Peter S. Arno

The complexities of measuring access to parks and physical activity sites in New York City: a quantitative and qualitative approach

BackgroundProximity to parks and physical activity sites has been linked to an increase in active behaviors, and positive impacts on health outcomes such as lower rates of cardiovascular disease, diabetes, and obesity. Since populations with a low socio-economic status as well as racial and ethnic minorities tend to experience worse health outcomes in the USA, access to parks and physical activity sites may be an environmental justice issue. Geographic Information systems were used to conduct quantitative and qualitative analyses of park accessibility in New York City, which included kernel density estimation, ordinary least squares (global) regression, geographically weighted (local) regression, and longitudinal case studies, consisting of field work and archival research. Accessibility was measured by both density of park acreage and density of physical activity sites. Independent variables included percent non-Hispanic black, percent Hispanic, percent below poverty, percent of adults without high school diploma, percent with limited English-speaking ability, and population density.ResultsThe ordinary least squares linear regression found weak relationships in both the park acreage density and the physical activity site density models (Ra2 = .11 and .23, respectively; AIC = 7162 and 3529, respectively). Geographically weighted regression, however, suggested spatial non-stationarity in both models, indicating disparities in accessibility that vary over space with respect to magnitude and directionality of the relationships (AIC = 2014 and -1241, respectively). The qualitative analysis supported the findings of the local regression, confirming that although there is a geographically inequitable distribution of park space and physical activity sites, it is not globally predicted by race, ethnicity, or socio-economic status.ConclusionThe combination of quantitative and qualitative analyses demonstrated the complexity of the issues around racial and ethnic disparities in park access. They revealed trends that may not have been otherwise detectable, such as the spatially inconsistent relationship between physical activity site density and socio-demographics. In order to establish a more stable global model, a number of additional factors, variables, and methods might be used to quantify park accessibility, such as network analysis of proximity, perception of accessibility and usability, and additional park quality characteristics. Accurate measurement of park accessibility can therefore be important in showing the links between opportunities for active behavior and beneficial health outcomes.

The Impact of Housing Status on Health Care Utilization Among Persons With HIV Disease

This study sought to identify the prevalence of unstable housing situations, and for whom they occurred, and to examine differences in health care utilization by housing status. Housing status and inpatient and outpatient health care utilization of 1,851 HIV-infected individuals was ascertained through interviews. Nine percent of respondents were in unstable housing situations. Unstable housing was associated with significantly lower functional status. The unstably housed were more likely to visit an emergency room (p < 0.05) and had fewer ambulatory visits than persons with stable housing (p < 0.03). They incurred nearly five more hospital days and their average hospitalization was approximately 1.5 days longer than the stably housed, although these differences were not significant. Utilization of ambulatory care is lower among unstably housed persons with HIV disease, which may have led to their increased reliance upon emergency rooms and hospitals. Helping HIV-infected individuals maintain adequate housing could reverse this pattern.

Utilization of mental health and substance abuse care for people living with HIV/AIDS, chronic mental illness, and substance abuse disorders.

Objective:To examine the effects of race/ethnicity, insurance, and type of substance abuse (SA) diagnosis on utilization of mental health (MH) and SA services among triply diagnosed adults with HIV/AIDS and co-occurring mental illness (MI) and SA disorders. Data Source:Baseline (2000 to 2002) data from the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. Study Design:A multiyear cooperative agreement with 8 study sites in the United States. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) was administered by trained interviewers to determine whether or not adults with HIV/AIDS had co-occurring MI and SA disorders. Data Collection/Extraction Methods:Subjects were interviewed in person about their personal characteristics and utilization of MH and SA services in the prior 3 months. Data on HIV viral load were abstracted from their medical records. Principal Findings:Only 33% of study participants received concurrent treatment for MI and SA, despite meeting diagnostic criteria for both: 26% received only MH services, 15% received only SA services, and 26% received no services. In multinomial logistic analysis, concurrent utilization of MH and SA services was significantly lower among nonwhite and Hispanic participants as a group and among those who were not dependent on drugs and alcohol. Concurrent utilization was significantly higher for people with Veterans Affairs Civilian Health and Medical Program of the Uniformed Services (VA CHAMPUS) insurance coverage. Two-part models were estimated for MH outpatient visits and 3 SA services: (1) outpatient, (2) residential, and (3) self-help groups. Binary logistic regression was estimated for any use of psychiatric drugs. Nonwhites and Hispanics as a group were less likely to use 3 of the 5 services; they were more likely to attend SA self-help groups. Participants with insurance were significantly more likely to receive psychiatric medications and residential SA treatment. Those with Medicaid were more likely to receive MH outpatient services. Participants who were alcohol dependent but not drug dependent were significantly less likely to receive SA services than those with dual alcohol and drug dependence. Conclusion:Among adults with HIV/AIDS and co-occurring MH and SA disorders, utilization of MH and SA services needs to be improved.

Socio-economic status, neighbourhood food environments and consumption of fruits and vegetables in New York City.

OBJECTIVE Recommendations for fruit and vegetable consumption are largely unmet. Lower socio-economic status (SES), neighbourhood poverty and poor access to retail outlets selling healthy foods are thought to predict lower consumption. The objective of the present study was to assess the interrelationships between these risk factors as predictors of fruit and vegetable consumption. DESIGN Cross-sectional multilevel analyses of data on fruit and vegetable consumption, socio-demographic characteristics, neighbourhood poverty and access to healthy retail food outlets. SETTING Survey data from the 2002 and 2004 New York City Community Health Survey, linked by residential zip code to neighbourhood data. SUBJECTS Adult survey respondents (n 15 634). RESULTS Overall 9?9% of respondents reported eating

Income inequality and infant mortality in New York City.

5 servings of fruits or vegetables in the day prior to the survey. The odds of eating

The Economic Impact of Tuberculosis in Hospitals in New York City: A Preliminary Analysis

5 servings increased with higher income among women and with higher educational attainment among men and women. Compared with women having less than a high-school education, the OR was 1?12 (95% CI 0?82, 1?55) for high-school graduates, 1?95 (95% CI 1?43, 2?66) for those with some college education and 2?13 (95% CI 1?56, 2?91) for college graduates. The association between education and fruit and vegetable consumption was significantly stronger for women living in lower- v. higher-poverty zip codes (P for interaction,0?05). The density of healthy food outlets did not predict consumption of fruits or vegetables. CONCLUSIONS Higher SES is associated with higher consumption of produce, an association that, in women, is stronger for those residing in lower-poverty neighbourhoods.

Rare diseases, drug development, and AIDS: the impact of the Orphan Drug Act.

A series of studies have demonstrated that people who live in regions where there are disparities in income have poorer average health status than people who live in more economically homogeneous regions. To test whether such disparities might explain health variations within urban areas, we examined the possible association between income inequality and infant mortality for zip code regions within New York City using data from the 1990 census and the New York City Department of Health. Both infant mortality and income inequality (percentage of income received by the poorest 50% of households) varied widely across these regions (range in infant mortality: 0.6–29.6/1,000 live births: range in income inequality: 12.7–27.3). An increase of one standard deviation in income inequality was associated with an increase of 0.80 deaths/1,000 live births (P<.001), controlling for other socioeconomic factors. This finding has important implications for public health practice and social epidemiological research in large urban areas, which face significant disparities both in health and in social and economic conditions.

Local policy responses to the AIDS epidemic: New York and San Francisco

here is a nationwide resurgence of tuberculosis (TB) in the country’s urban centers; New York City stands T at the forefront of this resurgence. The root causes are increased homelessness, drug addiction and poverty, all symbols of deteriorating social and economic conditions in the city. The inadequate level of public health resources devoted to TB has also contributed to its spread. Still, even with these factors, it is questionable whether the escalating number of TB cases in this country would have occurred without the reservoir of immunosuppressed persons, who are less resistant to the disease, created by the AIDS epidemic. The fear and urgency of this public health crisis, which has been emerging since the beginning of the last decade, are fueled by the rise of TB strains resistant to the first-line drugs and by the disease’s contagiousness. The economic implications of TB are far-reaching, including expenditures on inpatient and outpatient medical treatment; infrastructural changes needed to minimize the transmission of TB in large institutions such as hospitals, nursing homes, and correctional facilities; and education, prevention, and surveillance efforts. There has been no comprehensive study of the national economic costs of the TB epidemic. In New York City, home to nearly 15 percent of the nation’s TB cases and more than triple the caseload of any other major city in the country, these costs are undoubtedly substantial.’ Due to the paucity of reliable data sources for all forms of health care delivery in the city, we have chosen to focus on the most costly component of TB-related care-acute care hospitalizations. However, this is not to minimize the amount of outpatient services devoted to persons with TB. For example, nearly 140,000 TB-related visits were made to the city’s 10 chest clinics and to outpatient facilities operated by the city’s Health and Hospitals Corporation during a recent one year period between 1991 and 1992.* Given the number of other hospital clinics and private physicians treating TB patients, the total number of outpatient visits in the city may well be in the range of several hundred thousand per year. However, even at this level, the magnitude of these costs would be dwarfed by the resources devoted to inpatient care. To assess the inpatient impact of TB in New York City, we undertook a study of all TB-related hospitalizations from 1983 to 1990. This paper reviews our data, which include: the number of TB-related hospitalizations; the demographics of persons hospitalized; and estimated costs and payment sources. In addition, we examine the relationship between HIV and TB by analyzing the hospitalizations

Bringing health and social policy together: The case of the earned income tax credit

The Orphan Drug Act provides public subsidies and incentives to spur the development of drugs for rare diseases--drugs that the private sector might otherwise consider unprofitable to produce. Although the act has achieved numerous successes, the high prices and extraordinary sales generated by some orphan drugs lead to a pivotal policy question: how can the act be used to meet the legislative goal of stimulating drug development for small patient populations without resulting in prices that make drugs inaccessible? This question is explored using the example of AIDS drugs, many of which received subsidies under the act, to illustrate central points. The history of the act, its weaknesses, and strategies for reform are described as well.

Costs of care for people living with combined HIV/AIDS, chronic mental illness, and substance abuse disorders

The epidemic of acquired immunodeficiency syndrome (AIDS) has been concentrated in a few large cities. Thus far, New York City and San Francisco have reported more AIDS cases than any other cities in the world. Together they account for 40% of the total number of cases reported in the United States through the end of 1986.