety. Our results show it is important to take concurrent interactions between neighbourhood features into account when examining their health impact.

School Performance: A Matter of Health or Socio-Economic Background? Findings from the PIAMA Birth Cohort Study.

BACKGROUND: Performance in primary school is a determinant of children's educational attainment and their socio-economic position and health inequalities in adulthood. We examined the relationship between five common childhood health conditions (asthma symptoms, eczema, general health, frequent respiratory infections, and overweight), health related school absence and family socio-economic status on children's school performance. METHODS: We used data from 1,865 children in the Dutch PIAMA birth cohort study. School performance was measured as the teacher's assessment of a suitable secondary school level for the child, and the child's score on a standardized achievement test (Cito Test). Both school performance indicators were standardised using Z-scores. Childhood health was indicated by eczema, asthma symptoms, general health, frequent respiratory infections, overweight, and health related school absence. Children's health conditions were reported repeatedly between the age of one to eleven. School absenteeism was reported at age eleven. Highest attained educational level of the mother and father indicated family socio-economic status. We used linear regression models with heteroskedasticity-robust standard errors for our analyses with adjustment for sex of the child. RESULTS: The health indicators used in our study were not associated with children's school performance, independently from parental educational level, with the exception of asthma symptoms (-0.03 z-score / -0.04 z-score with Cito Test score after adjusting for respectively maternal and paternal education) and missing more than 5 schooldays due to illness (-0.18 z-score with Cito Test score and -0.17 z-score with school level assessment after adjustment for paternal education). The effect estimates for these health indicators were much smaller though than the effect estimates for parental education, which was strongly associated with children's school performance. CONCLUSION: Children's school performance was affected only slightly by a number of common childhood health problems, but was strongly associated with parental education.

Are area-based initiatives able to improve area safety in deprived areas? A quasi-experimental evaluation of the Dutch District Approach.

BACKGROUND: Numerous area-based initiatives have been implemented in deprived areas across Western-Europe with the aim to improve the socio-economic and environmental conditions in these areas. Only few of these initiatives have been scientifically evaluated for their impact on key social determinants of health, like perceived area safety. Therefore, this study aimed to assess the impact of a Dutch area-based initiative called the District Approach on trends in perceived area safety and underlying problems in deprived target districts. METHODS: A quasi-experimental design was used. Repeated cross-sectional data on perceived area safety and underlying problems were obtained from the National Safety Monitor (2005-2008) and its successor the Integrated Safety Monitor (2008-2011). Study population consisted of 133,522 Dutch adults, including 3,595 adults from target districts. Multilevel logistic regression analyses were performed to assess trends in self-reported general safety, physical order, social order, and non-victimization before and after the start of the District Approach mid-2008. Trends in target districts were compared with trends in various control groups. RESULTS: Residents of target districts felt less safe, perceived less physical and social order, and were victimized more often than adults elsewhere in the Netherlands. For non-victimization, target districts showed a somewhat more positive change in trend after the start of the District Approach than the rest of the Netherlands or other deprived districts. Differences were only statistically significant in women, older adults, and lower educated adults. For general safety, physical order, and social order, there were no differences in trend change between target districts and control groups. CONCLUSIONS: Results suggest that the District Approach has been unable to improve perceptions of area safety and disorder in deprived areas, but that it did result in declining victimization rates.

The association between adolescents' health and disparities in school career: a longitudinal cohort study.

BACKGROUND: Literature suggests that children's educational achievement is associated with their health status and the socioeconomic position of their parents. Few studies have investigated this association in adolescence, while this is an important period affecting future life trajectories. Our study investigates the relationship between adolescents' health and their subsequent school career, taking into account their parents' socioeconomic position. METHODS: Data of all Dutch adolescents who entered secondary education in 2003, according to the national education register, were linked to electronic health records from general practices and to data from the Dutch population register on a patient by patient basis. Secondary school career data of 2455 adolescents were available for several years, resulting in a longitudinal prospective cohort. School career was measured by the completion of secondary education within the research period. RESULTS: For most health problems, adolescents' health status at the moment of entering secondary education showed no association with the subsequent course of their school career. However, adolescents who had more frequent contact with their general practitioner for acute psychosocial problems (e.g. enuresis or overactive/hyperkinetic disorder), were less likely to complete their secondary education, also after adjustment for parental socioeconomic position. They were also less likely to complete their secondary education at the level of entry. CONCLUSIONS: Adolescents' secondary school career is negatively affected by the presence of acute psychosocial health problems, but not by the presence of physical health problems. This underlines the importance of adequately addressing mental health problems in adolescence.

What causes environmental inequalities and related health effects? An analysis of evolving concepts.

Early environmental justice studies were exposure-oriented, lacked an integrated approach, and did not address the health impact of environmental inequalities. A coherent conceptual framework, needed to understand and tackle environmental inequalities and the related health effects, was lacking. We analyzed the more recent environmental justice literature to find out how conceptual insights have evolved. The conceptual framework of the WHO Commission on Social Determinants of Health (CSDH) was analyzed for additional explanations for environmental inequalities and the related health effects. This paper points out that recent environmental justice studies have broadened their scope by incorporating a broader set of physical and social environmental indicators, and by focusing on different geographic levels and on health impacts of environmental inequalities. The CSDH framework provided additional elements such as the role of structural determinants, the role of health-related behavior in relation to the physical and social environment, access to health care, as well as the life course perspective. Incorporating elements of the CSDH framework into existing environmental justice concepts, and performing more empirical research on the interactions between the different determinants at different geographical levels would further improve our understanding of environmental inequalities and their health effects and offer new opportunities for policy action.

The impact of area-based initiatives on physical activity trends in deprived areas; a quasi-experimental evaluation of the Dutch District Approach.

BACKGROUND: Numerous area-based initiatives (ABIs) have been implemented in deprived neighbourhoods across Europe. These large-scale initiatives aim to tackle the socio-economic and environmental problems in these areas that might influence physical activity (PA). There is little robust evidence of their impact on PA. This study aimed to assess the impact of a Dutch ABI called the District Approach on trends in leisure-time PA in deprived districts. METHODS: Repeated cross-sectional data on 48401 adults across the Netherlands were obtained from the Integrated Survey on Household Living Conditions (POLS) 2004-2011. 1517 of these adults resided in deprived target districts and 46884 adults resided elsewhere in the Netherlands. In a quasi-experimental interrupted time-series design, multilevel logistic regression analyses were performed to assess trends in leisure-time walking, cycling, and sports before and during the intervention. Trends in deprived target districts were compared with trends in various control groups. The role of the intensity of environmental interventions was also assessed. RESULTS: Deprived target districts showed a significantly positive change in walking trend between the pre-intervention and intervention period. The trend change in the deprived target districts was significantly larger compared to the rest of the Netherlands, but not compared to other deprived districts. For cycling and sports, neither deprived districts nor control districts showed a significant trend change. For all leisure-time PA outcomes, trend changes were not related to the intensity of environmental interventions in the deprived target districts. CONCLUSION: Some evidence was found to suggest that ABIs like the District Approach have a positive impact on leisure-time PA in deprived districts, regardless of the intensity of environmental interventions.

Area-based interventions to ameliorate deprived Dutch neighborhoods in practice: does the Dutch District Approach address the social determinants of health to such an extent that future health impacts may be expected?

OBJECTIVE: We studied the local manifestation of a national procedural program that addressed problems regarding employment, education, housing and the physical neighborhood environment, social cohesion, and safety in the most deprived neighborhoods in the Netherlands. We aimed to assess if such a program, without the explicit aim to improve health, results in area-based interventions that address the social determinants of health to such an extent that future health impacts may be expected. METHODS: We used standardized questionnaires and face-to-face interviews with 39 local district managers. We analyzed the content of the area-based interventions to assess if the activities addressed the social determinants of health. We assessed the duration and scale of the activities in order to estimate their potential to change social determinants of health. RESULTS: Most districts addressed all six categories of social determinants of health central to the procedural program. Investments in broad-based primary schools, housing stock, green space, and social safety seemed to have the potential to result in district-level changes in social determinants. The scale of activities aimed at employment, income, educational attainment, and the social environment seemed too small to expect an impact at the district level. CONCLUSION: We conclude that the area-based interventions addressed the neighborhood environment to such an extent that future health impacts of the Dutch District Approach may be expected. The health effects in the long term might be more substantial when area-based interventions were devoted more to the improvement of the socioeconomic circumstances of residents.

Tobacco control policies specified according to socioeconomic status: health disparities and cost-effectiveness.

INTRODUCTION: Little is known about the cost-effectiveness of tobacco control policy for different socioeconomic status (SES) groups. We aimed to evaluate SES-specific cost-effectiveness ratios of policies with known favorable effect in low-SES groups: a tobacco tax increase and reimbursement of cessation support. METHODS: A computer model of the adult population specified by smoking behavior (never/current/former smoker), age, gender, and SES simulated policy scenarios reflecting the implementation of a €0.22 tobacco tax increase or full reimbursement of cessation support, which were compared. Relating differences in costs to quality-adjusted life years (QALYs) gained generated cost-effectiveness ratios for each SES group. RESULTS: In a cohort of 11 million people, the tobacco tax increase resulted in 27,000 additional quitters after 5 years, who were proportionally divided among the SES groups. Reimbursement led to 59,000 additional quitters, with relatively more quitters in higher-SES groups. The number of QALYs gained were 3,400-6,200 among the various SES groups for the tax increase and 6,300-14,000 for the reimbursement scenario. For both interventions, favorability of the cost-effectiveness ratios increased with SES: costs per QALY decreased from €6,100 to €4,500 for the tax increase and from €21,000 to €11,000 for reimbursement. CONCLUSIONS: The reimbursement policy produced the greatest overall health gain. Surprisingly, neither tax increase nor reimbursement reduced health disparities. Differences in use were too small to compensate for improved health gains per quitter among higher-SES groups. Both policies qualified as cost-effective overall, with more favorable cost-effectiveness ratios for high-SES than for low-SES groups.

Environmental interventions in low-SES neighbourhoods to promote healthy behaviour: enhancing and impeding factors.

BACKGROUND: Social and physical environments are important drivers of socioeconomic inequalities in health behaviour. Although many interventions aiming to improve such environments are being implemented in underprivileged neighbourhoods, implementation processes are rarely studied. Acquiring insight into successful implementation may improve future interventions. The present study aimed to investigate factors influencing the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) of social and physical environmental interventions aimed at promoting healthy behaviour in underprivileged neighbourhoods in The Netherlands. METHODS: A large set of theory-based factors of successful implementation was assessed for 18 implemented interventions in three underprivileged neighbourhoods. Expert and target group panels scored the RE-AIM dimensions for each intervention. We analyzed the statistical significance of associations between theory-based factors and the actual RE-AIM in a statistical model, to identify factors associated with increased RE-AIM. RESULTS: Six factors were identified: effectiveness and implementation success were higher when the target group was involved in the planning process, whereas maintenance increased in the absence of competition with other projects. If the current situation was inventoried during intervention development, the effectiveness, adoption and implementation were higher. These dimensions were also higher when the target group was informed before implementation. Involvement of the target group during implementation resulted in higher reach, effectiveness and adoption. Finally, lack of intervention staff worsened the reach. DISCUSSION: This study contributes to the evidence base for effective implementation of environmental measures aimed at promoting healthy behaviours. In particular, interventions in which the target group was involved in the implementation process were associated with higher RE-AIM outcomes.

What moves them? Active transport among inhabitants of Dutch deprived districts.

BACKGROUND: Active modes of transport like walking and cycling have been shown to be valuable contributions to daily physical activity. The current study investigates associations between personal and neighbourhood environmental characteristics and active transport among inhabitants of Dutch deprived districts. METHOD: Questionnaires about health, neighbourhoods, and physical activity behaviour were completed by 742 adults. Data was analysed by means of multivariate linear regression analyses. RESULTS: Being younger, female, and migrant and having a normal weight were associated with more walking for active transport. Being younger, male, and native Dutch and having a normal weight were associated with more cycling for active transport. Neighbourhood characteristics were generally not correlated with active transport. Stratified analyses, based on significant person-environment interactions, showed that migrants and women walked more when cars did not exceed maximum speed in nearby streets and that younger people walked more when speed of traffic in nearby streets was perceived as low. Among migrants, more cycling was associated with the perceived attractiveness of the neighbourhood surroundings. DISCUSSION AND CONCLUSION: Results indicated that among inhabitants of Dutch deprived districts, personal characteristics were associated with active transport, whereas neighbourhood environmental characteristics were generally not associated with active transport. Nevertheless, interaction effects showed differences among subgroups that should be considered in intervention development.

The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study.

Quantifying the impact of different modifiable behavioral and biological risk factors on socioeconomic disparities in coronary heart disease (CHD) may help inform targeted, population-specific strategies to reduce the unequal distribution of the disease. Previous studies have used analytic approaches that limit our ability to disentangle the relative contributions of these risk factors to CHD disparities. The goal of this study was to assess mediation of the effect of low education on incident CHD by multiple risk factors simultaneously. Analyses are based on 15,067 participants of the Dutch Monitoring Project on Risk Factors for Chronic Diseases aged 20-65 years examined 1994-1997 and followed for events until January 1, 2008. Path analysis was used to quantify and test mediation of the low education-CHD association by behavioral (current cigarette smoking, heavy alcohol use, poor diet, and physical inactivity) and biological (obesity, hypertension, diabetes, and hypercholesterolemia) risk factors. Behavioral and biological risk factors accounted for 56.6 % (95 % CI 42.6-70.8 %) of the low education-incident CHD association. Smoking was the strongest mediator, accounting for 27.3 % (95 % CI 17.7-37.4 %) of the association, followed by obesity (10.2 %; 95 % CI 4.5-16.1 %), physical inactivity (6.3 %; 95 % CI 2.7-10.0 %), and hypertension (5.3 %; 95 % CI: 2.8-8.0 %). In summary, in a Dutch cohort, the majority of the relationship between low education and incident CHD was mediated by traditional behavioral and biological risk factors. Addressing barriers to smoking cessation, blood pressure and weight management, and physical activity may be the most effective approaches to eliminating socioeconomic inequalities in CHD.

The contribution of diet and lifestyle to socioeconomic inequalities in cardiovascular morbidity and mortality.

BACKGROUND: The role of differences in diet on the relationship between socioeconomic factors and cardiovascular diseases remains unclear. We studied the contribution of diet and other lifestyle factors to the explanation of socioeconomic inequalities in cardiovascular diseases. METHODS: We prospectively examined the incidence of coronary heart disease (CHD) and stroke events amongst 33,106 adults of the EPIC-NL cohort. Education and employment status indicated socioeconomic status. We used Cox proportional models to estimate hazard ratios ((HR (95% confidence intervals)) for the association of socioeconomic factors with CHD and stroke and the contribution of diet and lifestyle. RESULTS: During 12 years of follow-up, 1617 cases of CHD and 531 cases of stroke occurred. The risks of CHD and stroke were higher in lowest (HR=1.98 (1.67;2.35); HR=1.55 (1.15;2.10)) and lower (HR=1.50 (1.29;1.75); HR=1.42 (1.08;1.86)) educated groups than in the highest. Unemployed and retired subjects more often suffered from CHD (HR=1.37 (1.19;1.58); HR=1.20 (1.05;1.37), respectively), but not from stroke, than the employed. Diet and lifestyle, mainly smoking and alcohol, explained more than 70% of the educational differences in CHD and stroke and 65% of employment status variation in CHD. Diet explained more than other lifestyle factors of educational and employment status differences in CHD and stroke (36% to 67% vs. 9% to 27%). CONCLUSION: The socioeconomic distribution of diet, smoking and alcohol consumption largely explained the inequalities in CHD and stroke in the Netherlands. These findings need to be considered when developing policies to reduce socioeconomic inequalities in cardiovascular diseases.