Cross-sectional Ecological Study Research Articles

COVID-19 Cases and the Built Environment: Initial Evidence from New York City

Social distancing (e.g., maintaining two-meter distance between people, restricting group gatherings) is recommended to reduce the risk of COVID-19 transmission. Social distancing guidelines might not broadly consider the varying built environment contexts in which people live, however. Controlling for key covariates, we examined the association of several built environment characteristics with COVID-19 cases in New York City. This cross-sectional ecological study used ZIP code tabulation area (ZCTA) data from New York City. We found positive, significant adjusted associations between the COVID-19 case rate and average people per household, percentage of Black or African American population, percentage of Hispanic population, and percentage of the population over sixty-five years old. Population per square kilometer and percentage taking public transit to work were both negatively associated with case rates. Percentage of sidewalks was negatively associated with case rates, but parks were not significant. ZCTAs with higher percentage area of sidewalks were associated with lower case rates, controlling for potential confounders. Consideration of the local characteristics of the built environment could inform context-specific COVID-19 prevention guidelines, such as increasing street space for pedestrian use in high-density neighborhoods.

Internações hospitalares por Diabetes Mellitus e características dos locais de moradia

Resumo Objetivo: Analisar a ocorrência de internações por diabetes mellitus segundo bairros residenciais de um grande centro urbano. Métodos: Estudo transversal, do tipo ecológico, que considerou o conjunto de internações hospitalares causadas por diabetes mellitus, nos 160 bairros do município do Rio de Janeiro. Para investigar a relação entre internações por diabetes mellitus e as condições de vida da população residente nestes bairros, calcularam-se alguns indicadores demográficos e socioeconômicos, no período de 2010 a 2015. As regiões foram comparadas através [...]

Effect of Co-Morbidities on Mortality from COVID-19 in Mexico: an Ecological Study

With the emergence of a SARS-CoV-2 infection pandemic in China and its spread to other countries, mortality was shown to be high and to a greater extent if there were underlying pathologies. It is said {or an ecological analytical cross-sectional study, of the open records of confirmed and discarded cases for COVID-19 of the General Directorate of Epidemiology of the Secretary of Health of Mexico. A specific mortality of 9.79% is reported; being higher in men between the ages of 20 to 59 and over 60 years. Mortality rates from underlying diseases were higher than those reported in the USA in early May 2020. Asthma was found to be a protective factor for COVID-19 mortality. It is concluded that mortality was higher in the presence of comorbidities.

The geographic distribution of retail tobacco outlets in Yogyakarta, Indonesia.

Tobacco smoking prevalence in Indonesia is among the highest in the world. Research worldwide identifies that physical access to tobacco through retail outlets is related to increased tobacco smoking. Tobacco outlet density is very high in many Indonesian cities, so tobacco access may contribute to the high prevalence of tobacco use in that country. The aim of this study was to examine distributions of tobacco outlets in one Indonesian city, Yogyakarta, in relation to social and physical environmental conditions. For this cross-sectional ecological study, we virtually audited randomly selected street segments (n = 1099) using Google Street View. The outcome of interest was a count of tobacco advertising banners (indicating the presence of retail outlets). Exposures were physical environmental conditions (scales of main roads, physical decay, presence of schools, mosques, churches) and social conditions measured at the neighbourhood level (concentrated disadvantage, age composition, population density). Tobacco banners were present on 36.4% of sampled street segments, including 55 (37%) of 147 streets with schools; a total of 1381 banners were identified. Multilevel negative binomial regression models for street segments nested within neighbourhoods found the prevalence of tobacco banners per 100 m was lower near schools (RR = 0.66, 95% CI 0.45, 0.97) and was not associated with other exposure measures. Retail tobacco outlets are ubiquitous in Yogyakarta. Although they are relatively less prevalent on streets with schools, the high absolute values and wide spatial distribution means all residents of Yogyakarta are exposed to tobacco outlets.

Effect of Socioeconomic and Ethnic Characteristics on COVID-19 Infection: the Case of the Ultra-Orthodox and the Arab Communities in Israel.

BackgroundDuring infectious disease outbreaks, the weakest communities are more vulnerable to infection and its deleterious effects. In Israel, the Arab and Ultra-Orthodox Jewish communities have unique demographic and cultural characteristics that place them at higher risk of infection.ObjectiveTo examine socioeconomic and ethnic differences in rates of COVID-19 testing, confirmed cases and deaths, and to analyze patterns of transmission in ethnically diverse communities.MethodsA cross-sectional ecologic study design was used. Consecutive data on rates of COVID-19 diagnostic testing, lab-confirmed cases, and deaths collected from March 31 through May 1, 2020, in 174 localities across Israel (84% of the population) were analyzed by socioeconomic ranking and ethnicity.ResultsTests were performed on 331,594 individuals (4.29% of the total population). Of those, 14,865 individuals (4.48%) were positive for COVID-19 and 203 died (1.37% of confirmed cases). Testing rate was 26% higher in the lowest SE category compared with the highest. The risk of testing positive was 2.16 times higher in the lowest socioeconomic category, compared with the highest. The proportion of confirmed cases was 4.96 times higher in the Jewish compared with the Arab population.The rate of confirmed cases in 2 Ultra-Orthodox localities increased relatively early and quickly. Other Jewish and Arab localities showed consistently low rates of confirmed COVID-19 cases, regardless of socioeconomic ranking.ConclusionsCulturally different communities reacted differently to the COVID-19 outbreak and to government measures, resulting in different outcomes. Socioeconomic and ethnic variables cannot fully explain communities’ reaction to the pandemic. Our findings stress the need for a culturally adapted approach for dealing with health crises.

Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment

Introduction: Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions. Methods: We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume). Results: There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05). Conclusions: Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.

Breast cancer incidence and the air pollution level in the communes of Chile: an ecological study.

There is evidence linking air pollutants associated with vehicular traffic such as polycyclic aromatic hydrocarbons with breast carcinogenesis. Epidemiological studies have shown conflicting results regarding air pollution and breast cancer risk, which could be explained by the multitude of other risk factors that could affect the association. In Chile, air pollution has reached alarming levels, either due to motorised vehicle traffic or the combustion of wood for heating; therefore, our objective was to evaluate the association between the incidence of breast cancer and the concentration of the main air pollutants monitored in the country.We carried out a cross-sectional ecological study that evaluated the association between the average incidence of breast cancer in years (2016 to 2018) and the average annual concentration of six atmospheric pollutants in the 5 years prior to the estimation of the rate in communes of Chile, using the population of beneficiaries of Instituto Oncológico Fundación Arturo López Pérez. The annual incidence of breast cancer was 72.21 cases per 100,000 women and it varied significantly in the communes studied compared to the human development index (HDI) and to the proportion of women in the age group at highest risk. Assessing the relationship between the incidence of breast cancer and the average concentration of atmospheric pollutants, we only found a direct correlation between the level of nitrogen dioxide and the rate (R = 0.82; p = 0.044), whose significance tends to be lost when age and the communal HDI are included in a regression model.

Preventive Metformin Monotherapy Medication Prescription, Redemption and Socioeconomic Status in Hungary in 2018-2019: A Cross-Sectional Study.

This study was designed to characterize the spatial distribution of metformin medication used as first-line monotherapy for prevention of T2DM in relationship with the socioeconomic status (level of deprivation) and T2DM mortality at district level in a nationwide cross-sectional ecological study for the first time in a European country, Hungary. Risk analysis was used to estimate the relationships between socioeconomic status, characterized by tertiles of deprivation index, and mortality caused by diabetes, and metformin medication (both prescription and redemption) for the years of 2018 and 2019 at the district level. The spatial distribution of districts with a higher relative frequency of metformin prescriptions and redemptions showed a positive correlation with socio-economic deprivation. Significant association between the relatively high T2DM mortality and the highest level of deprivation could also be detected, but less-deprived regions with high T2DM mortality and low metformin utilization could also be identified. Although the statistical associations detected in this ecological study do not indicate a causal relationship, it is reasonable to suppose that the underuse of metformin medication may contribute to the unfavourable T2DM mortality in certain regions. Our findings underline the need for more effective preventive services including metformin medication to decrease T2DM morbidity and mortality burden.

Significant bioaccumulation and biotransformation of methyl mercury by organisms in rice paddy ecosystems: A potential health risk to humans.

Rice has been confirmed as one of the principal intake pathways for methylmercury (MeHg) in human, however, the impact of edible organisms, such as snails, loaches and eels, living in the rice-based ecosystem to the overall MeHg intake has been overlooked. Here, we conducted a cross-sectional ecological study, and the results showed that bioaccumulation of MeHg in these edible organisms was significantly higher than in paddy soils and rice roots (p<0.001), even though rice roots and grains have significantly higher total Hg (THg) (p<0.001). The MeHg/THg ratios were consistently and significantly higher in those edible organisms than in rice grains, suggesting a potential elevated MeHg exposure risk through consumption. Based on results of bioaccumulation factors (BAFs) for MeHg, it was clear that MeHg was bioaccumulated and biotransformed from paddy soils to earthworms and then to eels, as well as from paddy soils to snails and then to eels and loaches, potentially indicating that the consumption of eels and loaches was absolutely pernicious to people regularly feeding on them. Overall, MeHg was biomagnified along the food chain of the paddy ecosystem from soil to the organisms, and it was of potential higher risks for local residents to eat them, especially eels and loaches. Therefore, it is intensely indispensable for people fond of such diets to attenuate their consumption of rice, eels and loaches, thus mitigating their MeHg exposure risks.

The Significant Association between Health Examination Results and Population Health: A Cross-Sectional Ecological Study Using a Nation-Wide Health Checkup Database in Japan.

In Japan, population health with life expectancy (LE) and healthy life expectancy (HALE) as indicators varies across the 47 prefectures (administrative regions). This study investigates how health examination results, including attitude toward improving life habits, are associated with population health. The association between health checkup variables and summary population health outcomes (i.e., life expectancy and healthy life expectancy) was investigated using a cross-sectional ecological design with prefectures as the unit of analysis. The medical records, aggregated by prefecture, gender, and age in the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) Open Data Japan, were used as health checkup variables. Body weight, blood pressure, liver enzymes, drinking habits, smoking habits, diabetes, serum lipids, and answers to questions regarding attitude toward improving health habits were significantly correlated to population health outcomes. Multiple regression analysis also revealed significant influence of these variables on population health. This study highlights that health examination results, including attitude toward improving health habits, are positively associated with population health. Consequently, implementing measures to improve health habits in response to the examination results could help the population maintain a healthy life.

Sex differences in the management of patients with acute coronary syndrome: A population-based ecological cross-sectional study in Spain

Introduction and objectivesDespite evidence of a reduction in the incidence and mortality of acute coronary syndrome (ACS), some studies have highlighted differences in outcomes between men and women. We aimed to explore sex differences in the management and treatment of patients with ACS in Spain. MethodsThis ecological cross-sectional study combined ACS data from 10 Spanish registries (54 centres). Meta-regression analysis was performed using aggregated data of baseline characteristics, interventional procedures, treatments, and events that occurred during hospitalization and one-year follow-up. ResultsAggregated data from 34605 patients (75.1% men) was included. ST-segment elevation myocardial infarction was the most frequent diagnosis (58.9%) and almost 80% of patients were Killip Class I. Compared to men, women were older (mean age: 71.0 vs 63.3 years) and presented higher rates of hypertension (68.1% vs 51.7%) and diabetes (37.7% vs 26.5%). Women were also less likely to undergo percutaneous coronary interventions, revascularization surgery, and to receive drug-eluting stents during hospitalization. Regarding to antiplatelet therapy, even though indicated, 23.1% of women were not treated with P2Y12 inhibitors (vs 14.2% of men; P<.001); clopidogrel was the most frequently administered agent (> 60%). Significantly higher in-hospital (5.4% vs 3.7%) and 1-year (8.2% vs 4.9%) mortality was observed among women compared to men, which was mainly attributed to cardiovascular causes. ConclusionsDespite older age and unfavourable risk profile, female ACS patients seem to be suboptimally treated with P2Y12 inhibitors. To reduce mortality associated with ACS, improved prevention and optimized therapeutic approaches are needed.

Income inequality and periodontal diseases in rich countries: an ecological cross-sectional study

There are adverse effects of income inequality on morbidity and mortality. This relationship has not been adequately examined in relation to oral health. To examine the relationship between income inequality and periodontal disease in rich countries. Adults aged 35-44 years in 17 rich countries with populations of more than 2 million. National level data on periodontal disease, income inequality and absolute national income were collected from 17 rich countries with populations of more than 2m. Pearson and partial correlations were used to examine the relationship between income inequality and percentage of 35-44-year-old adults with periodontal pockets > or = 4 mm and > or = 6 mm deep, adjusting for absolute national income. Higher levels of income inequality were significantly associated with higher levels of periodontal disease, independently of absolute national income. Absolute income was not associated with levels of periodontal disease in these 17 rich countries. Income inequality appears to be an important contextual determinant of periodontal disease. The results emphasise the importance of relative income rather than absoluteincome in relation to periodontal disease in rich countries.

Public water supply fluoridation: an analysis from the equity principle

Introdução: A fluoretação das águas de abastecimento público representa uma importante medida de saúde pública para prevenção da cárie dentária, devendo ser monitorada quanto ao teor de fluoreto em dose ideal, bem como em relação ao seu alcance populacional na perspectiva de reduzir as desigualdades e proporcionar benefícios em saúde bucal. Objetivo: O estudo avaliou a equidade na distribuição de água fluoretada na cidade de Manaus/AM, por meio da relação entre indicadores contextuais de desenvolvimento municipal e os teores de fluoreto na água de abastecimento dos bairros que compõem os distritos sanitários da cidade. Método: Realizou-se estudo ecológico transversal no período de 2016 a 2018. Amostras de água foram coletadas mensalmente de cada distrito sanitário, cujas concentrações de fluoreto foram determinadas utilizando-se um eletrodo específico. Índice de Desenvolvimento Humano Municipal (IDHM), mortalidade Infantil,número de crianças fora da escola e expectativa de vida representaram os indicadores contextuais do município, obtidos a partir do Atlas do Desenvolvimento Humano no Brasil. Os dados foram submetidos a uma análise descritiva, estatística bivariada e análise espacial. Resultados: Observou-se grande variação nos teores de fluoreto das amostras, das quais 50,02% apresentaram concentrações de fluoreto inadequadas e as maiores concentrações predominaram nas amostras coletadas no segundo semestre do ano. A distribuição espacial indicou que os bairros com melhores valores de IDHM, mortalidade infantil, número de crianças fora da escola e expectativa de vida apresentaram melhor concentração de fluoreto na água de abastecimento. Conclusões: Evidenciou-se a ausência de equidade na distribuição de água fluoretada, sugerindo que o acesso à água fluoretada reflete as desigualdades sociais presentes na própria cidade.

Social Determinants of Health Mediate COVID-19 Disparities in South Florida.

BackgroundThere are several reports of health disparities related to COVID-19. Understanding social determinants of health (SDoH) could help develop mitigation strategies to prevent further COVID-19 spread. Our aim is to evaluate self-reported and census-based SDoH as a mediator of health disparities in COVID-19.MethodsWe conducted a cross-sectional ecological study and included all COVID-19 cases report by the COVID-19 Florida dashboard as the dependent variable. The independent variables were census-based median household income, population and household size, and self-reported SDoH using a validated survey. We calculated the incidence rate ratio (IRR) of COVID-19 by zip code using Poisson regression and structured equation modelling to evaluate the mediation effect of income and SDoH on COVID-19 cases.ResultsWe included 97,594 COVID-19 positive cases across 79 Miami-Dade ZIP codes with a median age of 43 years; females represented 50.7% of the cases. The highest IRR (4.44) were for ZIP code 33125 (income $21,106, 6% Black, 93% Hispanic), while the lowest IRR (0.86) was for ZIP code 33146 (median household incomes $96,609, 3% Black and 53% Hispanic). In structured equation models, the indirect coefficient of income in the relationship between race/ethnicity and COVID-19 were only significant for Blacks and not Hispanics.ConclusionsThis ecological analysis using ZIP code and aggregate individual-level SDoH shows that in Miami-Dade county, COVID infection is associated with economic disadvantage in a particular geographical area and not with racial/ethnic distribution.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06341-9.

Suicide Rate, Depression and the Human Development Index: An Ecological Study From Mexico.

Objective: To assess the contribution of depression, the human development index (HDI) including the health, education and income indexes as well as the households structure to the suicide rate in Mexican population from 15 to 49 years old.Methods: An ecological cross-sectional study was carried out in people between 15 and 49 years old. The health index (HI), education index (EI), income index (II), and HDI were constructed. The suicide rate, educational level, per capita income, poverty, and rate of households were collected from official databases. Pearson's correlation coefficient (r) was used to determine the strength between the suicide rate and the per capita income, unemployment, poverty, HI, EI, II, HDI, non-family household, and depression incidence rate. A multiple linear regression model was used to know the association between suicide rates and HDI.Results: The suicide rate was 8.76/100,000 inhabitants. The HDI of the 32 Mexican states were low 16%, middle 41%, high 22%, and extremely high 13%. A direct and positive intensity relationship between suicide rate and non-family households, was found (r = 0.352; p < 0.001); on the other hand, the suicide rate is significantly and negatively related to family households with Pearson (r = −0.350; p < 0.001).Conclusion: The states of the Mexican Republic with the highest prevalence of non-family households had a positive association with the suicide rate. Based on the result of this study, it is possible to assume that, as the HDI increases, there is a greater possibility of living alone and having suicidal behavior.

Association between tree cover and academic performance in New York City schools

Background: Exposure to nature is linked with increased attentional capacity and reduced stress levels. Emerging evidence links greenspace exposure with improved academic performance in children and reduced crime. We conducted an ecological cross-sectional study to examine the association between school-level tree cover and metrics of academic performance in New York City public schools. We also evaluated high school graduation rates and crime as secondary outcomes of interest. Methods: School-level tree cover estimates based on Light Detection and Ranging (LiDAR) data with 8-in resolution were developed at multiple radiuses (100m, 250m, and 500m) around NYC (N=1,822) schools. School-level estimates for multiple air pollutants and noise were derived from published spatial models. We evaluated math and ELA test scores among students in grades 3-8; graduation rates for students in grades 9-12; and frequency of major and non-major crimes. Generalized linear mixed models were applied to study the association between school-level tree cover and the outcomes, adjusting for school-level demographics, air pollution, and noise; census-tract level median income; and borough and geographical area as random effects. Results: School-level tree cover at 500m radius was significantly associated with higher math scores among students in grades 3-5. Tree cover was also positively associated (p-value&lt;0.10) with higher ELA scores among students in grades 3-5. Road noise was significantly associated with lower graduation rates among high school students. Higher school-level tree cover was also significantly associated with lower major crime rates. Conclusions: The findings from this study suggest that higher school-level tree cover is associated with improved test scores in elementary school students, while noise from traffic is negatively associated with academic performance amongst high school students. Additional studies are needed to examine the potentially causal relationship between greenspace exposures and academic performance.

The effect of food insecurity on the prevalence of adult obesity in New Jersey counties

Abstract Obesity and food insecurity are prevalent public health concerns that influence factors at both the individual and community levels. Given that obesity is linked to a number of health concerns including heart disease and diabetes, national efforts have been formed to reduce obesity rates among these populations. The purpose of the study is to determine the effect of food-insecure households and associated risk factors on the prevalence of obesity among adults in New Jersey counties. The researchers hypothesized that counties with higher rates of food-secure households and associated risk factors would yield higher rates of obesity among the adult population. An ecological cross-sectional study was performed using secondary data from New Jersey Health Assessment and Census databases focused specifically on all 21 counties in New Jersey. The independent variables were selected from the social indicators available in the datasets consulted: food insecurity rate, physical activity rate, median household income, frequent mental health distress, routine health visit, and percent of adults self-reporting good, very good, or excellent health status. These independent variables were tested against adult obesity rates among New Jersey counties. It was revealed that rising obesity rates among adults were linked to increased rates of food insecurity, lower median household income, and lower perceived health status. Future research may investigate additional social determinants in relation to obesity rates in order to improve public health interventions within communities to increase health outcomes among adults. Key messages Obesity and food insecurity are prevalent public health concerns that influence factors at both the individual and community levels. Rising obesity rates among adults are linked to increased rates of food insecurity, lower median household income, and lower perceived health status.

Spatial distribution of gambling: two indexes in support of the reduction of health inequalities

Abstract Background Many studies have showed that disadvantaged areas residents have greater access to gambling sites and are more affected by gambling. Our research proposes an innovative method to characterize gambling environments in Quebec and addresses social inequality with respect to gambling exposure. Methods This cross-sectional ecological study was carried out in 3 stages: a Gambling Exposure Index (GEI) was built and is composed of 3 dimensions: spatial accessibility to gambling sites, density of gambling places, and relative risk associated with the types of game. The two-step floating catchment area (2SFCA) method was used to combine these dimensions into an overall GEI index. Data was retrieved from a geocoded directory of gambling sites and commercial databases. The relative risk of games is expressed by prevalence rates for those specific games in a Quebec population prevalence survey. A Vulnerability to Gambling Index (VGI) was produced based on 6 socio-economic proxies of problem gambling from the 2016 Canadian census, which were weighted and aggregated at the dissemination area (DA) level. Spatial and descriptive statistical analyses were conducted to explore the relationship between VGI and GEI, and to identify highly exposed and vulnerable areas. Results Our analyzes reveal significant associations between the GEI and the VGI in 2 599 out of 13 420 Quebec DAs (p &amp;lt; 0.05). Sectors with a high GEI show an average distance to the closest gambling sites of 2.8 km compared with 13.5 km for more advantaged sectors. Conclusions The interactive online mapping of the two indexes and statistical analysis of the results are beneficial to the professionals working in several fields such as risk monitoring, management of zoning, licensing and gambling distribution, prevention and treatment services. The method and the associated tools can be adapted to address the problem of increased accessibility to other unhealthy products in vulnerable neighborhoods. Key messages Two innovative ecological indexes show that increased accessibility to gambling correlates with a higher vulnerability to gambling in many Quebec regions. The online interactive map on gambling exposure and vulnerability provides reliable criteria to municipal, regional and governmental bodies for a safer distribution of gambling offer.

Exploring reasons for state-level variation in incidence of dialysis-requiring acute kidney injury (AKI-D) in the United States

BackgroundThere is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation.MethodsNational cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state.ResultsThe state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer.ConclusionsResults from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.

Spatial distribution of gambling exposure and vulnerability: an ecological tool to support health inequality reduction

ObjectivesRecent research by Public Health has redefined harmful gambling, shifting the focus from problematic people with irresponsible behaviour to ‘gamblogenic’ environments. The aim of this research was to support this alternative perspective with concrete ecological tools for characterizing harmful environments. Studies that analyse the spatial distribution of gambling show that people living in the most disadvantaged areas have greater access to gambling and are more affected by the harms of gambling. Despite their quality methodology and usefulness, the scope of geographic access measures has been partially limited. These measures have been mostly structured around a single form of gambling, focus on only one dimension of accessibility (density or proximity) and few of them take into account the risks associated with each type of the game.The main goal of our research was to propose an innovative method to characterize gambling environments in Quebec and address social inequality with respect to gambling exposure. This article more specifically describes the method we used to address the aforementioned shortcomings by developing the gambling exposure index (GEI), a more comprehensive ecological index of all games—weighted by their relative level of risk—to which populations are exposed. Study designThe study design is a cross-sectional ecological study. MethodsThe methodological approach was carried out in three stages. A GEI was operationalized and is composed of three dimensions: A dimension of spatial accessibility to gambling sites, a dimension of density of gambling places and a dimension of relative risk associated with different types of game. The two-step floating catchment area (2SFCA) method was used to combine these three dimensions into an overall GEI index. Data were retrieved from a geocoded directory of all gambling sites from Loto-Québec and other commercial databases. The relative risk of each type of game has been expressed by prevalence rates for those specific games in a Quebec population prevalence survey. A vulnerability to gambling index (VGI) was produced based on 6 socio-economic proxies of problem gambling from the 2016 Canadian census. The six variables were weighted and aggregated at the dissemination area (DA) level. Spatial and descriptive statistical analyses were conducted to explore the relationship between VGI and GEI and to identify areas that are highly vulnerable and have a high gambling exposure. ResultsThe findings of our analysis reveal widespread geographic exposure to gambling and a significant positive linear relationship between the GEI and the VGI. In many areas, increased accessibility to gambling is significantly associated with a higher vulnerability to gambling. Our findings demonstrate that in 1328 DAs in Quebec, there is a particularly unequal and potentially harmful geographical distribution of gambling, exposing 9% of the population which are theoretically vulnerable to gambling to an increased presence of gambling. ConclusionThis research applied a spatial analytical approach to assess the association between environments, gambling and vulnerability. The GEI and VGI at the DA level can serve as a monitoring tool for policy-makers regarding gambling exposure in the most vulnerable sectors and contribute to prevention and intervention strategies better adapted to the population. The general findings raise the ethical implications of increased marketing development in vulnerable neighbourhoods. As the GEI takes into account both the environmental determinants and the relative risk of games, it is in contributing to the shift in public and scientific discourse, redefining the subject from problematic people to problematic games and environments.