1. Place and health Dahn Jeong 11 February, 2013 EPI6181 University of Ottawa

2. So what about place and health? Historically… In the “modern” epidemiology and public health… Different perspectives on health and place Illustration by Jason Blower, from Alberta Venture

3. Conventional vs. Relational views of place Conventional view Geographical boundaries and specific scale Separated by physical distanceResident local communitiesStatic and fixed area definitions Relational view Nodes in networks, multi-scale Separated by socio-relational distance Individuals are mobile daily and over their life course Dynamic and fluid area definitions Adapted from Cummins S, Curtis S, Diez-Roux AV, Macintyre S. Understanding and representing 'place' in health research: a relational appraoch. Soc Sci Med 2007; 65: 1825-1838.

4. Defining place Murdoch (1998): Spaces of prescription Spaces of negotiation Context and composition Interdependent Mutual reinforcement Reciprocal relationship between people and place ©Jasper James, 2012

5. Research Cummins, Curtis, Diez-Roux, Macintyre (2007): Relationship between specific features of places and health outcomes Ex: place effects on health of immigrants Multi-level models to assess different levels of risk factors in different settings Ex: Shouls, Congdon, and Curtis (1996) Empirical research distinguishing between context and composition Processes and interactions between people and places over timeApplications

6. Place in time and space ‘Place’ varies in time and space ‘Time-Space biographies’ Movement and exposure: vary individually Then, current measures of ‘neighbourhood’ exposures: an underestimation of the effect?  Varying contribution of different ‘contexts’ over time and space  Life-course factors Individual life-course Life-course of the ‘places’: changing composition of area The role of research

7. Public health programs and policies Better identify areas in need of resources to improve the Quality of life Health policy implementation and resource distribution Reducing health inequities Strengthening neighbourhood

8. In Canada Large land mass and low population density Uneven distribution of population Unequal distribution of health care resources Difficulties accessing some health services

9. Rural health in Canada Rural Canada Approximately 95% of Canada’s land mass Almost 30% of the Canadian population Unique characteristics and values … Indian reserves, Inuit and Métis communities form a significant proportion of Canada’s remote area

10. Rural health: disparities Rural Canadians in comparison to urban Canadians Poorer health Less healthy behaviours Shorter life expectancies Higher mortality rates Determinant of health illustrating the disparity Socio-economic status Limited access to health care services Distance to health care providers and facilities Discrepancy between the proportion of rural residents and availability of health care services

11. Rural health: possible solutions Re-defining rural Canada Developing a common definition of what constitutes “rural” A common definition would… New model centered around the sustainability Community-based solutions Approaches that involve strengthening the local forces Community development Rural incentive plans Recruitment and retention Telehealth

12. In conclusion…

13. References Cummins S, Curtis S, Diez-Roux AV, Macintyre S. Understanding and representing 'place' in health research: a relational approach. Soc Sci Med 2007; 65: 1825-1838. Dunn JR, Schaub P, Ross NA. Unpacking Income Inequality and Population Health: The Peculiar Absence of Geography. Can J of Public Health 2007; 98, S1: S10-S17. Herbert R. Canada's Health Care Challenge: Recognizing and Addressing the Health Needs of Rural Canadians. Lethbridge Undergraduate Research Journal 2007; 2(1). Lagacé C, Desmeules M, Pong RW, Heng D. Non-communicable Disease and Injury related Mortality in Rural and Urban Places of Residence. Can J of Public Health 2007; 98, S1: S62-S69. Riva M, Gauvin L, Barnett TA. Toward the next generation of research into small area effects on health: a synthesis of multilevel investigations published since July 1998. J Epidemiol Community Health 2007; 61: 853-861. Patychuk DL. Bridging place-based research and action for health. Can J Public Health 2007; 98 (July-August issue, Suppl 1), S70-S73. Schuurman N, Bell N, Dunn JR, Oliver L. Deprivation indices, population health and geography: an evaluation of the spatial effectiveness of indices at multiple scales. Journal of Urban Health: Bulletin of the NY Academy of Medicine 2007; 84(4): 591-603.