The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience.

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Conceptual and operational considerations in identifying socioenvironmental factors associated with disability among community-dwelling adults.

Disability is conceived as a person-context interaction. Physical and social environments are identified as intervention targets for improving social participation and independence. In comparison to the body of research on place and health, relatively few reports have been published on residential environments and disability in the health sciences literature. We reviewed studies evaluating the socioenvironmental correlates of disability. Searches were conducted in Medline, Embase and CINAHL databases for peer-reviewed articles published between 1997 and 2014. We found many environmental factors to be associated with disability, particularly area-level socioeconomic status and rurality. However, diversity in conceptual and methodological approaches to such research yields a limited basis for comparing studies. Conceptual inconsistencies in operational measures of disability and conceptual disagreement between studies potentially affect understanding of socioenvironmental influences. Similarly, greater precision in socioenvironmental measures and in study designs are likely to improve inference. Consistent and generalisable support for socioenvironmental influences on disability in the general adult population is scarce.

Interactions between neighborhood characteristics and individual functional status in relation to disability among Québec urbanites.

BACKGROUND: Disability is conceived as a person-context interaction. Neighborhoods are among the contexts potentially influencing disability. It is thus expected that neighborhood characteristics will be associated with disability prevalence and that such associations will be moderated by individual-level functional status. Empirical research targeting the influences of features of urban environments is relatively rare. OBJECTIVES: To evaluate the presence of contextual differences in disability prevalence and to assess the moderating role of individual functional status on the association between neighborhood characteristics and disability prevalence. METHODS: Multi-level analyses of individual-level data obtained from the Canadian Community Health Survey and neighborhood-level data derived from the Canada census. RESULTS: A contextual component was observed in the variability of disability prevalence. Significant neighborhood-level differences in disability were found across levels of social deprivation. Evidence of person-place interaction was equivocal. CONCLUSIONS: The contextual component of the variability in disability prevalence offers potential for targeting interventions to neighborhoods. The pathway by which social structure is associated with disability prevalence requires further research. Analyses of particular functional limitations may enhance our understanding of the mechanisms by which socioenvironmental factors affect disability. Publicly available survey data on disability in the general Canadian population, while useful, has limitations with respect to estimating socioenvironmental correlates of disability and potential person-place interactions.

Association between activity space exposure to food establishments and individual risk of overweight.

OBJECTIVE: Environmental exposure to food sources may underpin area level differences in individual risk for overweight. Place of residence is generally used to assess neighbourhood exposure. Yet, because people are mobile, multiple exposures should be accounted for to assess the relation between food environments and overweight. Unfortunately, mobility data is often missing from health surveys. We hereby test the feasibility of linking travel survey data with food listings to derive food store exposure predictors of overweight among health survey participants. METHODS: Food environment exposure measures accounting for non-residential activity places (activity spaces) were computed and modelled in Montreal and Quebec City, Canada, using travel surveys and food store listings. Models were then used to predict activity space food exposures for 5,578 participants of the Canadian Community Health Survey. These food exposure estimates, accounting for daily mobility, were used to model self-reported overweight in a multilevel framework. Median Odd Ratios were used to assess the proportion of between-neighborhood variance explained by such food exposure predictors. RESULTS: Estimates of food environment exposure accounting for both residential and non-residential destinations were significantly and more strongly associated with overweight than residential-only measures of exposure for men. For women, residential exposures were more strongly associated with overweight than non-residential exposures. In Montreal, adjusted models showed men in the highest quartile of exposure to food stores were at lesser risk of being overweight considering exposure to restaurants (OR = 0.36 [0.21-0.62]), fast food outlets (0.48 [0.30-0.79]), or corner stores (0.52 [0.35-0.78]). Conversely, men experiencing the highest proportion of restaurants being fast-food outlets were at higher risk of being overweight (2.07 [1.25-3.42]). Women experiencing higher residential exposures were at lower risk of overweight. CONCLUSION: Using residential neighbourhood food exposure measures may underestimate true exposure and observed associations. Using mobility data offers potential for deriving activity space exposure estimates in epidemiological models.

Weighing the contributions of material and social area deprivation to preterm birth.

Evidence suggests that individual socioeconomic status is a better predictor of preterm birth (PTB) than other individual social characteristics, but it is not clear if socioeconomic (material) area context is likewise more strongly related to PTB than social area characteristics. We compared material and social area deprivation to determine which was more strongly associated with PTB. Live singleton births from Québec, Canada were obtained for 1999-2006 (N = 581,898). PTB was defined as <37 completed gestational weeks. Two composite indices representing area-level material and social deprivation were used in Cox proportional hazards regression models to compute hazard ratios (HR) and 95% confidence intervals (CI) for PTB, accounting for individual-level characteristics including maternal education. Results indicated that PTB rates were higher for areas with high material (7.1%) and social (6.8%) deprivation than those with low material (5.5%) and social (5.9%) deprivation. Adjusted hazards of PTB were slightly greater for material deprivation than social deprivation. These findings indicate that material area deprivation is marginally more strongly associated with PTB than social deprivation, but it is not clear that interventions to prevent PTB should focus on material deprivation any more than on social area deprivation.

Investigating maternal risk factors as potential targets of intervention to reduce socioeconomic inequality in small for gestational age: a population-based study.

BACKGROUND: The major aim of this study was to investigate whether maternal risk factors associated with socioeconomic status and small for gestational age (SGA) might be viable targets of interventions to reduce differential risk of SGA by socioeconomic status (socioeconomic SGA inequality) in the metropolitan area of Vancouver, Canada. METHODS: This study included 59,039 live, singleton births in the Vancouver Census Metropolitan Area (Vancouver) from January 1, 2006 to September 17, 2009. To identify an indicator of socioeconomic SGA inequality, we used hierarchical logistic regression to model SGA by area-level variables from the Canadian census. We then modelled SGA by area-level average income plus established maternal risk factors for SGA and calculated population attributable SGA risk percentages (PAR%) for each variable. Associations of maternal risk factors for SGA with average income were investigated to identify those that might contribute to SGA inequality. Finally, we estimated crude reductions in the percentage and absolute differences in SGA risks between highest and lowest average income quintiles that would result if interventions on maternal risk factors successfully equalized them across income levels or eliminated them altogether. RESULTS: Average income produced the most linear and statistically significant indicator of socioeconomic SGA inequality with 8.9% prevalence of SGA in the lowest income quintile compared to 5.6% in the highest. The adjusted PAR% of SGA for variables were: bottom four quintiles of height (51%), first birth (32%), bottom four quintiles of average income (14%), oligohydramnios (7%), underweight or hypertension, (6% each), smoking (3%) and placental disorder (1%). Shorter height, underweight and smoking during pregnancy had higher prevalence in lower income groups. Crude models assuming equalization of risk factors across income levels or elimination altogether indicated little potential change in relative socioeconomic SGA inequality and reduction in absolute SGA inequality for shorter height only. CONCLUSIONS: Our findings regarding maternal height may indicate trans-generational aetiology for socioeconomic SGA inequalities and/or that adult height influences social mobility. Conditions affecting foetal and childhood growth might be viable targets to reduce absolute socioeconomic SGA inequality in future generations, but more research is needed to determine whether such an approach is appropriate.

Local context influence, activity space, and foodscape exposure in two canadian metropolitan settings: is daily mobility exposure associated with overweight?

It has become increasingly common to attribute part of the obesity epidemic to changes in the environment. Identification of a clear and obvious role for contextual risk factors has not yet been demonstrated. The objectives of this study were to explain differences in local overweight risk in two different urban settings and to explore sex-specific associations with estimated mobility patterns. Overweight was modeled within a multilevel framework using built environmental and socioeconomic contextual indicators and individual-level estimates of activity space exposure to fast-food restaurants (or exposure to visited places). Significant variations in local levels in overweight risk were observed. Physical and socioeconomic contexts explained more area-level differences in overweight among men than among women and among inhabitants of Montreal than among inhabitants of Quebec City. Estimated activity space exposure to fast-food outlets was significantly associated with overweight for men in Montreal. Local-level analyses are required to improve our understanding of contextual influences on obesity, including multiple influences in people's daily geographies.

An area-based material and social deprivation index for public health in Québec and Canada.

OBJECTIVES: To overcome the absence of socio-economic information in administrative databases and to monitor social inequalities in health, a material and social deprivation index was developed for Québec and Canada. METHODS: The index is based on the smallest area unit used in Canadian censuses, with 400 to 700 persons on average. It includes six socio-economic indicators grouped along two dimensions - material and social - produced from principal component analyses. The index exists for 1991, 1996, 2001 and 2006 and in different versions, from local areas to the whole of Canada. Numerous products related to the index are available online free of charge. RESULTS: The index has been used extensively in the field of health and social services, mainly in the province of Québec but also elsewhere in Canada. It has had four main uses, all related to public health: describing geographic variations of deprivation, illustrating inequalities in population health status and in service use according to deprivation, supporting the development of health reports and policies, and guiding regional resource allocation. These applications are facilitated by a close partnership between the producers and users of the index. CONCLUSION: The deprivation index is a marker of social inequalities in health. It allows for monitoring of inequalities over time and space, and constitutes a useful tool for public health planning, intervention and service delivery.

Concept mapping of diet and physical activity: uncovering local stakeholders perception in the Quebec City region.

Overweight and obesity are major public health concerns that are neither evenly distributed among the population nor between regions. Many studies suggest that beyond individual characteristics, the place where one lives influences lifestyle choices that underpin overweight and obesity. We observed such a situation in the province of Quebec (Canada), and because data availability from surveys was limited to a local level, the observed overweight disparities between local communities could not be entirely explained. Aiming to uncover local factors not captured by national survey data sets and in order to aid local level intervention, we investigated how the overweight problem was perceived by stakeholders through a concept mapping methodology. Concept mapping is a mixed method that relies upon stakeholders' perception as well as statistical techniques to draw a synthesis of the problem in the form of a conceptual map. A total of 45 stakeholders working in four areas with contrasting overweight prevalence in the Quebec City region were involved in the process. The map enables a global understanding of stakeholders' perception. This perception is not necessarily in line with public health knowledge however. For example, key concepts on the map suggest that physical activity is perceived to be much more important than diet with regards to population overweight and that urban design elements seem to be of low concern. Concept mapping is an innovative tool for planning and evaluation and can help stakeholders to develop adapted interventions to promote healthy lifestyle. It also provides relevant information to enhance the comprehension of local health disparities with a geographical perspective where data availability is limited.

Using experienced activity spaces to measure foodscape exposure.

Researchers are increasingly interested in understanding how food environments influence eating behavior and weight-related health outcomes. Little is known about the dose-response relationship between foodscapes and behavior or weight, with measures of food exposure having mainly focused on fixed anchor points including residential neighborhoods, schools, or workplaces. Recent calls have been made to extend the consideration of environmental influences beyond local neighborhoods and also to shift away from place-based, to people-based, measures of exposure. This report presents analyses of novel activity-space measures of exposure to foodscapes, combining travel survey data with food store locations in Montreal and Quebec City, Canada. The resulting individual activity-space experienced foodscape exposure measures differ from traditional residential-based measures, and show variations by age and income levels. Furthermore, these activity-space exposure measures once modeled, can be used as predictors of health outcomes. Hence, travel surveys can be used to estimate environmental exposure for health survey participants.

The geography of overweight in Quebec: analyzing and visualizing spatial inequalities using second-level residuals.

OBJECTIVE: To discuss critically the contribution of using second-level residuals from multilevel analyses to further the understanding of how place relates to health and to visualize areas, in the province of Quebec (Canada), with above- and below-average levels of overweight. METHODS: Data on 20,449 individuals are from the Canadian Community Health Survey (CCHS Cycle 2.1) and were linked to 51 spatial units. Area-level residuals were computed from a multilevel analysis examining individual and area characteristics associated with the risk of overweight. Mapping the area-level residuals indicates geographic areas where the risk of overweight is higher or lower compared to the provincial adjusted prevalence. RESULTS: Controlling for socio-economic conditions and lifestyle, distinct spatial patterns of overweight were observed, indicating that the processes linking place to health may differ between men and women and between regional contexts. In some regions, the probability of overweight differed by 23% for men and 38% for women living in privileged conditions in comparison to the province's adjusted prevalence of overweight. CONCLUSIONS: Analyzing and visualizing area-level residuals provides multi-scaled information that could enhance the understanding of the geographic distribution of overweight and has the potential to support more integrated and locally relevant interventions.

Health inequalities, deprivation, immigration and aboriginality in Canada: a geographic perspective.

OBJECTIVE: This study explores the contribution of deprivation, immigration and Aboriginal status to survival in various parts of Canada. It is hypothesized that differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated when immigration and Aboriginal status are accounted for. METHODS: The study is based on a file linking the 1991 census and a follow-up of mortality from 1991 to 2001. Geographic areas are the Canadian regions, the census metropolitan areas (CMAs) of Montréal, Toronto and Vancouver as well as the metropolitan-influenced zones. Deprivation is measured through a Canadian deprivation index. Immigration is based on declared place of birth and Aboriginal status on ethnic origin, registered treaty Indian status and Band or First Nation membership. Survival is modelized through Cox regression and two sets of models are produced for every geographic area. RESULTS: Survival is associated with deprivation, immigration and Aboriginal status in most parts of Canada. After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities related to deprivation across Canada are attenuated. Such inequalities are highly reduced in the Prairies and remote hinterland and slightly increased in the CMA of Toronto. Nevertheless, high survival inequalities related to deprivation remain in Canada, namely in the Prairies and, to a lesser degree, in British Columbia and the CMA of Vancouver. CONCLUSION: After accounting for immigration and Aboriginal status, differences in the magnitude of survival inequalities according to deprivation across Canada are attenuated but not completely eliminated.

Health inequalities in urban and rural Canada: comparing inequalities in survival according to an individual and area-based deprivation index.

Social health inequalities are smaller in rural than urban areas because, some argue, people's social conditions are estimated at a small-area level, hiding variability at the individual or household level. This paper compares inequalities in survival according to an individual and area-based version of a deprivation index among a large sample of Canadians living in various urban and rural settings. Results show that survival inequalities in small towns and rural areas are lower than elsewhere when an area-based index is used, except in the remote hinterland, but of equal magnitude when the individual version of this index is considered.

The geography of overweight in Quebec: a multilevel perspective.

OBJECTIVES: Explore the contextual aspects of overweight in Quebec through multilevel modelling, using a purposely designed set of spatial units and a few area-based characteristics. METHODS: Data came from the Canadian Community Health Survey (CCHS Cycle 2.1). Multilevel logistic regressions were performed to test for the presence of an independent contextual effect on overweight and obesity (BMI > or = 25 kg/m2), separately for men and women. Modelling considered individual attributes, including some lifestyle aspects, and contextual characteristics. A geographic grid integrating spatial elements related to overweight and obesity in the literature was developed. Also, an area-level residuals analysis was carried out to identify spatial units presenting higher or lower odds of being overweight. RESULTS: After accounting for individual and area-level characteristics, there remain significant geographic variations in overweight in Quebec. Although this contextual effect is small for men and women, many spatial units differ significantly from the provincial average. There are differences between the geography of overweight in men and women which suggest that socio-economic mechanisms and land use patterns underlying overweight might be different between genders. Also, there is considerable variability within rural and urban areas. CONCLUSION: A complex geography of overweight is revealed. Small-scale studies, as well as methodological and data developments, are needed to deepen our understanding of this geography.

A comparison of individual and area-based socio-economic data for monitoring social inequalities in health.

BACKGROUND: Area-based indicators are commonly used to measure and track health outcomes by socioeconomic group. This is largely because of the absence of socio-economic information about individuals in health administrative databases. The literature shows that the magnitude of differences in health outcomes varies depending on whether the socio-economic indicators are at the individual level or are area-based. This study compares the two types of indicators. DATA AND METHODS: The data are from a file linking the results of the 1991 Census with deaths that occurred from 1991 to 2000--a 15% sample of the Canadian population aged 25 or older. The socio-economic indicator used for comparison is a material and social deprivation index, in individual and area-based versions. The health indicators are life expectancy and disability-free life expectancy, and risks of mortality and disability. RESULTS: The individual version of the deprivation index yields wider gaps in life expectancy and disability-free life expectancy than does the area-based version. These gaps vary by sex and geographic setting. However, both versions are associated with inequalities in mortality and disability, independent of each other. INTERPRETATION: Despite some limitations, area-based socioeconomic indicators are useful in assessing inequalities in health. The inequalities that they identify are significant, consistent and reliable and can be tracked through time and for different geographic settings.

Recent changes in the geography of social disparities in premature mortality in Québec.

Most recent research reveals that social inequalities in premature mortality are widening. Such findings mainly apply to countries as a whole. In this study, we model recent changes in the association between premature mortality and a deprivation index (a small area-based index) in four geographic settings in Québec, namely the Montréal metropolitan area, other Québec metropolitan areas, mid-size cities, and small towns and rural areas. Deaths from all-cause and specific causes of mortality among people under age 75 are considered for the periods 1989-1993 and 1999-2003. Mortality rates are modeled using negative binomial regressions. Models are fitted for the overall population and for men and women, separately, in every geographic setting. Three measures of inequalities are used: mortality rates for different population groups, rate ratios and rate differences. Results show that social inequalities in premature mortality increase everywhere in Québec except in the Montréal metropolitan area. Presently, the highest mortality rates among deprived groups are found in mid-size cities, small towns and rural areas; the highest rate ratios in the Montréal metropolitan area and other metropolitan areas of Québec; and the highest rate differences in the Montréal metropolitan area, other metropolitan areas of Québec and mid-size cities. These results are discussed with reference to possible explanatory factors, namely relative deprivation, smoking, immigration and internal migration. Indications on future research and policy implications are provided.

Living environments and health at the local level: the case of three localities in the Québec city region.

BACKGROUND: To arrive at a better understanding of the combined impact of social health determinants on health inequities a research project was carried out in three localities in the Québec city region. This paper aims to show how residents' health status and health determinants can be explored through various data sources and analytic perspectives, and how these can then be combined to create a more comprehensive picture of health status at the local level. METHODS: A multidisciplinary approach was adopted. Both quantitative and qualitative methods were used: information from databases entered into a geographic information system, telephone survey and face-to-face interviews with key informants, telephone surveys with representative samples of the population in each locality and in-depth interviews with citizens. The localities were subdivided into neighbourhood units to refine the analysis on local environment. RESULTS: The results obtained in the locality of Saint-Louis, which displays the worst scores of the three localities, illustrate the research strategy's potential. Socio-economic and health indicators show that Saint-Louis is less well-off than the two other localities and that huge disparities among neighbourhoods are present within this locality. Results from the interviews with key informants, the telephone survey and interviews with citizens confirm this overall picture, raising many hypotheses about the various factors interacting to contribute to levels of health. INTERPRETATION: Two main methodological conclusions can also be drawn from this study: that defining the appropriate spatial scale to study the impact of living environments is crucially important, and that a life course approach is essential to understanding how inequities develop.

A multi-perspective approach for defining neighbourhood units in the context of a study on health inequalities in the Quebec City region.

BACKGROUND: Identification of socioeconomic and health inequalities at the local scale is facilitated by using relevant small geographical sectors. Although these places are routinely defined according to administrative boundaries on the basis of statistical criteria, it is important to carefully consider the way they are circumscribed as they can create spatial analysis problems and produce misleading information. This article introduces a new approach to defining neighbourhood units which is based on the integration of elements stemming from the socioeconomic situation of the area, its history, and how it is perceived by local key actors. RESULTS: Using this set of geographical units shows important socioeconomic and health disparities at the local scale. These disparities can be seen, for example, in a 16-year difference in disability-free life expectancy at birth, and a $10,000-difference in average personal income between close neighbourhoods. The geographical units also facilitate information transfer to local stakeholders. CONCLUSION: The context of this study has made it possible to explore several relevant methodological issues related to the definition of neighbourhood units. This multi-perspective approach allows the combination of many different elements such as physical structures, historical and administrative boundaries, material and social deprivation of the population, and sense of belonging. Results made sense to local stakeholders and helped them to raise important issues to improve future developments.

Exploring rural health inequalities at a local scale: the case of Portneuf, Québec.

BACKGROUND: The most common way of accounting for the countryside in health studies has been to compare it, as a whole, to the city. Furthermore, most of the work on small area health inequalities has been confined to major urban centres. To counter this trend, in this paper, we explore small area health inequalities in the predominantly rural county of Portneuf (population = 44,545), Québec. Such information can be of interest for local health planning. METHODS: Three sources of data were used to define neighbourhood units: historical data, socio-economic data and perceptions of local stakeholders. Demographic, socioeconomic and general health status indicators were calculated by neighbourhood unit. For health status indicators, data came from mortality files (1998 to 2002), hospitalization files (2001/02) and the 2001 census for disability (individuals who reported being often limited in their daily activities) and the reference population. RESULTS: The county of Portneuf was subdivided into 8 neighbourhoods. Differences between neighbourhoods were noticeable for demographic, socio-economic and all health status indicators. The greatest differences were found between the town of Pont-Rouge (population=4975) and the hinterland of the towns of Donnacona (population=6125) and Saint-Marc-des-Carrières (population=3160). The most striking was a difference of 6 to 8 years of disability-free life expectancy between the two groups, to the advantage of Pont-Rouge. CONCLUSION: Although measuring rural health inequalities at a local level has some methodological limitations, true health inequalities exist in the county of Portneuf. These now need to be examined further.

Perception of place and health: differences between neighbourhoods in the Québec City region.

This paper addresses two questions: (1) Can people's perceptions of problems and social cohesion in the neighbourhood be considered as contextual variables; and (2) are these perceptions related to people's health? Data come from a general health survey carried out in 2004 among 1634 individuals living in three localities of the region of Québec City, namely a downtown, a suburban and a rural area, which were further subdivided into 34 smaller spatial units, hereafter called neighbourhoods. The survey included questions on individuals' perception of problems (social and environmental) and social cohesion (attraction to neighbourhood, neighbouring and psychological sense of community) in the neighbourhood, as well as questions on self-rated health, long-term disability and self-mastery. A first set of logistic multilevel models was performed to ascertain the existence of neighbourhood variations in the perception of problems and social cohesion, after accounting for individual attributes. A second set of multilevel models was carried out to examine the association between perceived problems and social cohesion in the neighbourhood and people's health. Results show that, after accounting for individual attributes, the perception of problems and social cohesion varies significantly by neighbourhood and/or localities and can be considered as contextual variables. Furthermore, these perceptions of place appear to be significant predictors of people's health.