“Before big data, our analysis was usually limited to testing a small number of hypotheses that we defined well before we even collected the data. When we let the data speak, we can make connections that we had never thought existed.”
Viktor Mayer-Schönberger and Kenneth Cukier. Big Data. HarperCollins, Kindle Edition. (2014) p. 14.
Equity in accessibility to health services is central to social justice. It is also a key element of the Health in All Policies approach to intersectoral action for achieving the Sustainable Development Goals of the United Nations Agenda 2030.11. Anaf J, Baum F, Freeman T, et al. Factors shaping intersectoral action in primary health care services. Aust N Z J Public Health. 2014;38:553-9. Available from https://onlinelibrary.wiley.com/doi/abs/10.1111/1753-6405.12284.
https://onlinelibrary.wiley.com/doi/abs/... Geographical accessibility, a determinant of health that requires intersectoral action, is vital to achieving universal access to health care.22. WHO. 53rd Directing Council, 66th Session of the Regional Committee of WHO for the Americas. Strategy for Universal Access to Health and Universal Health Coverage [Internet]. Pan American Health Organization /World Health Organization; 2014. Available from: https://iris.paho.org/handle/10665.2/28276.
https://iris.paho.org/handle/10665.2/282... However, urban planning has rarely incorporated relevant research that measures and improves equity in geographical accessibility to health services. Moreover, much of that research has used sampling techniques that offered limited practical value.
Despite high-level calls for intersectoral action, few implementation strategies show how to shift the standard approach to intersectoral collaborations that address the determinants of health.33. Pan American Health Organization. Universal Health in the 21st Century: 40 Years of Alma-Ata. Report of the High-Level Commission. Washington, D.C., USA: PAHO/WHO; 2019. 126 p. (Accessed 2022 Apr 18). Available from: https://iris.paho.org/handle/10665.2/50960.
https://iris.paho.org/handle/10665.2/509... ,44. Chircop A, Bassett R, Taylor E, Evidence on how to practice intersectoral collab- oration for health equity: a scoping review. Crit Public Health. 2015;25:178-91. Available from: https://doi.org/10.1080/09581596.2014.887831.
https://doi.org/10.1080/09581596.2014.88... Community engagement, a driver for intersectoral action, requires involved stakeholders to communicate effectively, share their understanding of issues, and agree how to use knowledge and metrics.55. Jull J, Graham ID, Kristjansson E, et al. Taking an integrated knowledge trans- lation approach in research to develop the CONSORT-Equity 2017 reporting guideline: an observational study. BMJ Open. 2019;9:e026866. Available from: https://bmjopen.bmj.com/content/9/7/e026866.
https://bmjopen.bmj.com/content/9/7/e026... ,66. Amri M, Chatur A, O'Campo P. Intersectoral and multisectoral approaches to health policy: an umbrella review protocol. Health Res Policy Syst. 2022;20:21. Available from: https://doi.org/10.1186/s12961-022-00826-1.
https://doi.org/10.1186/s12961-022-00826...
This editorial examines the emergence of studies that show the value of adopting accurate, dynamic travel times to assess equity in geographic accessibility to essential health services. These studies are novel for using readily available data coupled with digital technologies and big data analytics to reveal new data and correlations using metrics that stakeholders can understand and share. Emerging studies can thus spur intersectoral collaboration and democratic urban and health services planning. Using big data offers new insights into what is happening and allows researchers and stakeholders to make predictions that would otherwise be impossible. Big data thus arms citizens, governments, and consumers with new tools to address equity and accessibility.
Place of residence is a spatial determinant of health and health equity. It defines which populations can reach health services in a timely and affordable manner by different means of transportation.77. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. WHO; 2008. (Accessed 2022 Mar 19). Available from: https://apps.who.int/iris/handle/10665/43943.
https://apps.who.int/iris/handle/10665/4...
8. Buzai GD, Santana Juárez MV. Condicionantes Socioespaciales de la Salud (CSS): bases y alcance conceptual. Annu Div Geogr. 2018:170-84. Available from http://ri.unlu.edu.ar/xmlui/handle/rediunlu/626.
http://ri.unlu.edu.ar/xmlui/handle/rediu... -99. O'Neill J, Tabish H, Welch V, et al. Applying an equity lens to interventions: using PROGRESS ensures consideration of socially stratifying factors to illu- minate inequities in health. J Clin Epidemiol. 2014;67:56-64. Available from: https://www.jclinepi.com/article/S0895-4356(13)00334-X/fulltext.
https://www.jclinepi.com/article/S0895-4... The inability to reach essential health services can harm people and cause financial hardship.1010. Kelly C, Hulme C, Farragher T, et al. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open. 2016;6:e013059. Available from https://bmjopen.bmj.com/content/6/11/e013059.
https://bmjopen.bmj.com/content/6/11/e01...
11. Sánchez-Mangas R, García-Ferrrer A, de Juan A, et al. The probability of death in road traffic accidents How important is a quick medical response? Accid Anal Prev. 2010;42:1048-56. Available from https://doi.org/10.1016/j.aap.2009.12.012.
https://doi.org/10.1016/j.aap.2009.12.01... -1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0...
Common approaches for assessing accessibility to health services study the shortest distance or time to the nearest facility.1313. Higgins C, Palm M, DeJohn A, et al. Calculating place-based transit acces- sibility: Methods, tools and algorithmic dependence. J Transp Land Use. 2022;15:95-116. Available from: https://doi.org/10.5198/jtlu.2022.2012.
https://doi.org/10.5198/jtlu.2022.2012... ,1414. Carrasco-Escobar G, Manrique E, Tello-Lizarraga K, et al. Travel time to health facilities as a marker of geographical accessibility across heterogeneous land coverage in Peru. Front Public Health. 2020;8:498. Available from https://doi.org/10.3389/fpubh.2020.00498.
https://doi.org/10.3389/fpubh.2020.00498... Traditionally, these assessments are proxy measures that rely on distance or fixed travel-time estimates.1515. Frenk J. The concept and measurement of accessibility. In: White K, editor. Health Services Research: an anthology. Washington DC: Pan American Health Organization /World Health Organization; 1992. p. 8-42855. Available from: https://www.researchgate.net/profile/Julio-Frenk/publication/19080047Conceptandmeasurementofaccessibility/links/5575db2708ae75363751a314/Concept-and-measurement-of-accessibility.pdf.
https://www.researchgate.net/profile/Jul... For example, actual travel distances on road networks and travel times are often estimated with traffic and transportation models from static data and on typical days captured with samples through surveys and field gauging.1616. Kajalic J, Celar N, Stankovic S. Travel time estimation on urban street segment. Promet - Traffic&Transportation. 2018;30:115-20. Available from https://hrcak.srce.hr/195122.
https://hrcak.srce.hr/195122... These estimates are suboptimal as they use small sample sizes, rarely focus on specific health services and do not account for temporospatial variations of accessibility, such as those resulting from traffic congestion.
Dynamic accessibility assessments are needed to account for the substantial traffic variations that are common in busy urban settings and emerging reports and preprints show that this approach is being adopted.1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... ,1717. García-Albertos P, Picornell M, Salas-Olmedo MH, et al. Exploring the potential of mobile phone records and online route planners for dynamic accessibility analysis. Transp Res Part Policy Pract. 2019;125:294-307. Available from https://doi.org/10.1016/j.tra.2018.02.008.
https://doi.org/10.1016/j.tra.2018.02.00...
18. Kim K, Kwon K. Time-varying spatial accessibility of primary healthcare services based on temporal variations in demand, supply, and traffic conditions: a case study of Seoul, South Korea [Preprint]. Res Sq. 2022 Apr 14; 18. (Accessed 2022 Apr 19). Available from: https://www.researchsquare.com/article/rs-1548274/v1.
https://www.researchsquare.com/article/r...
19. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/... -2020. Sleszynski P, Olszewski P, Dybicz T, et al. The ideal isochrone: assessing the efficiency of transport systems. Res Transp Bus Manag. 2022 Jan;19:100779 (Accessed 2022 Jan 27. Available from: https://www-sciencedirect-com.are.uab.cat/science/article/pii/S2210539521001620).
https://www-sciencedirect-com.are.uab.ca...
These reports mostly follow sophisticated methods and use jargon and complex formulas that require advanced field expertise to understand.1010. Kelly C, Hulme C, Farragher T, et al. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open. 2016;6:e013059. Available from https://bmjopen.bmj.com/content/6/11/e013059.
https://bmjopen.bmj.com/content/6/11/e01... ,2121. Wang F. Measurement, optimization, and impact of health care accessibility: a methodological review. Ann Assoc Am Geogr. 2012;102:1104-12. Available from: https://doi.org/10.1080/00045608.2012.657146.
https://doi.org/10.1080/00045608.2012.65... Many stakeholders may thus find these reports difficult to access or understand and would struggle to communicate their methods and findings to their peers and counterparts. These complications are an important limitation hindering the use and implementation of the knowledge such reports contribute.2222. Whitty CJM. What makes an academic paper useful for health policy? BMC Med. 2015;13:301. Available from: https://doi.org/10.1186/s12916-015-0544-8.
https://doi.org/10.1186/s12916-015-0544-... They require access to specialized sources that many stakeholders lack, and some are behind paywalls. The complexity of these reports and their lack of simple communication materials make them difficult for diverse stakeholders to use. Stakeholders need to grasp essential issues, communicate findings to others, and explore their relevance in specific settings.2222. Whitty CJM. What makes an academic paper useful for health policy? BMC Med. 2015;13:301. Available from: https://doi.org/10.1186/s12916-015-0544-8.
https://doi.org/10.1186/s12916-015-0544-... ,2323. Beran D, Pesantes MA, Berghusen MC, et al. Rethinking research processes to strengthen co-production in low and middle income countries. BMJ. 2021;372:m4785. Available from https://doi.org/10.1136/bmj.m4785.
https://doi.org/10.1136/bmj.m4785...
Research that drives societal change must be accessible to stakeholders who shape decisions and plans for health services that must consider land use, mobility, public health, and smart cities.2323. Beran D, Pesantes MA, Berghusen MC, et al. Rethinking research processes to strengthen co-production in low and middle income countries. BMJ. 2021;372:m4785. Available from https://doi.org/10.1136/bmj.m4785.
https://doi.org/10.1136/bmj.m4785... ,2424. Redman S, Greenhalgh T, Adedokun L, et al., Committee on behalf of the C production of KCS. Co-production of knowledge: the future. BMJ. 2021;372:n434. Available from https://doi.org/10.1136/bmj.n434.
https://doi.org/10.1136/bmj.n434... These stakeholders include representatives from the government (e.g., local authorities from different sectors, lawmakers), the community (e.g., watchdogs, academics), and service users and providers (e.g., insurers, service providers, consumer representatives, patients).2323. Beran D, Pesantes MA, Berghusen MC, et al. Rethinking research processes to strengthen co-production in low and middle income countries. BMJ. 2021;372:m4785. Available from https://doi.org/10.1136/bmj.m4785.
https://doi.org/10.1136/bmj.m4785... ,2525. Abimbola S. Beyond positive a priori bias: reframing community engagement in LMICs. Health Promot Int. 2020;35:598-609. Available from https://doi.org/10.1093/heapro/daz023.
https://doi.org/10.1093/heapro/daz023...
Stakeholders can spur collaborations and knowledge uptake by contributing to the research process and to deliberations that shape the implementation of policies, plans, and programs.55. Jull J, Graham ID, Kristjansson E, et al. Taking an integrated knowledge trans- lation approach in research to develop the CONSORT-Equity 2017 reporting guideline: an observational study. BMJ Open. 2019;9:e026866. Available from: https://bmjopen.bmj.com/content/9/7/e026866.
https://bmjopen.bmj.com/content/9/7/e026... ,2626. Wallerstein N, Duran B, Oetzel JG, et al. Community-based participatory research for health: advancing social and health equity. San Francisco, CA: John Wiley & Sons;. 2017. 482 p.,2727. Lavis JN, Boyko JA, Gauvin FP. Evaluating deliberative dialogues focussed on healthy public policy. BMC Public Health. 2014;14:1287. Available from https://doi.org/10.1186/1471-2458-14-1287.
https://doi.org/10.1186/1471-2458-14-128... .
How then to approach the challenges presented here in a way that promotes equitable accessibility and is scalable?
Adopting these technologies paired with data science is a dramatic step forward. These technologies simplify assessments of accessibility by using metrics that all stakeholders understand, such as time to destination. Simplified assessments generate action-oriented data that lets stakeholders explore variations in the assessments under different assumptions and reveals equity implications. Emerging reports present these benefits.1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... ,1919. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/...
When data is available in simple interactive platforms, knowledge users can quickly adopt and adapt these data to deliver accurate estimates of travel times and equity analyses while exploring different assumptions and scenarios. The essential value of these data is that they expose the interactions between traffic congestion, the sociodemographic characteristics of the population, and travel to (or from) health services. This perspective has been missing in urban and health services planning. It is relevant to land use, urbanism, mobility, smart cities, and health services. This perspective also benefits service providers and users, advocacy groups and researchers seeking to address social justice issues through intersectoral approaches.1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... , 1818. Kim K, Kwon K. Time-varying spatial accessibility of primary healthcare services based on temporal variations in demand, supply, and traffic conditions: a case study of Seoul, South Korea [Preprint]. Res Sq. 2022 Apr 14; 18. (Accessed 2022 Apr 19). Available from: https://www.researchsquare.com/article/rs-1548274/v1.
https://www.researchsquare.com/article/r... , 1919. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/...
What if these data were combined with the location of health services and sociodemographic population data to reveal equity and accessibility measurements that inform health services planning and land use?
These digital technologies' superior accuracy, speed, and affordability distinguishes them from traditional origin-destination study methods. The data these digital technologies generate is thus more likely to be available in time to challenge current thinking and inform plans, increasing the value of these data.1010. Kelly C, Hulme C, Farragher T, et al. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open. 2016;6:e013059. Available from https://bmjopen.bmj.com/content/6/11/e013059.
https://bmjopen.bmj.com/content/6/11/e01... ,1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... ,2020. Sleszynski P, Olszewski P, Dybicz T, et al. The ideal isochrone: assessing the efficiency of transport systems. Res Transp Bus Manag. 2022 Jan;19:100779 (Accessed 2022 Jan 27. Available from: https://www-sciencedirect-com.are.uab.cat/science/article/pii/S2210539521001620).
https://www-sciencedirect-com.are.uab.ca... ,2222. Whitty CJM. What makes an academic paper useful for health policy? BMC Med. 2015;13:301. Available from: https://doi.org/10.1186/s12916-015-0544-8.
https://doi.org/10.1186/s12916-015-0544-...
While traditional studies rely on few measurements, widely available technologies use millions of travel time measurements (big data) accumulated from mobile phone apps to promptly deliver detailed data that constantly improves in accuracy.1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... ,1717. García-Albertos P, Picornell M, Salas-Olmedo MH, et al. Exploring the potential of mobile phone records and online route planners for dynamic accessibility analysis. Transp Res Part Policy Pract. 2019;125:294-307. Available from https://doi.org/10.1016/j.tra.2018.02.008.
https://doi.org/10.1016/j.tra.2018.02.00... ,1919. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/... ,2020. Sleszynski P, Olszewski P, Dybicz T, et al. The ideal isochrone: assessing the efficiency of transport systems. Res Transp Bus Manag. 2022 Jan;19:100779 (Accessed 2022 Jan 27. Available from: https://www-sciencedirect-com.are.uab.cat/science/article/pii/S2210539521001620).
https://www-sciencedirect-com.are.uab.ca... ,2222. Whitty CJM. What makes an academic paper useful for health policy? BMC Med. 2015;13:301. Available from: https://doi.org/10.1186/s12916-015-0544-8.
https://doi.org/10.1186/s12916-015-0544-... ,2828. Ashford LS. Demystifying big data for demography and global health. Popul Bull. 2022;76:34. Available from: https://www.prb.org/resources/demystifying-big-data-for-demography-and-global-health/.
https://www.prb.org/resources/demystifyi... This is an important advantage over one-time assessments.
Frequent users of ambulatory care services incur costs to access those services. These costs can become barriers to access and force tough choices between risking health or suffering financial hardship.1010. Kelly C, Hulme C, Farragher T, et al. Are differences in travel time or distance to healthcare for adults in global north countries associated with an impact on health outcomes? A systematic review. BMJ Open. 2016;6:e013059. Available from https://bmjopen.bmj.com/content/6/11/e013059.
https://bmjopen.bmj.com/content/6/11/e01... ,1515. Frenk J. The concept and measurement of accessibility. In: White K, editor. Health Services Research: an anthology. Washington DC: Pan American Health Organization /World Health Organization; 1992. p. 8-42855. Available from: https://www.researchgate.net/profile/Julio-Frenk/publication/19080047Conceptandmeasurementofaccessibility/links/5575db2708ae75363751a314/Concept-and-measurement-of-accessibility.pdf.
https://www.researchgate.net/profile/Jul... ,2121. Wang F. Measurement, optimization, and impact of health care accessibility: a methodological review. Ann Assoc Am Geogr. 2012;102:1104-12. Available from: https://doi.org/10.1080/00045608.2012.657146.
https://doi.org/10.1080/00045608.2012.65... Assessments of equity in accessibility to health services help to identify and address the social injustice harming the most vulnerable populations, who pay a greater share of their income to reach adequate essential health services.2929. Fiscella K, Shin P. The Inverse care law: implications for healthcare of vulnerable populations. J Ambulatory Care Manage. 2005;28:304-12. Available from https://journals.lww.com/ambulatorycaremanagement/Abstract/2005/10000/TheInverseCareLawImplicationsforHealthcare.5.aspx.
https://journals.lww.com/ambulatorycarem...
Other than providing a situational analysis, what else could be done?
Beyond providing situational analyses, digital platforms and analytics could predict changes and help to optimize accessibility. Digital platforms can thus broaden the understanding of possible solutions, considering different ranges of assumptions.
For example, predictive and prescriptive analytics help planners anticipate the impact that changes in infrastructure (e.g., new roads, road closures, adding or removing services), population (e.g., migration), or traffic conditions (changes in traffic congestion or service schedules) have on equity in accessibility.2828. Ashford LS. Demystifying big data for demography and global health. Popul Bull. 2022;76:34. Available from: https://www.prb.org/resources/demystifying-big-data-for-demography-and-global-health/.
https://www.prb.org/resources/demystifyi...
The capacity to accurately predict and swiftly identify the effects of changes in service schedules or availability, or a new situation (e.g., changes to traffic during a public health emergency, such as COVID-19 pandemic travel restrictions) merits further assessment and is already being explored.1919. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/... It is possible to, for example, identify the areas where new services would reach the most people under new traffic conditions.3030. Ministerio de Tecnología y Comunicaciones de Colombia. DS4A Colombia 2020 /Grand Finale. 2020 (Accessed 2020 Aug 16). Available from: https://youtu.be/sdjJWz9BqiQ?t=7362.
https://youtu.be/sdjJWz9BqiQ?t=7362...
Importantly, these approaches are adaptable to and scalable in many high-, middle-, and low-income settings where essential data is publicly available. These data include inputs such as georeferenced population data with sociodemographic characteristics, the location of health services, and travel-time big data. Integrating these data make it possible to deliver clear statistics and visualizations (e.g., choropleth maps and frequency tables and graphs) that reveal equity in accessibility to or from health services that stakeholders and decision makers can quantify, understand and share.1212. Jin T, Cheng L, Wang K, et al. Examining equity in accessibility to multi-tier healthcare services across different income households using estimated travel time. Transp Policy. 2022;121:1-13. Available from https://doi.org/10.1016/j.tranpol.2022.03.014.
https://doi.org/10.1016/j.tranpol.2022.0... ,1919. Cuervo LG, Herrera EM, Osorio L, et al. Cross-sectional equity analysis of accessibility by automobile to tertiary care emergency services in Cali, Colombia in 2020. medRxiv; 2022. (Accessed Feb 4). Available from: https://www.medrxiv.org/content/10.1101/2022.02.03.22269929v1.
https://www.medrxiv.org/content/10.1101/... ,2222. Whitty CJM. What makes an academic paper useful for health policy? BMC Med. 2015;13:301. Available from: https://doi.org/10.1186/s12916-015-0544-8.
https://doi.org/10.1186/s12916-015-0544-...
These data are game-changing and can be further refined if more elaborate analyses were needed to account for insurance, preference, means and direction of transportation, service capacity and quality.
Similar technologies have transformed the hospitality and commodities sectors. It is time to adopt them to reveal and address the needs of citizens as we move towards a healthier and fairer society that meets the Sustainable Development Goals of the United Nations Agenda 2030.
References
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Funding
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Publication Dates
- Publication in this collection
22 May 2023 - Date of issue
Nov-Dec 2022
