Niamh K. Shortt

Neighborhood Environments and Socioeconomic Inequalities in Mental Well-Being

INTRODUCTION It has been suggested that socioeconomic inequalities in health might be reduced among populations with good access to green space. However, the potential for other neighborhood characteristics to reduce socioeconomic health inequalities, or to confound the effects of green space, has not been well explored. Therefore, this study investigates which, if any, neighborhood characteristics are associated with narrower socioeconomic inequalities in mental well-being in a large, international sample of urban residents. METHODS The 2012 European Quality of Life Survey provided data on 21,294 urban residents from 34 European nations. Associations between mental well-being (captured by the WHO-5 scale) and level of financial strain were assessed for interaction with five different neighborhood characteristics, including reported access to recreational/green areas, financial services, transport, and cultural facilities. Multilevel regression models allowed for clustering of individuals within region and country in this cross-sectional, observational study. Data were analyzed in 2014. RESULTS Socioeconomic inequality in mental well-being was 40% (8.1 WHO-5 points) narrower among respondents reporting good access to green/recreational areas, compared with those with poorer access. None of the other neighborhood characteristics or services were associated with narrower inequality. CONCLUSIONS If societies cannot, or will not, narrow socioeconomic inequality, research should explore the so-called equigenic environments-those that can disrupt the usual conversion of socioeconomic inequality to health inequality. This large, international, observational study suggests that access to recreational/green areas may offer such a disruption.

Developing summary measures of health-related multiple physical environmental deprivation for epidemiological research

Socioeconomic deprivation accounts for much of the spatial inequality in health in the UK, but a significant proportion remains unexplained. It is highly likely that the physical environment is a key factor in this unexplained variation. The role of the socioeconomic environment in health inequalities has been studied using small-area measures of multiple socioeconomic deprivation that capture the burden of socioeconomic adversity. Although similar composite measures of the physical environment would greatly assist investigations of environmental determinants of health no such measures are available. In this study we developed two small-area measures of health-related multiple physical environmental deprivation for the UK. A thorough review and evidence appraisal process was used to identify health-relevant dimensions of physical environmental deprivation. As a result we selected both health-detrimental (air pollution, cold climate, industrial facilities) and health-beneficial (ultraviolet radiation and green space) dimensions. Datasets describing each of the selected dimensions were acquired, and rendered to UK Census Area Statistics wards (n = 10 654, average population = 5518). We developed two summary measures: the multiple environmental deprivation index (MEDIx) and classification (MEDClass). MEDIx, on an ordinal scale, can be used to distinguish areas exposed to greater or lesser environmental deprivation. MEDClass groups areas with similar environmental characteristics and will be useful for exploring health effects of specific types of environment. Mapping these measures demonstrated a wide variation in physical environmental deprivation across the UK. MEDIx revealed greater environmental deprivation in urban and industrial areas, and at more northerly latitudes. Although created using a different methodology MEDClass also differentiated these environmental types. We concluded that it is possible to capture and characterise multiple attributes of health-related physical environmental deprivation in the UK, at a small area level. The measures we developed offer opportunities to researchers and policy makers for developing our understanding of the role of exposure to multiple dimensions of physical environmental deprivation on health outcomes.

Fuel poverty in Scotland: Refining spatial resolution in the Scottish Fuel Poverty Indicator using a GIS-based multiple risk index

Fuel poverty describes a complex interaction between households with low income and energy inefficiency. The Scottish Executive has charged local Scottish authorities with the task of eradicating fuel poverty by 2016. In order to direct investment and tackle fuel poverty, a local authority must know which areas are more likely to contain fuel poor households. Currently, local area fuel poverty indicators, based on small area statistics, are used to identify target areas. This paper proposes an innovative methodology for refinement of the Scottish Fuel Poverty Indicator using GIS as a framework for integrating census data with georeferenced energy efficiency data on local housing stock. This allows a multi-scale mapping of fuel poverty risk at both a census output area level and an individual dwelling level. The proposed methodology highlights small areas, and households, possibly susceptible to fuel poverty previously masked by the aggregation of statistics to large geographic units.

The density of tobacco retailers in home and school environments and relationship with adolescent smoking behaviours in Scotland

Background Neighbourhood retailing of tobacco products has been implicated in affecting smoking prevalence rates. Long-term smoking usually begins in adolescence and tobacco control strategies have often focused on regulating ‘child spaces’, such as areas in proximity to schools. This cross-sectional study examines the association between adolescent smoking behaviour and tobacco retail outlet density around home and school environments in Scotland. Methods Data detailing the geographic location of every outlet registered to sell tobacco products in Scotland were acquired from the Scottish Tobacco Retailers Register and used to create a retail outlet density measure for every postcode. This measure was joined to individual responses of the Scottish Schools Adolescent Lifestyle and Substance Use Survey (n=20 446). Using logistic regression models, we explored the association between the density of retailers, around both home and school address, and smoking behaviours. Results Those living in the areas of highest density of retailers around the home environment had 53% higher odds of reporting having ever smoked (95% CI 1.27 to 1.85, p<0.001) and 47% higher odds of reporting current smoking (95% CI 1.13 to 1.91 p<0.01). Conversely, those attending schools in areas of highest retail density had lower odds of having ever smoked (OR 0.66, 95% CI 0.50 to 0.86 p<0.01) and lower odds of current smoking (OR 0.75, 95% CI 0.59 to 0.95, p<0.05). Conclusions The density of tobacco retail outlets in residential neighbourhoods is associated with increased odds of both ever smoked and current smoking among adolescents in Scotland. Policymakers may be advised to focus on reducing the overall density of tobacco outlets, rather than concentrating on ‘child spaces’.

Evidence-based selection of environmental factors and datasets for measuring multiple environmental deprivation in epidemiological research

This Environment and Human Health project aims to develop a health-based summary measure of multiple physical environmental deprivation for the UK, akin to the measures of multiple socioeconomic deprivation that are widely used in epidemiology. Here we describe the first stage of the project, in which we aimed to identify health-relevant dimensions of physical environmental deprivation and acquire suitable environmental datasets to represent population exposure to these dimensions at the small-area level. We present the results of this process: an evidence-based list of environmental dimensions with population health relevance for the UK, and the spatial datasets we obtained and processed to represent these dimensions. This stage laid the foundations for the rest of the project, which will be reported elsewhere.

Particulate air pollution and health inequalities: a Europe-wide ecological analysis

BackgroundEnvironmental disparities may underlie the unequal distribution of health across socioeconomic groups. However, this assertion has not been tested across a range of countries: an important knowledge gap for a transboundary health issue such as air pollution. We consider whether populations of low-income European regions were a) exposed to disproportionately high levels of particulate air pollution (PM10) and/or b) disproportionately susceptible to pollution-related mortality effects.MethodsEurope-wide gridded PM10 and population distribution data were used to calculate population-weighted average PM10 concentrations for 268 sub-national regions (NUTS level 2 regions) for the period 2004–2008. The data were mapped, and patterning by mean household income was assessed statistically. Ordinary least squares regression was used to model the association between PM10 and cause-specific mortality, after adjusting for regional-level household income and smoking rates.ResultsAir quality improved for most regions between 2004 and 2008, although large differences between Eastern and Western regions persisted. Across Europe, PM10 was correlated with low household income but this association primarily reflected East–West inequalities and was not found when Eastern or Western Europe regions were considered separately. Notably, some of the most polluted regions in Western Europe were also among the richest. PM10 was more strongly associated with plausibly-related mortality outcomes in Eastern than Western Europe, presumably because of higher ambient concentrations. Populations of lower-income regions appeared more susceptible to the effects of PM10, but only for circulatory disease mortality in Eastern Europe and male respiratory mortality in Western Europe.ConclusionsIncome-related inequalities in exposure to ambient PM10 may contribute to Europe-wide mortality inequalities, and to those in Eastern but not Western European regions. We found some evidence that lower-income regions were more susceptible to the health effects of PM10.

Life Course, Green Space and Health: Incorporating Place into Life Course Epidemiology

Researchers interested in the relationships between place and health have been slow to incorporate a life course perspective, probably due to the lack of readily available historical environmental data. This hinders the identification of causal relationships. It also restricts our understanding as to whether there are accumulative effects over the life course and if there are critical periods in people’s lives when places are particularly pertinent. This study considers the feasibility of constructing longitudinal data on the availability of urban green space. The suitability of various historical and contemporary data sources is considered, including paper maps, aerial photographs and tabular land use data. Measures of urban green space are created for all neighbourhoods across the Edinburgh region of Scotland at various points during the past 100 years. We demonstrate that it is feasible to develop such measures, but there are complex issues involved in doing so. We also test the utility of the measures via an analysis of how accessibility to green space might alter over the life course of both people, and their residential neighbourhoods. The findings emphasise the potential for utilising historical data to significantly enhance understanding of the relationships between nature and health, and between health and place more generally. We encourage researchers to use data from other locations to consider including a longitudinal perspective to examine relationships between people’s health and their environment.

The mechanism behind environmental inequality in Scotland: which came first, the deprivation or the landfill?

Research suggests that people living in deprived areas of the UK are more likely to be exposed to hazardous environments than those in more affluent areas, but the mechanism behind this trend is not clear. Discrimination in the siting of undesirable land uses has often been blamed, leading to claims of environmental injustice. However, environmental inequalities may also arise through postsiting processes that lead to selective migration: the presence of an undesirable land use may devalue local property, encouraging affluent households to move away and deprived households to move in to surrounding areas. Ascertaining the underlying process at work is important as this has significant implications for guiding policies aimed at delivering environmental justice. We investigated the distribution of municipal landfill sites in Scotland and local exposure to their airborne emissions. Geographical information system techniques were used to construct a wind-weighted, emissions-weighted, and distance-weighted model with which small-area exposure to landfills could be classified. This model gave the exposure classification a degree of realism not generally incorporated in similar studies. We found clear evidence of environmental inequality: socially deprived areas of Scotland are disproportionately exposed to municipal landfills and have been since at least 1981. We then asked which came first, the deprivation or the landfill? Our results suggest that both disproportionate siting and postsiting market dynamics may play a role: area deprivation may have preceded disproportionate landfill siting to some extent, particularly in the 1980s, but landfill siting also preceded a relative increase in deprivation in exposed areas. Areas that became exposed to a municipal landfill in the 1980s were subsequently 1.65 times more likely to be classified as deprived by 2001 than areas that remained unexposed.

Integrating Environmental Justice and Socioecological Models of Health to Understand Population-Level Physical Activity

The uneven geographical distribution of environmental pathogens and salutogens, as well as the political, social, and cultural antecedents leading to this sociospatial arrangement, have been posited as a partial explanation for the stark inequalities in health across many high-income nations. Whilst there is significant international evidence for the maldistribution of health-related environmental features, few studies have examined the material outcomes (including health) of this unequal environmental ‘exposure’. In this paper we utilise the theoretical stances offered by work in the fields of environmental justice and socioecological models of health to consider the pathway between physical environmental deprivation and health. We consider the influence of multiple aspects of the ‘natural’ physical environment on individual-level levels of physical activity—both utilitarian and physical activity for leisure. We found that, for physical activity conducted for recreational purposes, there is a strong relationship with the natural physical environment: those living in the least deprived physical environments are most likely to engage in physical activity. However, for utilitarian physical activity, physical activity whose primary purpose is not the activity itself, we observed increased levels in the most environmentally deprived areas. Finally, the important role that the environment may play in shaping capabilities, particularly during the current economic and political climate, is recognised. Our results show that the environment matters and that rhetoric regarding ‘lifestyle choice’ needs to be viewed in a broader environmental context.

A Regional Measure of Neighborhood Multiple Environmental Deprivation: Relationships with Health and Health Inequalities

The health impacts of simultaneous exposure to multiple adverse environmental factors are of concern in the United Kingdom. UK-wide indicators exist, but context-specific finer resolution measures are lacking. An environmental deprivation index was developed for 398 neighborhoods (average population = 760) in a Scottish council area, including measures of air pollution, noise pollution, traffic environment, undesirable land uses, and crime. Adverse environmental conditions were related to ill health in the region and implicated in wider socioeconomic health inequalities. The results suggest an independent role for environmental deprivation in explaining poor health and health inequalities.