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International journal of health geographics [journal]
- The effect of spatial aggregation on performance when mapping a risk of disease. [JOURNAL ARTICLE]
- Int J Health Geogr 2014 Mar 13; 13(1):9.
Spatial data on cases are available either in point form (e.g. longitude/latitude), or aggregated by an administrative region (e.g. zip code or census tract). Statistical methods for spatial data may accommodate either form of data, however the spatial aggregation can affect their performance. Previous work has studied the effect of spatial aggregation on cluster detection methods. Here we consider geographic health data at different levels of spatial resolution, to study the effect of spatial aggregation on disease mapping performance in locating subregions of increased disease risk.We implemented a non-parametric disease distance-based mapping (DBM) method to produce a smooth map from spatially aggregated childhood leukaemia data. We then simulated spatial data under controlled conditions to study the effect of spatial aggregation on its performance. We used an evaluation method based on ROC curves to compare performance of DBM across different geographic scales.Application of DBM to the leukaemia data illustrates the method as a useful visualization tool. Spatial aggregation produced expected degradation of disease mapping performance. Characteristics of this degradation, however, varied depending on the interaction between the geographic extent of the higher risk area and the level of aggregation. For example, higher risk areas dispersed across several units did not suffer as greatly from aggregation. The choice of centroids also had an impact on the resulting mapping.DBM can be implemented for continuous and discrete spatial data, but the resulting mapping can lose accuracy in the second setting. Investigation of the simulations suggests a complex relationship between performance loss, geographic extent of spatial disturbances and centroid locations. Aggregation of spatial data destroys information and thus impedes efforts to monitor these data for spatial disturbances. The effect of spatial aggregation on cluster detection, disease mapping, and other useful methods in spatial epidemiology is complex and deserves further study.
- Social differences in avoidable mortality between small areas of 15 European cities: an ecological study. [JOURNAL ARTICLE]
- Int J Health Geogr 2014 Mar 12; 13(1):8.
Health and inequalities in health among inhabitants of European cities are of major importance for European public health and there is great interest in how different health care systems in Europe perform in the reduction of health inequalities. However, evidence on the spatial distribution of cause-specific mortality across neighbourhoods of European cities is scarce. This study presents maps of avoidable mortality in European cities and analyses differences in avoidable mortality between neighbourhoods with different levels of deprivation.We determined the level of mortality from 14 avoidable causes of death for each neighbourhood of 15 large cities in different European regions. To address the problems associated with Standardised Mortality Ratios for small areas we smooth them using the Bayesian model proposed by Besag, York and Mollie. Ecological regression analysis was used to assess the association between social deprivation and mortality.Mortality from avoidable causes of death is higher in deprived neighbourhoods and mortality rate ratios between areas with different levels of deprivation differ between gender and cities. In most cases rate ratios are lower among women. While Eastern and Southern European cities show higher levels of avoidable mortality, the association of mortality with social deprivation tends to be higher in Northern and lower in Southern Europe.There are marked differences in the level of avoidable mortality between neighbourhoods of European cities and the level of avoidable mortality is associated with social deprivation. There is no systematic difference in the magnitude of this association between European cities or regions. Spatial patterns of avoidable mortality across small city areas can point to possible local problems and specific strategies to reduce health inequality which is important for the development of urban areas and the well-being of their inhabitants.
- Characteristics of residential areas and transportational walking among frail and non-frail Dutch elderly: does the size of the area matter? [Journal Article]
- Int J Health Geogr 2014; 13(1):7.
A residential area supportive for walking may facilitate elderly to live longer independently. However, current evidence on area characteristics potentially important for walking among older persons is mixed. This study hypothesized that the importance of area characteristics for transportational walking depends on the size of the area characteristics measured, and older person's frailty level.The study population consisted of 408 Dutch community-dwelling persons aged 65 years and older participating in the Elderly And their Neighborhood (ELANE) study in 2011-2012. Characteristics (aesthetics, functional features, safety, and destinations) of areas surrounding participants' residences ranging from a buffer of 400 meters up to 1600 meters (based on walking path networks) were linked with self-reported transportational walking using linear regression analyses. In addition, interaction effects between frailty level and area characteristics were tested.An increase in functional features (e.g. presence of sidewalks and benches) within a 400 meter buffer, in aesthetics (e.g. absence of litter and graffiti) within 800 and 1200 meter buffers, and an increase of one destination per buffer of 400 and 800 meters were associated with more transportational walking, up to 2.89 minutes per two weeks (CI 1.07-7.32; p < 0.05). No differences were found between frail and non-frail elderly.Better functional and aesthetic features, and more destinations in the residential area of community-dwelling older persons were associated with more transportational walking. The importance of area characteristics for transportational walking differs by area size, but not by frailty level. Neighbourhood improvements may increase transportational walking among older persons, thereby contributing to living longer independently.
- A spatially filtered multilevel model to account for spatial dependency: application to self-rated health status in South Korea. [Journal Article]
- Int J Health Geogr 2014; 13(1):6.
This study aims to suggest an approach that integrates multilevel models and eigenvector spatial filtering methods and apply it to a case study of self-rated health status in South Korea. In many previous health-related studies, multilevel models and single-level spatial regression are used separately. However, the two methods should be used in conjunction because the objectives of both approaches are important in health-related analyses. The multilevel model enables the simultaneous analysis of both individual and neighborhood factors influencing health outcomes. However, the results of conventional multilevel models are potentially misleading when spatial dependency across neighborhoods exists. Spatial dependency in health-related data indicates that health outcomes in nearby neighborhoods are more similar to each other than those in distant neighborhoods. Spatial regression models can address this problem by modeling spatial dependency. This study explores the possibility of integrating a multilevel model and eigenvector spatial filtering, an advanced spatial regression for addressing spatial dependency in datasets.In this spatially filtered multilevel model, eigenvectors function as additional explanatory variables accounting for unexplained spatial dependency within the neighborhood-level error. The specification addresses the inability of conventional multilevel models to account for spatial dependency, and thereby, generates more robust outputs.The findings show that sex, employment status, monthly household income, and perceived levels of stress are significantly associated with self-rated health status. Residents living in neighborhoods with low deprivation and a high doctor-to-resident ratio tend to report higher health status. The spatially filtered multilevel model provides unbiased estimations and improves the explanatory power of the model compared to conventional multilevel models although there are no changes in the signs of parameters and the significance levels between the two models in this case study.The integrated approach proposed in this paper is a useful tool for understanding the geographical distribution of self-rated health status within a multilevel framework. In future research, it would be useful to apply the spatially filtered multilevel model to other datasets in order to clarify the differences between the two models. It is anticipated that this integrated method will also out-perform conventional models when it is used in other contexts.
- How well do modelled routes to school record the environments children are exposed to?: a cross-sectional comparison of GIS-modelled and GPS-measured routes to school. [Journal Article]
- Int J Health Geogr 2014; 13(1):5.
The school journey may make an important contribution to children's physical activity and provide exposure to food and physical activity environments. Typically, Geographic Information Systems (GIS) have been used to model assumed routes to school in studies, but these may differ from those actually chosen. We aimed to identify the characteristics of children and their environments that make the modelled route more or less representative of that actually taken. We compared modelled GIS routes and actual Global Positioning Systems (GPS) measured routes in a free-living sample of children using varying travel modes.Participants were 175 13-14 yr old children taking part in the Sport, Physical activity and Eating behaviour: Environmental Determinants in Young people (SPEEDY) study who wore GPS units for up to 7 days. Actual routes to/from school were extracted from GPS data, and shortest routes between home and school along a road network were modelled in a GIS. Differences between them were assessed according to length, percentage overlap, and food outlet exposure using multilevel regression models.GIS routes underestimated route length by 21.0% overall, ranging from 6.1% among walkers to 23.2% for bus users. Among pedestrians food outlet exposure was overestimated by GIS routes by 25.4%. Certain characteristics of children and their neighbourhoods that improved the concordance between GIS and GPS route length and overlap were identified. Living in a village raised the odds of increased differences in length (odds ratio (OR) 3.36 (1.32-8.58)), while attending a more urban school raised the odds of increased percentage overlap (OR 3.98 (1.49-10.63)). However none were found for food outlet exposure. Journeys home from school increased the difference between GIS and GPS routes in terms of food outlet exposure, and this measure showed considerable within-person variation.GIS modelled routes between home and school were not truly representative of accurate GPS measured exposure to obesogenic environments, particularly for pedestrians. While route length may be fairly well described, especially for urban populations, those living close to school, and those travelling by foot, the additional expense of acquiring GPS data seems important when assessing exposure to route environments.
- Mapping the capacities of fixed health facilities to cover people at risk of gambiense human African trypanosomiasis. [Journal Article, Research Support, Non-U.S. Gov't]
- Int J Health Geogr 2014.:4.
The emphasis placed on the activities of mobile teams in the detection of gambiense human African trypanosomiasis (HAT) can at times obscure the major role played by fixed health facilities in HAT control and surveillance. The lack of consistent and detailed data on the coverage of passive case-finding and treatment further constrains our ability to appreciate the full contribution of the health system to the control of HAT.A survey was made of all fixed health facilities that are active in the control and surveillance of gambiense HAT. Information on their diagnostic and treatment capabilities was collected, reviewed and harmonized. Health facilities were geo-referenced. Time-cost distance analysis was conducted to estimate physical accessibility and the potential coverage of the population at-risk of gambiense HAT.Information provided by the National Sleeping Sickness Control Programmes revealed the existence of 632 fixed health facilities that are active in the control and surveillance of gambiense HAT in endemic countries having reported cases or having conducted active screening activities during the period 2000-2012. Different types of diagnosis (clinical, serological, parasitological and disease staging) are available from 622 facilities. Treatment with pentamidine for first-stage disease is provided by 495 health facilities, while for second-stage disease various types of treatment are available in 206 health facilities only. Over 80% of the population at-risk for gambiense HAT lives within 5-hour travel of a fixed health facility offering diagnosis and treatment for the disease.Fixed health facilities have played a crucial role in the diagnosis, treatment and coverage of at-risk-population for gambiense HAT. As the number of reported cases continues to dwindle, their role will become increasingly important for the prospects of disease elimination. Future updates of the database here presented will regularly provide evidence to inform and monitor a rational deployment of control and surveillance efforts. Support to the development and, if successful, the implementation of new control tools (e.g. new diagnostics and new drugs) is crucial, both for strengthening and expanding the existing network of fixed health facilities by improving access to diagnosis and treatment and for securing a sustainable control and surveillance of gambiense HAT.
- Urban sprawl, obesity, and cancer mortality in the United States: cross-sectional analysis and methodological challenges. [Journal Article]
- Int J Health Geogr 2014.:3.
Urban sprawl has the potential to influence cancer mortality via direct and indirect effects on obesity, access to health services, physical activity, transportation choices and other correlates of sprawl and urbanization.This paper presents a cross-sectional analysis of associations between urban sprawl and cancer mortality in urban and suburban counties of the United States. This ecological analysis was designed to examine whether urban sprawl is associated with total and obesity-related cancer mortality and to what extent these associations differed in different regions of the US. A major focus of our analyses was to adequately account for spatial heterogeneity in mortality. Therefore, we fit a series of regression models, stratified by gender, successively testing for the presence of spatial heterogeneity. Our resulting models included county level variables related to race, smoking, obesity, access to health services, insurance status, socioeconomic position, and broad geographic region as well as a measure of urban sprawl and several interactions. Our most complex models also included random effects to account for any county-level spatial autocorrelation that remained unexplained by these variables.Total cancer mortality rates were higher in less sprawling areas and contrary to our initial hypothesis; this was also true of obesity related cancers in six of seven U.S. regions (census divisions) where there were statistically significant associations between the sprawl index and mortality. We also found significant interactions (p < 0.05) between region and urban sprawl for total and obesity related cancer mortality in both sexes. Thus, the association between urban sprawl and cancer mortality differs in different regions of the US.Despite higher levels of obesity in more sprawling counties in the US, mortality from obesity related cancer was not greater in such counties. Identification of disparities in cancer mortality within and between geographic regions is an ongoing public health challenge and an opportunity for further analytical work identifying potential causes of these disparities. Future analyses of urban sprawl and health outcomes should consider exploring regional and international variation in associations between sprawl and health.
- Mapping for maternal and newborn health: the distributions of women of childbearing age, pregnancies and births. [Journal Article, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't]
- Int J Health Geogr 2014.:2.
The health and survival of women and their new-born babies in low income countries has been a key priority in public health since the 1990s. However, basic planning data, such as numbers of pregnancies and births, remain difficult to obtain and information is also lacking on geographic access to key services, such as facilities with skilled health workers. For maternal and newborn health and survival, planning for safer births and healthier newborns could be improved by more accurate estimations of the distributions of women of childbearing age. Moreover, subnational estimates of projected future numbers of pregnancies are needed for more effective strategies on human resources and infrastructure, while there is a need to link information on pregnancies to better information on health facilities in districts and regions so that coverage of services can be assessed.This paper outlines demographic mapping methods based on freely available data for the production of high resolution datasets depicting estimates of numbers of people, women of childbearing age, live births and pregnancies, and distribution of comprehensive EmONC facilities in four large high burden countries: Afghanistan, Bangladesh, Ethiopia and Tanzania. Satellite derived maps of settlements and land cover were constructed and used to redistribute areal census counts to produce detailed maps of the distributions of women of childbearing age. Household survey data, UN statistics and other sources on growth rates, age specific fertility rates, live births, stillbirths and abortions were then integrated to convert the population distribution datasets to gridded estimates of births and pregnancies.These estimates, which can be produced for current, past or future years based on standard demographic projections, can provide the basis for strategic intelligence, planning services, and provide denominators for subnational indicators to track progress. The datasets produced are part of national midwifery workforce assessments conducted in collaboration with the respective Ministries of Health and the United Nations Population Fund (UNFPA) to identify disparities between population needs, health infrastructure and workforce supply. The datasets are available to the respective Ministries as part of the UNFPA programme to inform midwifery workforce planning and also publicly available through the WorldPop population mapping project.
- Mapping amyotrophic lateral sclerosis lake risk factors across northern New England. [Journal Article, Research Support, N.I.H., Extramural, Research Support, U.S. Gov't, Non-P.H.S.]
- Int J Health Geogr 2014.:1.
Amyotrophic lateral sclerosis (ALS) is a progressive, fatal neurodegenerative disease with a lifetime risk of developing as 1 in 700. Despite many recent discoveries about the genetics of ALS, the etiology of sporadic ALS remains largely unknown with gene-environment interaction suspected as a driver. Water quality and the toxin beta methyl-amino-alanine produced by cyanobacteria are suspected environmental triggers. Our objective was to develop an eco-epidemiological modeling approach to characterize the spatial relationships between areas of higher than expected ALS incidence and lake water quality risk factors derived from satellite remote sensing as a surrogate marker of exposure.Our eco-epidemiological modeling approach began with implementing a spatial clustering analysis that was informed by local indicators of spatial autocorrelation to identify locations of normalized excess ALS counts at the census tract level across northern New England. Next, water quality data for all lakes over 6 hectares (n = 4,453) were generated using Landsat TM band ratio regression techniques calibrated with in situ lake sampling. Derived lake water quality risk maps included chlorophyll-a (Chl-a), Secchi depth (SD), and total nitrogen (TN). Finally, a spatially-aware logistic regression modeling approach was executed characterizing relationships between the derived lake water quality metrics and ALS hot spots.Several distinct ALS hot spots were identified across the region. Remotely sensed lake water quality indicators were successfully derived; adjusted R² values ranged between 0.62-0.88 for these indicators based on out-of-sample validation. Map products derived from these indicators represent the first wall-to-wall metrics of lake water quality across the region. Logistic regression modeling of ALS case membership in localized hot spots across the region, i.e., census tracts with higher than expected ALS counts, showed the following: increasing average SD within a radius of 30 km corresponds with a decrease in the odds of belonging to an ALS hot spot by 59%; increasing average TN within a radius of 30 km and average Chl-a concentration within a radius of 10 km correspond with increased odds of belonging to an ALS hot spot by 167% and 4%, respectively.The strengths of satellite remote sensing information can help overcome traditional field limitations and spatiotemporal data gaps to provide the public health community valuable exposure data. Geographic scale needs to be diligently considered when evaluating relationships among ecological processes, risk factors, and human health outcomes. Broadly, we found that poorer lake water quality was significantly associated with increased odds of belonging to an ALS cluster in the region. These findings support the hypothesis that sporadic ALS (sALS) can, in part, be triggered by environmental water-quality indicators and lake conditions that promote harmful algal blooms.
- An objective index of walkability for research and planning in the Sydney Metropolitan Region of New South Wales, Australia: an ecological study. [Journal Article]
- Int J Health Geogr 2013.:61.
Walkability describes the capacity of the built environment to support walking for various purposes. This paper describes the construction and validation of two objective walkability indexes for Sydney, Australia.Walkability indexes using residential density, intersection density, land use mix, with and without retail floor area ratio were calculated for 5,858 Sydney Census Collection Districts in a geographical information system. Associations between variables were evaluated using Spearman's rho (ρ). Internal consistency and factor structure of indexes were estimated with Cronbach's alpha and principal components analysis; convergent and predictive validity were measured using weighted kappa (κw) and by comparison with reported walking to work at the 2006 Australian Census using logistic regression. Spatial variation in walkability was assessed using choropleth maps and Moran's I.A three-attribute abridged Sydney Walkability Index comprising residential density, intersection density and land use mix was constructed for all Sydney as retail floor area was only available for 5.3% of Census Collection Districts. A four-attribute full index including retail floor area ratio was calculated for 263 Census Collection Districts in the Sydney Central Business District. Abridged and full walkability index scores for these 263 areas were strongly correlated (ρ=0.93) and there was good agreement between walkability quartiles (κw=0.73). Internal consistency ranged from 0.60 to 0.71, and all index variables loaded highly on a single factor. The percentage of employed persons who walked to work increased with increasing walkability: 3.0% in low income-low walkability areas versus 7.9% in low income-high walkability areas; and 2.1% in high income-low walkability areas versus 11% in high income-high walkability areas. The adjusted odds of walking to work were 1.05 (0.96-1.15), 1.58 (1.45-1.71) and 3.02 (2.76-3.30) times higher in medium, high and very high compared to low walkability areas. Associations were similar for full and abridged indexes.The abridged Sydney Walkability Index has predictive validity for utilitarian walking, will inform urban planning in Sydney, and will be used as an objective measure of neighbourhood walkability in a large population cohort. Abridged walkability indexes may be useful in settings where retail floor area data are unavailable.