Inequalities in health: definitions, concepts, and theories

Individuals from different backgrounds, social groups, and countries enjoy different levels of health. This article defines and distinguishes between unavoidable health inequalities and unjust and preventable health inequities. We describe the dimensions along which health inequalities are commonly examined, including across the global population, between countries or states, and within geographies, by socially relevant groupings such as race/ethnicity, gender, education, caste, income, occupation, and more. Different theories attempt to explain group-level differences in health, including psychosocial, material deprivation, health behavior, environmental, and selection explanations. Concepts of relative versus absolute; dose–response versus threshold; composition versus context; place versus space; the life course perspective on health; causal pathways to health; conditional health effects; and group-level versus individual differences are vital in understanding health inequalities. We close by reflecting on what conditions make health inequalities unjust, and to consider the merits of policies that prioritize the elimination of health disparities versus those that focus on raising the overall standard of health in a population

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

Background: Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women's clinical diagnoses. Methods and Findings: Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status. The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age. Conclusions: Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use. Please see later in the article for the Editors' Summar

A Health Impact Assessment of Proposed Public Transit Service Cuts and Fare Increases in Boston, Massachusetts

Transportation decisions have health consequences that are often not incorporated into policy-making processes. Health Impact Assessment (HIA) is a process that can be used to evaluate health effects of transportation policy. We present a rapid HIA evaluating health and economic effects of proposed fare increases and service cuts to Boston, Massachusetts’ public transit system. We used transportation modeling in concert with tools allowing for quantification and monetization of multiple pathways. We estimated health and economic costs of proposed transit system changes to be hundreds of millions of dollars per year, exceeding the budget gap the transit authority was required to close. Significant health pathways included crashes, air pollution, and physical activity. The HIA enabled stakeholders to advocate for more modest fare increases and service cuts, which were eventually adopted. This HIA was among the first to quantify and monetize multiple pathways linking transportation decisions with health and economic outcomes, using approaches that could be applied in different settings. Including health costs in transportation decisions can lead to policy choices with both economic and public health benefits

A Health Impact Assessment of a Proposed Bill to Decrease Speed Limits on Local Roads in Massachusetts (U.S.A.)

Decreasing traffic speeds increases the amount of time drivers have to react to road hazards, potentially averting collisions, and makes crashes that do happen less severe. Boston’s regional planning agency, the Metropolitan Area Planning Council (MAPC), in partnership with the Massachusetts Department of Public Health (MDPH), conducted a Health Impact Assessment (HIA) that examined the potential health impacts of a proposed bill in the state legislature to lower the default speed limits on local roads from 30 miles per hour (mph) to 25 mph. The aim was to reduce vehicle speeds on local roads to a limit that is safer for pedestrians, cyclists, and children. The passage of this proposed legislation could have had far-reaching and potentially important public health impacts. Lower default speed limits may prevent around 18 fatalities and 1200 serious injuries to motorists, cyclists and pedestrians each year, as well as promote active transportation by making local roads feel more hospitable to cyclists and pedestrians. While a lower speed limit would increase congestion and slightly worsen air quality, the benefits outweigh the costs from both a health and economic perspective and would save the state approximately $62 million annually from prevented fatalities and injuries

Role of health in predicting moves to poor neighborhoods among Hurricane Katrina survivors

In contrast to a large literature investigating neighborhood effects on health, few studies have examined health as a determinant of neighborhood attainment. However, the sorting of individuals into neighborhoods by health status is a substantively important process for multiple policy sectors. We use prospectively collected data on 569 poor, predominantly African American Hurricane Katrina survivors to examine the extent to which health problems predicted subsequent neighborhood poverty. Our outcome of interest was participants’ 2009-2010 census tract poverty rate. Participants were coded as having a health problem at baseline (2003-2004) if they self-reported a diagnosis of asthma, high blood pressure, diabetes, high cholesterol, heart problems, or any other physical health problems not listed, or complained of back pain, migraines, or digestive problems at baseline. While health problems were not associated with neighborhood poverty at baseline, those with baseline health problems ended up living in higher poverty areas by 2009-2010. Differences persisted after adjustment for personal characteristics, baseline neighborhood poverty, hurricane exposure, and residence in the New Orleans metropolitan area, with baseline health problem(s) predicting a 3.4 percentage point higher neighborhood poverty rate (95% CI: 1.41,5.47). Results suggest that better health was protective against later neighborhood deprivation in a highly mobile, socially vulnerable population. Researchers should consider reciprocal associations between health and neighborhoods when estimating and interpreting neighborhood effects on health. Understanding whether and how poor health impedes poverty deconcentration efforts may help inform programs and policies designed to help low income families move to, and stay in, higher opportunity neighborhoods.Sociolog

Understanding the Effects of the Neighbourhood Built Environment on Public Health with Open Data

The investigation of the effect of the built environment in a neighbourhood and how it impacts residents' health is of value to researchers from public health policy to social science. The traditional methods to assess this impact is through surveys which lead to temporally and spatially coarse grained data and are often not cost effective. Here we propose an approach to link the effects of neighbourhood services over citizen health using a technique that attempts to highlight the cause-effect aspects of these relationships. The method is based on the theory of {\em propensity score matching with multiple `doses'} and it leverages existing fine grained open web data. To demonstrate the method, we study the effect of sport venue presence on the prevalence of antidepressant prescriptions in over 600 neighbourhoods in London over a period of three years. We find the distribution of effects is approximately normal, centred on a small negative effect on prescriptions with increases in the availability of sporting facilities, on average. We assess the procedure through some standard quantitative metrics as well as matching on synthetic data generated by modelling the real data. This approach opens the door to fast and inexpensive alternatives to quantify and continuously monitor effects of the neighborhood built environment on population health.Cambridge Trust and King's Colleg

Hospital Differences in Cesarean Deliveries in Massachusetts (US) 2004–2006: The Case against Case-Mix Artifact

Objective: We examined the extent to which differences in hospital-level cesarean delivery rates in Massachusetts were attributable to hospital-level, rather than maternal, characteristics. Methods: Birth certificate and maternal in-patient hospital discharge records for 2004–06 in Massachusetts were linked. The study population was nulliparous, term, singleton, and vertex births (NTSV) (n = 80,371) in 49 hospitals. Covariates included mother's age, race/ethnicity, education, infant birth weight, gestational age, labor induction (yes/no), hospital shift at time of birth, and preexisting health conditions. We estimated multilevel logistic regression models to assess the likelihood of a cesarean delivery. Results: Overall, among women with NTSV births, 26.5% births were cesarean, with a range of 14% to 38.3% across hospitals. In unadjusted models, the between-hospital variance was 0.103 (SE 0.022); adjusting for demographic, socioeconomic and preexisting medical conditions did not reduce any hospital-level variation 0.108 (SE 0.023). Conclusion: Even after adjusting for both socio-demographic and clinical factors, the chance of a cesarean delivery for NTSV pregnancies varied according to hospital, suggesting the importance of hospital practices and culture in determining a hospital's cesarean rate

Developing Core Capabilities for Local Health Departments to Engage in Land Use and Transportation Decision Making for Active Transportation

OBJECTIVE: To develop a core set of capabilities and tasks for local health departments (LHDs) to engage in land use and transportation policy processes that promote active transportation. DESIGN: We conducted a 3-phase modified Delphi study from 2015 to 2017. SETTING: We recruited a multidisciplinary national expert panel for key informant interviews by telephone and completion of a 2-step online validation process. PARTICIPANTS: The panel consisted of 58 individuals with expertise in local transportation and policy processes, as well as experience in cross-sector collaboration with public health. Participants represented the disciplines of land use planning, transportation/public works, public health, municipal administration, and active transportation advocacy at the state and local levels. MAIN OUTCOME MEASURES: Key informant interviews elicited initial capabilities and tasks. An online survey solicited rankings of impact and feasibility for capabilities and ratings of importance for associated tasks. Feasibility rankings were used to categorize capabilities according to required resources. Results were presented via second online survey for final input. RESULTS: Ten capabilities were categorized according to required resources. Fewest resources were as follows: (1) collaborate with public officials; (2) serve on land use or transportation board; and (3) review plans, policies, and projects. Moderate resources were as follows: (4) outreach to the community; (5) educate policy makers; (6) participate in plan and policy development; and (7) participate in project development and design review. Most resources were as follows: (8) participate in data and assessment activities; (9) fund dedicated staffing; and (10) provide funding support. CONCLUSIONS: These actionable capabilities can guide planning efforts for LHDs of all resource levels

Exploring how socioeconomic status affects neighbourhood environments? : effects on obesity risks : a longitudinal study in Singapore

Research on how socioeconomic status interacts with neighbourhood characteristics to influence disparities in obesity outcomes is currently limited by residential segregation-induced structural confounding, a lack of empirical studies outside the U.S. and other 'Western' contexts, and an over-reliance on cross-sectional analyses. This study addresses these challenges by examining how socioeconomic status modifies the effect of accumulated exposures to obesogenic neighbourhood environments on children and mothers' BMI, drawing from a longitudinal mother-child birth cohort study in Singapore, an Asian city-state with relatively little residential segregation. We find that increased access to park connectors was associated with a decrease in BMI outcomes for mothers with higher socioeconomic status, but an increase for those with lower socioeconomic status. We also find that increased access to bus stops was associated with an increase in BMIz of children with lower socioeconomic status, but with a decrease in BMIz of children with higher socioeconomic status, while increased access to rail stations was associated with a decrease in BMIz of children with lower socioeconomic status only. Our results suggest that urban interventions might have heterogeneous effects by socioeconomic status.Peer reviewe

Exploring green gentrification in 28 global North cities : the role of urban parks and other types of greenspaces

Unidad de excelencia María de Maeztu CEX2019-000940-MAlthough cities globally are increasingly mobilizing re-naturing projects to address diverse urban socio-environmental and health challenges, there is mounting evidence that these interventions may also be linked to the phenomenon known as green gentrification. However, to date the empirical evidence on the relationship between greenspaces and gentrification regarding associations with different greenspace types remains scarce. This study focused on 28 mid-sized cities in North America and Western Europe. We assessed improved access to different types of greenspace (i.e. total area of parks, gardens, nature preserves, recreational areas or greenways [i] added before the 2000s or [ii] added before the 2010s) and gentrification processes (including [i] gentrification for the 2000s; [ii] gentrification for the 2010s; [iii] gentrification throughout the decades of the 2000s and 2010s) in each small geographical unit of each city. To estimate the associations, we developed a Bayesian hierarchical spatial model foreach city and gentrification time period (i.e. a maximum of three models per city). More than half of our models showed that parks-together with other factors such as proximity to the city center-are positively associated with gentrification processes, particularly in the US context, except in historically Black disinvested postindustrial cities with lots of vacant land. We also find than in half of our models newly designated nature preserves are negatively associated with gentrification processes, particularly when considering gentrification throughout the 2000s and the 2010s and in the US. Meanwhile, for new gardens, recreational spaces and greenways, our research shows mixed results (some positive, some negative and some no effect associations). Considering the environmental and health benefits of urban re-naturing projects, cities should keep investing in improving park access while simultaneously implementing anti-displacement and inclusive green policies