Peter Spreeuwenberg

Green space, urbanity, and health: how strong is the relation?

Study objectives: To investigate the strength of the relation between the amount of green space in people’s living environment and their perceived general health. This relation is analysed for different age and socioeconomic groups. Furthermore, it is analysed separately for urban and more rural areas, because the strength of the relation was expected to vary with urbanity. Design: The study includes 250 782 people registered with 104 general practices who filled in a self administered form on sociodemographic background and perceived general health. The percentage of green space (urban green space, agricultural space, natural green space) within a one kilometre and three kilometre radius around the postal code coordinates was calculated for each household. Methods: Multilevel logistic regression analyses were performed at three levels—that is, individual level, family level, and practice level—controlled for sociodemographic characteristics. Main results: The percentage of green space inside a one kilometre and a three kilometre radius had a significant relation to perceived general health. The relation was generally present at all degrees of urbanity. The overall relation is somewhat stronger for lower socioeconomic groups. Elderly, youth, and secondary educated people in large cities seem to benefit more from presence of green areas in their living environment than other groups in large cities. Conclusions: This research shows that the percentage of green space in people’s living environment has a positive association with the perceived general health of residents. Green space seems to be more than just a luxury and consequently the development of green space should be allocated a more central position in spatial planning policy.

Natural Environments—Healthy Environments? An Exploratory Analysis of the Relationship between Greenspace and Health

Are people living in greener areas healthier than people living in less green areas? This hypothesis was empirically tested by combining Dutch data on the self-reported health of over 10 000 people with land-use data on the amount of greenspace in their living environment. In the multilevel analysis we controlled for socioeconomic and demographic characteristics, as well as urbanity. Living in a green environment was positively related to all three available health indicators, even stronger than urbanity at the municipal level. Analyses on subgroups showed that the relationship between greenspace and one of the health indicators was somewhat stronger for housewives and the elderly, two groups that are assumed to be more dependent on, and therefore exposed to, the local environment. Furthermore, for all three health indicators the relationship with greenspace was somewhat stronger for lower educated people. Implications for policymaking and spatial planning are discussed briefly.

Morbidity is related to a green living environment

Background: As a result of increasing urbanisation, people face the prospect of living in environments with few green spaces. There is increasing evidence for a positive relation between green space in people’s living environment and self-reported indicators of physical and mental health. This study investigates whether physician-assessed morbidity is also related to green space in people’s living environment. Methods: Morbidity data were derived from electronic medical records of 195 general practitioners in 96 Dutch practices, serving a population of 345 143 people. Morbidity was classified by the general practitioners according to the International Classification of Primary Care. The percentage of green space within a 1 km and 3 km radius around the postal code coordinates was derived from an existing database and was calculated for each household. Multilevel logistic regression analyses were performed, controlling for demographic and socioeconomic characteristics. Results: The annual prevalence rate of 15 of the 24 disease clusters was lower in living environments with more green space in a 1 km radius. The relation was strongest for anxiety disorder and depression. The relation was stronger for children and people with a lower socioeconomic status. Furthermore, the relation was strongest in slightly urban areas and not apparent in very strongly urban areas. Conclusion: This study indicates that the previously established relation between green space and a number of self-reported general indicators of physical and mental health can also be found for clusters of specific physician-assessed morbidity. The study stresses the importance of green space close to home for children and lower socioeconomic groups.

Physical activity as a possible mechanism behind the relationship between green space and health: A multilevel analysis

BackgroundThe aim of this study was to investigate whether physical activity (in general, and more specifically, walking and cycling during leisure time and for commuting purposes, sports and gardening) is an underlying mechanism in the relationship between the amount of green space in peoples direct living environment and self-perceived health. To study this, we first investigated whether the amount of green space in the living environment is related to the level of physical activity. When an association between green space and physical activity was found, we analysed whether this could explain the relationship between green space and health.MethodsThe study includes 4.899 Dutch people who were interviewed about physical activity, self-perceived health and demographic and socioeconomic background. The amount of green space within a one-kilometre and a three-kilometre radius around the postal code coordinates was calculated for each individual. Multivariate multilevel analyses and multilevel logistic regression analyses were performed at two levels and with controls for socio-demographic characteristics and urbanicity.ResultsNo relationship was found between the amount of green space in the living environment and whether or not people meet the Dutch public health recommendations for physical activity, sports and walking for commuting purposes. People with more green space in their living environment walked and cycled less often and fewer minutes during leisure time; people with more green space garden more often and spend more time on gardening. Furthermore, if people cycle for commuting purposes they spend more time on this if they live in a greener living environment. Whether or not people garden, the time spent on gardening and time spent on cycling for commuting purposes did not explain the relationship between green space and health.ConclusionOur study indicates that the amount of green space in the living environment is scarcely related to the level of physical activity. Furthermore, the amount of physical activity undertaken in greener living environments does not explain the relationship between green space and health.

Patient Satisfaction with the General Practitioner: A Two-level Analysis

OBJECTIVES The authors examine how patient satisfaction with health care providers relates to either the individual characteristics of respondents or the characteristics of health care providers and the structural setting in which they work. METHODS Measures of three dimensions of patient satisfaction with the general practitioner (GP)--accessibility, interpersonal relationship, information given--were derived from an existing data set. Patients were nested with GPs. Multilevel analysis was used as the analyzing technique. RESULTS Between 90% and 95% of the variance in patient satisfaction scores is at the patient level, whereas the remaining 5% to 10% is at the GP or practice level. At the patient level, in addition to the usual predictor variables such as age and morbidity, which explain approximately 5% of the variance at this level, previous experiences with the general practitioner in the form of misunderstandings or incidents may play an important role in the emergence of dissatisfaction among patients. CONCLUSIONS This study demonstrated the usefulness of multilevel analysis in studying patient satisfaction scores. Findings indicate that the effectiveness of strategies directed at health care providers or services and aiming to improve the quality of care through the patients eyes can be questioned when these strategies are based on general satisfaction scores only. More attention should be paid to the interaction process between patient and GP.

Greenspace in urban neighbourhoods and residents' health: adding quality to quantity

Background Previous research shows a positive link between the amount of green area in ones residential neighbourhood and self-reported health. However, little research has been done on the quality of the green area, as well as on quantity and quality of smaller natural elements in the streetscape. This study investigates the link between the objectively assessed quantity and quality of (1) green areas and (2) streetscape greenery on the one hand and three self-reported health indicators on the other. Methods 80 Dutch urban neighbourhoods were selected, varying in the amount of nearby green area per dwelling, as determined by Geographic Information System analysis. The quality of green areas, as well as the quantity and quality of streetscape greenery, was assessed by observers using an audit tool. Residents of each neighbourhood were asked to complete a questionnaire on their own health (N=1641). In multilevel regression analyses, we examined the relationship between greenspace indicators and three health indicators, controlling for socio-demographic and socioeconomic characteristics. Results Both indicators for the quantity of greenspace were positively related to all three health indicators. Quantity and quality indicators were substantially correlated in the case of streetscape greenery. Nevertheless, the quality indicators tended to have added predictive value for the health indicators, given that the quantity information was already included in the model. Conclusions The quantity and also the quality of greenspace in ones neighbourhood seem relevant with regard to health. Furthermore, streetscape greenery is at least as strongly related to self-reported health as green areas.

Behavioral and Mood Effects of Snoezelen Integrated into 24-Hour Dementia Care

Objectives: To investigate the effectiveness of snoezelen, integrated in 24‐hour daily care, on the behavior and mood of demented nursing home residents.

The relationship between health, education, and health literacy: results from the Dutch Adult Literacy and Life Skills Survey.

Health literacy has been put forward as a potential mechanism explaining the well-documented relationship between education and health. However, little empirical research has been undertaken to explore this hypothesis. The present study aims to study whether health literacy could be a pathway by which level of education affects health status. Health literacy was measured by the Health Activities and Literacy Scale, using data from a subsample of 5,136 adults between the ages of 25 and 65 years, gathered within the context of the 2007 Dutch Adult Literacy and Life Skills Survey. Linear regression analyses were used in separate models to estimate the extent to which health literacy mediates educational disparities in self-reported general health, physical health status, and mental health status as measured by the Short Form-12. Health literacy was found to partially mediate the association between low education and low self-reported health status. As such, improving health literacy may be a useful strategy for reducing disparities in health related to education, as health literacy appears to play a role in explaining the underlying mechanism driving the relationship between low level of education and poor health.

Measuring patient safety culture: an assessment of the clustering of responses at unit level and hospital level

Objectives: To test the claim that the Hospital Survey on Patient Safety Culture (HSOPS) measures patient safety culture instead of mere individual attitudes and to determine the most appropriate level (individual, unit or hospital level) for interventions aimed at improving the culture of patient safety. Methods: National patient safety culture data were used from 1889 hospital staff working at 87 units in 19 hospitals across The Netherlands. The multilevel structure of the variation of responses to the 11 dimensions of the questionnaire was explored by fitting three-level random intercept models: individual, unit and hospital level. Results: The unit level was the dominating level for the clustering of responses to the 11 dimensions. Intraclass correlations (ICC) at unit level ranged from 4.3 to 31.7, representing considerable higher-level variation. For three dimensions of patient safety culture, there was significant clustering of responses at hospital level as well: (1) Feedback about and learning from error, (2) Teamwork across hospital units and (3) Non-punitive response to error. Conclusions: At a conceptual level, the detection of clustering of responses within units and hospitals confirms the claim that the HSOPS measures group culture and not just individual attitudes. In addition, the results have implications for interventions on patient safety culture. Improvement efforts should be directed at their most relevant organisational level. In general, improvement efforts on patient safety culture should be addressed at the unit level, rather than the individual or hospital level.

Direct medical costs of adverse events in Dutch hospitals

BackgroundUp to now, costs attributable to adverse events (AEs) and preventable AEs in the Netherlands were unknown. We assessed the total direct medical costs associated with AEs and preventable AEs in Dutch hospitals to gain insight in opportunities for cost savings.MethodsTrained nurses and physicians retrospectively reviewed 7926 patient records in 21 hospitals. Additional patient information of 7889 patients was received from the Dutch registration of hospital information. Direct medical costs attributable to AEs were assessed by measuring excess length of stay and additional medical procedures after an AE occurred. Costs were valued using Dutch standardized cost prices.ResultsThe annual direct medical costs in Dutch hospitals were estimated at a total of euro 355 million for all AEs and euro 161 million for preventable AEs in 2004. The total number of hospital admissions in which a preventable AE occurred was 30,000 (2.3% of all admissions) and more than 300,000 (over 3% of all bed days) bed days were attributable to preventable AEs in 2004. Multilevel analysis showed that variance in direct medical costs was not determined by differences between hospitals or hospital departments.ConclusionThe estimates of the total preventable direct medical costs of AEs indicate that they form a substantial part (1%) of the expenses of the national health care budget and are of importance to hospital management. The cost driver of the direct medical costs is the excess length of stay (including readmissions) in a hospital. Insight in which determinants are associated with high preventable costs will offer useful information for policymakers and hospital management to determine starting points for interventions to reduce the costs of preventable AEs.