Dementia, dementia's risk factors and premorbid brain structure are concentrated in disadvantaged areas: National register and birth-cohort geographic analyses.

INTRODUCTION: Dementia risk may be elevated in socioeconomically disadvantaged neighborhoods. Reasons for this remain unclear, and this elevation has yet to be shown at a national population level. METHODS: We tested whether dementia was more prevalent in disadvantaged neighborhoods across the New Zealand population (N = 1.41 million analytic sample) over a 20-year observation. We then tested whether premorbid dementia risk factors and MRI-measured brain-structure antecedents were more prevalent among midlife residents of disadvantaged neighborhoods in a population-representative NZ-birth-cohort (N = 938 analytic sample). RESULTS: People residing in disadvantaged neighborhoods were at greater risk of dementia (HR per-quintile-disadvantage-increase = 1.09, 95% confidence interval [CI]:1.08-1.10) and, decades before clinical endpoints typically emerge, evidenced elevated dementia-risk scores (CAIDE, LIBRA, Lancet, ANU-ADRI, DunedinARB; ß's 0.31-0.39) and displayed dementia-associated brain structural deficits and cognitive difficulties/decline. DISCUSSION: Disadvantaged neighborhoods have more residents with dementia, and decades before dementia is diagnosed, residents have more dementia-risk factors and brain-structure antecedents. Whether or not neighborhoods causally influence risk, they may offer scalable opportunities for primary dementia prevention.

The effects of contemporary redlining on the mental health of Black residents.

Understanding how structural racism, including institutionalized practices such as redlining, influence persistent inequities in health and neighborhood conditions is still emerging in urban health research. Such research often focuses on historical practices, giving the impression that such practices are a thing of the past. However, mortgage lending bias can be readily detected in contemporary datasets and is an active form of structural racism with implications for health and wellbeing. The objective of the current study was to test for associations among multiple measures of mental health and a measure of contemporary redlining. We linked a redlining index constructed using Home Mortgage Disclosure Act data (2007-2013) to 2021 health data for Black/African American participants in the Study of Active Neighborhoods in Detroit (n = 220 with address data). We used multilevel regression models to examine the relationship between redlining and a suite of mental health outcomes (perceived stress, anxiety, depressive symptoms, and satisfaction with life), accounting for covariates including racial composition of the neighborhood. We considered three mediating factors: perceived neighborhood cohesion, aesthetics, and discrimination. Although all participants lived in redlined neighborhoods compared to the complete Detroit Metropolitan area, participants with very low income, low levels of experienced discrimination, and lower perceptions of neighborhood aesthetics resided in highly redlined neighborhoods (score ≥5). We observed that higher resident-reported neighborhood aesthetics were found in neighborhoods with lower redlining scores and were associated with higher levels of satisfaction with life. We found that lower levels of redlining were significantly associated with higher levels of perceived discrimination, which was significantly, positively associated with anxiety, depressive symptoms, and perceived stress scores. Our findings highlight that contemporary redlining practices may influence the aesthetics of the built environment because these neighborhoods experience less investment, with implications for residents' satisfaction with life. However, areas with lower redlining may be areas where Black/African American people experience increased perceived discrimination.

Selecting Health Need Indicators for Spatial Equity Analysis in the New Zealand Primary Care Context.

PURPOSE: To examine potential indicators of health need for primary care in spatial equity research, and evidence of the Inverse Care Law in the Waikato region of New Zealand. METHODS: A cross-sectional analysis of 7 health need indicators (ambulatory sensitive hospitalizations; cancer rate; mortality rate; New Zealand index of multiple deprivation-health domain; age; New Zealand index of deprivation; smoking rate) that were identified through a systematic review was carried out. Values of indicators were mapped and analyzed using geographic information systems (GIS). Spearman's correlations were calculated between indicators, and clusters of high need were identified through spatial autocorrelation. The impact of incorporating indicator-based weightings into an accessibility model was tested using analysis of variance and Spearman's correlations. General practice service spatial equity was assessed by comparing clusters of high access versus need, and quantified through the Gini coefficient. FINDINGS: Ambulatory sensitive hospitalization (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and a Gini coefficient of 0.281 suggest that services are not equitably distributed. CONCLUSION: ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. Area-level socioeconomic deprivation measures incorporate some social determinants of health, and they have potential for wider use. High need clusters vary spatially according to the indicator used. GIS techniques can identify "hot-spots" of need, but these can be masked in accessibility models.

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.

Cash water expenditures are associated with household water insecurity, food insecurity, and perceived stress in study sites across 20 low- and middle-income countries.

Billions of people globally, living with various degrees of water insecurity, obtain their household and drinking water from diverse sources that can absorb a disproportionate amount of a household's income. In theory, there are income and expenditure thresholds associated with effective mitigation of household water insecurity, but there is little empirical research about these mechanisms and thresholds in low- and middle-income settings. This study used data from 3655 households from 23 water-insecure sites in 20 countries to explore the relationship between cash water expenditures (measured as a Z-score, percent of income, and Z-score of percent of income) and a household water insecurity score, and whether income moderated that relationship. We also assessed whether water expenditures moderated the relationships between water insecurity and both food insecurity and perceived stress. Using tobit mixed effects regression models, we observed a positive association between multiple measures of water expenditures and a household water insecurity score, controlling for demographic characteristics and accounting for clustering within neighborhoods and study sites. The positive relationships between water expenditures and water insecurity persisted even when adjusted for income, while income was independently negatively associated with water insecurity. Water expenditures were also positively associated with food insecurity and perceived stress. These results underscore the complex relationships between water insecurity, food insecurity, and perceived stress and suggest that water infrastructure interventions that increase water costs to households without anti-poverty and income generation interventions will likely exacerbate experiences of household water insecurity, especially for the lowest-income households.

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.

The population randomization observation process (PROP) assessment method: using systematic habitation observations of street segments to establish household-level epidemiologic population samples.

BACKGROUND: Identifying and intervening on health disparities requires representative community public health data. For cities with high vacancy and transient populations, traditional methods of population estimation for refining random samples are not feasible. The aim of this project was to develop a novel method for systematic observations to establish community epidemiologic samples. RESULTS: We devised a four-step population randomization observation process for Flint, Michigan, USA: (1) Use recent total population data for community areas (i.e., neighborhoods) to establish the proportional sample size for each area, (2) Randomly select street segments of each community area, (3) Deploy raters to conduct observations about habitation for each randomly selected segment, and (4) Complete observations for second and third street segments, depending on vacancy levels. We implemented this systematic observation process on 400 randomly selected street segments. Of these, 130 (32.5%) required assessment of secondary segments due to high vacancy. Among the 130 primary segments, 28 (21.5%) required assessment of tertiary (or more) segments. For 71.5% of the 400 primary street segments, there was consensus among raters on whether the dwelling inhabited or uninhabited. CONCLUSION: Houses observed with this method could have easily been considered uninhabited via other methods. This could cause residents of ambiguous dwellings (likely to be the most marginalized residents with highest levels of unmet health needs) to be underrepresented in the resultant sample.

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.

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.

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.

Measuring Blue Space Visibility and 'Blue Recreation' in the Everyday Lives of Children in a Capital City.

Blue spaces (water bodies) may promote positive mental and physical health through opportunities for relaxation, recreation, and social connections. However, we know little about the nature and extent of everyday exposure to blue spaces, particularly in settings outside the home or among children, nor whether exposure varies by individual or household characteristics. Wearable cameras offer a novel, reliable method for blue space exposure measurement. In this study, we used images from cameras worn over two days by 166 children in Wellington, New Zealand, and conducted content and blue space quantification analysis on each image (n = 749,389). Blue space was identified in 24,721 images (3.6%), with a total of 23 blue recreation events. Visual exposure and participation in blue recreation did not differ by ethnicity, weight status, household deprivation, or residential proximity to the coastline. Significant differences in both visual exposure to blue space and participation in blue recreation were observed, whereby children from the most deprived schools had significantly higher rates of blue space exposure than children from low deprivation schools. Schools may be important settings to promote equitable blue space exposures. Childhood exposures to blue space may not follow the expected income inequality trends observed among adults.

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.

Mobile Phones and Mental Well-Being: Initial Evidence Suggesting the Importance of Staying Connected to Family in Rural, Remote Communities in Uganda.

Due to the ubiquity of mobile phones around the globe, studies are beginning to analyze their influence on health. Prior work from developed countries highlights negative mental health outcomes related to overuse of mobile phones. However, there is little work on mental health impacts of mobile phone use or ownership in developing countries. This is an important gap to address because there are likely variations in mental health impacts of mobile phones between developing and developed countries, due to cultural nuances to phone use and distinct variations in financial models for obtaining mobile phone access in developing countries. To address this gap, this study analyzes survey data from 92 households in sparse, rural villages in Uganda to test two hypotheses about mobile phone ownership and mental health in a developing country context: (i) Mobile phone ownership is higher among more privileged groups, compared to less privileged groups (ie, wealth and ethnicity); and (ii) mobile phone ownership is positively associated with a culturally-relevant indicator of mental health, 'feelings of peace'. Results indicate that households with mobile phones had higher levels of wealth on average, yet no significant differences were detected by ethnicity. As hypothesized, mobile phone ownership was associated with increased mental well-being for persons without family nearby (in the District) (p = 0.038) after adjusting for wealth, ethnicity and amount of land for crops and land for grazing. Mobile phone ownership was not significantly associated with increased mental well-being for persons with family nearby. These findings are consistent with studies of mobile phone use in other sub-Saharan African countries which find that phones are important tools for social connection and are thus beneficial for maintaining family ties. One might infer then that this increased feeling of mental well-being for persons located farther from family stems from the ability to maintain family connections. These findings are quite different from work in developed countries where mobile phone use is a source of technology-related stress or technostress.

Premature mortality resilience and wellbeing within urban Maori communities.

Maori (the indigenous peoples of Aotearoa New Zealand) experience of colonisation has negatively affected access to many of the resources (e.g. income, adequate housing) that enable health and well-being. However Maori have actively responded to the challenges they have faced. With the majority of the Maori population now living in urban settings this exploratory study aimed to understand factors contributing to mortality resilience despite exposure to socio-economic adversity with reference to Maori well-being. Resilient urban neighborhoods were defined as those that had lower than expected premature mortality among Maori residents despite high levels of socio-economic adversity. Selected resilience indicators theoretically linked to a Maori well-being framework were correlated with the novel Maori_RINZ resilience index. Of the selected indicators, only exposure to crime showed a clear gradient across the resilience index as predicted by the Maori well-being framework. Future research is needed as unclear trends for other indicators may reflect limitations in the indicators used or the need to develop a more comprehensive measure of well-being.

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.].

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.

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.

Residential exposure to visible blue space (but not green space) associated with lower psychological distress in a capital city.

As urbanisation escalates globally, urban neighbourhood features which may improve physical and mental health are of growing importance. Using a cross-sectional survey of adults and the application of novel geospatial techniques, this study investigated whether increased visibility of nature (green and blue space) was associated with lower psychological distress (K10 scores), in the capital city of Wellington, New Zealand. To validate, we also tested whether visibility of blue space was associated missing teeth in the same sample. Cluster robust, linear regression models were fitted to test the association between visibility of nature and K10 scores, adjusted for age, sex, personal income, neighbourhood population density, housing quality, crime and deprivation. Higher levels of blue space visibility were associated with lower psychological distress (ß=-0.28, p<0.001). Importantly, blue space visibility was not significantly associated with tooth loss. Further research is needed to confirm whether increased visibility of blue space could promote mental well-being and reduce distress in other cities.