Neil Coffee

International variation in neighborhood walkability, transit, and recreation environments using geographic information systems: the IPEN adult study.

BackgroundThe World Health Organization recommends strategies to improve urban design, public transportation, and recreation facilities to facilitate physical activity for non-communicable disease prevention for an increasingly urbanized global population. Most evidence supporting environmental associations with physical activity comes from single countries or regions with limited variation in urban form. This paper documents variation in comparable built environment features across countries from diverse regions.MethodsThe International Physical Activity and the Environment Network (IPEN) study of adults aimed to measure the full range of variation in the built environment using geographic information systems (GIS) across 12 countries on 5 continents. Investigators in Australia, Belgium, Brazil, Colombia, the Czech Republic, Denmark, China, Mexico, New Zealand, Spain, the United Kingdom, and the United States followed a common research protocol to develop internationally comparable measures. Using detailed instructions, GIS-based measures included features such as walkability (i.e., residential density, street connectivity, mix of land uses), and access to public transit, parks, and private recreation facilities around each participant’s residential address using 1-km and 500-m street network buffers.ResultsEleven of 12 countries and 15 cities had objective GIS data on built environment features. We observed a 38-fold difference in median residential densities, a 5-fold difference in median intersection densities and an 18-fold difference in median park densities. Hong Kong had the highest and North Shore, New Zealand had the lowest median walkability index values, representing a difference of 9 standard deviations in GIS-measured walkability.ConclusionsResults show that comparable measures can be created across a range of cultural settings revealing profound global differences in urban form relevant to physical activity. These measures allow cities to be ranked more precisely than previously possible. The highly variable measures of urban form will be used to explain individuals’ physical activity, sedentary behaviors, body mass index, and other health outcomes on an international basis. Present measures provide the ability to estimate dose–response relationships from projected changes to the built environment that would otherwise be impossible.

Is walkability associated with a lower cardiometabolic risk

Walkability of residential environments has been associated with more walking. Given the health benefits of walking, it is expected that people living in locations with higher measured walkability should have a lower risk of cardiometabolic diseases. This study tested the hypothesis that higher walkability was associated with a lower cardiometabolic risk (CMR) for two administrative spatial units and three road buffers. Data were from the North West Adelaide Health Study first wave of data collected between 2000 and 2003. CMR was expressed as a cumulative sum of six clinical risk markers, selected to reflect components of the metabolic syndrome. Walkability was based on an established methodology and operationalised as dwelling density, intersection density, land-use mix and retail footprint. Walkability was associated with lower CMR for the three road buffer representations of the built environment but not for the two administrative spatial units. This may indicate a limitation in the use of administrative spatial units for analyses of walkability and health outcomes.

Application of Geographic Modeling Techniques to Quantify Spatial Access to Health Services Before and After an Acute Cardiac Event The Cardiac Accessibility and Remoteness Index for Australia (ARIA) Project

Background Access to cardiac services is essential for appropriate implementation of evidence-based therapies to improve outcomes. The Cardiac Accessibility and Remoteness Index for Australia (Cardiac ARIA) aimed to derive an objective, geographic measure reflecting access to cardiac services. Methods and Results An expert panel defined an evidence-based clinical pathway. Using Geographic Information Systems (GIS), the team developed a numeric/alphabetic index at 2 points along the continuum of care. The acute category (numeric) measured the time from the emergency call to arrival at an appropriate medical facility via road ambulance. The aftercare category (alphabetic) measured access to 4 basic services (family doctor, pharmacy, cardiac rehabilitation, and pathology services) when a patient returned to his or her community. The numeric index ranged from 1 (access to principal referral center with cardiac catheterization service ≤1 hour) to 8 (no ambulance service, >3 hours to medical facility, air transport required). The alphabetic index ranged from A (all 4 services available within a 1-hour drive-time) to E (no services available within 1 hour). The panel found that 13.9 million Australians (71%) resided within Cardiac ARIA 1A locations (hospital with cardiac catheterization laboratory and all aftercare within 1 hour). Those outside Cardiac 1A were overrepresented by people >65 years of age (32%) and indigenous people (60%). Conclusions The Cardiac ARIA index demonstrated substantial inequity in access to cardiac services in Australia. This methodology can be used to inform cardiology health service planning and could be applied to other common disease states within other regions of the world. # Clinical Perspective {#article-title-42}Background Access to cardiac services is essential for appropriate implementation of evidence-based therapies to improve outcomes. The Cardiac Accessibility and Remoteness Index for Australia (Cardiac ARIA) aimed to derive an objective, geographic measure reflecting access to cardiac services. Methods and Results An expert panel defined an evidence-based clinical pathway. Using Geographic Information Systems (GIS), the team developed a numeric/alphabetic index at 2 points along the continuum of care. The acute category (numeric) measured the time from the emergency call to arrival at an appropriate medical facility via road ambulance. The aftercare category (alphabetic) measured access to 4 basic services (family doctor, pharmacy, cardiac rehabilitation, and pathology services) when a patient returned to his or her community. The numeric index ranged from 1 (access to principal referral center with cardiac catheterization service ⩽1 hour) to 8 (no ambulance service, >3 hours to medical facility, air transport required). The alphabetic index ranged from A (all 4 services available within a 1-hour drive-time) to E (no services available within 1 hour). The panel found that 13.9 million Australians (71%) resided within Cardiac ARIA 1A locations (hospital with cardiac catheterization laboratory and all aftercare within 1 hour). Those outside Cardiac 1A were overrepresented by people >65 years of age (32%) and indigenous people (60%). Conclusions The Cardiac ARIA index demonstrated substantial inequity in access to cardiac services in Australia. This methodology can be used to inform cardiology health service planning and could be applied to other common disease states within other regions of the world.

Food environment, walkability, and public open spaces are associated with incident development of cardio-metabolic risk factors in a biomedical cohort

We investigated whether residential environment characteristics related to food (unhealthful/healthful food sources ratio), walkability and public open spaces (POS; number, median size, greenness and type) were associated with incidence of four cardio-metabolic risk factors (pre-diabetes/diabetes, hypertension, dyslipidaemia, abdominal obesity) in a biomedical cohort (n=3205). Results revealed that the risk of developing pre-diabetes/diabetes was lower for participants in areas with larger POS and greater walkability. Incident abdominal obesity was positively associated with the unhealthful food environment index. No associations were found with hypertension or dyslipidaemia. Results provide new evidence for specific, prospective associations between the built environment and cardio-metabolic risk factors.

Comparative Effectiveness of Population Interventions to Improve Access to Reperfusion for ST-Segment–Elevation Myocardial Infarction in Australia

Background— Improving timely access to reperfusion is a major goal of ST-segment–elevation myocardial infarction care. We sought to compare the population impact of interventions proposed to improve timely access to reperfusion therapy in Australia. Methods and Results— Australian hospitals, population, and road network data were integrated using Geographical Information Systems. Hospitals were classified into those that provided primary percutaneous coronary intervention (PPCI) or fibrinolysis. Population impact of interventions proposed to improve timely access to reperfusion (PPCI, fibrinolysis, or both) were modeled and compared. Timely access to reperfusion was defined as the proportion of the population capable of reaching a fibrinolysis facility ⩽60 minutes or a PPCI facility ⩽120 minutes from emergency medical services activation. The majority (93.2%) of the Australian population has timely access to reperfusion, mainly (53%) through fibrinolysis. Only 40.2% of the population had timely access to PPCI, and access to PPCI services is particularly limited in regional and nonexistent in remote areas. Optimizing the emergency medical services’ response or increasing PPCI services resulted in marginal improvement in timely access (1.8% and 3.7%, respectively). Direct transport to PPCI facilities and interhospital transfer for PPCI improves timely access to PPCI for 19.4% and 23.5% of the population, respectively. Prehospital fibrinolysis markedly improved access to timely reperfusion in regional and remote Australia. Conclusions— Significant gaps in timely provision of reperfusion remain in Australia. Systematic implementation of changes in service delivery has potential to improve timely access to PPCI for a majority of the population and improve access to fibrinolysis to those living in regional and remote areas.

Relative residential property value as a socio-economic status indicator for health research

BackgroundResidential property is reported as the most valuable asset people will own and therefore provides the potential to be used as a socio-economic status (SES) measure. Location is generally recognised as the most important determinant of residential property value.Extending the well-established relationship between poor health and socio-economic disadvantage and the role of residential property in the overall wealth of individuals, this study tested the predictive value of the Relative Location Factor (RLF), a SES measure designed to reflect the relationship between location and residential property value, and six cardiometabolic disease risk factors, central obesity, hypertriglyceridemia, reduced high density lipoprotein (HDL), hypertension, impaired fasting glucose, and high low density lipoprotein (LDL). These risk factors were also summed and expressed as a cumulative cardiometabolic risk (CMR) score.MethodsRLF was calculated using a global hedonic regression model from residential property sales transaction data based upon several residential property characteristics, but deliberately blind to location, to predict the selling price of the property. The predicted selling price was divided by the actual selling price and the results interpolated across the study area and classified as tertiles. The measures used to calculate CMR were collected via clinic visits from a population-based cohort study. Models with individual risk factors and the cumulative cardiometabolic risk (CMR) score as dependent variables were respectively tested using log binomial and Poisson generalised linear models.ResultsA statistically significant relationship was found between RLF, the cumulative CMR score and all but one of the risk factors. In all cases, participants in the most advantaged and intermediate group had a lower risk for cardio-metabolic diseases. For the CMR score the RR for the most advantaged was 19% lower (RR = 0.81; CI 0.76-0.86; p <0.0001) and the middle group was 9% lower (RR = 0.91; CI 0.86-0.95; p <0.0001) than the least advantaged group.ConclusionsThis paper advances the understanding of the nexus between place, health and SES by providing an objective spatially informed SES measure for testing health outcomes and reported a robust association between RLF and several health measures.

Do Relationships Between Environmental Attributes and Recreational Walking Vary According to Area-Level Socioeconomic Status?

Residents of areas with lower socioeconomic status (SES) are known to be less physically active during leisure time. Neighborhood walkability has been shown to be related to recreational walking equally in low and high SES areas. This cross-sectional study tested whether associations of specific environmental attributes, measured objectively and subjectively, with walking for recreation were moderated by area-level SES. The data of the North West Adelaide Health Study collected in 2007 (n = 1500, mean age 57) were used. Self-reported walking frequency was the outcome of the study. Environmental exposure measures included objectively measured walkability components (residential density, intersection density, land use mix, and net retail area ratio) and perceived attributes (access to destinations, neighborhood esthetics, walking infrastructure, traffic/barriers, and crime safety). Participants’ suburbs were categorized into low and high SES areas using an indicator of socioeconomic disadvantage. Low SES areas had lower scores in residential density, neighborhood esthetics, walking infrastructure, traffic/barriers, and crime safety. Recreational walking was associated with residential density, access to destinations, esthetics, traffic/barriers, and crime safety. Effect modification was observed for two attributes (out of nine): residential density was associated with walking only in low SES areas, while walking infrastructure was associated with walking only in high SES areas. The associations of neighborhood environmental attributes with recreational walking were largely consistent across SES groups. However, low SES areas were disadvantaged in most perceived environmental attributes related to recreational walking. Improving such attributes in low SES neighborhoods may help close socioeconomic disparities in leisure time physical activity.

Access to cardiac rehabilitation does not equate to attendance

Background/Aims: Timely access to appropriate cardiac care is critical for optimizing positive outcomes after a cardiac event. Attendance at cardiac rehabilitation (CR) remains less than optimal (10%–30%). Our aim was to derive an objective, comparable, geographic measure reflecting access to cardiac services after a cardiac event in Australia. Methods: An expert panel defined a single patient care pathway and a hierarchy of the minimum health services for CR and secondary prevention. Using geographic information systems a numeric/alpha index was modelled to describe access before and after a cardiac event. The aftercare phase was modelled into five alphabetical categories: from category A (access to medical service, pharmacy, CR, pathology within 1 h) to category E (no services available within 1 h). Results: Approximately 96% or 19 million people lived within 1 h of the four basic services to support CR and secondary prevention, including 96% of older Australians and 75% of the indigenous population. Conversely, 14% (64,000) indigenous people resided in population locations that had poor access to health services that support CR after a cardiac event. Conclusion: Results demonstrated that the majority of Australians had excellent ‘geographic’ access to services to support CR and secondary prevention. Therefore, it appears that it is not the distance to services that affects attendance. Our ‘geographic’ lens has identified that more research on socioeconomic, sociological or psychological aspects to attendance is needed.

Residential Living Structure as a Basis for the Spatial Delineation of Residential Submarkets

Abstract Whilst it is generally accepted that residential submarkets exist, this is not the case for either a definition or delineation of residential submarkets. There is a need to incorporate a full range of property attributes (including structural, environmenta, and socioeconomic) describing all dwellings in the study area in order to provide an understanding of the whole residential structure in which submarkets reside. This paper proposes the derivation of a residential living structure (RLS) to achieve this. Principal Component Analysis (PCA) is used to derive the underlying RLS from a wide range of variables including age, size, building construction, house condition, amenity, accessibility to various services and the CBD, together with a range of socio-economic variables. Altogether 65 variables were collected for each of the approximate 440,000 residential properties in the study area. The results presented in this paper reveal 15 underlying components of the RLS in the metropolitan area of Adelaide, South Australia explaining 74% of the variation in the original data. This study extends the existing work in this area by including a wide range of property attributes for all properties in the study area and by establishing the resulting principal components as a set of comprehensive and independent surrogate property characteristics as a basis for further submarket analysis.

Area-level socioeconomic characteristics, prevalence and trajectories of cardiometabolic risk.

This study examines the relationships between area-level socioeconomic position (SEP) and the prevalence and trajectories of metabolic syndrome (MetS) and the count of its constituents (i.e., disturbed glucose and insulin metabolism, abdominal obesity, dyslipidemia, and hypertension). A cohort of 4,056 men and women aged 18+ living in Adelaide, Australia was established in 2000–2003. MetS was ascertained at baseline, four and eight years via clinical examinations. Baseline area-level median household income, percentage of residents with a high school education, and unemployment rate were derived from the 2001 population Census. Three-level random-intercepts logistic and Poisson regression models were performed to estimate the standardized odds ratio (SOR), prevalence risk ratio (SRR), ratio of SORs/SRRs, and (95% confidence interval (CI)). Interaction between area- and individual-level SEP variables was also tested. The odds of having MetS and the count of its constituents increased over time. This increase did not vary according to baseline area-level SEP (ratios of SORs/SRRs ≈ 1; p ≥ 0.42). However, at baseline, after adjustment for individual SEP and health behaviours, median household income (inversely) and unemployment rate (positively) were significantly associated with MetS prevalence (SOR (95%CI) = 0.76 (0.63–0.90), and 1.48 (1.26–1.74), respectively), and the count of its constituents (SRR (95%CI) = 0.96 (0.93–0.99), and 1.06 (1.04–1.09), respectively). The inverse association with area-level education was statistically significant only in participants with less than post high school education (SOR (95%CI) = 0.58 (0.45–0.73), and SRR (95%CI) = 0.91 (0.88–0.94)). Area-level SEP does not predict an elevated trajectory to developing MetS or an elevated count of its constituents. However, at baseline, area-level SEP was inversely associated with prevalence of MetS and the count of its constituents, with the association of area-level education being modified by individual-level education. Population-level interventions for communities defined by area-level socioeconomic disadvantage are needed to reduce cardiometabolic risks.