Longitudinal Ecological Analysis Research Articles

The Relationship Between Regional Growth in Neonatal Intensive Care Capacity and Perinatal Risk.

The supply of US neonatal intensive care unit (NICU) beds and neonatologists is known to vary markedly across regions, but there have been no investigation of patterns of recent growth (1991-2017) in NICUs in relation to newborn need. The objective of this study was to test the hypothesis that greater growth in NICU capacity occurred in neonatal intensive care regions with higher perinatal risk. A longitudinal ecological analysis with neonatal intensive care regions (n=246) as the units of analysis. Associations were tested using linear regression. All US live births ≥400g in 1991 (n=4,103,528) and 2017 (n=3,849,644). Primary measures of risk were the proportions of low-birth weight and very low-birth weight newborns and mothers who were Black or had low educational attainment. Over 26 years, the numbers of NICU beds and neonatologists per live birth increased 42% and 200%, respectively, with marked variation in growth across regions (interquartile range: 0.3-4.1, beds; neonatologists, 0.4-1.0 per 1000 live births). A weak association of capacity with perinatal risk in 1991 was absent in 2017. There was no meaningful (ie, clinical or policy relevant) association between regional changes in capacity and regions with higher perinatal risk or lower capacity in 1991; higher increases in perinatal risk were not associated with higher capacity growth. The lack of association between newborn medical needs and the supply of NICU resources raises questions about the current effectiveness of newborn care at a population level.

For-profit outsourcing and its effects on placement stability and locality for children in care in England, 2011–2022: A longitudinal ecological analysis

BackgroundThe responsibility of local authorities in England to provide children in care with stable, local placements has become increasingly difficult due to the rising number of children in need of care and a shortage of available placements. It is unclear if the trend of outsourcing children's social care to private companies has exacerbated this challenge. This paper examines how the outsourcing of children's social care to the private market has influenced placement locality and long-term stability over time. MethodsWe created a novel dataset of multiple administrative data sources on the outsourcing, placement locality and stability, and characteristics of children in care between 2011 and 2022. We conducted time-series fixed-effects regression analysis of the impact of for-profit outsourcing on placement locality and stability from 2011 to 2022. ResultsOur fully adjusted models demonstrate that for-profit outsourcing is consistently associated with more children being placed outside their home local authority and greater placement instability. We found that an increase of 1 % point of for-profit outsourcing was associated with an average increase of 0.10 % points (95 % CI 0.02–0.17; p = 0.01) more children experiencing placement disruption, and 0.23 % points (95 % CI 0.15–0.30; p < 0.001) more children being placed outside their home local authority. We estimate that an additional 17,001 (95 % CI 9015–24,987) out-of-area placements can be attributed to increases in for-profit provision. DiscussionOur analyses show that placement stability and distance have deteriorated or stagnated over the last decade, and that the local authorities that rely most on outsourcing have the highest rates of placement disruptions and out-of-area placements.

Socioeconomic inequalities in distance to and participation in a community-based running and walking activity: A longitudinal ecological study of parkrun 2010 to 2019.

ObjectivesTo conduct a longitudinal ecological analysis of the distance to and participation in free weekly outdoor physical activity events (parkrun) in England from 2010 to 2019, and related socioeconomic and ethnic inequalities, to inform policies to support participation in physically active community events.MethodsWe calculate distance to the nearest parkrun event for each English Lower Layer Super Output Area (LSOA) each month from January 2010 to December 2019. We then report the trends in distance to and participation in parkrun by Index of Multiple Deprivation quintile. We also report trends in the Relative Index of Inequality (RII) by deprivation for participation and distance to nearest event. We go on to investigate trends in LSOA level determinants (e.g. deprivation and ethnic density) of parkrun participation between 2010 and 2019, using multivariable Poisson regression models.ResultsMean distance to the nearest parkrun event decreased from 34.1 km in 2010, to 4.6 km in 2019. Throughout the period, parkrun events tended to be situated closer to deprived areas compared to less deprived areas. Participation rates increased superlinearly (greater than linear increase) from 2010 to 2013 before slowing to linear growth. Participation over the period exhibits a clear socioeconomic gradient, with people from deprived areas having consistently lower participation rates over the period. parkrun participation rates became more equal between 2010 and 2013 (RII improved from 189 to 39), before stabilising at an RII between 32.9 and 39.6 from 2014 to 2019. The results of the Poisson regression model validate this finding; the coefficients on IMD score initially increased from −0.050 in 2010 to −0.038 in 2013, and then remained relatively stable to 2019 (−0.035).ConclusionsOver the past 10 years, geodesic distance to the nearest parkrun decreased from a mean of 34 km to 5 km. In 2010, there was equality between the least and most deprived areas but by 2017 the distance of the most deprived areas was 29% that of the least deprived. Participation was shown to have increased over the past 10 years which can be split into two distinct phases: from 2010 to 2013 participation increased super-linearly and inequality in participation fell dramatically; from 2013 to 2019 participation increased linearly, and inequality in participation remained stable. Despite parkrun's ambitions of creating inclusive events and engaging with deprived communities, the socioeconomic gradient in participation rates remained high and stable since 2013. Gaining a better understanding of the reasons why parkrun grew so quickly may be useful for other physical activity movements, while further analysis of the relatively lower participation rates in areas with higher socioeconomic deprivation is important for developing initiatives to encourage physical activity in these communities.

Shifts towards overweight and double burden of malnutrition among socio-economically vulnerable children: a longitudinal ecological analysis of Brazilian municipalities.

To investigate the shifts and factors associated with different scenarios resulting from the prevalence of child stunting and overweight in Brazilian municipalities. This is an ecological study using municipality-level panel data of stunting and overweight prevalence and socio-economic characteristics from 2008 to 2014. The municipalities were classified according to the WHO-UNICEF prevalence thresholds for stunting and overweight and were categorised into four nutritional scenarios: no burden (prevalence of stunting < 20 % and overweight < 10 %), stunting burden (prevalence of stunting ≥ 20 % and overweight < 10 %), overweight burden (prevalence of stunting < 20 % and overweight ≥ 10 %) and double burden (prevalence of stunting ≥ 20 % and overweight ≥ 10 %). Totally, 4443 Brazilian municipalities. Aggregated data of children under 5 years old enrolled in the Brazil's conditional cash transfer programme (Bolsa Família). A mean reduction from 14·2 % to 12·7 % in the prevalence of stunting and an increase from 17·2 % to 18·4 % in the prevalence of overweight were observed. The predominant scenarios were overweight burden and double burden. The odds of both scenarios increased with higher gross domestic product (GDP) per capita and decreased with higher unemployment rates. Stunting and double burden decreased with higher expected years of schooling, and stunting burden increased with household crowding. Our findings indicate an advanced nutrition transition stage in Brazil, associated mainly with municipal GDP per capita growth, which has contributed to increasing the burden of overweight alone or coexisting with stunting (double burden) among children in the most socio-economically vulnerable strata of the population.

Neighbourhood unemployment and other socio-demographic predictors of emergency hospitalisation for infectious intestinal disease in England: A longitudinal ecological study

Previous studies have observed that infectious intestinal disease (IID) related hospital admissions are higher in more deprived neighbourhoods. These studies have mainly focused on paediatric populations and are cross-sectional in nature. This study examines recent trends in emergency IID admission rates, and uses longitudinal methods to investigate the effects of unemployment (as a time varying measure of neighbourhood deprivation) and other socio-demographic characteristics on IID admissions for adults and children in England. A longitudinal ecological analysis was performed using Hospital Episode Statistics on emergency hospitalisations for IID, collected over the time period 2012-17 across England. Analysis was conducted at the neighbourhood (Lower-layer Super Output Area) level for three age groups (0-14; 15-64; 65+ years). Mixed-effect Poisson regression models were used to assess the relationship between trends in neighbourhood unemployment and emergency IID admission rates, whilst controlling for measures of primary and secondary care access, underlying morbidity and the ethnic composition of each neighbourhood. From 2012-17, declining trends in emergency IID admission rates were observed for children and older adults overall, while rates increased for some sub-groups in the population. Each 1 percentage point increase in unemployment was associated with a 6.3, 2.4 and 4% increase in the rate of IID admissions per year for children [IRR=1.06, 95%CI 1.06-1.07], adults [IRR=1.02, 95%CI 1.02-1.03] and older adults [IRR=1.04, 95%CI 1.036-1.043], respectively. Increases in poor primary care access, the percentage of people from a Pakistani ethnic background, and the prevalence of long-term health problems, in a neighbourhood, were also associated with increases in IID admission rates. Increasing trends in neighbourhood deprivation, as measured by unemployment, were associated with increases in emergency IID admission rates for children and adults in England, despite controlling for measures of healthcare access, underlying morbidity and ethnicity. Research is needed to improve understanding of the mechanisms that explain these inequalities, so that effective policies can be developed to reduce the higher emergency IID admission rates experienced by more disadvantaged communities.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54,253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Primary health care contribution to improve health outcomes in Bogota-Colombia: a longitudinal ecological analysis

BackgroundColombia has a highly segmented and fragmented national health system that contributes to inequitable health outcomes. In 2004 the district government of Bogota initiated a Primary Health Care (PHC) strategy to improve health care access and population health status. This study aims to analyse the contribution of the PHC strategy to the improvement of health outcomes controlling for socioeconomic variables.MethodsA longitudinal ecological analysis using data from secondary sources was carried out. The analysis used data from 2003 and 2007 (one year before and 3 years after the PHC implementation). A Primary Health Care Index (PHCI) of coverage intensity was constructed. According to the PHCI, localities were classified into two groups: high and low coverage. A multivariate analysis using a Poisson regression model for each year separately and a Panel Poisson regression model to assess changes between the groups over the years was developed. Dependent variables were infant mortality rate, under-5 mortality rate, infant mortality rate due to acute diarrheal disease and pneumonia, prevalence of acute malnutrition, vaccination coverage for diphtheria, pertussis, tetanus (DPT) and prevalence of exclusive breastfeeding. The independent variable was the PHCI. Control variables were sewerage coverage, health system insurance coverage and quality of life index.ResultsThe high PHCI localities as compared with the low PHCI localities showed significant risk reductions of under-5 mortality (13.8%) and infant mortality due to pneumonia (37.5%) between 2003 and 2007. The probability of being vaccinated for DPT also showed a significant increase of 4.9%. The risk of infant mortality and of acute malnutrition in children under-5 years was lesser in the high coverage group than in the low one; however relative changes were not statistically significant.ConclusionsDespite the adverse contextual conditions and the limitations imposed by the Colombian health system itself, Bogota’s initiative of a PHC strategy has successfully contributed to the improvement of some health outcomes.

Efecto de las partículas de diámetro inferior a 2,5 micras (PM 2,5) sobre los ingresos hospitalarios en niños menores de 10 años en Madrid

Introduction The last report of World Health Organization's Air Quality Guidelines establishes a value of 10 μg/m 3 as the annual mean particulate PM 2.5 concentration. However, in large cities such as Madrid, this value is doubled and consequently an association between PM 2.5 values and effects on morbidity and mortality is to be expected. Objective To analyze and quantify the influence of PM 2.5 concentrations on daily hospital admissions in 0–10-year-olds in Madrid. Material and methods We analyzed the daily number of emergency hospital admissions for all causes (ICD-10: A00-R99) except traumatisms to the Gregorio Marañón General University Hospital in Madrid from 2003 to 2005. The age groups analyzed were 0–10 years and 0–1 year. A longitudinal ecological analysis of time series was performed using Poisson Regression Models. Seasonalities, trends, days of the week, and autocorrelation between morbidity series were controlled. Influenza epidemics, air pollutants, and noise and pollen concentrations were used as control variables. Results The only primary pollutant found to be statistically significant in the models was PM 2.5 concentration. The relative risk associated with an increase of 10 μg/m 3 in PM 2.5 concentration was 1.03 (95%CI 1.00–1.05) for children less than 10 years old and 1.03 (95%CI 1.00–1.06) for infants less than 1 year old. The attributable risk was 2.7 and 2.8%, respectively. Conclusions PM 2.5 concentrations are an excellent indicator of the health impact of primary pollutants in Madrid. The results obtained demonstrate the need to implement measures to reduce PM 2.5 concentrations in the atmosphere in large cities.

Social Organization, Resource Management, and Child Nutrition in the Taita Hills, Kenya

A comparative and longitudinal ecological analysis is used to explore agricultural sources of variation in child nutritional status in the Taita Hills, Kenya. National policies, formal institutions, the natural environment, and the local-level social organization of agricultural resource access define the agrarian context within which distinct production strategies emerge. The effects of alternative production choices on child nutrition are neither consistent nor unidimensional, arguing for a rethinking of conventional approaches to food policy decision making.