There has been considerable work done in recent years exploring the value of urban green space for health and wellbeing. Urban green spaces provide environmental benefits through their effects on negating urban heat, offsetting greenhouse gas emissions, and attenuating storm water. They also have direct health benefits by providing urban residents spaces for physical activity and social interaction, and allowing psychological restoration to take place. Consequently, there is a real need to understand the mechanisms by which these benefits accrue. Previously, much of the focus has been on the characteristics of the urban green space that are likely to influence its use, such as its accessibility, quality, facilities, attractiveness, and security. This assumes a causal relationship, when in reality the relationship is more complex and multifactorial. It is more likely that it is the functionality of the green space, be it for exercise or sociocultural activities, rather than its character, which translates to the reported benefits. Challenges exist, such as competing urban planning priorities, economic considerations, and market forces. There is thus a need for urban planning to match the health benefits sought with the needs of the community and the functionality that the urban green space will serve.

Study objective: To investigate whether the Index of Multiple Deprivation 2000 (IMD) is more strongly related to inequalities in health in rural areas than traditional deprivation indices. To explore the contribution of the IMD domain “geographical access to services” to understanding rural health variations. Design: A geographically based cross sectional study. Setting: Nine counties in the south west region of England. Participants: All those aged below 65 who reported a limiting long term illness in the 1991 census, and all those who died during 1991–96, aged less than 65 years. Main results: The IMD is comparable with the Townsend score in its overall correlation with premature mortality (r ² = 0.44 v 0.53) and morbidity (r ² = 0.79 v 0.76). Correlation between the Townsend score and population health is weak in rural areas but the IMD maintains a strong correlation with rates of morbidity (r ² = 0.70). The “geographical access to services” domain of the IMD is not strongly correlated with rates of morbidity in rural areas (r ² = 0.04), and in urban areas displays a negative correlation (r ² = −0.47). Conclusions: The IMD has a strong relation with health in both rural and urban areas. This is likely to be the result of the inclusion of data in the IMD on the numbers of people claiming benefits related to ill health and disability. The domain “geographical access to services” is not associated with health in rural areas, although it displays some association in urban areas. This domain is potentially important but, as yet, inadequately specified in the IMD for the purposes of health research.

Background and aim: This study examined the association between socioeconomic deprivation, travel distance, urban-rural status, location and type of screening unit, and breast screening uptake. Screening was provided at 13 locations—1 fixed and 12 mobile (3 at non-health locations). Methods: The study examined data from 1998 to 2001 for 34 868 women aged 50–64 years, calculated road travel distance, used 1991 enumeration district level Townsend socioeconomic deprivation scores, and a ward level urban-rural classification. Results: Odds of attendance for screening decreased with increasing socioeconomic deprivation, with an adjusted odds ratio of 0.64 (95%CI 0.59 to 0.70) in the most deprived relative to the least deprived category. 87% of women lived within 8 km of their screening location. The odds ratio for a 10 km increase in distance was 0.87 (95%CI 0.79 to 0.95). The odds ratios were 1.18 (95%CI 1.08 to 1.28) for screening at a non-health relative to a health location, 1.00 (95%CI 0.94 to 1.07) for the fixed site relative to the mobile unit and 1.00 (95%CI 0.91 to 1.09) for mainly rural relative to mainly urban areas. Conclusions: Socioeconomic inequality in breast screening uptake seems to persist in an established service. There was a small decrease with increasing distance, no difference between fixed and mobile units, and no difference between urban and rural areas but uptake seemed to be higher at non-health sites. Further work is needed to identify effective methods of decreasing socioeconomic inequalities in uptake and to confirm if non-health locations are associated with higher screening uptake.

This paper explores the geographical accessibility of health services in urban and rural areas of the South West of England, comparing two measures of geographical access and characterising the areas most remote from hospitals. Straight-line distance and drive-time to the nearest general practice (GP) and acute hospital (DGH) were calculated for postcodes and aggregated to 1991 Census wards. The correlation between the two measures was used to identify wards where straight-line distance was not an accurate predictor of drive-time. Wards over 25 km from a DGH were classified as 'remote', and characterised in terms of rurality, deprivation, age structure and health status of the population. The access measures were highly correlated (r²>0.93). The greatest differences were found in coastal and rural wards of the far South West. Median straight-line distance to GPs was 1 km (IQR = 0.6–2 km) and to DGHs, 12 km (IQR = 5–19 km). Deprivation and rates of premature limiting long term illness were raised in areas most distant from hospitals, but there was no evidence of higher premature mortality rates. Half of the wards remote from a DGH were not classed as rural by the Office for National Statistics. Almost a quarter of households in the wards furthest from hospitals had no car, and the proportion of households with access to two or more cars fell in the most remote areas. Drive-time is a more accurate measure of access for peripheral and rural areas. Geographical access to health services, especially GPs, is good, but remoteness affects both rural and urban areas: studies concentrating purely on rural areas may underestimate geographical barriers to accessing health care. A sizeable minority of households still had no car in 1991, and few had more than one car, particularly in areas very close to and very distant from hospitals. Better measures of geographical access, which integrate public and private transport availability with distance and travel time, are required if an accurate reflection of the experience those without their own transport is to be obtained.

To investigate the relationship between survival in colorectal cancer patients and the number of lymph nodes examined by a pathologist, previously attributed to stage migration, we used data from a cohort of 5174 colorectal cancer patients recruited between September 1991 and August 1994, and followed-up for 5 years. We selected cases with data present on all prognostic variables, and stratified them into three groups by number of nodes examined. We made a multivariate survival comparison using a Cox regression model. In all, there were 3592 cases with data present on all prognostic variables. Patients who had >10 nodes identified had a significant survival advantage over those who had 5–10 identified, who had in turn a similar advantage over those with 0–4 identified (P<0.001). This effect was present in the whole group and at all Dukes' stages, although statistically significant only in stages B (P=0.004) and C (P=0.019). The effect remained after adjustment in a Cox regression model in which the mean number of nodes taken out by each surgical firm did not predict survival. In a sub-group with data on lymphocytic infiltration into the primary tumour a survival advantage was noted in those with prominent rather than mild infiltration (P<0.001): the former also tended to have more nodes found (P=0.015). Stage migration alone cannot explain these results, as survival advantages are noted across the whole population independent of stage. Lymphocytic infiltration into the primary tumour is prognostically important, and is associated with the number of nodes found. Reactive enlargement of lymph nodes in the mesentery may make them easier to find, reflect immune response to the tumour, and thus indirectly impact upon survival.

This paper is concerned with geographical access to hospital services by public transport. By taking advantage of newly available public transport timetable data, a software tool is developed for the analysis of bus travel times under specified journey scenarios. The example of population access to Derriford Hospital in Devon, England, is used to illustrate the application of these methods, and the social and spatial pattern of accessibility by bus is explored. The analysis reveals substantial differences between access by public and private transport, and highlights the difficulty of combining conventional drive-time analysis with the discontinuous accessibility provided by public transport. There is a need for more attention to be paid to the incorporation of public transport in accessibility modelling.