Defining and measuring poverty: implications for the health of Canadians

This paper examines the implications that the conceptualizationand measurement of poverty have for policies that aim to improvethe health of Canadians. In recent years, poverty has been identifiedas an issue of policy importance within the health sector inCanada. Policy makers are recognizing that efforts to improvethe health of Canadians are related to the development and implementationof policies that decrease the proportion of people who livein poverty. At the same time, the Statistics Canada Low-IncomeCut-Offs (LICOs), which are the most commonly used tool formeasuring poverty in Canada, are being called into question.One of the most frequently cited criticisms of the LICOs isthat they are too high, and as such do not measure poverty.Critics who argue that the LICOs are too high disagree withthe relative conceptualization of poverty which underlies theLICOs. In this paper, we discuss the LICOs, their underlyingassumption that poverty is relative in nature, and the criticismthat the LICOs are too high. In addition, we discuss the Sarlo/FraserInstitute poverty lines, which are based on the assumption thatpoverty is absolute in nature. The manner in which poverty isconceptualized and measured has implications for the types,characteristics and ultimately the success of policies thatare developed to reduce poverty and its effect on health. Weargue that the success of efforts to enhance the health of Canadianswith a reduction in poverty depends on a commitment by policymakers to a relative conceptualization and measurement of poverty.We further contend that policy makers in the health sector cannotindependently reduce poverty and its detrimental effects onhealth. The complex nature of poverty indicates the need forpolicy makers in the health sector to work collaboratively withtheir counterparts from a broad range of government and non-governmentsectors to develop an innovative network of social assistance,economic and employment policies that effectively reduce theproportion of Canadians who experience material and social deprivation.     

Social and built-environment factors related to children's independent mobility: The importance of neighbourhood cohesion and connectedness

This study examines aspects of neighbourhood social environments (namely, neighbourhood safety, cohesion and connection) and child-specific built environment attributes in relation to children's independent mobility. The results suggest that children aged 8–13 years with parents who perceive their neighbourhood as more cohesive and more connected, and are located closer to school, engaged in higher levels of independently mobile trips. The qualitative component of this research revealed that for NZ European, Māori, Samoan and other Pacific parents, ‘people danger’ was the most common concern for letting their children go out alone, whereas for Asian and Indian parents, ‘traffic danger’ was the most common reason for their concern.     

The effect of neighbourhood social capital on child injuries: A gender-stratified analysis

We designed a longitudinal retrospective cohort study to analyse the associations between neighbourhood social capital and child injures. Register data from the Umeå Simsam Lab in Sweden was used to measure child injuries and demographic and socioeconomic factors at individual, household and neighbourhood level. A social capital score from a previous survey was used to measure neighbourhood social capital. We conducted a three-level multilevel negative binomial regression analysis, with children (level 1, N = 77,193) nested within households (level 2, N = 10,465), and households nested within neighbourhoods (level 3, N = 49). The incidence rate of child injuries was lower in high social capital neighbourhoods. When controlling for factors at individual, household and neighbourhood levels, living in a high social capital neighbourhood was protective of injuries among girls, but not among boys. Promoting social capital in local neighbourhoods could be seen as a prevention strategy for injuries among girls.     

Considering daily mobility for a more comprehensive understanding of contextual effects on social inequalities in health: A conceptual proposal

Despite growing interest in integrating people׳s daily mobility into contextual studies of social inequalities in health, the links between daily mobility and health inequalities remain inadequately conceptualised. This conceptual proposal anchors the relationship between daily mobility and contextual influences on social inequalities in health into the concept of mobility potential, which encompasses the opportunities and places individuals can choose (or are constrained) to access. Mobility potential is realized as actual mobility through agency. Being shaped by socially-patterned personal and geographic characteristics, mobility potential is unequally distributed across social groups. Social inequalities in realized mobility may thus result. We discuss pathways by which these may contribute to contextual influences on social inequalities in health. One pathway is reflected in disadvantaged groups encountering more fast-food outlets during their daily activities, which may relate to their higher risk of unhealthy eating. This proposal lays the bases for empirical research explicitly testing hypotheses regarding the contribution of daily mobility to social inequalities in health.     

The role of daily mobility in mental health inequalities: the interactive influence of activity space and neighbourhood of residence on depression

The literature reports an association between neighbourhood deprivation and individual depression after adjustment for individual factors. The present paper investigates whether vulnerability to neighbourhood features is influenced by individual "activity space" (i.e., the space within which people move about or travel in the course of their daily activities). It can be assumed that a deprived residential environment can exert a stronger influence on the mental health of people whose activity space is limited to their neighbourhood of residence, since their exposure to their neighbourhood would be greater. Moreover, we studied the relationship between activity space size and depression. A limited activity space could indeed reflect spatial and social confinement and thus be associated with a higher risk of being depressed, or, conversely, it could be linked to a deep attachment to the neighbourhood of residence and thus be associated with a lower risk of being depressed. Multilevel logistic regression analyses of a representative sample consisting of 3011 inhabitants surveyed in 2005 in the Paris, France metropolitan area and nested within 50 census blocks showed, after adjusting for individual-level variables, that people living in deprived neighbourhoods were significantly more depressed that those living in more advantaged neighbourhoods. We also observed a statistically significant cross-level interaction between activity space and neighbourhood deprivation, as they relate to depression. Living in a deprived neighbourhood had a stronger and statistically significant effect on depression in people whose activity space was limited to their neighbourhood than in those whose daily travels extended beyond it. In addition, a limited activity space appeared to be a protective factor with regard to depression for people living in advantaged neighbourhoods and a risk factor for those living in deprived neighbourhoods. It could therefore be useful to take activity space into consideration more often when studying the social and spatial determinants of depression.     

Effects of an urban regeneration program on related social determinants of health in Chile: A pre-post intervention study

Urban regeneration programs, such as "Programa Quiero mi Barrio" (PQMB) that is carried out in neighborhoods with greater deprivation across Chile, can improve health and quality of life in socio-economically deprived neighborhoods. The aim of this study was to analyze the effects of this program on the physical, social, and safety environments of neighborhoods intervened between 2011 and 2018, according to gender and socioeconomic position. Four indices and six sub-indices were constructed to measure physical, social, and safety environments of the neighborhoods. We conducted a pre- and post-intervention analysis with 2095 people using linear models adjusted for repeated measurements. After the intervention, participants had an improved perception of physical, social, and safety environments, as well as the use of spaces, particularly among women and people with higher levels of education. Therefore, the PQMB program is a form of public policy that can improve the quality of life and health of people living in underprivileged areas.     

Moving health professionals as an alternative to moving patients: The contribution of overseas visiting medical specialists to the health system in Malta

Cross-border healthcare has become a major policy issue in the past years across the European Union. Professional mobility, as a means of providing specialised health services has not been given sufficient attention in both the research and policy agendas. This paper presents a case study of the contribution made by visiting overseas medical specialists to the health system in Malta. Twenty-five semi-structured interviews were conducted. A grounded theory approach was utilised in view of the limited amount of literature available on the subject. Qualitative content analysis revealed one superordinate theme, being the value of the service, and three further subthemes, which include the quality of the service provided, its longevity and durability, as well as the critical contributions of expatriates. The service is an integral component of the local health service. This study makes an important contribution to the literature on cross-border healthcare. Lessons learnt may be transferable to other small island states and territories. The European Reference Networks being developed at EU level may need to focus more on the benefits that can accrue through short term professional mobility than has been the case to date. The findings also serve to propose several important features that need to be in place to increase the chances of longevity, sustainability, quality and cost effectiveness in cross border health care services.     

Conceptualizing the healthscape: Contributions of time geography,location technologies and spatial ecology to place and health research

Geomatics and related technologies allow for the application of integrated approaches to the analysis of individual spatial and temporal activities in the context of place and health research. The ability to track individuals as they make decisions and negotiate space may provide a fundamental advance. This paper introduces the need to move beyond conventional place-based perspectives in health research, and invokes the theoretical contributions of time geography and spatial ecology as opportunities to integrate human agency into contextual models of health. Issues around the geographical representation of place are reviewed, and the concept of the healthscape is introduced as an approach to operationalizing context as expressed by the spatial and temporal activities of individuals. We also discuss how these concepts have the potential to influence and contribute to empirical place and health research.     

贫困、疾病及精准健康扶贫政策:基于贫困居民生命质量评价

目的:将生命质量评价引入精准健康识别与干预政策中,通过比较不同类别贫困居民生命质量特征,揭示扶贫对象各维度现状,为完善精准健康扶贫政策提供参考。方法:评价工具采用WHOQOL-BREF量表,通过入户调查方式收集数据,采用t检验分析与中国常模数据进行比较。结果:贫困居民其人群分布表现为男性(71.7%)多于女性,年龄普遍偏大(平均55岁)。贫困居民与中国常模比较,健康组和疾病组的生命质量评价评分均显著低于中国常模的对照组,说明贫困对于居民生命质量评价的负面影响十分显著。不论处于何种收入水平,健康贫困居民总体评价均高于患病贫困居民。对于患病贫困居民而言,收入越高、其心理和总体评价越好;反之亦然。结论:健康对于贫困居民总体评价具有显著正影响、而患病对于贫困居民总体评价具有显著负影响。收入提高对于患病贫困居民的心理和总体评价改善有效。     

The contextual effects of social capital on health: a cross-national instrumental variable analysis

Past research on the associations between area-level/contextual social capital and health has produced conflicting evidence. However, interpreting this rapidly growing literature is difficult because estimates using conventional regression are prone to major sources of bias including residual confounding and reverse causation. Instrumental variable (IV) analysis can reduce such bias. Using data on up to 167,344 adults in 64 nations in the European and World Values Surveys and applying IV and ordinary least squares (OLS) regression, we estimated the contextual effects of country-level social trust on individual self-rated health. We further explored whether these associations varied by gender and individual levels of trust. Using OLS regression, we found higher average country-level trust to be associated with better self-rated health in both women and men. Instrumental variable analysis yielded qualitatively similar results, although the estimates were more than double in size in both sexes when country population density and corruption were used as instruments. The estimated health effects of raising the percentage of a country's population that trusts others by 10 percentage points were at least as large as the estimated health effects of an individual developing trust in others. These findings were robust to alternative model specifications and instruments. Conventional regression and to a lesser extent IV analysis suggested that these associations are more salient in women and in women reporting social trust. In a large cross-national study, our findings, including those using instrumental variables, support the presence of beneficial effects of higher country-level trust on self-rated health. Previous findings for contextual social capital using traditional regression may have underestimated the true associations. Given the close linkages between self-rated health and all-cause mortality, the public health gains from raising social capital within and across countries may be large.     

Urban regeneration and mental health: Investigating the effects of an area-based intervention using a modified intention to treat analysis with alternative outcome measures

A quasi-experimental study of the mental health impacts of regeneration was carried out across fifteen communities in Glasgow, UK, grouped into five and then four types of intervention area. Regression modelling was undertaken to examine the effects of living in each type of area upon mental health (MCS-12 and SF-12 MH) and mental wellbeing (WEMWBS). Living in regeneration areas had no impacts on mental health or wellbeing, possibly due to incomplete implementation. Positive impacts from living in areas of housing improvement were not evident separately for areas of high-rise housing. Areas surrounding regeneration areas exhibited gains in mental health and wellbeing, contrary to notions of negative spillover. Moving between areas had negative effects, especially for those moving beyond the study areas. Changes in mental wellbeing appear less substantial compared with changes in mental health.     

Placing poverty on the agenda of a primary health care team: an evaluation of an action research project

The period of the last Government in the UK was marked by increases in poverty and social exclusion, with the gap widening between rich and poor, and differentials being associated with, and further entrenched by, inequalities in health. In 1994, the Audit Commission pointed to the potential contribution which proactive and well coordinated health and welfare services could make to meeting the needs of vulnerable families, and suggested the setting up of local demonstration projects. This paper reports on the achievements and limitations of Nottingham's 2-year Strategies for Practice in Disadvantaged Areas (SPIDA) Project which tested a model of team learning about poverty in relation to those registered with an inner-city doctor's practice. Members of a primary health care team engaged in a self-directed development programme which, despite numerous staff changes, enabled them to learn how to learn together, enhanced their understandings of what it means to live in poverty, and facilitated the establishment of collaborative and productive interagency working relationships at a neighbourhood level. It is suggested that staff in health and welfare organizations wishing to implement anti-poverty strategies could usefully consider adopting this model of team learning to promote collective action and change.     

Achieving the SDGs: Evaluating indicators to be used to benchmark and monitor progress towards creating healthy and sustainable cities

In 2016, the World Health Organization declared that ‘Health is one of the most effective markers of any city’s successful sustainable development’ (World Health Organisation, 2016). With estimates that around 6.7 billion people will live in cities by 2050, 21^st century city planning decisions will play a critical role in achieving the United Nations (UN) Sustainable Development Goals (SDGs). They will determine the city structure and access to health-enhancing (or health-damaging) urban environments, and ultimately lifestyle choices that impact both individual and planetary health. Benchmarking, monitoring and evaluating city planning policies and interventions is therefore critical to optimise urban outcomes. In 2017, the UN adopted a global SDG indicator framework, calling for complementary national and regional indicators to be collected by member countries. UN Habitat has also developed an indicator action framework specifically for cities. This paper examined the extent to which the UN indicators will help cities evaluate their efforts to deliver sustainability and health outcomes. It identified inconsistencies between the two UN indicator frameworks. Many of the SDG indicators assess outcomes, rather than the comprehensive and integrated ‘upstream’ policies and interventions required to deliver outcomes on-the-ground. Conversely, the UN Habitat framework incorporates intervention indicators, but excludes health outcome indicators. A more comprehensive approach to benchmarking, monitoring and evaluating policies designed to achieve healthy and sustainable cities and assessing spatial inequities is proposed.     

Towards an epidemiological understanding of the effects of long-term institutional changes on population health: a case study of Canada versus the USA

This paper uses a comparative case study of Canada and the USA to argue that, in order to fully understand the associations between population health and the socioeconomic environment we must begin to place importance on the dynamic aspect of these factors--examining them as they evolve over time. In particular, for institutional and policy shifts that often unfold over decades, population health must attend to these big, slow moving processes by adopting a historical perspective to the knowledge base. We compare Canada and the USA on basic health outcomes and a range of determinants of health for which routine data have been collected for all or most of the period between 1950 and the present. During the analysis that follows, we are able to establish that, at the level of society (i) greater economic well being and spending on health care does not yield better health outcomes, that (ii) public provision and income redistribution trump economic success where population health is concerned, and (iii) that the gradual development of public provision represents the buildup of social infrastructure that has long-lasting effects on health status. Our case study shows what can be gleaned from a comparative perspective and a long-term view. The long view allows us to detect the gradual divergence in health status between these two societies and to trace potential institutional causes that would otherwise go unnoticed. The perspective introduced here, and in particular the comparison of Canada and the USA, provides strong support for the use of cross-national comparative work, and a historical perspective on the investigation of societies that successfully support population health.     

The heterogeneous causal effects of neonatal care: a model of endogenous demand for multiple treatment options based on geographical access to care

Neonatal units in the UK are organised into three levels, from highest Neonatal Intensive Care Unit (NICU), to Local Neonatal Unit (LNU) to lowest Special Care Unit (SCU). We model the endogenous treatment selection of neonatal care unit of birth to estimate the average and marginal treatment effects of different neonatal designations on infant mortality, length of stay and hospital costs. We use prognostic factors, survival and hospital care use data on all preterm births in England for 2014–2015, supplemented by national reimbursement tariffs and instrumental variables of travel time from a geographic information system. The data were consistent with a model of demand for preterm birth care driven by physical access. In‐hospital mortality of infants born before 32 weeks was 8.5% overall, and 1.2 (95% CI: ?0.7, 3.2) percentage points lower for live births in hospitals with NICU or SCU compared to those with an LNU according to instrumental variable estimates. We find imprecise differences in average total hospital costs by unit designation, with positive unobserved selection of those with higher unexplained absolute and incremental costs into NICU. Our results suggest a limited scope for improvement in infant mortality by increasing in‐utero transfers based on unit designation alone.