BACKGROUND:Severe Acute Malnutrition (SAM) remains a major public health issue for children under five in Senegal, particularly in rural areas. Community-based management of acute malnutrition (CMAM) has expanded access to treatment, yet distance to health centres may hinder adherence and lead to defaulting treatment, referred to as 'abandonment' in Senegal. We used data from the Traitement Intégré de la Sous-Nutrition Aiguë (TISA) trial in northern Senegal to assess whether travel time from households to health centres was associated with outpatient treatment adherence and defaulting. METHODS:We combined GPS coordinates of participants' households and health centres with remotely sensed spatial data, such as road networks and landcover, to model travel times. Additional covariates, including rainfall, temperature, and a wealth index, were included in logistic regression and random-effects models to evaluate associations with treatment defaulting. RESULTS:Among 1165 children included, 562 (48.2%) missed more than three of eight scheduled health centre visits and 353 (30.3%) defaulted treatment. The average modelled travel time to health centres was 57.7 min, and 16.2% lived more than 2 h away. After adjustment, each additional hour of travel time was associated with 1.20-fold higher odds of defaulting (95% CI 1.03-1.40). The highest category of cumulative rainfall (>90 mm) was associated with higher odds of defaulting (odds ratio [OR] 1.53, 95% CI 1.04-2.24), whereas the highest category of maximum temperature (>38°C) was not significantly associated with defaulting (OR 1.39, 95% CI 0.98-1.96. CONCLUSIONS:Longer travel times were significantly associated with defaulting treatment. Nearly one in five children lived more than 2 h from care. Improving geographic access could enhance treatment completion and outcomes within CMAM programmes.
Telemedicine abortion is not equally accessible in the United States. Prior to Dobbs v. Jackson Women's Health Organization (2022), state-level restrictions on telemedicine abortion meant that abortion seekers in 18 states could not access telemedicine abortion services within their state - reinforcing extant geographical inequity in abortion access. However, understanding the benefits of telemedicine abortion to increase the availability of abortion, abortion providers and seekers co-developed a strategy for access, which this paper calls cross-border telemedicine abortion (CBTA). Rather than access care remotely, as is typical of telehealth, patients physically travel across state borders to have a phone consultation and pick up their pills from the post office. This paper describes this phenomenon and nuances discussion of the potential of telemedicine and digital health to transcend distance and resolve rural health inequalities. This paper draws on a case study of telemedicine abortion provider Just The Pill and semi-structured interviews with staff and rural patients who accessed this abortion care pathway prior to Dobbs. It suggests that distance may not be the paramount barrier to care for rural women because they are still travelling long distances. Rather, the phenomenon of CBTA suggests that a combination of barriers influences abortion decision-making for rural women and that CBTA may present a viable spatial solution to these barriers.
Spatiotemporal modelling is increasingly employed to understand how geographic patterns of disease vary over time; however, most studies report minimal information, often neglecting uncertainty altogether. This represents a missed opportunity to understand changes in disease risk at a fine granularity and to provide a valuable, actionable evidence base.This study describes generalisable methods for extracting key metrics from the outputs of Bayesian relative risk spatiotemporal models for epidemiological applications, such as the magnitude of relative change between defined periods and the level of evidence that any change was non-zero. Analytical approaches are introduced for identifying types of cancers or areas with particularly notable changes in rates and for visualising areas where both high rates and large changes in rates coincide. These metrics and analytical approaches enhance the interpretability of complex spatiotemporal patterns and can inform targeted interventions and support evidence-based prioritisation.To demonstrate these methods, we present a novel, flexible Bayesian hierarchical spatiotemporal disease model and describe how different implementations of the model can be used to understand either temporal changes by geographic area or shifts in geographic patterns over time. Variations on model specifications are described to support different temporal and space-time interaction models. Finally, we discuss practical considerations and challenges encountered in implementing spatiotemporal models.Overall, this work demonstrates how spatiotemporal modelling outputs can be systematically interpreted to generate actionable insights for public health planning and evaluation.
Climate change and related extreme weather events (EWE) harm the health and well-being of people living in climate-affected regions such as Kenya. Populations facing unique challenges related to EWE and related resource insecurities (e.g., food, water) include nomadic pastoralist communities whose livelihoods are reliant on agriculture, and refugees living in humanitarian settlements disproportionately exposed to EWE. Knowledge gaps persist on the experiences of EWE and related resource insecurities among youth in these communities. To address these gaps, this study applied the resource insecurity framework to examine the relationships between extreme weather (i.e., drought, flooding), resource insecurities (i.e., food, water, sanitation), and related health vulnerabilities among youth in two Kenyan regions: Isiolo, a county reliant on nomadic pastoralist agriculture, and Kalobeyei, a refugee settlement. This qualitative study applied the SenseMaker data collection tool to engage a purposive sample of youth (aged 16-24) in Isiolo (n = 11) and Kalobeyei (n = 11). Framework thematic analysis was used to examine narratives on the interconnections of EWE, resource insecurities, and health. Participant narratives highlighted three key themes: (1) EWE increase resource insecurities and related stressors; 2) Resource insecurities harm mental and physical health; 3) Resource insecurities increase sexual and gender-based violence risks. Recommendations to improve health among youth in Isiolo and Kalobeyei included addressing co-occurring resource insecurities, fostering community development, offering mental health support, and providing targeted interventions to empower girls and women. Multi-level and contextually tailored interventions that address the nexus of livelihoods, resource insecurity, and health are required to advance wellbeing among climate-affected Kenyan youth.
While numerous studies have examined the negative effects of noise on people's noise-related annoyance, limited attention has been paid to the spatio-temporal nonstationarity of noise levels and annoyance during work. To address this research gap, we employed Global Positioning System (GPS) devices, mobile noise sensors, and activity diaries to collect continuous noise exposure data from 482 participants in Hong Kong over one working day and one non-working day, capturing both noise exposure and perceived noise annoyance during at-home and workplace-based work episodes. We then examined how annoyance responses to work-related noise vary by spatial (at home vs. workplace-based) and temporal contexts (working vs. non-working days), with particular focus on differences across different chronotype groups. The results revealed that: (a) significant differences exist in both noise exposure and annoyance between at-home and workplace-based work; (b) work noise exposure differs significantly between working and non-working days, whereas perceived noise annoyance does not; and (c) different chronotype groups exhibit distinct work patterns, noise exposure levels and annoyance. In particular, morning-type individuals experience lower work noise exposure and annoyance and demonstrate a moderating effect on the association between work noise and perceived annoyance. These findings enhance our understanding of potential stationarity bias in work-related noise exposure and perceived annoyance across spatial and temporal contexts, and provide valuable insights for the development of noise management policies tailored to different chronotype groups.
Although mounting evidence supports that neighborhood greenspaces (e.g., trees and parks) may benefit cognitive health in older age, fewer studies have investigated benefits to brain health measured via magnetic resonance imaging (MRI). We used data on 892 older adults without dementia from three Alzheimer's Disease Research Centers, examining whether neighborhood greenspace (i.e., greenness and percentage park space) is associated with white matter hyperintensity (WMH) and hippocampal volumes from MRI. We also examined whether associations varied by sex, racial group, urbanicity, or apolipoprotein E genotype (genetic risk factor for Alzheimer's disease). Linear regression models that accounted for neighborhood clustering controlled for demographics, research center, cognitive function, neighborhood deprivation, and comorbidities (e.g., hypertension, diabetes, obesity). Interaction terms (e.g., greenness×sex) were added to the models to evaluate potential effect modification. Living in greener neighborhoods was associated with fewer WMH and greater hippocampal volume in the overall sample. In stratified analyses, the beneficial greenness-WMH association was restricted to Black (not White) participants (i.e., significant interaction). In contrast, an adverse association between park space and lower hippocampal volumes was detected among Black (not White) participants (i.e., significant interaction). Overall, this study suggests associations between living in neighborhoods with more greenspace and MRI biomarkers of lower cerebrovascular and dementia risk, although results were mixed for Black individuals. Our findings need replication in other cohorts that are ethnoracially diverse and that represent different geographic regions, and future studies are needed explain the counterintuitive associations between park space and hippocampal volume among Black older adults.
Measuring the impact of climate change on food security and the implications for child nutrition remains a challenge. While urban areas typically have better nutritional indicators, substantial heterogeneity exists and is masked by the commonly used urban-rural binary. Linking four Demographic and Health Surveys from Burkina Faso (2010 and 2021), and Kenya (2014 and 2022) with a high frequency temperature dataset, we implement a cross-sectional secondary analysis to measure recent exposure to high temperatures (average maximum daily temperature as well as the number of days above 32 °C in the 14 and 30 days preceding each survey). We further incorporate a satellite-based degree of urbanization measure. We estimate logistic regression models, adjusting for demographic characteristics, to understand how temperature and urbanicity affect minimum dietary diversity (MDD) and wasting in children 6-23 months. In all four surveys, as local average maximum temperature over the preceding 30 days increased, the odds of attaining MDD reduced 6% in Burkina Faso (2010) (Odds Ratio = 0.94; 95% confidence interval 0.89, 0.99), 9% in Burkina Faso (2021) (OR = 0.91; 95% CI 0.85, 0.99), 10% in Kenya (2014) (OR = 0.90; 95% CI 0.88, 0.93) and 4% in Kenya (2022) (OR = 0.96; 95% CI 0.92, 0.99). This was driven mainly by children in rural areas. Programs to prevent malnutrition will need to be geographically targeted and tailored to local climatic and urban contexts. Dietary diversity is an easy to collect, standardized measure that may serve as an early warning indicator of acute malnutrition and key time point for intervention.
Outdoor artificial light at night (ALAN) may impact human health through disturbing human circadian rhythms. Laboratory experiments have shown that spectral differences in ALAN may lead to disparities in disturbing human circadian rhythms, but such spectral differences are overlooked in past urban studies due to the difficulties in measuring exposure. This study employed SDGSAT-1 data with multispectral nighttime light and the most advanced mobility-oriented research paradigm to investigate the different effects of outdoor ALAN exposures associated with different spectral bands. Based on surveys in Hong Kong, 502 participants provided their socio-demographic attributes, sleep quality, and GPS-derived trajectories. Outdoor ALAN exposures were derived at 10-m or 40-m spatial resolution using a 60-m buffer at each visited place and then spatiotemporally accumulated. The residence-based, mobility-based, and non-residential outdoor ALAN exposures were measured using red, green, blue, and panchromatic bands, respectively. Linear mixed-effects models were employed to estimate the associations between outdoor ALAN exposures in different spectral bands and the sleep quality indicators. The results indicated that panchromatic outdoor ALAN exposure measurements are the most accurate and comprehensive exposure measurements that minimize spectral configuration errors for sleep quality modeling. Along with the decreasing wavelength (from red to blue), the magnitude of estimated health associations and the confidence of estimation both decreased. This phenomenon can be well explained by Rayleigh scattering and spectral configuration errors. Consequently, this study provided essential implications for a range of studies in urban health and sustainability that need accurate outdoor ALAN exposures and improved outdoor ALAN settings.
PURPOSE:This systematic review aimed to identify where children and adolescents are physically active using studies combining GPS, GIS, and accelerometry, and to examine how physical activity (PA) contexts vary by age and across countries. METHODS:A systematic search was conducted across four databases. Observational studies objectively assessing PA contexts in children and adolescents were included. Records were screened using AI-assisted active learning by two independent reviewers. Data extraction and study quality assessment were conducted independently by two reviewers, and findings were synthesized narratively by age group and country. RESULTS:Thirty-five studies from 12 countries were included. Children accumulated PA across a broad range of contexts, including recreational areas, home, and school, whereas adolescents' PA was more concentrated in school and home settings. Studies including mixed-age samples often reported higher PA in residential and recreational areas, partly reflecting differences in spatial definitions and classification. Across all age groups, school and home environments consistently contributed to PA, while commercial locations contributed little. Cross-country synthesis showed variation in dominant PA contexts, with residential areas appearing more prominent in the United States, school-based activity in Denmark and Switzerland, and more distributed patterns in countries such as the Netherlands and the United Kingdom. CONCLUSION:Children and adolescents are physically active across multiple contexts, but the relative importance of these settings varies by age and country and is influenced by methodological differences. Distinguishing age groups and improving consistency in spatial definitions are essential for accurately identifying PA contexts and informing context-specific interventions.
Families living in socioeconomically disadvantaged neighbourhoods are disproportionately exposed to unhealthy food outlets. Yet less is known about how families perceive and navigate these local food environments in everyday life. Parents play a key intermediary role in translating neighbourhood food environments into family food purchasing decisions. As such, this qualitative study explored how parents of children aged 8 to 10 years perceive and experience their neighbourhood food environment in Rotterdam (the Netherlands). Fifteen semi-structured interviews were conducted with parents from socioeconomically diverse neighbourhoods. Data were analysed inductively using a constructivist grounded theory approach. Two overarching themes conceptualised parents' engagement with the food environment as a relational and adaptive process, whereby "perceiving the neighbourhood food environment" was continually recalibrated through parents' "use of the food environment in everyday life". Perceptions were shaped by what felt available, acceptable, and accessible, extending to digital food retail and influenced by community norms and safety. These perceptions were recalibrated as families actively engaged with their food environment through planning grocery shopping, navigating in-store trade-offs between price, quality and health or environmental values, and outsourcing meals for time management or enjoyment. Experiences of using the food environment, in turn, reshaped perceptions, forming a dynamic perceive-use-recalibrate feedback loop. Public health interventions should address both neighbourhood and consumer food environments, combining urban planning with strategies attuned to how families perceive and navigate food choices in everyday life.
Neighbourhood socioeconomic disadvantage has been consistently associated with an increased risk of poor mental health. Beyond socioeconomic conditions, neighbourhood environmental attributes have the potential to shape mental health, either supporting or harming wellbeing. While numerous reviews have examined the relationship between various neighbourhood characteristics and mental health, evidence on whether objectively measured environmental attributes moderate this relationship in the context of neighbourhood socioeconomic disadvantage is yet to be synthesised. This systematic review synthesised evidence from studies examining environmental attributes as moderators of the relationship between neighbourhood socioeconomic disadvantage and mental health. From seven databases and a grey literature search 19 studies were identified for inclusion. Moderation findings were mixed. Greenness and blue space were generally protective in disadvantaged neighbourhoods, while air pollution exacerbated poor mental health. Evidence for parks and walkability was inconsistent and may reflect unmeasured factors such as safety and quality. Noise and elder support centres were examined in one study each, highlighting the limited evidence on these attributes. In addition, more longitudinal research examining a broader range of environmental attributes is needed to inform urban planning policies aimed at reducing mental health inequalities.
BACKGROUND:Evidence on the long-term impact of urban green and blue spaces (UGBS) interventions remains limited. This study is a 15-year evaluation of an urban greenway development in Belfast (United Kingdom), assessing the potential effects of this UGBS intervention on physical activity (PA), mental wellbeing and co-benefits. METHODS:Using natural experimental design, a repeated cross-sectional survey was conducted in 2010 (baseline), 2017 (post-opening) and 2023 (long-term follow-up) with about 1200 adults participated each wave. Outcomes included PA, mental wellbeing, general health, quality of life, social capital and environmental perception. Multilevel mixed-effect regressions were performed to examine within-group changes at long-term follow-up. Difference-in-differences analysis investigated the between-group changes that might be attributed to the greenway. Additional comparative analyses included distance-decay analysis and comparison with population trends in Northern Ireland. RESULTS:At six years after completion, the greenway intervention appears to buffer a decline in duration of PA - mainly from moderate-intensity activity (decline lower by 118.6 min/week, 95%CI: 3.9-232.2) but with no significant impact on the proportion of the population meeting the recommended PA level. The intervention is associated with a smaller decline in self-rated health (4.98 units; 95%CI: 0.62-9.34) relative to control group. Intervention association with mental wellbeing was positive but not significant (p = 0.30). The greenway also showed positive effects on social capital and environmental perceptions, with impacts most evident in improving safety and trust in the local area. CONCLUSION:This study provides evidence to support the public health impact of UGBS and its long-term health and social benefits.
BACKGROUND:The climate crisis plays a central role in the displacement of millions each year in Sub-Saharan Africa (SSA). Few studies have explored the burden of poor health outcomes among climate-related migrants (CRMs) in SSA. This scoping review aimed to summarize this limited body of literature and identify gaps for future research. METHODS:A protocol was developed and registered with OSF before performing the literature search. Four databases were systematically searched, identifying 392 unique records. After screening the titles and abstracts of these articles for relevance, 18 articles were sought for full-text review to assess alignment with the pre-defined inclusion criteria. Ten articles were reviewed in depth and summarized to identify key themes. RESULTS:Included articles originated from Western, Eastern, and Southern Africa and focused primarily on flooding, droughts, and environmental degradation. The five key health outcomes identified were (i) poor mental health and solastalgia, (ii) poor physical health, (iii) loss of financial livelihood, (iv) reduced access to healthcare, and (v) poor social health. Sense of place was also observed to be disrupted, as CRMs reported feelings of solastalgia. CONCLUSIONS:CRMs experience significant and wide-ranging health and place-based struggles. These outcomes are deeply connected and contribute to many quality-of-life challenges. This study highlights a critical research gap in understanding how displacement and climate change contribute to poor health outcomes and disruptions to sense of place, especially in SSA.
BACKGROUND:Epidemiologic analyses are central to identifying geographic variation in health outcomes, yet they often provide limited insight into the contextual, social, and organizational mechanisms that produce these patterns. Mixed methods research offers a structured approach for extending population-level surveillance by integrating qualitative inquiry that is sensitive to place and context. METHODS:This paper presents a methodological framework that embeds epidemiologic analysis within an explanatory sequential mixed methods design guided by extreme case selection. County-level colorectal cancer (CRC) mortality-to-incidence ratios (MIRs) are used as an illustrative epidemiologic indicator to identify high- and low-performing places. These quantitative contrasts inform purposive selection of community sites for qualitative inquiry, including focus groups with community members and interviews with healthcare providers. ILLUSTRATIVE APPLICATION:Rather than presenting empirical results, this paper demonstrates how epidemiologic stratification can be used to structure qualitative data collection and integration in ways that enhance interpretive depth and attention to place. CONCLUSION:Coupling epidemiologic surveillance with explanatory sequential mixed methods design, and extreme case sampling, strengthens the capacity of place-based health research to move from description to explanation. This framework offers a replicable methodological approach for researchers seeking to translate population health data into contextually grounded hypotheses and intervention design without treating qualitative and quantitative methods as analytically separate.
Hot food takeaways typically serve food that is energy dense and high in fat and sugar, leading to concerns around their contribution to population prevalence of excess weight. Local authorities have adopted a range of planning policy approaches to regulate new hot food takeaways across England. We used a systematic approach to describe health-focused hot food takeaway policies adopted by all local authorities to inform future policy development. We obtained Local Plans and other relevant planning guidance documents from local authority websites in November 2024. Documents were systematically reviewed, and health-focused hot food takeaway policies extracted for analysis of intent and mechanisms. Of 296 local authorities with planning power in England, 101 had adopted a health-focused hot food takeaway policy. Six main regulatory mechanisms were identified, with takeaway management zones (sometimes referred to as "exclusion zones") around schools and other approaches designed to prevent over-proliferation or over-concentration of takeaways adopted by around three-quarters of local authorities. Whilst six broad regulatory mechanisms were identified, there were numerous variations in policy approaches between local authorities. Furthermore, whilst some policies were clear and unambiguous, other policies lacked clarity, with potential implications for application and enforcement. With an increasing number of local planning authorities adopting hot food takeaway policies, this review provides a comprehensive overview of policy approaches successfully implemented across England that can be used to inform policy development.
Those who produce and share research on geographic health inequalities face calls to communicate evidence more effectively to various audiences, including the public and policymakers. Data visualisation is a key tool available to these communicators, but little is known about how they approach this in practice or how existing visualisation guidance aligns with real-world constraints. Through 20 semi-structured interviews with these communicators in the UK, we identify recurring challenges faced at three stages of decision-making: why (not) to produce visualisations; what data to show; and how to go about doing that. Challenges include concerns about clarity, stigmatisation, the choice between absolute versus relative measures, and whether or how to visualise uncertainty. We show how these challenges are shaped both by organisational contexts - particularly time, skills, and collaboration - and by gaps between existing visualisation research and the needs of practitioners. Given these constraints, we highlight opportunities for improved practice, including greater collaboration between analysts and designers and more actionable, context-specific guidance. Finally, we call for more research on how to produce maps and charts in this context, considering both the technical and socio-political aspects of geographic health inequalities.
Objective Zoning codes influence the built environments of communities in the United States (U.S.), which in turn have potential to promote social connections. This study assessed associations between code reform zoning (CRZ) and activity-oriented zoning (AOZ) exposure and perceived neighborhood social connectedness and whether these associations were mediated by walkability and park coverage. Methods Data from the Current Population Survey September 2019 Volunteering and Civic Life Supplement were linked to U.S. county-level data on (1) population-level exposure to CRZ and an index of 10 AOZ measures as of 2010, (2) EPA's 2021 National Walkability Index, and (3) proportion of area devoted to parks from the 2018 National Neighborhood Data Archive (n = 21,616). Multivariable logistic regression models with robust standard errors examined associations between CRZ and AOZ exposure and three perceived neighborhood social connectedness measures and mediation analyses examined mediation by walkability and park coverage. Results CRZ (OR: 1.22, 95% CI: 1.08-1.36) and each additional AOZ measure (OR: 1.03, 95% CI: 1.01-1.05) were associated with having conversations or spending time with neighbors. CRZ (OR: 1.22, 95% CI: 1.10-1.35) was also associated with neighbors doing favors for each other, as was AOZ (OR: 1.03, 95% CI: 1.01-1.04). None of these associations were mediated by walkability or park coverage. CRZ (OR: 1.29, 95% CI: 1.14-1.46) and AOZ (OR: 1.04, 95% CI: 1.02-1.06) were associated with neighbors getting together to do something positive; both associations were mediated by walkability but not park coverage. Conclusion Zoning is a policy lever that can promote neighborhood social connectedness.
The experience of urban stress can profoundly influences health and well-being of city residents. Importantly, stress is experienced differently depending on social and individual factors, making certain groups more vulnerable than others. This paper presents a literature review of wearable biosensing research on stress in urban settings. It analyzes how physiological measures, including heart-rate metrics (HRV/ECG), electrodermal activity (EDA) and electroencephalography (EEG), have been used to link built environments to individual stress experiences. Drawing on feminist theory, the review asks whether biosensing research acknowledges that stress is not experienced uniformly but reflects social inequalities. The findings show limited attention of published studies to different perceptions of stress. Most studies analyze urban stress in an aggregated form with only about one-third of the identified publications focusing on subgroup differences related to age, mental health, or gender. The paper argues that future research should use biosensing not only to map stress but to create insights into how underrepresented groups physiologically respond to urban space by systematically focusing on social and cultural contexts and embodied differences next to environmental aspects.
