- Pre-registration nursing students
- No definition of master’s degree in nursing described in the publication
After the search, we collated and uploaded all the identified records into EndNote v.X8 (Clarivate Analytics, Philadelphia, Pennsylvania) and removed any duplicates. Two independent reviewers (MCS and SA) screened the titles and abstracts for assessment in line with the inclusion criteria. They retrieved and assessed the full texts of the selected studies while applying the inclusion criteria. Any disagreements about the eligibility of studies were resolved by discussion or, if no consensus could be reached, by involving experienced researchers (MZ-S and RP).
The first reviewer (MCS) extracted data from the selected publications. For this purpose, an extraction tool developed by the authors was used. This tool comprised the following criteria: author(s), year of publication, country, research question, design, case definition, data sources, and methodologic and data-analysis triangulation. First, we extracted and summarized information about the case study design. Second, we narratively summarized the way in which the data and methodological triangulation were described. Finally, we summarized the information on within-case or cross-case analysis. This process was performed using Microsoft Excel. One reviewer (MCS) extracted data, whereas another reviewer (SA) cross-checked the data extraction, making suggestions for additions or edits. Any disagreements between the reviewers were resolved through discussion.
A total of 149 records were identified in 2 databases. We removed 20 duplicates and screened 129 reports by title and abstract. A total of 46 reports were assessed for eligibility. Through hand searches, we identified 117 additional records. Of these, we excluded 98 reports after title and abstract screening. A total of 17 reports were assessed for eligibility. From the 2 databases and the hand search, 63 reports were assessed for eligibility. Ultimately, we included 8 articles for data extraction. No further articles were included after the reference list screening of the included studies. A PRISMA flow diagram of the study selection and inclusion process is presented in Figure 1 . As shown in Tables 2 and and3, 3 , the articles included in this scoping review were published between 2010 and 2022 in Canada (n = 3), the United States (n = 2), Australia (n = 2), and Scotland (n = 1).
PRISMA flow diagram.
Characteristics of Articles Included.
Author | Contandriopoulos et al | Flinter | Hogan et al | Hungerford et al | O’Rourke | Roots and MacDonald | Schadewaldt et al | Strachan et al |
---|---|---|---|---|---|---|---|---|
Country | Canada | The United States | The United States | Australia | Canada | Canada | Australia | Scotland |
How or why research question | No information on the research question | Several how or why research questions | What and how research question | No information on the research question | Several how or why research questions | No information on the research question | What research question | What and why research questions |
Design and referenced author of methodological guidance | Six qualitative case studies Robert K. Yin | Multiple-case studies design Robert K. Yin | Multiple-case studies design Robert E. Stake | Case study design Robert K. Yin | Qualitative single-case study Robert K. Yin Robert E. Stake Sharan Merriam | Single-case study design Robert K. Yin Sharan Merriam | Multiple-case studies design Robert K. Yin Robert E. Stake | Multiple-case studies design |
Case definition | Team of health professionals (Small group) | Nurse practitioners (Individuals) | Primary care practices (Organization) | Community-based NP model of practice (Organization) | NP-led practice (Organization) | Primary care practices (Organization) | No information on case definition | Health board (Organization) |
Overview of Within-Method, Between/Across-Method, and Data-Analysis Triangulation.
Author | Contandriopoulos et al | Flinter | Hogan et al | Hungerford et al | O’Rourke | Roots and MacDonald | Schadewaldt et al | Strachan et al |
---|---|---|---|---|---|---|---|---|
Within-method triangulation (using within-method triangulation use at least 2 data-collection procedures from the same design approach) | ||||||||
: | ||||||||
Interviews | X | x | x | x | x | |||
Observations | x | x | ||||||
Public documents | x | x | x | |||||
Electronic health records | x | |||||||
Between/across-method (using both qualitative and quantitative data-collection procedures in the same study) | ||||||||
: | ||||||||
: | ||||||||
Interviews | x | x | x | |||||
Observations | x | x | ||||||
Public documents | x | x | ||||||
Electronic health records | x | |||||||
: | ||||||||
Self-assessment | x | |||||||
Service records | x | |||||||
Questionnaires | x | |||||||
Data-analysis triangulation (combination of 2 or more methods of analyzing data) | ||||||||
: | ||||||||
: | ||||||||
Deductive | x | x | x | |||||
Inductive | x | x | ||||||
Thematic | x | x | ||||||
Content | ||||||||
: | ||||||||
Descriptive analysis | x | x | x | |||||
: | ||||||||
: | ||||||||
Deductive | x | x | x | x | ||||
Inductive | x | x | ||||||
Thematic | x | |||||||
Content | x |
The following sections describe the research question, case definition, and case study design. Case studies are most appropriate when asking “how” or “why” questions. 1 According to Yin, 1 how and why questions are explanatory and lead to the use of case studies, histories, and experiments as the preferred research methods. In 1 study from Canada, eg, the following research question was presented: “How and why did stakeholders participate in the system change process that led to the introduction of the first nurse practitioner-led Clinic in Ontario?” (p7) 19 Once the research question has been formulated, the case should be defined and, subsequently, the case study design chosen. 1 In typical case studies with mixed methods, the 2 types of data are gathered concurrently in a convergent design and the results merged to examine a case and/or compare multiple cases. 10
“How” or “why” questions were found in 4 studies. 16 , 17 , 19 , 22 Two studies additionally asked “what” questions. Three studies described an exploratory approach, and 1 study presented an explanatory approach. Of these 4 studies, 3 studies chose a qualitative approach 17 , 19 , 22 and 1 opted for mixed methods with a convergent design. 16
In the remaining studies, either the research questions were not clearly stated or no “how” or “why” questions were formulated. For example, “what” questions were found in 1 study. 21 No information was provided on exploratory, descriptive, and explanatory approaches. Schadewaldt et al 21 chose mixed methods with a convergent design.
A total of 5 studies defined the case as an organizational unit. 17 , 18 - 20 , 22 Of the 8 articles, 4 reported multiple-case studies. 16 , 17 , 22 , 23 Another 2 publications involved single-case studies. 19 , 20 Moreover, 2 publications did not state the case study design explicitly.
This section describes within-method triangulation, which involves employing at least 2 data-collection procedures within the same design approach. 6 , 7 This can also be called data source triangulation. 8 Next, we present the single data-collection procedures in detail. In 5 studies, information on within-method triangulation was found. 15 , 17 - 19 , 22 Studies describing a quantitative approach and the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review.
Five studies used qualitative data-collection procedures. Two studies combined face-to-face interviews and documents. 15 , 19 One study mixed in-depth interviews with observations, 18 and 1 study combined face-to-face interviews and documentation. 22 One study contained face-to-face interviews, observations, and documentation. 17 The combination of different qualitative data-collection procedures was used to present the case context in an authentic and complex way, to elicit the perspectives of the participants, and to obtain a holistic description and explanation of the cases under study.
All 5 studies used qualitative interviews as the primary data-collection procedure. 15 , 17 - 19 , 22 Face-to-face, in-depth, and semi-structured interviews were conducted. The topics covered in the interviews included processes in the introduction of new care services and experiences of barriers and facilitators to collaborative work in general practices. Two studies did not specify the type of interviews conducted and did not report sample questions. 15 , 18
In 2 studies, qualitative observations were carried out. 17 , 18 During the observations, the physical design of the clinical patients’ rooms and office spaces was examined. 17 Hungerford et al 18 did not explain what information was collected during the observations. In both studies, the type of observation was not specified. Observations were generally recorded as field notes.
In 3 studies, various qualitative public documents were studied. 15 , 19 , 22 These documents included role description, education curriculum, governance frameworks, websites, and newspapers with information about the implementation of the role and general practice. Only 1 study failed to specify the type of document and the collected data. 15
In 1 study, qualitative documentation was investigated. 17 This included a review of dashboards (eg, provider productivity reports or provider quality dashboards in the electronic health record) and quality performance reports (eg, practice-wide or co-management team-wide performance reports).
This section describes the between/across methods, which involve employing both qualitative and quantitative data-collection procedures in the same study. 6 , 7 This procedure can also be denoted “methodologic triangulation.” 8 Subsequently, we present the individual data-collection procedures. In 3 studies, information on between/across triangulation was found. 16 , 20 , 21
Three studies used qualitative and quantitative data-collection procedures. One study combined face-to-face interviews, documentation, and self-assessments. 16 One study employed semi-structured interviews, direct observation, documents, and service records, 20 and another study combined face-to-face interviews, non-participant observation, documents, and questionnaires. 23
All 3 studies used qualitative interviews as the primary data-collection procedure. 16 , 20 , 23 Face-to-face and semi-structured interviews were conducted. In the interviews, data were collected on the introduction of new care services and experiences of barriers to and facilitators of collaborative work in general practices.
In 2 studies, direct and non-participant qualitative observations were conducted. 20 , 23 During the observations, the interaction between health professionals or the organization and the clinical context was observed. Observations were generally recorded as field notes.
In 2 studies, various qualitative public documents were examined. 20 , 23 These documents included role description, newspapers, websites, and practice documents (eg, flyers). In the documents, information on the role implementation and role description of NPs was collected.
In 1 study, qualitative individual journals were studied. 16 These included reflective journals from NPs, who performed the role in primary health care.
Only 1 study involved quantitative service records. 20 These service records were obtained from the primary care practices and the respective health authorities. They were collected before and after the implementation of an NP role to identify changes in patients’ access to health care, the volume of patients served, and patients’ use of acute care services.
In 2 studies, quantitative questionnaires were used to gather information about the teams’ satisfaction with collaboration. 16 , 21 In 1 study, 3 validated scales were used. The scales measured experience, satisfaction, and belief in the benefits of collaboration. 21 Psychometric performance indicators of these scales were provided. However, the time points of data collection were not specified; similarly, whether the questionnaires were completed online or by hand was not mentioned. A competency self-assessment tool was used in another study. 16 The assessment comprised 70 items and included topics such as health promotion, protection, disease prevention and treatment, the NP-patient relationship, the teaching-coaching function, the professional role, managing and negotiating health care delivery systems, monitoring and ensuring the quality of health care practice, and cultural competence. Psychometric performance indicators were provided. The assessment was completed online with 2 measurement time points (pre self-assessment and post self-assessment).
This section describes data-analysis triangulation, which involves the combination of 2 or more methods of analyzing data. 6 Subsequently, we present within-case analysis and cross-case analysis.
Three studies combined qualitative and quantitative methods of analysis. 16 , 20 , 21 Two studies involved deductive and inductive qualitative analysis, and qualitative data were analyzed thematically. 20 , 21 One used deductive qualitative analysis. 16 The method of analysis was not specified in the studies. Quantitative data were analyzed using descriptive statistics in 3 studies. 16 , 20 , 23 The descriptive statistics comprised the calculation of the mean, median, and frequencies.
Two studies combined deductive and inductive qualitative analysis, 19 , 22 and 2 studies only used deductive qualitative analysis. 15 , 18 Qualitative data were analyzed thematically in 1 study, 22 and data were treated with content analysis in the other. 19 The method of analysis was not specified in the 2 studies.
In 7 studies, a within-case analysis was performed. 15 - 20 , 22 Six studies used qualitative data for the within-case analysis, and 1 study employed qualitative and quantitative data. Data were analyzed separately, consecutively, or in parallel. The themes generated from qualitative data were compared and then summarized. The individual cases were presented mostly as a narrative description. Quantitative data were integrated into the qualitative description with tables and graphs. Qualitative and quantitative data were also presented as a narrative description.
Of the multiple-case studies, 5 carried out cross-case analyses. 15 - 17 , 20 , 22 Three studies described the cross-case analysis using qualitative data. Two studies reported a combination of qualitative and quantitative data for the cross-case analysis. In each multiple-case study, the individual cases were contrasted to identify the differences and similarities between the cases. One study did not specify whether a within-case or a cross-case analysis was conducted. 23
This section describes confirmation or contradiction through qualitative and quantitative data. 1 , 4 Qualitative and quantitative data were reported separately, with little connection between them. As a result, the conclusions on neither the comparisons nor the contradictions could be clearly determined.
In 3 studies, the consistency of the results of different types of qualitative data was highlighted. 16 , 19 , 21 In particular, documentation and interviews or interviews and observations were contrasted:
Both types of data showed that NPs and general practitioners wanted to have more time in common to discuss patient cases and engage in personal exchanges. 21 In addition, the qualitative and quantitative data confirmed the individual progression of NPs from less competent to more competent. 16 One study pointed out that qualitative and quantitative data obtained similar results for the cases. 20 For example, integrating NPs improved patient access by increasing appointment availability.
Although questionnaire results indicated that NPs and general practitioners experienced high levels of collaboration and satisfaction with the collaborative relationship, the qualitative results drew a more ambivalent picture of NPs’ and general practitioners’ experiences with collaboration. 21
The studies included in this scoping review evidenced various research questions. The recommended formats (ie, how or why questions) were not applied consistently. Therefore, no case study design should be applied because the research question is the major guide for determining the research design. 2 Furthermore, case definitions and designs were applied variably. The lack of standardization is reflected in differences in the reporting of these case studies. Generally, case study research is viewed as allowing much more freedom and flexibility. 5 , 24 However, this flexibility and the lack of uniform specifications lead to confusion.
Methodologic triangulation, as described in the literature, can be somewhat confusing as it can refer to either data-collection methods or research designs. 6 , 8 For example, methodologic triangulation can allude to qualitative and quantitative methods, indicating a paradigmatic connection. Methodologic triangulation can also point to qualitative and quantitative data-collection methods, analysis, and interpretation without specific philosophical stances. 6 , 8 Regarding “data-collection methods with no philosophical stances,” we would recommend using the wording “data source triangulation” instead. Thus, the demarcation between the method and the data-collection procedures will be clearer.
Yin 1 advocated the use of multiple sources of evidence so that a case or cases can be investigated more comprehensively and accurately. Most studies included multiple data-collection procedures. Five studies employed a variety of qualitative data-collection procedures, and 3 studies used qualitative and quantitative data-collection procedures (mixed methods). In contrast, no study contained 2 or more quantitative data-collection procedures. In particular, quantitative data-collection procedures—such as validated, reliable questionnaires, scales, or assessments—were not used exhaustively. The prerequisites for using multiple data-collection procedures are availability, the knowledge and skill of the researcher, and sufficient financial funds. 1 To meet these prerequisites, research teams consisting of members with different levels of training and experience are necessary. Multidisciplinary research teams need to be aware of the strengths and weaknesses of different data sources and collection procedures. 1
When using multiple data sources and analysis methods, it is necessary to present the results in a coherent manner. Although the importance of multiple data sources and analysis has been emphasized, 1 , 5 the description of triangulation has tended to be brief. Thus, traceability of the research process is not always ensured. The sparse description of the data-analysis triangulation procedure may be due to the limited number of words in publications or the complexity involved in merging the different data sources.
Only a few concrete recommendations regarding the operationalization of the data-analysis triangulation with the qualitative data process were found. 25 A total of 3 approaches have been proposed 25 : (1) the intuitive approach, in which researchers intuitively connect information from different data sources; (2) the procedural approach, in which each comparative or contrasting step in triangulation is documented to ensure transparency and replicability; and (3) the intersubjective approach, which necessitates a group of researchers agreeing on the steps in the triangulation process. For each case study, one of these 3 approaches needs to be selected, carefully carried out, and documented. Thus, in-depth examination of the data can take place. Farmer et al 25 concluded that most researchers take the intuitive approach; therefore, triangulation is not clearly articulated. This trend is also evident in our scoping review.
Few studies in this scoping review used a combination of qualitative and quantitative analysis. However, creating a comprehensive stand-alone picture of a case from both qualitative and quantitative methods is challenging. Findings derived from different data types may not automatically coalesce into a coherent whole. 4 O’Cathain et al 26 described 3 techniques for combining the results of qualitative and quantitative methods: (1) developing a triangulation protocol; (2) following a thread by selecting a theme from 1 component and following it across the other components; and (3) developing a mixed-methods matrix.
The most detailed description of the conducting of triangulation is the triangulation protocol. The triangulation protocol takes place at the interpretation stage of the research process. 26 This protocol was developed for multiple qualitative data but can also be applied to a combination of qualitative and quantitative data. 25 , 26 It is possible to determine agreement, partial agreement, “silence,” or dissonance between the results of qualitative and quantitative data. The protocol is intended to bring together the various themes from the qualitative and quantitative results and identify overarching meta-themes. 25 , 26
The “following a thread” technique is used in the analysis stage of the research process. To begin, each data source is analyzed to identify the most important themes that need further investigation. Subsequently, the research team selects 1 theme from 1 data source and follows it up in the other data source, thereby creating a thread. The individual steps of this technique are not specified. 26 , 27
A mixed-methods matrix is used at the end of the analysis. 26 All the data collected on a defined case are examined together in 1 large matrix, paying attention to cases rather than variables or themes. In a mixed-methods matrix (eg, a table), the rows represent the cases for which both qualitative and quantitative data exist. The columns show the findings for each case. This technique allows the research team to look for congruency, surprises, and paradoxes among the findings as well as patterns across multiple cases. In our review, we identified only one of these 3 approaches in the study by Roots and MacDonald. 20 These authors mentioned that a causal network analysis was performed using a matrix. However, no further details were given, and reference was made to a later publication. We could not find this publication.
Because it focused on the implementation of NPs in primary health care, the setting of this scoping review was narrow. However, triangulation is essential for research in this area. This type of research was found to provide a good basis for understanding methodologic and data-analysis triangulation. Despite the lack of traceability in the description of the data and methodological triangulation, we believe that case studies are an appropriate design for exploring new nursing roles in existing health care systems. This is evidenced by the fact that case study research is widely used in many social science disciplines as well as in professional practice. 1 To strengthen this research method and increase the traceability in the research process, we recommend using the reporting guideline and reporting checklist by Rodgers et al. 9 This reporting checklist needs to be complemented with methodologic and data-analysis triangulation. A procedural approach needs to be followed in which each comparative step of the triangulation is documented. 25 A triangulation protocol or a mixed-methods matrix can be used for this purpose. 26 If there is a word limit in a publication, the triangulation protocol or mixed-methods matrix needs to be identified. A schematic representation of methodologic and data-analysis triangulation in case studies can be found in Figure 2 .
Schematic representation of methodologic and data-analysis triangulation in case studies (own work).
This study suffered from several limitations that must be acknowledged. Given the nature of scoping reviews, we did not analyze the evidence reported in the studies. However, 2 reviewers independently reviewed all the full-text reports with respect to the inclusion criteria. The focus on the primary care setting with NPs (master’s degree) was very narrow, and only a few studies qualified. Thus, possible important methodological aspects that would have contributed to answering the questions were omitted. Studies describing the triangulation of 2 or more quantitative data-collection procedures could not be included in this scoping review due to the inclusion and exclusion criteria.
Given the various processes described for methodologic and data-analysis triangulation, we can conclude that triangulation in case studies is poorly standardized. Consequently, the traceability of the research process is not always given. Triangulation is complicated by the confusion of terminology. To advance case study research in nursing, we encourage authors to reflect critically on methodologic and data-analysis triangulation and use existing tools, such as the triangulation protocol or mixed-methods matrix and the reporting guideline checklist by Rodgers et al, 9 to ensure more transparent reporting.
Acknowledgments.
The authors thank Simona Aeschlimann for her support during the screening process.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
BMC Public Health volume 24 , Article number: 2368 ( 2024 ) Cite this article
Metrics details
The built environment, as a critical factor influencing residents' cardiovascular health, has a significant potential impact on the incidence of cardiovascular diseases (CVDs).
Taking Xixiangtang District in Nanning City, Guangxi Zhuang Autonomous Region of China as a case study, we utilized the geographic location information of CVD patients, detailed road network data, and urban points of interest (POI) data. Kernel density estimation (KDE) and spatial autocorrelation analysis were specifically employed to identify the spatial distribution patterns, spatial clustering, and spatial correlations of built environment elements and diseases. The GeoDetector method (GDM) was used to assess the impact of environmental factors on diseases, and geographically weighted regression (GWR) analysis was adopted to reveal the spatial heterogeneity effect of environmental factors on CVD risk.
The results indicate that the built environment elements and CVDs samples exhibit significant clustering characteristics in their spatial distribution, with a positive correlation between the distribution density of environmental elements and the incidence of CVDs (Moran’s I > 0, p < 0.01). Further factor detection revealed that the distribution of healthcare facilities had the most significant impact on CVDs ( q = 0.532, p < 0.01), followed by shopping and consumption ( q = 0.493, p < 0.01), dining ( q = 0.433, p < 0.01), and transportation facilities ( q = 0.423, p < 0.01), while the impact of parks and squares ( q = 0.174, p < 0.01) and road networks ( q = 0.159, p < 0.01) was relatively smaller. Additionally, the interaction between different built environment elements exhibited a bi-factor enhancement effect on CVDs. In the local analysis, the spatial heterogeneity of different built environment elements on CVDs further revealed the regional differences and complexities.
The spatial distribution of built environment elements is significantly correlated with CVDs to varying degrees and impacts differently across regions, underscoring the importance of the built environment on cardiovascular health. When planning and improving urban environments, elements and areas that have a more significant impact on CVDs should be given priority consideration.
Peer Review reports
Cardiovascular diseases (CVDs) have become one of the most common lethal diseases worldwide, with both the number of affected individuals and the mortality rate continuously rising over the past two decades. Statistical data reveal that from 1990 to 2019, the number of individuals with CVDs globally increased from 271 to 523 million, while deaths climbed from 12.1 million to 18.6 million, accounting for approximately one-third of the total annual global deaths [ 1 ]. The severity of CVDs poses not only a global health challenge but also exerts immense pressure on the healthcare system and the economy [ 2 ]. According to the World Heart Federation, global medical costs for CVDs are projected to rise from approximately 863 billion US dollars in 2010 to 1044 billion US dollars by 2030 [ 3 ]. Thus, it is particularly important to deeply explore the mechanisms that influence CVDs and to develop effective and sustainable strategies to reduce risk and prevent these diseases.
The urban built environment refers to the comprehensive physical structure and man-made surroundings of an urban area, including buildings, transportation systems, infrastructure, land use planning, and elements of natural and artificial spaces [ 4 ]. Numerous studies have focused on the close connection between the built environment and human health, particularly with respect to cardiovascular health. Research indicates that the impact of the built environment on cardiovascular health is a process network structure with various influencing factors, including but not limited to factors contributing to CVDs such as obesity, diabetes, high blood pressure [ 5 , 6 , 7 , 8 , 9 , 10 ], environmental issues like traffic noise and air pollution [ 11 , 12 ], as well as aspects of physical exercise, psychological stress, and lifestyle [ 13 , 14 , 15 , 16 , 17 ], all of which collectively affect the pathogenesis of CVDs [ 18 , 19 , 20 ]. Studies show that optimizing urban design, such as rational land allocation and planning street layouts, can guide people to access more life services, cultivate proactive attitudes and healthy bodies, thereby reducing the risk of CVDs [ 21 , 22 ]. Urban spatially compact development models can encourage physical activity, reducing the risk of cardiovascular and metabolic issues [ 23 ]. In contrast, long commutes and high traffic density may lead to chronic stress and lack of exercise, increasing the risk of obesity and hypertension. Conversely, appropriate intersection density, land-use diversity, destination convenience, and accessibility might encourage walking, improve health, and reduce the risk of obesity, diabetes, hypertension, and dyslipidemia, which are cardiovascular-related problems [ 24 , 25 , 26 ]. The density and accessibility of supermarkets have a direct impact on the dietary habits of community residents, wherein excessive density may increase the risk of obesity and diabetes and correlate with blood pressure levels [ 27 ]. Urban green spaces and outdoor recreational areas have a positive effect on cardiovascular health; green spaces not only offer places for exercise and relaxation but also help alleviate stress, improve mental states, and enhance air quality, thus mitigating the harm caused by air pollution and protecting cardiac and vascular health [ 28 ]. Research also indicates that individuals residing in areas with high greenery rates are more likely to enjoy opportunities that promote physical activity, mental health, and healthy lifestyles, thereby minimizing CVD risks [ 29 , 30 ]. In summary, scientific and rational urban planning, such as diversified land use, appropriate building density, good street connectivity, convenient destinations, short-distance commuting, and beautiful environments, are key factors in promoting overall health and preventing CVDs.
Although numerous studies have focused on exploring the relationship between the built environment and CVDs, the specific mechanisms underlying this relationship remain unclear. This knowledge gap is mainly due to the complexity of the built environment itself and the multifactorial pathogenesis of CVDs. Current research mostly concentrates on individual aspects of the built environment, such as noise, air pollution, green spaces, and transportation [ 31 ], lacking consideration for the overall complexity of the built environment. Many elements of the built environment are interactive; for instance, pedestrian-friendly urban design may enhance physical activity and social interaction, yet it could also be counteracted by air and noise pollution caused by urban traffic [ 32 ]. Therefore, the same element of the built environment might have different effects in different contexts, adding complexity to the study of the built environment. Furthermore, while existing research has exhibited considerable depth and breadth in exploring the complex and dynamic relationship between the built environment and CVDs, many areas still require further improvement and deepening. Traditional linear correlation analyses, such as OLS and logistic regression models, have been widely used to assess the significance level between built environment characteristics and CVDs mortality rates, and to investigate factors such as intersection density, slope, greening, and commercial density [ 33 , 34 ]. However, these methods fall short in addressing the complexity and non-linear characteristics of spatial data.
Therefore, from a geographical perspective, it is particularly important to adopt more appropriate methods to capture the non-stationarity and heterogeneity of spatial data and to explore the spatial correlation characteristics between the built environment and CVDs. However, current research utilizing spatial models has mainly focused on macro-level perspectives, such as national or provincial levels. For example, ŞENER et al. employed spatial autocorrelation models and hot spot analysis models to assess the spatiotemporal variation characteristics of CVD mortality across multiple provincial administrative regions [ 35 ]. Baptista et al. analyzed the impact of factors such as per capita GDP, urbanization rate, education, and cigarette consumption on the growth trends of CVD incidence using spatial lag and spatial error models across different countries or regions [ 36 ]. Eun et al. used Bayesian spatial multilevel models to measure built environment variables in 546 administrative districts of Gyeonggi Province, South Korea, and evaluated the impact of the built environment on CVDs [ 37 ]. While these studies have, to some extent, revealed the spatial distribution characteristics of CVDs and their spatial relationships with environmental features, the scope of these studies is often large, and they tend to overlook the heterogeneity at the micro-level within cities and its specific impact on residents' health. As a result, it is challenging to accurately capture the differential effects of the built environment on CVD incidence across different areas within a city, and many critical environmental factors at the micro-geographical scale, which are directly related to the daily lives and health of residents, may be obscured.
Given this, we focus on Xixiangtang District in Nanning City, China, and construct a research framework centered on multi-source data, including the distribution of CVDs, road networks, and urban POI data. By employing KDE to reveal hotspot areas, spatial autocorrelation analysis to explore spatial dependence, the GDM to dissect key factors, and GWR to capture the spatial heterogeneity effects, we deeply analyze the complex mechanisms by which the urban built environment influences the incidence of CVDs. Our study aims to answer: Is there a significant spatial association between urban built environment elements and the incidence rate of CVDs? To what extent do different built environment elements impact CVDs? And, what are the regional differences in the impact of built environment elements on CVDs in different areas?
This study focuses on Xixiangtang District in Nanning City (Fig. 1 ), an important administrative district located in the northwest of Nanning City, covering an area of approximately 1,276 square kilometers with a permanent population of over one million. As an exemplary early-developed area of Nanning City, the built environment of Xixiangtang not only carries a rich historical and cultural heritage but also witnesses the transformation from a traditional old town to a modern emerging area, forming a unique urban–rural transitional zone. However, with the acceleration of urbanization, Xixiangtang District also faces numerous environmental challenges, such as declining air quality, congested traffic networks, increasing noise pollution, and continuously rising population density, all of which may pose potential threats to residents' cardiovascular health. Therefore, choosing the built environment of Xixiangtang as the core area of this study is not only due to its representativeness but also because the issues faced by this area are of profound practical significance for exploring the health impacts of urbanization and formulating effective environmental improvement strategies.
Location of study area
The CVD case data is sourced from the cardiovascular department's medical records at Guangxi National Hospital. Located in the southeastern core area of Xixiangtang District, near metro stations and densely populated areas, the hospital's superior geographical location and convenient transportation conditions greatly facilitate patient visits, especially for those seeking high-level cardiovascular medical services. Although spatial distance is an important consideration for patients when choosing a medical facility, our study on the spatial distribution patterns of CVDs also takes into account various influencing factors, including socioeconomic status, environmental factors, patient health conditions, and healthcare-seeking behaviors, ensuring the depth and accuracy of the results. Additionally, Guangxi National Hospital is one of the few top-tier (tertiary A) comprehensive hospitals in Xixiangtang District, with its cardiovascular department being a key specialty. The department's outstanding reputation and wide influence, combined with its advantages in equipment, technology, and healthcare costs compared to other non-specialized cardiovascular departments in the region, make it particularly attractive to patients in Xixiangtang, thus rendering the data relatively representative. To ensure the fairness of our study results, we have implemented multiple verification measures, including comprehensive data collection, independent evaluation of medical standards, rigorous statistical analysis, and consideration of healthcare costs.
With authorization from Guangxi National Hospital, we obtained and analyzed the cardiovascular department's data records. Our study adheres to ethical principles and does not involve any operations that have a substantial impact on patients. The cardiovascular data records include basic patient information (such as age, gender, address, etc.), diagnostic information (disease type, diagnosis date, etc.), and treatment records. We focused on CVD patients diagnosed between January 1, 2020, and December 31, 2022. Through systematic screening and organization, we constructed a database of CVD patients during this period. During the data processing procedure, we implemented a rigorous data cleaning process, identifying and excluding incomplete, duplicate, or abnormal data records. This included checking for missing data, logical errors (such as extremely large or small ages), and consistency in diagnostic codes, ensuring the quality and reliability of the data. After data cleaning, we selected 3,472 valid samples, which are representative in terms of disease types, patient characteristics, and geographic distribution. Considering the study involves geographic location analysis, we used a text-to-coordinate tool developed based on the Amap (Gaode) API to convert patient address information into precise geographic coordinates. Finally, using ArcGIS 10.8 software, we visualized the processed case data on a map.
As a multidimensional and comprehensive conceptual framework, the built environment encompasses a vast and intricate system of elements. Given the accessibility, completeness of data, and the robust foundation in current research domains, we have centered our in-depth analysis on two core components: the urban road system and urban POIs. Road data is primarily sourced from OpenStreetMap (OSM) and processed using ArcGIS 10.8 to filter and handle incomplete records. We ultimately selected five types of roads for analysis: highways, expressways, arterial roads, secondary roads, and local roads [ 38 ]. Urban POI data was selected based on existing research and obtained through Amap. Amap is a leading map service provider in China, known for its vast user data, precise geocoding system, and advanced intelligent analysis technology, which accurately captures and presents the spatial distribution and attribute characteristics of various urban facilities. We used Amap's API interface and offline map data package to obtain the coordinates and basic attributes of POIs in the study area, including six key environment elements: dining [ 39 ], parks [ 40 ], transportation [ 20 ], shopping [ 41 ], sports [ 42 ], and healthcare [ 43 ] (Table 1 ). These elements significantly reflect the distribution status of the urban built environment. This comprehensive and detailed data provides a solid foundation for further exploring the relationship between the built environment and cardiovascular health.
Based on existing research findings, we have identified key built environment factors that influence the occurrence of cardiovascular diseases (CVDs) and meticulously processed the data sourced from [ 34 , 35 , 44 ]. The preprocessed data was then subjected to spatial analysis utilizing software tools such as ArcGIS 10.8, Geoda, and the Geographic Detector. Through various methods including KDE, spatial autocorrelation analysis (encompassing both univariate and bivariate analyses), factor detection and interaction detection using the Geographic Detector, as well as GWR, we aimed to explore the potential links between the urban built environment and CVDs (Fig. 2 ).
Research framework
Before delving into the complex relationship between the built environment and CVDs, it is crucial to accurately depict the spatial distribution of these key elements within the study area. Given this need, KDE, an advanced non-parametric statistical technique, was introduced as our core analytical tool. KDE is a non-parametric method used to estimate the probability density function of a random variable, and we implemented it using ArcGIS 10.8 software. Compared to other density estimation methods, such as simple counting or histograms, KDE more accurately reflects the true distribution of spatial elements, helping us identify hotspots and cold spots in the city with greater precision. The core of this method lies in assigning a smooth kernel function to each observation point, which describes the influence range of the observation point on its surrounding space, known as bandwidth. The density distribution map of the entire area is then obtained by overlaying the kernel functions of all observation point [ 45 , 46 , 47 ]. In parameter settings, we set the cell size to 100 m, based on a comprehensive consideration of the study area's scope, the distribution characteristics of geographic phenomena, and computational resource limitations. This aimed to maintain sufficient precision while avoiding excessive computational burden and amplification of data noise. To further refine the analysis and visually present the continuous spatial distribution of CVDs, we used the natural breaks method to classify the KDE results into five levels. KDE visually displays the continuous spatial distribution of CVDs, identifying high-risk and low-risk areas, and provides foundational data support for subsequent spatial analyses.
Spatial autocorrelation analysis is a statistical method used to assess the similarity or correlation between observed values in geographic space. We derived the point attribute values from the kernel density transformation and conducted univariate global spatial autocorrelation analysis, as well as bivariate global spatial autocorrelation analysis between built environment factors and CVDs using Geoda software. Univariate global spatial autocorrelation analysis was used to study the spatial distribution characteristics of the overall dataset, using Moran's I to evaluate whether the dataset exhibits spatial autocorrelation, indicating clustering or dispersion trends [ 48 , 49 ]. Bivariate global spatial autocorrelation further analyzed the spatial correlation between different indicators [ 50 , 51 ]. Spatial autocorrelation analysis helps verify whether the spatial clustering in KDE results is significant and preliminarily explores whether there is spatial interdependence between environmental factors and CVDs.
The results of spatial autocorrelation analysis include the Moran's I index, which directly reflects the strength and direction of spatial autocorrelation, as well as key indicators such as p values and Z values, together constructing a comprehensive quantitative system for evaluating spatial autocorrelation. In the results of spatial autocorrelation analysis, when the p -value is less than 0.01, the confidence level reaches 99%, and the Z value is greater than 2.58, the null hypothesis can be rejected, indicating that the research results are highly reliable. The degree of spatial clustering of variables is measured by Moran's I. The range of Moran's I is [-1, 1]; if Moran's I > 0, it indicates positive correlation, with higher values indicating stronger clustering; if Moran's I < 0, it indicates negative correlation, with lower values indicating stronger clustering; and if Moran's I = 0, the variables are not clustered and show a dispersed distribution, with the correlation weakening as the value approaches 0 [ 52 ].
We analyzed the processed kernel density attribute data using the GDM to parse the influence of the built environment on CVDs and uncover the underlying driving factors. The geographic detector tool was developed by a team led by Researcher Jinfeng Wang at the Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences [ 53 ]. The GDM mainly includes factor detection, interaction detection, risk area detection, and ecological detection, and it has been widely applied in multiple fields. We used the factor detection function to evaluate the impact of environmental factors on the distribution of CVDs and utilized the interaction detection function to analyze the interaction between different environmental factors [ 54 , 55 ]. The purpose of the factor detector is to detect the extent to which independent variables explain the spatial differentiation of the dependent variable. It quantifies the influence of independent variables on the spatial distribution of the dependent variable to reveal which factors are the main contributors to the spatial distribution differences of the dependent variable. However, the impact of built environment elements on CVDs may not be determined by a single factor but rather by the synergistic effect of multiple built environment factors. Therefore, through the means of interaction detection, we further analyzed the synergistic impact of pairs of built environment elements on the spatial distribution of CVDs.
In this analysis, the q value was used as a quantitative indicator of the influence of environmental factors on CVDs, with values ranging between [0,1]. A higher q value indicates a more significant influence of the environmental factor, whereas a lower q value indicates a smaller influence. Additionally, a significance level of p < 0.01 further emphasizes the reliability of these factors' significant impact on the distribution of CVD samples.
However, while the GDM can reveal the overall impact of built environment elements on CVDs, its limitation lies in its difficulty to finely characterize the specific differences and dynamic changes of these impacts within different geographic spatial units. To address this shortcoming, we introduced the GWR model through the spatial analysis tools of ArcGIS 10.8 software for local analysis. This model dynamically maps the distribution and variation trajectory of regression coefficients in geographic space, incorporating the key variable of spatial location into the regression analysis. In this way, the GWR model can reveal the spatial heterogeneity of parameters at different geographic locations, accurately capturing the relationships between local variables, thus overcoming the limitations of traditional global regression models in handling spatial non-stationarity [ 56 , 57 ]. Compared to traditional global regression models, the GWR model excels in reducing model residuals and improving fitting accuracy.
When interpreting the results of the GWR model, it is necessary to consider the regression coefficients, R 2 (coefficient of determination), and adjusted R 2 comprehensively. The dynamic changes in regression coefficients in space reveal the complex relationships between independent and dependent variables at different geographic locations, with their sign and magnitude directly reflecting the nature and intensity of the impact. Although the R 2 value, as an indicator of the model's goodness of fit, focuses more on local effects in the GWR, its variation still helps to assess the explanatory power of the model in each area. These comprehensive indicators together form a thorough evaluation of the GWR model's performance. Through a comprehensive evaluation of the GWR model results, we can more precisely capture the relationships between local variables, revealing the specific impact of environmental factors on CVD risk within different regions.
By applying kernel density analysis, the spatial distribution pattern of CVD samples and various built environment elements was detailed, effectively capturing their spatial density characteristics. The obtained kernel density levels were divided into five tiers using the natural breaks method and arranged in descending order, as shown in Fig. 3 . Analysis results indicate that high-density areas of elements such as shopping, dining, transportation facilities, and medical care are mainly focused in the southeastern part of the city, i.e., the city center. The high-density areas of the road network extend along the southern Yonjiang belt and appear patchy in the city center. Dense areas of parks are mostly near the southern riverside areas, while high-density distributions of sports facilities extend in the southeastern and central regions. Overall, the distribution pattern of these environmental factors reveals that Xixiangtang District's development trend mainly extends from southeast to northwest, indicating that the northeastern part of the region is relatively underdeveloped, with a sparse population and a lack of various infrastructure layouts. Additionally, kernel density distribution characteristics show that high-incidence areas of CVDs are concentrated in the southeast, highly coinciding with the high-density areas of most built environment elements.
Distribution of nuclear density of each element in the study area
To explore the spatial relationship between urban built environment elements and the distribution of CVDs, spatial autocorrelation analysis was performed using Geoda software [ 58 ]. The study involved univariate and bivariate global spatial autocorrelation analyses (Table 2 ). The results of the analysis passed the significance level test at 0.01, with p values below 0.01 and Z values exceeding 2.58, achieving a 99% confidence level. This reinforces the reliability of the spatial autocorrelation results.
Univariate analysis is used to evaluate the clustering or dispersion status of feature points in space. In univariate analysis, the Moran's I value of the road network was 0.957, which significantly indicates a clustering trend in its spatial distribution. Moran's I values for other built environment elements, such as parks, transportation facilities, sports and fitness, and medical care, all exceeded 0.9, while the Moran's I values for shopping and dining also surpassed 0.8. By comparison, the Moran's I value for CVD samples was 0.697, approaching 0.7, revealing significant aggregation. Overall, the clustering nature of the built environment elements and CVD samples in Xixiangtang District implies that these elements are not randomly deployed but follow some patterns of hierarchical assembly.
Bivariate analysis, on the other hand, is used to evaluate the spatial correlation between different environmental factors and CVDs. Bivariate analysis further revealed the spatial interaction between environmental factors and CVDs. The results show that all considered environmental elements exhibited significant positive correlation with CVDs. The spatial association between medical care elements and CVDs was the strongest, with a Moran's I value of 0.431, surpassing the significant threshold of 0.4. Additionally, the Moran's I values for dining, transportation facilities, shopping, and sports and fitness were all over 0.3. Road networks and parks, on the other hand, showed relatively weaker correlations with CVDs, with Moran's I values around 0.1, indicating that in that region, the spatial connection between these built environment elements and CVDs is comparably weak.
A detailed analysis of the impact of various environmental factors on CVDs was achieved through the factor detection model of the GDM. According to the factor detection results shown in Table 3 , significant differences in the impact of environmental factors on the distribution of CVD samples were observed. The analysis results indicate that the environmental factors influencing the distribution of CVDs, in descending order of impact, are: healthcare services > shopping > dining > transportation facilities > sports and fitness > parks and squares > road networks. Specifically, healthcare services lead with a q value of 0.532, indicating that the spatial distribution of healthcare services has the most significant impact on the spatial distribution of CVDs. This highlights the importance of a high-density layout of healthcare facilities in the prevention and treatment of CVDs and suggests that individuals at risk for CVDs tend to prefer living in areas with convenient access to medical services [ 59 ].
Subsequently, shopping, dining, and transportation facilities all have q values exceeding 0.4, reflecting their significant effects on the urban built environment's clustering characteristics and regional commercial vitality. The concentration of human traffic brought about by these factors may, while increasing residents' lifestyle choices, also lead to certain psychological burdens and declining air quality, thereby indirectly placing a burden on the cardiovascular system. In contrast, parks and squares and road networks have relatively low q values (both less than 0.2), suggesting that the incidence of CVDs is lower in areas concentrated with these environmental elements, likely related to their ecological and transportation benefits.
Subsequently, interaction detection was used to analyze the synergistic impact of pairs of built environment elements on the spatial distribution of CVDs. From the results shown in Table 4 , it is evident that any two built environment elements exhibit a bi-factor enhancement effect on CVDs, suggesting that the combined influence of two built environment elements exceeds the effect of a single element. Among these, the interaction between healthcare services and shopping has the greatest impact on CVDs, with a value of 0.571. This indicates that CVDs patients or high-risk individuals tend to prefer living in areas rich in healthcare resources and convenient for shopping, as they can more easily access health services and daily necessities. Conversely, the interaction between road networks and parks and squares has the weakest impact on CVDs, with a value of 0.313. This suggests that their combined effect in reducing CVD risk is relatively limited, possibly due to the negative impacts of road networks, such as traffic congestion and air pollution, which may offset some of the health benefits provided by parks and squares. This result further validates an important point: the impact of the built environment on CVDs is not driven by a single element but by the synergistic effects of multiple environmental factors working together.
The GDM revealed the influence of built environment factors on CVDs. To further uncover the spatial heterogeneity effects of built environment elements on CVDs in different regions, we employed the GWR model. To ensure the rigor of the analysis, we conducted multicollinearity detection for all built environment elements before establishing the model. We confirmed that the Variance Inflation Factor (VIF) values for all elements did not exceed the conventional threshold of 5, effectively avoiding multicollinearity issues and ensuring the robustness of the model results. The GWR model results showed that the model's coefficient of determination R 2 was 0.596, and the adjusted R 2 was 0.575, indicating that the model could adequately explain the relationships between variables in the study. The analysis results also highlighted the spatial non-stationarity of the effects of built environment elements, manifested by different degrees of variation and fluctuation characteristics, as shown by the coefficient magnitudes and their dynamic changes in spatial distribution in Table 5 .
Looking more closely at the details, as demonstrated in Fig. 4 , the regression coefficients of the dining elements fluctuated relatively little, ranging from -0.372 to 0.471, reflecting a relatively balanced spatial effect. Moreover, although this factor's impact in the Xixiangtang District showed both positive and negative aspects in different areas, more than half of the analysis units indicated positive values, especially in the southern and northeastern parts of the Xixiangtang District. In contrast, the high-incidence areas of CVDs in the eastern part and areas in the north showed negative correlations.
Spatial distribution of regression coefficient of built-up environmental factors
The GWR coefficients and their fluctuations for parks were significant, ranging from -69.757 to 35.43, indicating significant spatial differences in their impact on the distribution of CVDs. Specifically, the spatial distribution of positive and negative impacts was nearly 1:1, revealing the complexity of its effects. In high-incidence areas of CVDs, the distribution of parks showed a significantly negative correlation with disease distribution, while a significant increase in positive correlation was observed north of the significantly negative regions. This implies the presence of other moderating factors influencing the direction of the impact of parks on CVDs.
The regression coefficients and fluctuations for shopping were the smallest among the seven environmental factors, confined to a range of -0.093 to 0.219, suggesting a high consistency in its spatial effects. In the Xixiangtang built-up area, nearly two-thirds of the spatial units yielded positive impacts. Particularly in the northern, northeastern, southern, and southeastern regions, the positive impacts of shopping were especially pronounced.
The regression coefficients and fluctuations for transportation facilities were relatively large, ranging from -0.487 to 7.363. For the Xixiangtang District, nearly three-quarters of the analysis units displayed positive spatial impacts, with the largest positive value areas concentrated in the southeastern part. However, areas with negative impacts from transportation facilities were relatively fewer, suggesting a clear positive correlation with the distribution of CVDs.
The fluctuation range for sports and fitness regression coefficients was also broad, from -10.578 to 33.256. The analysis indicated that only a quarter of the analysis units in the Xixiangtang District had a positive correlation. The most significant positive values were located near the high-density areas for CVDs, suggesting that sports and fitness facilities might have a positive correlation with the disease distribution in these areas. Meanwhile, the intensity of the negative correlation increased north of the areas with significant positive values, potentially pointing to other factors' potential moderating effects on the relationship between sports and CVDs.
The regression coefficients and their fluctuations for healthcare were relatively small, ranging from -1.235 to 3.352. In the Xixiangtang District, the vast majority of analysis units showed a positive correlation, especially in the northern regions. The southern areas exhibited negative correlations, highlighting potential differences in medical resources in that region.
Of all the built environment elements, road networks had the largest range of regression coefficients and fluctuations, swinging from -7905.743 to 411.617, demonstrating extremely strong spatial variability. Only a small portion of the spatial units in the Xixiangtang District showed positive correlations, while the significantly negative regions were mostly concentrated in high-incidence areas for CVDs. This phenomenon was similar to the negative correlation distribution trend of parks, pointing to a significantly negative correlation between park distribution and the distribution of CVDs. Notably, the effect of road networks was opposite to transportation facilities, which could be related to the connectivity of the road network and traffic congestion conditions, factors that could influence the incidence of CVDs.
This study reveals a high-density aggregation of CVDs and various built environment elements in the southeastern part of the study area, i.e., the urban central area. Through spatial statistical analysis, all examined environmental elements and CVDs showed high Moran's I values, indicating significant clustering in their spatial distribution. Furthermore, the positive spatial correlation between these environmental elements and CVDs corroborates the deep connection between the urban built environment and the incidence of CVDs.
Geodetector analysis reveals significant differences in the impact of different built environment elements on CVDs. Healthcare facilities had the most influence, followed by shopping, dining, and transportation facilities, while parks and road networks had relatively weaker impacts. Notably, the occurrence of CVDs is not only related to individual built environment elements but likely results from the combined effects of multiple elements. Further interaction detection analysis confirmed this hypothesis, finding that the joint impact of any two environmental elements was stronger than any individual element, showing a clear dual-factor enhancement effect. Specifically, the interaction between healthcare and shopping had the most significant impact on the distribution of CVDs, while the combined effect of road networks and parks was the least. By delving into individual factors and their interaction effects, this study reveals a comprehensive view of the impact of the built environment on CVDs, highlighting the complex relationships and differences between environmental elements and the occurrence of diseases.
The GWR model was used to analyze in detail how built environment elements affect CVDs in different regions, aiming to gain a deep understanding of the local effects of the built environment. The research results showed the regression coefficients of built environment elements and their range of variation. Specifically, the regression coefficients for dining exhibited relatively stable trends in spatial distribution. Although the overall impact was moderate, slight fluctuations revealed a slightly enhanced positive correlation in specific areas such as densely commercial or culturally vibrant dining regions. Particularly in the southern and northeastern parts, the combination of diverse dining options and frequent dining consumption patterns showed a slight positive correlation with CVD risk. This reflects the complex impact of dietary habits, food composition, and intake levels on cardiovascular health [ 60 , 61 ].
The regression coefficients for parks and squares showed relatively large fluctuations in spatial distribution, indicating significant regional heterogeneity. This is mainly due to factors such as differences in regional population density and per capita park and square area. In our study, the southeastern region, which is a high-incidence area for CVDs, exhibited negative regression coefficients for parks and squares. This is because this region is the central urban area with a high population density, leading to a significant shortage of per capita green space, thus showing a negative correlation. Conversely, in the northern region, where population distribution is more balanced and parks and squares are more abundant, the per capita green space is relatively sufficient. Therefore, CVD patients have more access to green spaces and exercise areas, showing a positive correlation [ 29 ].
The regression coefficients for shopping consumption showed the smallest fluctuations in spatial distribution. The positive and negative effects were not significantly different, with the positive effects being notably concentrated in the northern, northeastern, and southern commercial thriving areas. Compared to other regions, these areas might have relatively well-developed commercial facilities or superior shopping environments. This could indirectly affect CVD risk through various dimensions, such as physical exertion from walking or cycling during shopping and the regulation of psychological states like satisfaction and pleasure after shopping [ 44 ].
The regression coefficients for transportation facilities showed a significant positive correlation in high-incidence areas of CVDs, with notable fluctuations. This deeply reveals the direct and important impact of traffic conditions, especially congestion and pollution, on cardiovascular health across different regions. In traffic-dense areas such as city centers and transportation hubs, high traffic volume, severe congestion, and increased noise and air pollution collectively pose major threats to residents' cardiovascular health. This not only directly harms the cardiovascular system through accumulated psychological stress and exposure to air pollution but also further exacerbates the risk due to a lack of exercise opportunities [ 62 ].
The regression coefficients for sports and fitness facilities exhibited a high degree of heterogeneity in spatial distribution, showing a significant positive correlation in the southeastern high-incidence area for CVDs, which gradually shifts to a negative correlation towards the outer regions. This deeply reflects the regional differences in the allocation of sports and fitness facilities, residents' exercise habits, and participation rates. In areas with well-developed urban facilities and strong resident awareness of physical activity, the positive effects of sports and fitness activities on cardiovascular health are particularly significant. These activities effectively reduce CVD risk by enhancing physical activity, optimizing cardiopulmonary function, and lowering body fat percentage. However, in areas with relatively scarce sports facilities and poor exercise habits among residents, negative impacts may be observed, highlighting the potential threats to public health due to uneven distribution of sports resources and a lack of exercise culture [ 63 ].
The regression coefficients for healthcare services showed regional differences in spatial distribution. In the northern region, due to the lower population density, the abundance and superior quality of per capita healthcare resources have a significant positive effect on residents' cardiovascular health. In contrast, the southern region, with relatively scarce resources or limited service quality, fails to fully realize the potential benefits of healthcare services. This disparity not only reveals the current uneven distribution of healthcare resources but also emphasizes the importance of enhancing the equalization of healthcare services [ 64 ]. The positive impact of healthcare on CVDs is primarily achieved through efficient prevention, precise diagnosis, and timely treatment. Its effectiveness is influenced by multiple factors, including the sufficiency of medical resources, service quality, residents' healthcare-seeking behavior, medical policies, and technological advancements.
The road network and transportation facilities together constitute the urban transportation system. In the process of transportation planning, we advocate for the continuous optimization of the road network layout, reserving space for future traffic growth, and utilizing intelligent technology to optimize traffic signal management to alleviate congestion. Meanwhile, in the densely populated eastern and southeastern areas, we emphasize enhancing the convenience of public transportation by adding routes and optimizing station locations, making it the preferred mode of travel for residents. Additionally, measures such as the construction of sound barriers and green belts are implemented to effectively reduce noise and air pollution caused by public transportation. Furthermore, we actively promote green travel methods such as cycling and walking by building a comprehensive network of bike lanes and pedestrian paths, thereby promoting public health and environmental protection [ 20 ].
These findings provide a more comprehensive understanding of the complex interactions between built environment elements and CVDs. Therefore, it is essential to balance the integrated impact of these factors in urban planning and public health interventions. Based on a comprehensive analysis of existing research and our study's results, we propose the following viewpoints.
Firstly, healthcare is the primary factor influencing the distribution of CVDs. Living near medical institutions offers substantial benefits to cardiovascular patients, not only enhancing the accessibility of medical services but also helping to quickly respond to emergency medical situations, providing a sense of security for patients. We suggest establishing additional medical centers in the densely populated southeastern region to ensure that community members can easily access high-quality medical services [ 65 ].
Secondly, shopping and dining are the next most important factors affecting the spatial distribution of CVDs. Although the spatial variation of these factors is not significant, their long-term cumulative impact should not be overlooked. We recommend that future urban renewal or renovation efforts reasonably control and plan the density of commercial areas, especially in the eastern region. This requires ensuring that residents can enjoy convenient shopping services to meet their daily needs while avoiding the increased living costs and stress caused by excessive commercial concentration. Additionally, it is necessary to strengthen the management of dining environments, including encouraging dining establishments to offer more healthy food options, such as low-sugar, low-fat, and high-fiber dishes. It is also important to increase the availability of healthy dining options by establishing healthy restaurants and vegetarian eateries, while reasonably controlling and optimizing the layout and number of high-sugar and high-fat food outlets within communities to reduce health risks induced by frequent exposure to such foods [ 66 ].
Road networks and transportation facilities together form the city's transportation system. In transportation planning, we advocate for the continuous optimization of road network layouts, reserving space for future traffic growth, and leveraging intelligent technology to optimize traffic signal management to alleviate congestion. Additionally, enhancing the convenience of public transportation by adding routes and optimizing stops can make it the preferred mode of travel for residents. Complementing this with the construction of sound barriers and green belts can effectively reduce noise and air pollution caused by public transportation. Furthermore, promoting green travel methods such as cycling and walking by building a comprehensive network of cycling lanes and walking paths can foster both health and environmental benefits [ 20 ].
Sports and fitness facilities, along with parks and squares, are essential for improving residents' quality of life and promoting healthy lifestyles. During planning, sports and fitness facilities should be reasonably distributed, especially in the northern part of the study area, to ensure that all communities have convenient access to exercise amenities. Diverse fitness facilities catering to different age groups and exercise needs, such as basketball courts, soccer fields, and fitness equipment zones, should be provided to meet the varied exercise requirements of different groups. Additionally, parks and squares, as crucial spaces for residents' leisure and entertainment, should be planned with a harmonious balance of ecology and landscape. In densely populated and space-constrained southeastern areas, small green spaces, leisure seating, and children's play facilities can be added to provide residents with a pleasant environment for relaxation and nature interaction [ 67 ].
We have explored the mechanisms by which environmental elements impact CVDs and proposed suggestions for optimizing the urban built environment, but this paper still has certain limitations. The impact of the environment on health and disease is complex, and due to time and resource constraints, it was not possible to consider and analyze all potential variables comprehensively, which may have some impact on the research results. To further deepen the study of the relationship between the built environment and cardiovascular health, future research could consider the following aspects: first, expand the scope of research, collecting and analyzing data from different cities and regions to better understand geographical differences in the impact of the built environment on cardiovascular health; second, enhance the scientific nature of the research methods, using more objective and precise methods for data collection and analysis to improve the reliability and accuracy of the research; and finally, deepen the study of the mechanisms between the built environment and cardiovascular health, exploring biological and psychological mechanisms to better understand their relationship.
Focusing on the built-up area of Xixiangtang in Nanning City as the research area, this study delves into the intrinsic connection between the urban built environment and CVDs, uncovering several findings. Utilizing hospital cardiovascular data and urban POI data, and employing spatial analysis techniques such as KDE, spatial autocorrelation analysis, geodetectors, and GWR, we systematically assessed the extent and mechanisms through which various built environment elements impact CVDs. The results show a significant positive correlation between the urban built environment and CVDs. Particularly, healthcare facilities, shopping venues, restaurants, and transportation facilities have significant effects on the incidence and distribution of CVDs. The spatial aggregation of these elements and the dense distribution of CVDs demonstrate significant consistency, further confirming the close link between the built environment and CVDs. Simultaneously, we discovered spatial heterogeneity in the impact of different built environment elements on CVDs. This indicates that in planning and improving the urban environment, elements and areas with a greater impact on CVDs should be considered specifically.
The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.
Cardiovascular Disease
Geographically weighted regression
Multiscale geographically weighted regression
The GeoDetector method
OpenStreetMap
Kernel Density Estimation
Points of Interest
Variance Inflation Factor
Application Programming Interface
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Shuguang Deng, Jinlong Liang, Jinhong Su & Shuyan Zhu
School of Architecture, Guangxi Arts University, Nanning, 530009, Guangxi, China
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D.S. Provides research topics, conceptual guidance, translation, paper revision and financial support; L.J. Conceived the framework and wrote the original draft; P.Y. Manuscript checking, chart optimization; L.W. Provided suggestions for revision, and reviewed and edited them; S.J. Is responsible for data acquisition and editing; Z.S. Edits the visual map.
Correspondence to Jinlong Liang .
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Our study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki, as well as relevant national and institutional guidelines for human research. The study received approval from the Medical Ethics Committee of Guangxi Zhuang Autonomous Region Nationality Hospital (Approval No.: 2024–65). The de-identified data records from the cardiovascular department that we accessed and analyzed were authorized by Guangxi Nationality Hospital. These data were collected and maintained in compliance with the hospital's patient data management policies and procedures. Given that our study involved only a retrospective analysis of existing medical records, with no direct interaction with patients and no potential for causing any substantial harm, the Medical Ethics Committee of Guangxi Zhuang Autonomous Region Nationality Hospital determined that individual patient informed consent was not required. Nonetheless, we have ensured that all data used in the study were fully anonymized and protected, adhering to the highest standards of confidentiality and privacy.
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Deng, S., Liang, J., Peng, Y. et al. Spatial analysis of the impact of urban built environment on cardiovascular diseases: a case study in Xixiangtang, China. BMC Public Health 24 , 2368 (2024). https://doi.org/10.1186/s12889-024-19884-x
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Executive summary, cash-back transactions, benefits and costs to merchants.
Access to cash is a necessary component of a resilient financial system and dynamic economy. Many people rely on cash for day-to-day transactions due its privacy and reliability, and cash accessibility is particularly critical in the case of a disruption or outage of digital payment systems. While people use various means of getting cash, one common method is to get “cash back” at a store when making a purchase with a debit or prepaid card. This option may be particularly important in banking deserts and in areas where banks and ATM operators charge significant fees. Retailers are essentially filling a void in access to cash, which has historically been supplied by banks and credit unions in an affordable way.
Providing cash back is valuable to consumers and merchants. Survey data show that it is a popular method to get money via consumers’ bank debit or prepaid cards. Merchants offer cash back to attract customers and reduce their cash handling costs. In its recent engagement and market monitoring, the CFPB observed that some retailers charge a fee for this transaction.
This spotlight provides an overview of consumers’ use of cash back, the benefits and costs of such transactions to merchants, and the practices of other market actors which do not charge fees for this service. The CFPB also analyzed the cash-back fees of a sample of national retailers.
Fees for cash back may serve as a barrier and reduce people’s access to cash when they need it. The CFPB will continue to monitor developments related to the fees consumers pay for accessing cash, and the underlying failure of banks and credit unions to adequately supply cash throughout the country in an affordable manner.
This section summarizes the importance of cash availability and the use of cash-back as an access point for consumers.
Cash is a critical part of a resilient payment ecosystem. Surveys show people still try to have cash on hand 1 and nearly 90 percent of people used cash in the last 30 days. 2 Cash accessibility is necessary should other types of digital payment systems experience failures, 3 such as in the event of a natural disaster or some other catastrophe, 4 or a technological malfunction at a single company. 5 Additionally, some populations are more reliant on cash than others for day-to-day transactions. For example, cash is more frequently used by people with lower incomes, racial minorities, and older Americans than other populations. 6 As discussed below, cash back is a common method for obtaining cash for many consumers.
Consumers may obtain cash during the completion of a purchase transaction at certain stores when using a PIN-authenticated debit card or prepaid card at the register. Some merchants also provide cash back at self-service registers. Consumers typically must choose from pre-set withdrawal amount options presented at the payment terminal at the time of the transaction. In a cash-back transaction, consumers are usually limited to a maximum withdrawal amount ranging from $5 to $50, though some merchants may allow higher amounts.
CFPB analysis of data from the Diary and Survey of Consumer Payment Choice (Survey) found that from 2017 to 2022, cash withdrawals at retail locations made up 17 percent of all transactions by which people got cash from their checking account, savings account, or prepaid card. As shown in Figure 1, cash withdrawals at retail are second only to ATMs (61%) and more frequently used than bank tellers (14%). The Survey and methodology are discussed in the Tables and Notes section .
Source : CFPB tabulations of the Diary and Survey of Consumer Payment Choice.
The Survey data also show that from 2017 to 2022, cash withdrawals at a retail location (restricted to those where the source of funds was the consumer’s checking, savings, or a prepaid card) had a mean withdrawal amount of $34 (median: $20). 7 By contrast, during this same timeframe, the mean ATM withdrawal among survey participants was $126 (median: $100). 8 A study by researchers at the Federal Reserve Bank of Atlanta utilizing Survey data found that cash withdrawals at a retail store had the lowest average amount of cash withdrawal, and noted that “[t]he amount of cash received at a retail store is constrained by the store’s limits, so the amount of cash received in this way is not necessarily at the discretion of the consumer.” 9
Cash back may serve as a particularly important point of access in the absence of other banking services. A 2014 study by the Federal Reserve Bank of Richmond analyzed cash-back transactions from a national discount retail chain from 2010 to 2012. 10 Looking specifically at the Richmond bank’s district, the area with the highest frequency of cash-back transactions was in the southeastern region of South Carolina, an area “that has been subject to ‘persistent poverty’” and “has some of the sparsest dispersion of bank branches.” 11 The study also illustrated the lucrative nature of cash-back fees: During the course of this study period, the merchant introduced a fee for cash back. Data from this report indicates that the retailer collected approximately $21 million in cash-back fees in a year. 12
Merchants benefit from offering cash back at point-of-sale. First, the service may attract potential shoppers, either people making a purchase in order to get cash back or people who prefer one retail location over another in order to conveniently combine tasks. Second, it reduces merchants’ cash handling costs. 13 Dispensing cash to consumers, such as through cash-back transactions, reduces merchants’ supply of cash and therefore also reduces their cost of handling, transporting, and depositing excess cash.
Merchants incur costs for processing any type of payment transaction, including cash-back transactions. On any purchase using an electronic payment method, including a PIN-authorized debit-card or prepaid card, a merchant will incur a range of fees for processing that payment, such as interchange, network, and processing fees. While the merchant incurs these fees for a consumer’s purchase, there is an additional cost for providing cash back to the consumer.
To assess this additional transaction cost to the merchant for providing cash back, the CFPB modeled potential scenarios based on publicly available data and our market monitoring activities. The model incorporates estimates of merchant-incurred fees, such as interchange, network, processing, and fraud control fees. Methodology is discussed in detail in the Table and Figure Notes. The CFPB estimates that the additional marginal transactional cost to a merchant for processing a typical cash-back debit card transaction may range from a penny to about 20 cents (Table 1).
Example Retailer | Purchase Amount | Merchant Transaction Cost for Purchase Only | Additional Merchant Cost for $10 Cash Back | Additional Merchant Cost for $40 Cash Back |
---|---|---|---|---|
National Discount Chain | $20 | $0.33 | $0.05 | $0.19 |
National Grocery Store | $20 | $0.33 | $0.01 | $0.02 |
Source : CFPB calculations based on public data about industry practices and averages. See Table and Figure Notes below for methodology .
This section provides an analysis of cash-back fee practices of eight national retail chains. It includes a discussion of the variation of these practices among these national chains and other actors, such as local independent grocers. The analysis is supplemented by market monitoring discussions with merchants about fees, costs, and consumer trends, both among merchants who charge cash back fees and those who do not. The CFPB also conducted consumer experience interviews and reviewed consumer complaints submitted to the CFPB. It concludes with a discussion of how these fees appear to function differently than fees for cash withdrawals at ATMs.
As of August 2024, there is no publicly available survey data regarding merchants’ cash-back practices or fees. To establish a baseline, the CFPB documented the fee practices of eight large retail companies. The sample consists of the two largest retail actors, measured by number of locations, across four different sectors: Dollar Stores, Grocery Stores, Drugstores, and Discount Retailers. 14 Using this approach, the eight retailers sampled are: Dollar General and Dollar Tree Inc. (Dollar Stores), Kroger Co. and Albertsons Companies (Grocery Stores), Walgreens and CVS (Drugstores), and Walmart and Target (Discount Retailers).
All retailers in our sample offer cash-back services, but only Dollar General, Dollar Tree Inc., and Kroger Co. brands charge a fee. Other retailers offer cash-back for free, even for withdrawal amounts similar to or larger than those provided by the three retailers who charge. (Table 2). Among the national chains that charge these cash-back fees, the CFPB estimates that they collect over $90 million in fees annually for people to access their cash. 15
Company | U.S. Stores | Fee for Cash Back | Maximum Withdrawal Amount (Per Transaction) |
---|---|---|---|
Dollar General | 20,022 | $1 to $2.50, depending on amount and other variables | $40 |
Dollar Tree Inc. | 16,278 | Family Dollar: $1.50 | $50 |
Kroger Co. | 2,722 | Harris Teeter brand: | Harris Teeter brand: $200 |
Albertsons Brand | 2,271 | No | $200 |
Walmart | 5,214 | No | $100 |
Target | 1,956 | No | $40 |
Walgreens | 8,600 | No | $20 |
CVS | 7,500 | No | $60 |
Source : CFPB analysis of the retail cash-back market. See Table and Figure Notes for methodology .
Beyond these national chains, there are other providers offering cash back as a free service to their customers. Through its market monitoring activities, the CFPB observed that many local independent grocers offer the service, but do not charge a fee. They do not charge a fee even though they are likely to have thinner profit margins and less bargaining power than national chains to negotiate on pricing on costs they incur from wholesalers or fees for payment processors. The U.S. Postal Service also offers cash back on debit transactions, in increments of $10 up to a $50 maximum, free of charge. 16
Among the merchants sampled, Dollar General and Dollar Tree Inc. charge the highest fees for withdrawal amounts under $50. These fees combined with the constrained withdrawal amount may mean that the fee takes up a hefty percentage relative to the amount of cash withdrawn, and people may be less able to limit the impact of the fee by taking out more cash.
Additionally, the geographic distribution of dollar store chains and their primary consumer base raises concerns that these fees may be borne by economically vulnerable populations and those with limited banking access. Dollar stores are prevalent in rural communities, low-income communities, and communities of color – the same communities who may also face challenges in accessing banking services. 17 For example, Dollar General noted that in 2023 “approximately 80% of [its] stores are located in towns of 20,000 or fewer people,” 18 while Dollar Tree Inc. operated at least 810 dual-brand combination stores (Family Dollar and Dollar Tree in a single building) designed specifically “for small towns and rural communities…with populations of 3,000 to 4,000 residents.” 19
Though they are open to and serve consumers of all income levels, dollar stores report that they locate stores specifically to serve their core customers: lower-income consumers. 20 In urban communities, one study shows, “proximity to dollar stores is highly associated with neighborhoods of color even when controlling for other factors.” 21 These same communities may also face challenges in accessing banking services. Low-income communities and communities of color often face barriers to access to banking services, and rural communities are 10 times more likely to meet the definition of a banking desert than urban areas. 22
Though the dollar store concept existed as far back as the 1950s, it has experienced significant expansion and consolidation since the 2000s. 23 Dollar Tree Inc. acquired Family Dollar in 2015. 24 From 2018 to 2021, nearly half of all retail locations opened in the U.S. were dollar stores. 25 In research examining the impact of dollar store expansion, studies indicate that the opening of a dollar store is associated with the closure of nearby local grocery retailers. 26
In its scan of current market practices, the CFPB found variations in fee charges among store locations and brands owned by the same company. For example, as reflected in Table 2, Dollar Tree charges consumers $1 for cash back at Dollar Tree branded stores, but $1.50 in its Family Dollar stores. Similarly, Kroger Co. has two different fee tiers for its brands. In 2019, Kroger Co. rolled out a $0.50 cash-back fee for amounts of $100 or less, and $3.50 for amounts between $100 and $300. This took effect at brands such as Kroger, Fred Meyers, Ralph’s, QFC, Pick ‘N Save, and others. At the time of the rollout, the company noted two exceptions: Electronic benefits transfer (EBT) card users would not be charged a fee, and customers using their Kroger Plus card would not be charged for amounts under $100 but would be charged $0.50 for larger amounts. Kroger Co. acquired the southern grocery chain Harris Teeter in 2014, but it did not begin charging a cash-back fee at those stores until January 2024, at $0.75 for amounts of $100 or less, and $3 for larger amounts. 27
In its engagement with stakeholders, the CFPB learned that Dollar General’s fees appeared to vary in different locations. To better understand this potential variation, in December 2022, the CFPB mystery shopped at nine locations in one state, across a mix of rural, suburban, and urban communities. The CFPB acknowledges this is a small sample and is not intended to be representative. The data collected is based on the knowledge of the store associates at the time of each interaction.
In these findings, the CFPB learned of a range of fee variations across store locations: five of the nine respondents noted that the fee varies depending on the type of card used for the transaction. When probed for the meaning of “type of card,” most noted that it is dependent on the customer’s bank, though it is not exactly clear what fees will be triggered by what card type prior to initiating the transaction. Additionally, reported fees range from $1 to $2.50, with some stores reporting a flat fee structure of $1.50 and others reporting a range that tiered up with larger withdrawal amounts (with a cap of withdrawal amounts at $40). Most stores in this sample had a range of fees between $1.00 and $1.50, although two stores located in small, completely rural counties had a higher range of fees. The store located in the smallest and most isolated county within the sample, with only about 3,600 people, had the highest reported fee amount of $2.50.
One of the market dynamics likely contributing to retailers’ ability to charge these fees is the high fees also charged to consumers for using out-of-network automated teller machines (ATMs). One source estimates that the average out-of-network ATM fee is $4.77, accounting for both the surcharge fee charged by the ATM owner and the foreign fee charged by the consumer’s financial institution. 28 By comparison, a $2 fee for cash back at a retailer may appear cheaper, and usually does not trigger an additional fee by the consumers’ financial institution or prepaid card issuer. Notwithstanding the high ATM fees, there are reasons for focused attention on the consumer risk of cash-back fees charged by retailers, primarily the amount of the fee relative to the value of the cash withdrawal and the distribution of the fee burden across income groups.
In a typical ATM transaction, a consumer has a greater ability to distribute the cost of the fee across a larger amount of cash than with cash back. There may be some exceptions to this for consumers who have only $10 or $20 in their bank account, but as shown in Table 3, low-income consumers and others withdraw greater amounts at ATMs than via cash-back, on average. In cash-back transactions, lower withdrawal limits are in place, and consumers do not have that option to withdraw larger amounts. CFPB analysis of the Diary and Survey of Consumer Payment Choice from 2017 to 2022 show that even among consumers with incomes below $50,000, the amount withdrawn at an ATM is more than double the typical cash-back withdrawal amount. Additionally, for the average and median amounts, across all incomes the ATM withdrawal amounts are larger than cash-back withdrawal amounts. (Table 3).
Income | Average ATM Withdrawal | Average Cash-back Withdrawal | Median ATM Withdrawal | Median Cash-back Withdrawal |
---|---|---|---|---|
Less than $25,000 | $144 | $45 | $65 | $20 |
$25,000 to $49,999 | $113 | $35 | $60 | $25 |
$50,000 to $74,999 | $113 | $29 | $84 | $20 |
$75,000 to $99,000 | $114 | $45 | $100 | $26 |
$100,000 or more | $146 | $33 | $100 | $20 |
|
|
|
|
|
Source: CFPB tabulations of the Diary and Survey of Consumer Payment Choice. See Table and Figure Notes for methodology .
Further, while merchants limit the amount of a single withdrawal, there is no limit on the number of withdrawals. So, if a consumer needs $100 cash at a store which limits a single withdrawal to a maximum amount of $50 with a $2 fee, the consumer would have to make two $50 withdrawals for a $4 fee plus the cost of any otherwise unwanted purchase required to access the cash-back service.
Finally, the burden of cash-back fees may be distributed differently than ATM fee burdens. The share of borrowers who pay ATM fees for cash withdrawals is relatively evenly distributed across income levels, according to a study based on the Diary and Survey of Consumer Payment Choice. 29 The study found little variation in the percentage of consumers who encountered a fee for an ATM cash withdrawal by income quintile, though the study did not look at the amount of the ATM fees paid. Analogous data are not available for cash-back fees, but a similarly even distribution across incomes is unlikely given the demographics of the consumer base served by the largest retailers which charge fees (dollar stores).
While the use of digital payment methods is on the rise, cash accessibility remains a critical component of a resilient financial infrastructure and dynamic economy. Bank mergers, branch closures, and bank fee creep have reduced the supply of free cash access points for consumers. In this void, people may be more reliant on retailers for certain financial services historically provided by banks and credit unions, such as cash access. In this context, we observe that some retailers provide cash back as a helpful service to their customers, while other retailers may be exploiting these conditions by charging fees to their consumers for accessing their cash.
This spotlight examines the presence of retailer cash-back fees and impact to consumers. Cash-back fees are being levied by just a small handful of large retail conglomerates (Dollar General, Dollar Tree Inc., and Kroger Co.) amidst a backdrop of consolidation in these segments. Meanwhile, other larger retailers continue to offer cash-back services free. The CFPB estimates cash-back fees cost consumers about $90 million a year.
The CFPB is concerned that reduced access to cash undermines the resilience of the financial system and deprives consumers of a free, reliable, and private means of engaging in day-to-day transactions. The CFPB will continue to monitor developments related to the fees consumers pay for accessing cash, and work with agencies across the federal government to ensure people have fair and meaningful access to the money that underpins our economy.
Notes for figure 1.
The Federal Reserve Bank of Atlanta’s annual Diary and Survey of Consumer Payment Choice (Survey) tracks consumers’ self-reported payment habits over a three-day period in October using a nationally representative sample. The survey includes a question about whether and how consumers access cash, such as where they made the withdrawal, the source of the cash, and the amount of the withdrawal. Figure 1 provides a percentage of all cash-back withdrawal transactions from a bank account, checking account, or prepaid card reported between 2017 and 2022, by location (ATM, Retail point-of-sale, Bank teller, and Other). The number of observations during this time is 192 transactions. It does not include cash-back transactions made using a credit card cash advance feature or other form of credit.
This model assumes that 80 percent of the merchant transaction cost is due to interchange fees, 15 percent due to network fees, and 5 percent due to payment acquirer fees. It also includes a $0.01 fee for fraud protection. For regulated transactions, the interchange fees are $0.22 + 0.05% of the transaction amount. Regulated transactions are those where the debit card used is issued by a bank with more than $10 billion in assets, and subject to 15 U.S.C. § 1693o-2. Exempt transactions are those not subject to this statutory cap on interchange fees. While Mastercard does not publish its fees for exempt transactions, Visa does. This model uses Visa’s published fees as of October 2023 for card-present transactions: for the National Discount Chain, the fees for Exempt Retail Debit ($0.15 + 0.80%), and for the National Grocery Chain, Exempt Supermarket Debit ($0.30 flat fee). An October 2023 Federal Reserve report on interchange fee revenue found that in 2021, the most recent data available, 56.21 percent of debit transactions were regulated and 43.79 percent were exempt. This composition is reflected in the table.
The storefront counts for each of the retailers come from their websites, last visited on March 28, 2024, or their most recent reports to investors. Fee information was gathered either through publicly available information such as the merchant’s website, and/or verified through the CFPB’s market monitoring activities.
Dollar Tree Inc. announced on March 13, 2024 that it will close 1,000 of its Family Dollar and Dollar Tree brands stores over the course of the year. If those closures occur, Dollar Tree, Inc. will still have over 15,000 storefronts across the country.
In October 2022, Kroger Co. and Albertsons Companies announced their proposal to merge, though on February 26, 2024, the Federal Trade Commission and nine state attorneys general sued to block this proposal, alleging that the deal is anti-competitive. On April 22, 2024, Kroger Co. and Albertsons Companies announced a revised plan in which, if the merger is approved, the combined entity would divest 579 stores to C&S Wholesalers. If the divestiture occurs, the combined entity will still have over 4,400 stores across the country.
See above notes for Figure 1 about the Diary and Survey of Consumer Payment Choice (Survey). Table 3 provides mean and median amounts of ATM and Retail point-of-sale cash withdrawal transactions by income. In the Survey, participants were asked to report the total combined income of all family members over age 15 living in the household during the past 12 months. From these responses, we constructed five income brackets – four of $25,000 each plus a fifth bin for any respondents reporting more than $100,000 in annual household income for each respondent in each year.
See e.g., Jay Lindsay, A Fatal Cash Crash? Conditions Were Ripe for It After the Pandemic Hit, but It Didn’t Happen , Fed. Rsrv. Bank of Boston (Nov. 2, 2023), https://www.bostonfed.org/news-and-events/news/2023/11/cash-crash-pandemic-increasing-credit-card-use-diary-of-consumer-payment-choice.aspx
Kevin Foster, Claire Greene, & Joanna Stavins, The 2023 Survey and Diary of Consumer Payment Choice , Fed. Rsrv Bank of Atlanta (June 2024), https://doi.org/10.29338/rdr2024-01
See e.g., Hilary Allen, Payments Failure, Boston College Law Review, Forthcoming, American University, WCL Research Paper No. 2021- 11, (Feb. 21, 2020) available at https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3539797
See e.g., Scarlett Heinbuch, Cash Is Critical in Times of Crisis , Fed. Rsrv. Bank of Atlanta (Mar. 7, 2022), https://www.atlantafed.org/blogs/take-on-payments/2022/03/07/cash-in-crisis
See e.g., Carly Page, Square Says It Has Resolved Daylong Outage , TechCrunch, (Sept. 8, 2023), https://techcrunch.com/2023/09/08/square-day-long-outage-resolved/ . See also Caroline Haskins, The Global CrowdStrike Outage Triggered a Surprise Return to Cash , Wired, (July 19, 2024), https://www.wired.com/story/microsoft-crowdstrike-outage-cash/ .
See Berhan Bayeh, Emily Cubides and Shaun O’Brien, 2024 Findings from the Diary of Consumer Payment Choice , Fed. Rsrv. (May 13, 2024), https://www.frbservices.org/binaries/content/assets/crsocms/news/research/2024-diary-of-consumer-payment-choice.pdf (findings related to low-income consumers and older Americans use of cash); Emily Cubides and Shaun O’Brian, 2023 Findings from the Diary of Consumer Payment Choice , Fed. Rsrv., (May 19, 2024), https://www.frbsf.org/cash/wp-content/uploads/sites/7/2023-Findings-from-the-Diary-of-Consumer-Payment-Choice.pdf (findings related to unbanked households use of cash), and Michelle Faviero, , More Americans are Joining the ‘Cashless’ Economy ,” Pew Rsch. Ctr, (Oct. 5, 2022), https://www.pewresearch.org/short-reads/2022/10/05/more-americans-are-joining-the-cashless-economy/ (findings related to use of cash by race and other demographics).
Similarly, the average cash-back withdrawal amount was $33 in 2012, the most recent data available from the Federal Reserve Payments Study. The study was based on self-reported information from financial institutions surveyed by the Federal Reserve. Of the reported transactions, 73 percent were debit cards with an average amount of $33 and 27 percent on general purpose prepaid cards with an average withdrawal amount of $19. 2013 Federal Reserve Payments Study: Recent and Long-Term Payment Trends in the United States: 2003 – 2012 , Fed. Rsrv. Bd. (July 2014), https://www.frbservices.org/binaries/content/assets/crsocms/news/research/2013-fed-res-paymt-study-summary-rpt.pdf
The amounts in the Survey are lower than the average ATM withdrawal amounts reported in 2022 Federal Reserve Payments study, which utilizes data from surveying financial institutions. Per this study, in 2021, the average ATM withdrawal was $198. The Federal Reserve Payments Study: 2022 Triennial Initial Data Release , Fed. Rsrv. Bd. (Apr. 21, 2023), https://www.federalreserve.gov/paymentsystems/fr-payments-study.htm
Claire Green and Oz Shy, How Consumers Get Cash: Evidence from a Diary Survey , Fed. Rsrv. Bank of Atlanta, (Apr. 2019), at 5, https://www.atlantafed.org/-/media/documents/banking/consumer-payments/research-data-reports/2019/05/08/how-consumers-get-cash-evidence-from-a-diary-survey/rdr1901.pdf (finding, “For the largest amounts of cash, respondents mostly turned to employers, with an average dollar value of cash received of $227. At bank tellers and ATMs, consumers also received average dollar values greater than the overall average: $159 and $137, respectively. Consumers received smaller amounts from family or friends ($93) and, notably, cash back at a retail store ($34). All these dollar amounts are weighted. The amount of cash received at a retail store is constrained by the store’s limits, so the amount of cash received in this way is not necessarily at the discretion of the consumer.”)
Neil Mitchell and Ann Ramage, The Second Participant in the Consumer to Business Payments Study , Fed. Rsrv. Bank of Richmond (Sept. 15, 2014), https://www.richmondfed.org/~/media/richmondfedorg/banking/payments_services/understanding_payments/pdf/psg_ck_20141118.pdf
Id. at 8, Figures 7 and 8.
See e.g., Stan Sienkiewicz, The Evolution of EFT Networks from ATMs to New On-Line Debit Payment Products , Discussion Paper, Payment Cards Ctr. of the Fed. Rsrv. Bank of Philadelphia (Apr. 2002), https://www.philadelphiafed.org/-/media/frbp/assets/consumer-finance/discussion-papers/eftnetworks_042002.pdf?la=en&hash=88302801FC98A898AB167AC2F9131CE1 (“The cash back option became popular with supermarket retailers, since store owners recognized savings as a result of less cash to count at the end of the day, a chore that represented a carrying cost to the establishment.”).
These market segments and retailers for purposes of markets analysis are similar to those used in other academic literature related to dollar store locations in the context of food access or impact on other market dynamics, such as on local grocers. See e.g., El Hadi Caoui, Brett Hollenbeck, and Matthew Osbourne, The Impact of Dollar Store Expansion on Local Market Structure and Food Access ,” (June 22, 2022), available at https://ssrn.com/abstract=4163102 (finding "In 2021, there were more of these stores operating than all the Walmarts, CVS, Walgreens, and Targets combined by a large margin.”) and Yue Cao, The Welfare Impact of Dollar Stores ,” available at https://yuecao.dev/assets/pdf/YueCaoDollarStore.pdf (last visited Aug. 23, 2024) (using the categories of dollar stores, groceries, and mass merchandise (such as Walmart) for comparisons across retail segments and noting that dollar stores regard these other segments as competitors).
Estimate based on information voluntarily provided in the CFPB's market monitoring activities.
What Forms of Payment are Accepted? U.S. Postal Serv., https://faq.usps.com/s/article/What-Forms-of-Payment-are-Accepted (last visited Aug. 23, 2024).
See generally, Stacy Mitchell, Kennedy Smith, and Susan Holmberg , The Dollar Store Invasion , Inst. for Local Self Reliance (Mar. 2023), https://cdn.ilsr.org/wp-content/uploads/2023/01/ILSR-Report-The-Dollar-Store-Invasion-2023.pdf . There is also extensive research on dollar store locations in other contexts such as food access and impact on consumer spending habits. El Hadi Caoui, Brett Hollenbeck, and Matthew Osbourne, The Impact of Dollar Store Expansion on Local Market Structure and Food Access ,” at 5, (June 22, 2022), available at https://ssrn.com/abstract=4163102
Dollar General Annual Report (Form10-K) at 7 (Mar. 25. 2024), https://investor.dollargeneral.com/websites/dollargeneral/English/310010/us-sec-filing.html?format=convpdf&secFilingId=003b8c70-dfa4-4f21-bfe7-40e6d8b26f63&shortDesc=Annual%20Report .
Dollar Tree, Inc. Annual Report (Form 10-K) at 7 (Mar. 20. 2024), https://corporate.dollartree.com/investors/sec-filings/content/0000935703-23-000016/0000935703-23-000016.pdf
See e.g., Dollar General Annual Report (Form10-K) at 7 (Mar. 25. 2024) (“We generally locate our stores and plan our merchandise selections to best serve the needs of our core customers, the low and fixed income households often underserved by other retailers, and we are focused on helping them make the most of their spending dollar.” And, Dollar Tree, Inc. Annual Report (Form 10-K) at 6 (Mar. 20. 2024), (“Family Dollar primarily serves a lower than average income customer in urban and rural locations, offering great values on everyday items.”)
Dr. Jerry Shannon, Dollar Stores, Retailer Redlining, and the Metropolitan Geographies of Precarious Consumption , Ann. of the Am. Assoc. of Geographers, Vol. 111, No. 4, 1200-1218 (2021), (analyzing over 29,000 storefront locations of Dollar General, Dollar Tree, and Family Dollar locations across the three largest MSA in each of the nine U.S. Census Bureau-defined divisions.)
Kristen Broady, Mac McComas, and Amine Ouazad, An Analysis of Financial Institutions in Black-Majority Communities: Black Borrowers and Depositors Face Considerable Challenges in Accessing Banking Services ,” Brookings Inst., (Nov. 2, 2021), https://www.brookings.edu/articles/an-analysis-of-financial-institutions-in-black-majority-communities-black-borrowers-and-depositors-face-considerable-challenges-in-accessing-banking-services/ and Drew Dahl and Michelle Franke, Banking Deserts Become a Concern as Branches Dry Up , Fed. Rsrv. Bank of St. Louis, https://www.stlouisfed.org/publications/regional-economist/second-quarter-2017/banking-deserts-become-a-concern-as-branches-dry-up (July 25, 2017).
El Hadi Caoui, Brett Hollenbeck, and Matthew Osbourne, The Impact of Dollar Store Expansion on Local Market Structure and Food Access ,” (June 22, 2022), available at https://ssrn.com/abstract=4163102 .
Dollar Tree Completes Acquisition of Family Dollar , Dollar Tree Inc., (July 6, 2015), available at https://corporate.dollartree.com/news-media/press-releases/detail/120/dollar-tree-completes-acquisition-of-family-dollar
El Hadi Caoui, Brett Hollenbeck, and Matthew Osbourne, The Impact of Dollar Store Expansion on Local Market Structure and Food Access ,” (June 22, 2022), available at https://ssrn.com/abstract=4163102 and Yue Cao, The Welfare Impact of Dollar Stores, https://yuecao.dev/assets/pdf/YueCaoDollarStore.pdf (last visited Aug. 23. 2024).
Evan Moore, Harris Teeter Introduces New Fees that Have Customers Upset. What To Know Before You’re Charged , Charlotte Observer, (Mar. 14, 2024), https://amp.charlotteobserver.com/news/business/article286627340.html
Karen Bennett and Matthew Goldberg, Survey: ATM fees Reach 26-year High While Overdraft Fees Inch Back Up , Bankrate.com (Aug. 21, 2024), https://www.bankrate.com/banking/checking/checking-account-survey/
Oz Shy and Joanna Stavins, Who Is Paying All These Fees? An Empirical Analysis of Bank Account and Credit Card Fees , Fed. Rsrv. Bank of Boston, Working Paper No. 22-18, at Table 2, (Aug. 2022), https://www.bostonfed.org/publications/research-department-working-paper/2022/who-is-paying-all-these-fees-an-empirical-analysis-of-bank-account-and-credit-card-fees .
The eastern Agadir (Morocco) was selected for the urban expansion. However, it faces challenges owing to its location within an alluvial basin of weak and heterogeneous sediments, compounded by the scarcity of geotechnical data. This study aimed to create the first geotechnical zoning map of the area to support informed urban planning. Geophysical surveys were employed with available in situ investigations to address this data gap and delineate and characterize the main geotechnical zones. The electrical resistivity tomography (ERT) method was used to map the soil distribution horizontally and vertically, complemented by laboratory tests. The multichannel analysis of surface waves (MASW) and seismic refraction tomography (SRT) methods provided insights into important geotechnical and elastic-dynamic parameters. This analysis revealed three distinct geoseismic layers. The surface layer consisted of sand, silt, pebble, weathered limestone, and marlstone, whereas the underlying layer contained compacted silt, dense sand, conglomerate, sandstone, limestone, and marlstone. This layer exhibited higher seismic velocities and lower soil heterogeneity than the surface layer. The third layer, characterized by limestone, marlstone, and compacted deposits, serves as geotechnical bedrock. The V S30 velocities were calculated and classified according to the EUROCODE 8 scheme, which categorizes sites based on their geological characteristics and associated seismic risks. The study area was divided into Class A (rock), Class B (dense soil and soft rock), and Class C (medium dense sand and gravel). This classification is essential for assessing seismic response and designing earthquake-resistant structures. The majority of the sites were categorized as Class B. The final zoning map reveals five distinct geotechnical zones: Tagragra's Dome, the alluvial fans and floodplain, the alluvial terrace, the limestone plateau, and the sand dune zone. The calculated parameters revealed soil heterogeneities in horizontal and vertical directions. These results provide valuable key parameters for informed urban planning, with special attention paid to areas with weak soil during foundation design.
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Khadrouf, I., El Hammoumi, O., El Goumi, N. et al. Enhancing geotechnical zoning through near-surface geophysical surveys: a case study from eastern Agadir, Morocco. Med. Geosc. Rev. (2024). https://doi.org/10.1007/s42990-024-00137-3
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The main objective of this study is to find out the financial incentive factors behind employee motivation, especially in financial institutions in, Pakistan. Salary, housing allowance, and medical insurance were independent variables, and employee motivation was dependent. The sample size was 300, only collected from 190 financial institutions in Pakistan. Questionnaires collect primary data via Google Forms. We used a random sampling method for sample selection. Correlation analysis suggests that all variables have a strong positive correlation (r>0.70)—regression analysis is used to check the effect of financial incentives on employee motivation. The findings suggested that salary, housing allowance, and medical insurance have positive statistical significance (p<0.05) on employee motivation. This research supports that all organizations should focus on financial rewards to employees' motivations for better organizational performance.
Keywords : financial incentives, financial sector, employee motivation.
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The first of our financial statements examples is the cash flow statement. The cash flow statement shows the changes in a company's cash position during a fiscal period. The cash flow statement uses the net income figure from the income statement and adjusts it for non-cash expenses. This is done to find the change in cash from the beginning ...
A case study in data science is an in-depth analysis of a real-world problem using data-driven approaches. It involves collecting, cleaning, and analyzing data to extract insights and solve challenges, offering practical insights into how data science techniques can address complex issues across various industries.
Table of contents. Financial Analysis Examples. Top 4 Financial Statement Analysis Examples. Example #1 - Liquidity Ratios. Current Ratio. Quick Ratio. Example #2 - Profitability Ratios. Operating Profitability Ratio. Net Profit Ratio.
When evaluating potential risks in the financial case study, consider the following: Risk Assessment: Begin by conducting a thorough risk assessment to identify all potential threats to the financial analysis process. This includes market risks, regulatory risks, and operational risks that could impact the outcomes.
Advanced Analytics in BFSI - Benefits. Updating the data analytics use cases in banking and financial services with the evolving data science methodologies can help organizations sustain stronger customer relationships. Let us look at a few more benefits of advanced analytics. Customer 360-degree insights - By leveraging advanced analytics ...
Amazon (AMZN) Case Study. This course is built on a case study of Amazon, where students are tasked with building a financial modeling and performing comparable company analysis to value AMZN shares and make an investment recommendation. Through the course of the transaction, students will learn: How to build a detailed financial forecast of Amazon
Tarika Sikarwar. A Handbook of Case Studies in Finance. By Tarika Sikarwar. This book first published 2017. Cambridge Scholars Publishing. Lady Stephenson Library, Newcastle upon Tyne, NE6 2PA, UK. British Library Cataloguing in Publication Data. A catalogue record for this book is available from the British Library.
This chapter presents four case studies which provide examples of financial information upon which liquidity, leverage, profitability, and causal calculations may be performed. The first two case studies also contain example ratio summary and analysis. Two discussion cases are also provided, followed by questions related to the financial ...
Case study protocol is a formal document capturing the entire set of procedures involved in the collection of empirical material . It extends direction to researchers for gathering evidences, empirical material analysis, and case study reporting . This section includes a step-by-step guide that is used for the execution of the actual study.
Introduction. Financial analysis is the process of examining a company's performance in the context of its industry and economic environment in order to arrive at a decision or recommendation. Often, the decisions and recommendations addressed by financial analysts pertain to providing capital to companies—specifically, whether to invest in ...
Blockchain and cryptocurrency, mobile payment platforms, analytics-driven trading apps, lending software, and AI-based insurance products are just a few examples of fintech that is driven by data science. 9. General data management. As mentioned, financial institutions have access to huge amounts of data.
Financial analysis is the process of evaluating businesses, projects, budgets, and other finance-related transactions to determine their performance and suitability. Typically, financial analysis ...
Ratio analysis case studies provide actionable insights and practical applications for businesses and investors. Learning from these real-life examples empowers stakeholders to make informed decisions based on a thorough understanding of financial ratios. Introduction: Ratio analysis is a powerful tool in financial analysis, providing insights ...
by Carolin E. Pflueger, Emil Siriwardane, and Adi Sunderam. This paper sheds new light on connections between financial markets and the macroeconomy. It shows that investors' appetite for risk—revealed by common movements in the pricing of volatile securities—helps determine economic outcomes and real interest rates.
Abstract. Data analysis has become a cornerstone in the realm of finance management, transforming the way financial decisions are made and strategies are formulated. In an era where information is ...
The purpose of case study research is twofold: (1) to provide descriptive information and (2) to suggest theoretical relevance. Rich description enables an in-depth or sharpened understanding of the case. It is unique given one characteristic: case studies draw from more than one data source. Case studies are inherently multimodal or mixed ...
There are 4 modules in this course. In the final course of this certificate, you will apply your skills towards financial statement analysis. If you have the foundational concepts of accounting under your belt, you are ready to put them into action in this course. Here, you will learn how to reconcile different types of accounts, check for ...
There are 4 modules in this course. This course is the eighth and final course in the Google Data Analytics Certificate. You'll have the opportunity to complete a case study, which will help prepare you for your data analytics job hunt. Case studies are commonly used by employers to assess analytical skills. For your case study, you'll ...
In order to keep the bottom line of systemic financial risks and prevent the mitigation of major risks, this work focuses on the investigation of multi-source heterogeneous data fusion algorithms and cleaning technologies to establish a suitable style for data analysis and big data computation frame. In this paper, according to the above method, we provide the basis for early analysis of ...
From political polls to consumer surveys, quantitative data analysis techniques like weighting, sampling, and survey data adjustment are critical. Researchers employ methods like factor analysis, cluster analysis, and structural equation modeling. Case Studies Case Study 1: Netflix's Data-Driven Recommendations
Data source: Generalised experience Topics: Financial analysis; Ratio analysis of accounts; ... who need to provide a degree of financial analysis as part of a case study exercise, whose main concern is with management strategy. The guide looks not only at ratio analysis - sometimes the only tool of financial analysis used - but also at other ...
15-17,20,22 Three studies described the cross-case analysis using qualitative data. Two studies reported a combination of qualitative and quantitative data for the cross-case analysis. In each multiple-case study, the individual cases were contrasted to identify the differences and similarities between the cases.
A comprehensive comparison of early cellular responses with data from in vivo studies revealed that transcriptomics outperformed targeted protein analysis, correctly predicting up to 50% of in vivo effects. ... (2018) Adverse Outcome Pathway-Driven Analysis of Liver Steatosis in Vitro: A Case Study with Cyproconazole. Chem Res Toxicol 31(8):784 ...
The built environment, as a critical factor influencing residents' cardiovascular health, has a significant potential impact on the incidence of cardiovascular diseases (CVDs). Taking Xixiangtang District in Nanning City, Guangxi Zhuang Autonomous Region of China as a case study, we utilized the geographic location information of CVD patients, detailed road network data, and urban points of ...
The arrangement is a crucial step in data analysis; it comprises object groups of a data set into homogeneous classes . Within the present study, I utilized data mining methods to estimate the potential forecast of the chemical components. Data mining emerged in the 1990s to extract information from large databases . PCA's core concept is to ...
The amounts in the Survey are lower than the average ATM withdrawal amounts reported in 2022 Federal Reserve Payments study, which utilizes data from surveying financial institutions. Per this study, in 2021, the average ATM withdrawal was $198. The Federal Reserve Payments Study: 2022 Triennial Initial Data Release, Fed. Rsrv. Bd. (Apr. 21 ...
The eastern Agadir (Morocco) was selected for the urban expansion. However, it faces challenges owing to its location within an alluvial basin of weak and heterogeneous sediments, compounded by the scarcity of geotechnical data. This study aimed to create the first geotechnical zoning map of the area to support informed urban planning. Geophysical surveys were employed with available in situ ...
Abstract The main objective of this study is to find out the financial incentive factors behind employee motivation, especially in financial institutions in, Pakistan. Salary, housing allowance, and medical insurance were independent variables, and employee motivation was dependent. The sample size was 300, only collected from 190 financial institutions in Pakistan.