A systematic review of built environment and health

School and Neighborhood Predictors of Physical Fitness in Elementary School Students

BACKGROUND

We assessed the associations of 5 school and 7 neighborhood variables with fifth-grade students achieving Healthy Fitness Zone (HFZ) or Needs Improvement-Health Risk (NI-HR) on aerobic capacity (AC) and body composition (BC) physical fitness components of the state-mandated FITNESSGRAM^® physical fitness test.

METHODS

Data for outcome (physical fitness) and predictor (school and neighborhood) variables were extracted from various databases (eg, Data Quest, Walk Score^® ) for 160 schools located in San Diego, California. Predictor variables that were at least moderately correlated (|r| ≥ .30) with ≥1 outcome variables in univariate analyses were retained for ordinary least squares regression analyses.

RESULTS

The mean percentages of students achieving HFZ AC (65.7%) and BC (63.5%) were similar (t = 1.13, p = .26), while those for NI-HR zones were significantly different (AC = 6.0% vs BC = 18.6%; t = 12.60, p < .001). Correlations were greater in magnitude for school than neighborhood demographics and stronger for BC than AC. The school variables free/reduced-price lunch (negative) and math achievement (positive) predicted fitness scores. Among neighborhood variables, percent Hispanic predicted failure of meeting the HFZ BC criterion.

CONCLUSIONS

Creating school and neighborhood environments conducive to promoting physical activity and improving fitness is warranted.

Neighborhood walkability and hospital treatment costs: A first assessment

Health system expenditure is a global concern, with hospital cost a major component. Built environment has been found to affect physical activity and health outcomes. The purpose of the study was a first assessment of the relationship between neighborhood walkability and hospital treatment costs. For 88 neighborhoods in the Australian Capital Territory (ACT), 2011-2013, a total of 30,690 public hospital admissions for the treatment of four diagnostic groups (cancers, endocrine, nutritional and metabolic diseases, circulatory diseases and respiratory diseases) were extracted from the ACT admitted patient care database and analyzed in relation to the Walk Score® index as a measure of walkability. Hospital cost was calculated according to the cost weight of the diagnosis related group assigned to each admission. Linear regressions were used to analyze the associations of walkability with hospital cost per person, admissions per person and cost per admission at the neighborhood level. An inverse association with neighborhood walkability was found for cost per person and admissions per person, but not cost per admission. After adjusting for age, sex and socioeconomic status, a 20-unit increase in walkability was associated with 12.1% (95% CI: 7.1-17.0%) lower cost and 12.5% (8.1-17.0%) fewer admissions. These associations did not vary by neighborhood socioeconomic status. This exploratory analysis suggests the potential for improved population health and reduced hospital cost with greater neighborhood walkability. Further research should replicate the analysis with data from other urban settings, and focus on the behavioral mechanisms underlying the inverse walkability-hospital cost association.

City scale climate change policies: Do they matter for wellbeing?

Climate change mitigation policies aim to reduce climate change through reducing greenhouse gas (GHG) emissions whereas adaption policies seek to enable humans to live in a world with increasingly variable and more extreme climatic conditions. It is increasingly realised that enacting such policies will have unintended implications for public health, but there has been less focus on their implications for wellbeing. Wellbeing can be defined as a positive mental state which is influenced by living conditions. As part of URGENCHE, an EU funded project to identify health and wellbeing outcomes of city greenhouse gas emission reduction policies, a survey designed to measure these living conditions and levels of wellbeing in Kuopio, Finland was collected in December 2013. Kuopio was the northmost among seven cities in Europe and China studied. Generalised estimating equation modelling was used to determine which living conditions were associated with subjective wellbeing (measured through the WHO-5 Scale). Local greenspace and spending time in nature were associated with higher levels of wellbeing whereas cold housing and poor quality indoor air were associated with lower levels of wellbeing. Thus adaption policies to increase greenspace might, in addition to reducing heat island effects, have the co-benefit of increasing wellbeing and improving housing insulation.

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Climate change policies may change wellbeing-associated living conditions in a city.

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Local greenspace and nature immersion associated with higher levels of wellbeing.

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Climate change adaption policy to increase greenspace may increase wellbeing.

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Housing which is cold or has low quality indoor air associated with lower wellbeing.

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A housing insulation policy may increase wellbeing if ventilation is adequate.

Measuring policy and related effects of a health impact assessment related to connectivity

Health Impact Assessments are an important tool to help policymakers perceive the potential positive and negative contributions of decisions to public health. While they have been increasingly used in the United States, studies have not examined intermediate effects. Using key stakeholder interviews, this manuscript examines policy outcomes and other related effects of the HIA 21months after completing a Health Impact Assessment Report around connectivity policy. Further, it reflects on the measurement of these effects as part of the monitoring and evaluation stage of the Health Impact Assessment process.

Identifying mechanisms for facilitating knowledge to action strategies targeting the built environment

BACKGROUND

In recent years, obesity-related diseases have been on the rise globally resulting in major challenges for health systems and society as a whole. Emerging research in population health suggests that interventions targeting the built environment may help reduce the burden of obesity and type 2 diabetes. However, translation of the evidence on the built environment into effective policy and planning changes requires engagement and collaboration between multiple sectors and government agencies for designing neighborhoods that are more conducive to healthy and active living. In this study, we identified knowledge gaps and other barriers to evidence-based decision-making and policy development related to the built environment; as well as the infrastructure, processes, and mechanisms needed to drive policy changes in this area.

METHODS

We conducted a qualitative thematic analysis of data collected through consultations with a broad group of stakeholders (N = 42) from Southern Ontario, Canada, within various sectors (public health, urban planning, and transportation) and levels of government (federal, provincial, and municipalities). Relevant themes were classified based on the specific phase of the knowledge-to-action cycle (research, translation, and implementation) in which they were most closely aligned.

RESULTS

We identified 5 themes including: 1) the need for policy-informed and actionable research (e.g. health economic analyses and policy evaluations); 2) impactful messaging that targets all relevant sectors to create the political will necessary to drive policy change; 3) common measures and tools to increase capacity for monitoring and surveillance of built environment changes; (4) intersectoral collaboration and alignment within and between levels of government to enable collective actions and provide mechanisms for sharing of resources and expertise, (5) aligning public and private sector priorities to generate public demand and support for community action; and, (6) solution-focused implementation of research that will be tailored to meet the needs of policymakers and planners. Additional research priorities and key policy and planning actions were also noted.

CONCLUSION

Our research highlights the necessity of involving stakeholders in identifying inter-sectoral solutions to develop and translate actionable research on the built environment into effective policy and planning initiatives.

Is Walk Score associated with hospital admissions from chronic diseases? Evidence from a cross-sectional study in a high socioeconomic status Australian city-state

OBJECTIVES

To explore patterns of non-communicable diseases (NCDs) in the Australian Capital Territory (ACT).To ascertain the effect of the neighbourhood built environmental features and especially walkability on health outcomes, specifically for hospital admissions from NCDs.

DESIGN

A cross-sectional analysis of public hospital episode data (2007-2013).

SETTING

Hospitalisations from the ACT, Australia at very small geographic areas.

PARTICIPANTS

Secondary data on 75 290 unique hospital episodes representing 39 851 patients who were admitted to ACT hospitals from 2007 to 2013. No restrictions on age, sex or ethnicity.

MAIN EXPOSURE MEASURES

Geographic Information System derived or compatible measures of general practitioner access, neighbourhood socioeconomic status, alcohol access, exposure to traffic and Walk Score walkability.

MAIN OUTCOME MEASURES

Hospitalisations of circulatory diseases, specific endocrine, nutritional and metabolic diseases, respiratory diseases and specific cancers.

RESULTS

Geographic clusters with significant high and low risks of NCDs were found that displayed an overall geographic pattern of high risk in the outlying suburbs of the territory. Significant relationships between neighbourhood walkability as measured by Walk Score and the likelihood of hospitalisation with a primary diagnosis of myocardial infarction (heart attack) were found. A possible relationship was also found with the likelihood of being hospitalised with 4 major lifestyle-related cancers.

CONCLUSIONS

Our research augments the growing literature underscoring the relationships between the built environment and health outcomes. In addition, it supports the importance of walkable neighbourhoods, as measured by Walk Score, for improved health.

Cumulative Effects of Growing Up in Separate and Unequal Neighborhoods on Racial Disparities in Self-rated Health in Early Adulthood

Evidence suggests that living in a socioeconomically deprived neighborhood is associated with worse health. Yet most research relies on cross-sectional data, which implicitly ignore variation in longer-term exposure that may be more consequential for health. Using data from the 1970 to 2011 waves of the Panel Study of Income Dynamics merged with census data on respondents' neighborhoods (N = 1,757), this study estimates a marginal structural model with inverse probability of treatment and censoring weights to examine: (1) whether cumulative exposure to neighborhood disadvantage from birth through age 17 affects self-rated health in early adulthood, and (2) the extent to which variation in such exposure helps to explain racial disparities therein. Findings reveal that prolonged exposure to neighborhood disadvantage throughout childhood and adolescence is strikingly more common among nonwhite versus white respondents and is associated with significantly greater odds of experiencing an incidence of fair or poor health in early adulthood.

Neighborhood Conditions and Psychosocial Outcomes Among Middle-Aged African Americans

OBJECTIVE

We examined associations between observed neighborhood conditions (good/adverse) and psychosocial outcomes (stress, depressive symptoms, resilience, and sense of control) among middle-aged and older African Americans.

METHODS

The sample included 455 middle-aged and older African Americans examined in Wave 10 of the African American Health (AAH) study. Linear regression was adjusted for attrition, self-selection into neighborhoods, and potential confounders, and stratified by the duration at current address (<5 vs ≥5 years) because of its hypothesized role as an effect modifier.

RESULTS

Among individuals who lived at their current address for ≥5 years, residing in neighborhoods with adverse versus good conditions was associated with significantly less stress (standardized β = -0.18; P = .002) and depressive symptoms (standardized β = -0.12; P = .048). Among those who lived at their current address for <5 years, residing in neighborhoods with adverse versus good conditions was not significantly associated with stress (standardized β = 0.18; P = .305) or depressive symptoms (standardized β = 0.36; P = .080).

CONCLUSION

Neighborhood conditions appear to have significant, complex associations with psychosocial factors among middle-aged and older African Americans. This holds important policy implications, especially since adverse neighborhood conditions may still result in adverse physical health outcomes in individuals with >5 years at current residence despite being associated with better psychosocial outcomes.

Examining the role of urban street design in enhancing community engagement: A literature review

Streets are an integral part of the built environment with the capacity to promote community engagement, as one aspect of health and well-being. However, there have been few attempts to synthesize published studies and interventions to gain a broader understanding of what street design features hinder or facilitate community engagement. Data was extracted from 30 eligible articles into 16 key topic areas or themes. The most frequent topic areas were 'Aesthetics and Upkeep' (18), 'Access to Resources/Facilities' (15), 'Security and Safety' (15), and 'Walkability' (14). This review advances our understanding of how streets can be designed to enhance community engagement.

Complexity As Key to Designing Cognitive-Friendly Environments for Older People

The lived environment is the arena where our cognitive skills, preferences, and attitudes come together to determine our ability to interact with the world. The mechanisms through which lived environments can benefit cognitive health in older age are yet to be fully understood. The existing literature suggests that environments which are perceived as stimulating, usable and aesthetically appealing can improve or facilitate cognitive performance both in young and older age. Importantly, optimal stimulation for cognition seems to depend on experiencing sufficiently stimulating environments while not too challenging. Environmental complexity is an important contributor to determining whether an environment provides such an optimal stimulation. The present paper reviews a selection of studies which have explored complexity in relation to perceptual load, environmental preference and perceived usability to propose a framework which explores direct and indirect environmental influences on cognition, and to understand these influences in relation to aging processes. We identify ways to define complexity at different environmental scales, going from micro low-level perceptual features of scenes, to design qualities of proximal environments (e.g., streets, neighborhoods), to broad geographical areas (i.e., natural vs. urban environments). We propose that studying complexity at these different scales will provide new insight into the design of cognitive-friendly environments.

Are People Living in Walkable Areas Healthier and More Satisfied with Life?

Are people who live in more walkable areas healthier and more satisfied with life? This study investigates that question by using the 2005 Behavioral Risk Factors Surveillance System (BRFSS) survey, the largest telephone survey on health in the US (302,841 respondents from 989 metropolitan and micropolitan statistical areas [MSA]; 177,524 respondents from 703 MSAs had complete data). Using multilevel random coefficient modeling, we found that people living in walkable areas reported being generally healthier than people living in less walkable areas. In addition, aside from higher self-reported health, people living in walkable areas also had a lower body mass index (BMI). However, contrary to our prediction, people in more walkable areas were less satisfied with their lives than people in less walkable areas after controlling for various individual-level variables (age, gender, race, education, marital status, income, and unemployment). People who live in walkable areas are healthier but not happier than those living in less walkable areas.

Determinants of Quality of Life in Ageing Populations: Results from a Cross-Sectional Study in Finland, Poland and Spain

Purpose

To comprehensively identify the determinants of quality of life (QoL) in a population study sample of persons aged 18–50 and 50+.

Methods

In this observational, cross-sectional study, QoL was measured with the WHOQOL-AGE, a brief instrument designed to measure QoL in older adults. Eight hierarchical regression models were performed to identify determinants of QoL. Variables were entered in the following order: Sociodemographic; Health Habits; Chronic Conditions; Health State description; Vision and Hearing; Social Networks; Built Environment. In the final model, significant variables were retained. The final model was re-run using data from the three countries separately.

Results

Complete data were available for 5639 participants, mean age 46.3 (SD 18.4). The final model accounted for 45% of QoL variation and the most relevant contribution was given by sociodemographic data (particularly age, education level and living in Finland: 17.9% explained QoL variation), chronic conditions (particularly depression: 4.6%) and a wide and rich social network (4.6%). Other determinants were presence of disabling pain, learning difficulties and visual problems, and living in usable house that is perceived as non-risky. Some variables were specifically associated to QoL in single countries: age in Poland, alcohol consumption in Spain, angina in Finland, depression in Spain, and self-reported sadness both in Finland and Poland, but not in Spain. Other were commonly associated to QoL: smoking status, bodily aches, being emotionally affected by health problems, good social network and home characteristics.

Conclusions

Our results highlight the importance of modifiable determinants of QoL, and provide public health indications that could support concrete actions at country level. In particular, smoking cessation, increasing the level of physical activity, improving social network ties and applying universal design approach to houses and environmental infrastructures could potentially increase QoL of ageing population.

The association between built environment features and physical activity in the Australian context: a synthesis of the literature

BACKGROUND

There is growing evidence indicating that the built environment is a determinant of physical activity. However, despite the well-established health benefits of physical activity this is rarely considered in urban planning. We summarised recent Australian evidence for the association built environment-physical activity among adults. This summary aims to inform policy makers who advocate for the consideration of health in urban planning.

METHODS

A combination of built environment and physical activity terms were used to systematically identify relevant peer reviewed and grey literature.

RESULTS

A total of 23 studies were included, providing 139 tests of associations between specific built environment features and physical activity. Of the total, 84 relationships using objective measures of built environment attributes were evaluated, whereas 55 relationships using self-reported measures were evaluated. Our results indicate that walkable neighbourhoods with a wide range of local destinations to go to, as well as a diverse use of land, encourage physical activity among their residents.

CONCLUSIONS

This research provides a summary of recent Australian evidence on built environments that are most favourable for physical activity. Features of walkability and availability of destinations within walking distance should be accounted for in the development or redevelopment of urban areas. Our findings emphasise the importance of urban planning for health via its impact on population levels of physical activity.

Neighborhood Environments and Incident Hypertension in the Multi-Ethnic Study of Atherosclerosis

We examined relationships between neighborhood physical and social environments and incidence of hypertension in a cohort of 3,382 adults at 6 sites in the United States over 10 years of follow-up (2000-2011), using data from the Multi-Ethnic Study of Atherosclerosis. The sample was aged 45-84 years (mean = 59 years) and free of clinical cardiovascular disease and hypertension at baseline. Of the participants, 51% were female, 44% white, 23% Hispanic, 21% black, and 13% Chinese-American; 39% of participants developed hypertension during an average of 7.2 years of follow-up. Cox models were used to estimate associations of time-varying cumulative average neighborhood features (survey-based healthy food availability, walking environment, social cohesion, safety, and geographic information system-based density of favorable food stores and recreational resources) with incident hypertension. After adjustment for individual and neighborhood-level covariates, a 1-standard-deviation increase in healthy food availability was associated with a 12% lower rate of hypertension (hazard ratio = 0.88, 95% confidence interval: 0.82, 0.95). Other neighborhood features were not related to incidence of hypertension. The neighborhood food environment is related to the risk of hypertension.

Matching the Genotype in Resolution: Innovative Ways of Phenotype Capture

Social and spatial context are important determinants of morbidity and mortality. However, there is little clarity about the role of context for kidney disease specifically, particularly before the end stage. Meanwhile, research clarifying the clinical, cellular, molecular, and genetic causes of kidney disease is accelerating considerably. We postulate that without contextual information, even the most detailed biomedical information cannot fully capture the factors that ultimately drive the development and progression of kidney disease. The Nephrotic Syndrome Study Network is integrating detailed, state-of-the-art information on a social and spatial context to enable the exploration of the associations between the social environment and kidney disease. Here, we discuss the extant literature on social context and kidney disease, present information on sources of contextual information, and provide recommended further reading to facilitate future research on the contribution of the social context to kidney disease.

Neighbourhood walkability, road density and socio-economic status in Sydney, Australia

BACKGROUND

Planning and transport agencies play a vital role in influencing the design of townscapes, travel modes and travel behaviors, which in turn impact on the walkability of neighbourhoods and residents' physical activity opportunities. Optimising neighbourhood walkability is desirable in built environments, however, the population health benefits of walkability may be offset by increased exposure to traffic related air pollution. This paper describes the spatial distribution of neighbourhood walkability and weighted road density, a marker for traffic related air pollution, in Sydney, Australia. As exposure to air pollution is related to socio-economic status in some cities, this paper also examines the spatial distribution of weighted road density and walkability by socio-economic status (SES).

METHODS

We calculated walkability, weighted road density (as a measure of traffic related air pollution) and SES, using predefined and validated measures, for 5858 Sydney neighbourhoods, representing 3.6 million population. We overlaid tertiles of walkability and weighted road density to define "sweet-spots" (high walkability-low weighted road density), and "sour- spots" (low walkability-high weighted road density) neighbourhoods. We also examined the distribution of walkability and weighted road density by SES quintiles.

RESULTS

Walkability and weighted road density showed a clear east-west gradient across the region. Our study found that only 4 % of Sydney's population lived in sweet-spot" neighbourhoods with high walkability and low weighted road density (desirable), and these tended to be located closer to the city centre. A greater proportion of neighbourhoods had health limiting attributes of high weighted road density or low walkability (about 20 % each), and over 5 % of the population lived in "sour-spot" neighbourhoods with low walkability and high weighted road density (least desirable). These neighbourhoods were more distant from the city centre and scattered more widely. There were no linear trends between walkability/weighted road density and neighbourhood SES.

CONCLUSIONS

Our walkability and weighted road density maps and associated analyses by SES can help identify neighbourhoods with inequalities in health-promoting or health-limiting environments. Planning agencies should seek out opportunities for increased neighbourhood walkability through improved urban development and transport planning, which simultaneously minimizes exposure to traffic related air pollution.

European Healthy City Network Phase V: patterns emerging for healthy urban planning

There is a tradition of planning cities and their infrastructure to successfully tackle communicable disease arising from urban development. Non-communicable disease follows a different course. Development brings in its wake a basket of adverse health and health equity outcomes that are proving difficult to tackle. In response, within Phase V of the European Healthy Cities Network, municipalities have implemented a range of policy and physical interventions using a settings approach. Owing to the time lag between physical interventions and health outcomes, this research interrogates city activity itself to develop better understanding. Self-reported city case studies and questionnaire data were analysed to reveal patterns using an inductive approach. Findings indicate that some categories of intervention, such as whole city planning and transport, have a systemic impact across the wider determinants of health. Addressing transferability and stakeholder understanding helped cities create conditions for successful outcomes. Cities had varying urban development approaches for tackling climate change. Improvements to current practice are discussed, including; a distinction between supply side and demand side in healthy urban planning; valuing co-benefits and developing integrative approaches to the evidence-base. This evaluative article is important for cities wanting to learn how to maximize benefits to public health through urban development and for researchers exploring, with a systemic approach, the experiences of European cities acting at the interface of urban development and public health. This article also provides recommendations for future phases of the WHO European Healthy Cities programme, posing questions to better address governance and equity in spatial planning.

Assessment of Environmental Determinants of Physical Activity: a Study of Built Environment Indicators in Brno, Czech Republic

BACKGROUND

Research on physical activity in relation to obesity gradually becomes more focused on environmental determinants, which can potentially influence people's health choices. The present article addresses the topic of physical activity from a wider sociological perspective. Our pilot study was designed with the objective of testing the applicability of a method included in the EC 6th Framework Programme EURO-PREVOB, in the Czech context. The method examines specific determinants of the built environment that can have an impact on physical activity at the population level. In addition, the study aims to analyze possible differences in built environment indicators and their relation to the physical activity of people living in neighbourhoods with areas of varying socioeconomic status.

METHODS

The field study was carried out in the city of Brno, Czech Republic, in 5 neighbourhood quintiles, i.e. areas divided according to the socioeconomic status of local residents. In each quintile, we evaluated the quality of the built environment according to the quality, aesthetics and safety of segregated cycle facilities, playgrounds/playing areas, public open spaces, marked road crossings and pavements as well as signs of incivilities and devastation.

RESULTS

Between the five quintiles, significant differences were found in the quality of parks and playgrounds/playing areas, pavements, marking of pedestrian crossings, and in general aesthetics, i.e. signs of incivilities and devastation of the built environment. No differences were found in the quality and use of cycle facilities.

CONCLUSIONS

The method we used for the evaluation of the built environment proved highly applicable in Czech populated areas. Monitoring of built environment indicators in the Czech Republic should provide a basis for health maps, showing potential associations between the prevalence of high-incidence, non-infectious diseases and various social determinants of physical activity. This information might help in achieving an improvement in these determinants at a community level and promoting an increase in physical activity at the population level.

Neighbourhood typology based on virtual audit of environmental obesogenic characteristics

Virtual audit (using tools such as Google Street View) can help assess multiple characteristics of the physical environment. This exposure assessment can then be associated with health outcomes such as obesity. Strengths of virtual audit include collection of large amount of data, from various geographical contexts, following standard protocols. Using data from a virtual audit of obesity-related features carried out in five urban European regions, the current study aimed to (i) describe this international virtual audit dataset and (ii) identify neighbourhood patterns that can synthesize the complexity of such data and compare patterns across regions. Data were obtained from 4,486 street segments across urban regions in Belgium, France, Hungary, the Netherlands and the UK. We used multiple factor analysis and hierarchical clustering on principal components to build a typology of neighbourhoods and to identify similar/dissimilar neighbourhoods, regardless of region. Four neighbourhood clusters emerged, which differed in terms of food environment, recreational facilities and active mobility features, i.e. the three indicators derived from factor analysis. Clusters were unequally distributed across urban regions. Neighbourhoods mostly characterized by a high level of outdoor recreational facilities were predominantly located in Greater London, whereas neighbourhoods characterized by high urban density and large amounts of food outlets were mostly located in Paris. Neighbourhoods in the Randstad conurbation, Ghent and Budapest appeared to be very similar, characterized by relatively lower residential densities, greener areas and a very low percentage of streets offering food and recreational facility items. These results provide multidimensional constructs of obesogenic characteristics that may help target at-risk neighbourhoods more effectively than isolated features.

Application of space-time disease clustering by administrative databases in Italy: Adverse Reproductive Outcomes (AROs) and residential exposure

BACKGROUND

The aims of this study were to estimate the existence of clusters of AROs in the municipalities of the Marches Region (Central Italy) after complaints from residents living near an abandoned landfill site.

METHODS

Cases of AROs (i.e., congenital malformation, chromosomal abnormalities, and low birth weight) were retrieved from hospital discharge data. SaTScan and GeoDa were used to check for the presence of clusters at a regional and a small area level. Moreover, at a small area/neighborhood level, smoothed rates were calculated, and a case-control approach was used to assess the residence in proximity to the abandoned landfill as an independent risk factor for AROs.

RESULTS

AROs were associated with the price per square meter of the accommodations in the area of residence (OR 2.53, 95 % CI 2.06-3.10). On the other hand, residence within one kilometer of the landfill (OR 0.04, 95 % CI 0.01-0.23) and maternal age greater than 35 years (OR 0.96, 95 % CI 0.92-0.99) were protective.

CONCLUSIONS

Residency in proximity to the abandoned landfill was not a risk factor for the occurrence of AROs. The results show that basic information, such as the price of accommodations in different neighborhoods, could be of interest in order to target training programs for women living in difficult conditions and highlights the potential role of the building environment in perinatal health. However, we note that aside from the data provided by Geographic Information Systems in public health, collection of the patient's residential address was unreliable for selected conditions. Future efforts should emphasize the patient's residential address as information important for evaluating the health of individuals instead of being merely administrative data.

The Effects of the Urban Built Environment on Mental Health: A Cohort Study in a Large Northern Italian City

Mental health (MH) has a relevant burden on the health of populations. Common MH disorders (anxiety and non-psychotic depression) are well associated to socioeconomic individual and neighborhood characteristics, but little is known about the influence of urban structure. We analyzed among a Turin (Northwest Italy) urban population the association at area level of different urban structure characteristics (density, accessibility by public transport, accessibility to services, green and public spaces) and consumption of antidepressants. Estimates were adjusted by individual socio-demographic variables (education, housing tenure, employment) and contextual social environment (SE) variables (social and physical disorder, crime rates). Data was extracted from the Turin Longitudinal Study (TLS)-a census-based cohort study following up prospectively the mortality and morbidity of the population. As expected, individual characteristics show the strongest association with antidepressant drug consumption, while among built environment (BE) indicators accessibility by public transport and urban density only are associated to MH, being slightly protective factors. Results from this study, in agreement with previous literature, suggest that BE has a stronger effect on MH for people who spend more time in the neighborhood. Therefore, this research suggests that good accessibility to public transport, as well as a dense urban structure (versus sprawl), could contribute to reduced risk of depression, especially for women and elderly, by increasing opportunities to move around and have an active social life.

Health-Risk Behaviour in Deprived Neighbourhoods Compared with Non-Deprived Neighbourhoods: A Systematic Literature Review of Quantitative Observational Studies

BACKGROUND

There has been increasing interest in neighbourhoods' influence on individuals' health-risk behaviours, such as smoking, alcohol consumption, physical activity and diet. The aim of this review was to systematically review recent studies on health-risk behaviour among adults who live in deprived neighbourhoods compared with those who live in non-deprived neighbourhoods and to summarise what kind of operationalisations of neighbourhood deprivation that were used in the studies.

METHODS

PRISMA guidelines for systematic reviews were followed. Systematic searches were performed in PubMed, Embase, Web of Science and Sociological Abstracts using relevant search terms, Boolean operators, and truncation, and reference lists were scanned. Quantitative observational studies that examined health-risk behaviour in deprived neighbourhoods compared with non-deprived neighbourhoods were eligible for inclusion.

RESULTS

The inclusion criteria were met by 22 studies. The available literature showed a positive association between smoking and physical inactivity and living in deprived neighbourhoods compared with non-deprived neighbourhoods. In regard to low fruit and vegetable consumption and alcohol consumption, the results were ambiguous, and no clear differences were found. Numerous different operationalisations of neighbourhood deprivation were used in the studies.

CONCLUSION

Substantial evidence indicates that future health interventions in deprived neighbourhoods should focus on smoking and physical inactivity. We suggest that alcohol interventions should be population based rather than based on the specific needs of deprived neighbourhoods. More research is needed on fruit and vegetable consumption. In future studies, the lack of a uniform operationalisation of neighbourhood deprivation must be addressed.

Environment as 'Brain Training': A review of geographical and physical environmental influences on cognitive ageing

Global ageing demographics coupled with increased urbanisation pose major challenges to the provision of optimal living environments for older persons, particularly in relation to cognitive health. Although animal studies emphasize the benefits of enriched environments for cognition, and brain training interventions have shown that maintaining or improving cognitive vitality in older age is possible, our knowledge of the characteristics of our physical environment which are protective for cognitive ageing is lacking. The present review analyses different environmental characteristics (e.g. urban vs. rural settings, presence of green) in relation to cognitive performance in ageing. Studies of direct and indirect associations between physical environment and cognitive performance are reviewed in order to describe the evidence that our living contexts constitute a measurable factor in determining cognitive ageing.

The Relationship of Built Environment to Health-Related Behaviors and Health Outcomes in Elderly Community Residents in a Middle Income Country

Background

Few studies have examined the impact of the built environment (BE) on health behaviours and health outcomes in middle income countries. This study examines associations between self-assessed characteristics of the home and neighbourhood environment and health-related behaviours and health outcomes in an elderly population in Brazil

Design and methods

In a community sample of 6963 community dwellers 60 years old and older living in the state of Rio Grande do Sul, Brazil, associations between self-reported BE conditions and health behaviours and health outcomes were assessed using a structured questionnaire. Multivariate analysis was conducted to investigate these associations while accounting for other relevant characteristics.

Results

We found significant positive associations between adverse BE conditions and pulmonary, urinary conditions, gastrointestinal, problems, headache and depression. There were mixed associations between adverse BE conditions and musculoskeletal and sensory conditions, inverse associations with metabolic disorders. and no associations with dermatologic problems and cancer. After accounting for health related behaviours, results suggest a modest association between adverse BE conditions and hypertension, with no significant associations with other indicators of cardiovascular conditions (heart problems, stroke, varicose veins).

Conclusions

The findings in this study suggest links between adverse conditions in the BE and health related behaviours in the hypothesized direction. Associations with the health conditions examined here are mixed. We find the strongest evidence for effects of adverse BE conditions for pulmonary and infectious conditions. Significant associations between the adverse BE indicators and health outcomes persist after accounting for health related behaviours, suggesting that BE conditions are linked to health pathways above and beyond the health related behaviours assessed in this study.

Correcting bias in self-rated quality of life: an application of anchoring vignettes and ordinal regression models to better understand QoL differences across commuting modes

PURPOSE

Likert scales are frequently used in public health research, but are subject to scale perception bias. This study sought to explore scale perception bias in quality-of-life (QoL) self-assessment and assess its relationships with commuting mode in the Sydney Travel and Health Study.

METHODS

Multilevel ordinal logistic regression analysis was used to analyse the association between two global QoL items about overall QoL and health satisfaction, with usual travel mode to work or study. Anchoring vignettes were applied using parametric and simpler nonparametric methods to detect and adjust for differences in reporting behaviour across age, sex, education, and income groups.

RESULTS

The anchoring vignettes exposed differences in scale responses across demographic groups. After adjusting for these biases, public transport users (OR = 0.37, 95 % CI 0.21-0.65), walkers (OR = 0.44, 95 % CI 0.24-0.82), and motor vehicle users (OR = 0.47, 95 % CI 0.25-0.86) were all found to have lower odds of reporting high QoL compared with bicycle commuters. Similarly, the odds of reporting high health satisfaction were found to be proportionally lower amongst all competing travel modes: motor vehicle users (OR = 0.31, 95 % CI 0.18-0.56), public transport users (OR = 0.34, 95 % CI 0.20-0.57), and walkers (OR = 0.35, 95 % CI 0.20-0.64) when compared with cyclists. Fewer differences were observed in the unadjusted models.

CONCLUSION

Application of the vignettes by the two approaches removed scaling biases, thereby improving the accuracy of the analyses of the associations between travel mode and quality of life. The adjusted results revealed higher quality of life in bicycle commuters compared with all other travel mode users.

The Neighbourhood Built Environment and Trajectories of Depression Symptom Episodes in Adults: A Latent Class Growth Analysis

Aim

To investigate the effect of the neighbourhood built environment on trajectories of depression symptom episodes in adults from the general Canadian population.

Research Design and Methods

We used 10 years of data collection (2000/01-2010/11) from the Canadian National Population Health Study (n = 7114). Episodes of depression symptoms were identified using the Composite International Diagnostic Interview Short-Form. We assessed the presence of local parks, healthy food stores, fast food restaurants, health services and cultural services using geospatial data. We used latent class growth modelling to identify different trajectories of depression symptom episodes in the sample and tested for the effect of neighbourhood variables on the trajectories over time.

Results

We uncovered three distinct trajectories of depression symptom episodes: low prevalence (76.2% of the sample), moderate prevalence (19.2%) and high prevalence of depression symptom episodes (2.8%). The presence of any neighbourhood service (healthy food store, fast-food restaurant, health service, except for cultural service) was significantly associated with a lower probability of a depression symptom episode for those following a trajectory of low prevalence of depression symptom episodes. The presence of a local park was also a significant protective factor in trajectory groups with both low and moderate prevalence of depression symptom episodes. Neighbourhood characteristics did not significantly affect the trajectory of high prevalence of depression symptom episodes.

Conclusions

For individuals following a trajectory of low and moderate prevalence of depression symptom episodes, the neighbourhood built environment was associated with a shift in the trajectory of depression symptom episodes. Future intervention studies are recommended to make policy recommendations.

The roles of outlet density and norms in alcohol use disorder

BACKGROUND

Alcohol outlet density and norms shape alcohol consumption. However, due to analytic challenges we do not know: (a) if alcohol outlet density and norms also shape alcohol use disorder, and (b) whether they act in combination to shape disorder.

METHODS

We applied a new targeted minimum loss-based estimator for rare outcomes (rTMLE) to a general population sample from New York City (N = 4000) to examine the separate and combined relations of neighborhood alcohol outlet density and norms around drunkenness with alcohol use disorder. Alcohol use disorder was assessed using the World Mental Health Comprehensive International Diagnostic Interview (WMH-CIDI) alcohol module. Confounders included demographic and socioeconomic characteristics, as well as history of drinking prior to residence in the current neighborhood.

RESULTS

Alcohol use disorder prevalence was 1.78%. We found a marginal risk difference for alcohol outlet density of 0.88% (95% CI 0.00-1.77%), and for norms of 2.05% (95% CI 0.89-3.21%), adjusted for confounders. While each exposure had a substantial relation with alcohol use disorder, there was no evidence of additive interaction between the exposures.

CONCLUSIONS

Results indicate that the neighborhood environment shapes alcohol use disorder. Despite the lack of additive interaction, each exposure had a substantial relation with alcohol use disorder and our findings suggest that alteration of outlet density and norms together would likely be more effective than either one alone. Important next steps include development and testing of multi-component intervention approaches aiming to modify alcohol outlet density and norms toward reducing alcohol use disorder.

Outside the exam room: policies for connecting clinic to community in diabetes prevention and treatment

The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation’s Commission to Build a Healthier America recommended 3 strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.

Primary care patients' perspectives of barriers and enablers of primary prevention and health promotion-a meta-ethnographic synthesis

Background

Primary care (PC) patients have difficulties in committing to and incorporating primary prevention and health promotion (PP&HP) activities into their long-term care. We aimed to re-interpret, for the first time, qualitative findings regarding factors affecting PC patients' acceptance of PP&HP activities.

Methods and Findings

A meta-ethnographic synthesis was generated following electronic and manual searches that retrieved 29 articles. Papers were reviewed and translated to produce a re-interpretation of the extracted concepts. The factors affecting PC patients' receptiveness to PP&HP activities were framed in a four-level ecological model (intrapersonal, interpersonal, institutional and environment and society). Intrapersonal factors (patients' beliefs/attitudes, knowledge, skills, self-concept, motivation and resources) were the most numerous, with almost 25 different factors. Public health education to modify erroneous beliefs and values regarding PP&HP could encourage a transition to healthier lifestyles. Health care professionals' abilities to communicate and involve patients in the decision-making process can act as facilitators. Biopsychosocial training (with emphasis on communication skills) for health professionals must start with undergraduates. Increased consultation time, the use of reminders, follow-up visits and tools for communicating risk and motivating patients could be applied at the intrapersonal level. Collaborative care involving other health professionals (nutritionists or psychotherapists) and family and community stakeholders (teachers or gym trainers) was important in developing healthier habits. Patients also cited barriers related to the built environment and socioeconomic difficulties that highlighted the need for policies promoting social justice and equity. Encouraging PP&HP using social marketing strategies and regulating media to control its impact on health were also cited. Only the perspectives of PC patients in the context of chronic conditions were considered thus limiting extrapolation to other contexts.

Conclusions

Several factors affect PP&HP. This must be taken into account when designing PP&HP activities if they are to be successfully implemented and maintained in routine practice.

Built environment interventions aimed at improving physical activity levels in rural Ontario health units: a descriptive qualitative study

BACKGROUND

Few studies to date have explored the relationship between the built environment and physical activity specifically in rural settings. The Ontario Public Health Standards policies mandate that health units in Ontario address the built environment; however, it is unclear how public health practitioners are integrating the built environment into public health interventions aimed at improving physical activity in chronic disease prevention programs.

METHODS

This descriptive qualitative study explored interventions that have or are being implemented which address the built environment specifically related to physical activity in rural Ontario health units, and the impact of these interventions. Data were collected through twelve in-depth semi-structured interviews with rural public health practitioners and managers representing 12 of 13 health units serving rural communities. Key themes were identified using qualitative content analysis.

RESULTS

Themes that emerged regarding the types of interventions that health units are employing included: Engagement with policy work at a municipal level; building and working with community partners, committees and coalitions; gathering and providing evidence; developing and implementing programs; and social marketing and awareness raising. Evaluation of interventions to date has been limited.

CONCLUSIONS

Public health interventions, and their evaluations, are complex. Health units who serve large rural populations in Ontario are engaging in numerous activities to address physical activity levels. There is a need to further evaluate the impact of these interventions on population health.

Measuring physical neighborhood quality related to health

Although sociodemographic factors are one aspect of understanding the effects of neighborhood environments on health, equating neighborhood quality with socioeconomic status ignores the important role of physical neighborhood attributes. Prior work on neighborhood environments and health has relied primarily on level of socioeconomic disadvantage as the indicator of neighborhood quality without attention to physical neighborhood quality. A small but increasing number of studies have assessed neighborhood physical characteristics. Findings generally indicate that there is an association between living in deprived neighborhoods and poor health outcomes, but rigorous evidence linking specific physical neighborhood attributes to particular health outcomes is lacking. This paper discusses the methodological challenges and limitations of measuring physical neighborhood environments relevant to health and concludes with proposed directions for future work.

Interactive and independent associations between the socioeconomic and objective built environment on the neighbourhood level and individual health: a systematic review of multilevel studies

BACKGROUND

The research question how contextual factors of neighbourhood environments influence individual health has gained increasing attention in public health research. Both socioeconomic neighbourhood characteristics and factors of the built environment play an important role for health and health-related behaviours. However, their reciprocal relationships have not been systematically reviewed so far. This systematic review aims to identify studies applying a multilevel modelling approach which consider both neighbourhood socioeconomic position (SEP) and factors of the objective built environment simultaneously in order to disentangle their independent and interactive effects on individual health.

METHODS

The three databases PubMed, PsycINFO, and Web of Science were systematically searched with terms for title and abstract screening. Grey literature was not included. Observational studies from USA, Canada, Australia, New Zealand, and Western European countries were considered which analysed simultaneously factors of neighbourhood SEP and the objective built environment with a multilevel modelling approach. Adjustment for individual SEP was a further inclusion criterion.

RESULTS

Thirty-three studies were included in qualitative synthesis. Twenty-two studies showed an independent association between characteristics of neighbourhood SEP or the built environment and individual health outcomes or health-related behaviours. Twenty-one studies found cross-level or within-level interactions either between neighbourhood SEP and the built environment, or between neighbourhood SEP or the built environment and individual characteristics, such as sex, individual SEP or ethnicity. Due to the large variation of study design and heterogeneous reporting of results the identification of consistent findings was problematic and made quantitative analysis not possible.

CONCLUSIONS

There is a need for studies considering multiple neighbourhood dimensions and applying multilevel modelling in order to clarify their causal relationship towards individual health. Especially, more studies using comparable characteristics of neighbourhood SEP and the objective built environment and analysing interactive effects are necessary to disentangle health impacts and identify vulnerable neighbourhoods and population groups.

Trading quality for relevance: non-health decision-makers' use of evidence on the social determinants of health

OBJECTIVES

Local government services and policies affect health determinants across many sectors such as planning, transportation, housing and leisure. Researchers and policymakers have argued that decisions affecting wider determinants of health, well-being and inequalities should be informed by evidence. This study explores how information and evidence are defined, assessed and utilised by local professionals situated beyond the health sector, but whose decisions potentially affect health: in this case, practitioners working in design, planning and maintenance of the built environment.

DESIGN

A qualitative study using three focus groups. A thematic analysis was undertaken.

SETTING

The focus groups were held in UK localities and involved local practitioners working in two UK regions, as well as in Brazil, USA and Canada.

PARTICIPANTS

UK and international practitioners working in the design and management of the built environment at a local government level.

RESULTS

Participants described a range of data and information that constitutes evidence, of which academic research is only one part. Built environment decision-makers value empirical evidence, but also emphasise the legitimacy and relevance of less empirical ways of thinking through narratives that associate their work to art and philosophy. Participants prioritised evidence on the acceptability, deliverability and sustainability of interventions over evidence of longer term outcomes (including many health outcomes). Participants generally privileged local information, including personal experiences and local data, but were less willing to accept evidence from contexts perceived to be different from their own.

CONCLUSIONS

Local-level built environment practitioners utilise evidence to make decisions, but their view of 'best evidence' appears to prioritise local relevance over academic rigour. Academics can facilitate evidence-informed local decisions affecting social determinants of health by working with relevant practitioners to improve the quality of local data and evaluations, and by advancing approaches to improve the external validity of academic research.

Direct and indirect effects of neighborhood factors and self-care on glycemic control in adults with type 2 diabetes

AIM

To determine whether neighborhood factors have direct or indirect effects, via self-care behaviors on glycemic control.

METHODS

Adult patients with type 2 diabetes were recruited from an academic medical center and Veterans Affairs Medical Center in the southeastern United States. Confirmatory factor analysis was used to create latent variables for neighborhood factors and diabetes self-care behavior. Structural equation modeling was used to test direct and indirect effects between neighborhood factors and glycemic control as assessed by HbA1c levels.

RESULTS

CFA yielded four latent variables for neighborhood factors (neighborhood violence, access to healthy food, social support, and neighborhood aesthetics) and one latent variable diabetes self-care. We found that social support (β=0.28, z=4.86, p<0.001) and access to healthy foods (β=-0.17, z=-2.95, p=0.003) had direct effects on self-care; self-care (β=-0.15, z=-2.48, p=0.013) and neighborhood aesthetics (β=0.12, z=2.19, p=0.03) had direct effects on glycemic control; while social support (β=-0.04, z=-2.26, p=0.02) had an indirect effect on glycemic control via self-care.

CONCLUSION

This study showed that self-care behaviors and neighborhood aesthetics have direct effects on glycemic control, social support and access to health foods had direct effects on self-care, and social support had an indirect effect on glycemic control via self-care.

Community perceptions of health and chronic disease in South Indian rural transitional communities: a qualitative study

Background

Chronic diseases are now the leading cause of death and disability worldwide; this epidemic has been linked to rapid economic growth and urbanisation in developing countries. Understanding how characteristics of the physical, social, and economic environment affect behaviour in the light of these changes is key to identifying successful interventions to mitigate chronic disease risk.

Design

We undertook a qualitative study consisting of nine focus group discussions (FGDs) (n=57) in five villages in rural Andhra Pradesh, South India, to understand people's perceptions of community development and urbanisation in relation to chronic disease in rural transitional communities. Specifically, we sought to understand perceptions of change linked to diet, physical activity, and pollution (because these exposures are most relevant to chronic diseases), with the aim of defining future interventions. The transcripts were analysed thematically.

Results

Participants believed their communities were currently less healthy, more polluted, less physically active, and had poorer access to nutritious food and shorter life expectancies than previously. There were contradictory perceptions of the effects of urbanisation on health within and between individuals; several of the participants felt their quality of life had been reduced.

Conclusions

In the present study, residents viewed change and development within their villages as an inevitable and largely positive process but with some negative health consequences. Understanding how these changes are affecting populations in transitional rural areas and how people relate to their environment may be useful to guide community planning for health. Measures to educate and empower people to make healthy choices within their community may help reduce the spread of chronic disease risk factors in future years.

Tobacco Retail Outlet Density and Young Adult Tobacco Initiation

BACKGROUND

A growing body of evidence indicates that the density of tobacco retail outlets around the home residence may influence tobacco use among youth and adults. The purpose of this study was to examine the impact of neighborhood tobacco retail outlet density on young adult initiation of different tobacco product types.

METHODS

Cross-sectional data from a 2013 nationally representative sample of young adults aged 18-34 was examined in relation to a 2012 geocoded listing of all outlets likely to sell tobacco in the United States. Separate multivariable logistic regression analyses examined associations between neighborhood outlet density and past 6 months first use of cigarettes, non-cigarette combustible products, and noncombustible products among adults aged 18-24 and 25-34.

RESULTS

Outlet density was significantly associated with recent initiation of cigarettes and other combustibles, but this impact varied for younger and older groups. Increased density was significantly associated with a higher likelihood of initiating cigarette use among adults aged 25-34 (OR = 3.75, 95% CI = 1.18, 11.90), and of initiating non-cigarette combustible use among 18-24 year olds (OR = 3.16, 95% CI = 1.03, 9.74). There was no impact of outlet density on recent noncombustible product initiation among either group.

CONCLUSION

This study is the first to examine the impact of tobacco outlet density on young adult initiation of cigarettes and other tobacco products. Findings demonstrate that residential neighborhood outlet density is associated with recent initiation of combustible products and this effect varies by product type and age. The tobacco outlet environment may be a critical factor in promoting young adult tobacco use initiation.

The SPOTLIGHT virtual audit tool: a valid and reliable tool to assess obesogenic characteristics of the built environment

Background

A lack of physical activity and overconsumption of energy dense food is associated with overweight and obesity. The neighbourhood environment may stimulate or hinder the development and/or maintenance of a healthy lifestyle. To improve research on the obesogenicity of neighbourhood environments, reliable, valid and convenient assessment methods of potential obesogenic characteristics of neighbourhood environments are needed. This study examines the reliability and validity of the SPOTLIGHT-Virtual Audit Tool (S-VAT), which uses remote sensing techniques (Street View feature in Google Earth) for desk-based assessment of environmental obesogenicity.

Methods

A total of 128 street segments in four Dutch urban neighbourhoods – heterogeneous in socio-economic status and residential density – were assessed using the S-VAT. Environmental characteristics were categorised as walking related items, cycling related items, public transport, aesthetics, land use-mix, grocery stores, food outlets and physical activity facilities. To assess concordance of inter- and intra-observer reliability of the Street View feature in Google Earth, and validity scores with real life audits, percentage agreement and Cohen's Kappa (k) were calculated.

Results

Intra-observer reliability was high and ranged from 91.7% agreement (k = 0.654) to 100% agreement (k = 1.000) with an overall agreement of 96.4% (k = 0.848). Inter-observer reliability results ranged from substantial agreement 78.6% (k = 0.440) to high agreement, 99.2% (k = 0.579), with an overall agreement of 91.5% (k = 0.595). Criterion validity was substantial to high for most of the categories ranging from 87.3% agreement (k = 0.539) to 99.9% agreement (k = 0.887) with an overall score of 95.6% agreement (k = 0.747).

Conclusion

These study results suggest that the S-VAT is a highly reliable and valid remote sensing tool to assess potential obesogenic environmental characteristics.

Electronic supplementary material

The online version of this article (doi:10.1186/1476-072X-13-52) contains supplementary material, which is available to authorized users.

"It is about being outside": Canadian youth's perspectives of good health and the environment

Drawing on qualitative data generated from an ethnographic study exploring Canadian youth's understanding of health, this paper examines youth's perspectives of the relationships between health and environment. Seventy-one youth (12 to 19 years of age) took part in individual and focus group interviews, as well as in photovoice interviews. Although initial discourse about health mainly focused on healthy eating and exercise, youth were more enthused and able to share their thoughts and feelings about the relationships between health and environment during the photovoice interviews. For these youth, good health was defined and visualized as "being outside" in a safe, clean, green, and livable space. Youth talked about conditions contributing to healthy environments and how healthy environments contributed to a strong sense of place. Overall, the conversations about the environment evoked many feelings in the youth. Results are discussed in the context of current research and in relation to youth, but also more broadly in relation to research on health and environment.

Wellbeing impacts of city policies for reducing greenhouse gas emissions

To mitigate climate change, city authorities are developing policies in areas such as transportation, housing and energy use, to reduce greenhouse gas emissions. In addition to their effects on greenhouse gas emissions, these policies are likely to have consequences for the wellbeing of their populations for example through changes in opportunities to take physical exercise. In order to explore the potential consequences for wellbeing, we first explore what ‘wellbeing’ is and how it can be operationalized for urban planners. In this paper, we illustrate how wellbeing can be divided into objective and subjective aspects which can be measured quantitatively; our review of measures informs the development of a theoretical model linking wellbeing to policies which cities use to reduce greenhouse gas emissions. Finally, we discuss the extent to which the links proposed in the conceptual model are supported by the literature and how cities can assess wellbeing implications of policies.

A web-based survey of residents' views on advocating with patients for a healthy built environment in Canada

Purpose. To determine family medicine residents' perceived knowledge and attitudes towards the built environment and their responsibility for health advocacy and to identify their perceived educational needs and barriers to patient education and advocacy. Methods. A web-based survey was conducted in Canada with University of Toronto family medicine residents. Data were analyzed descriptively. Results. 93% agreed or strongly agreed that built environment significantly impacts health. 64% thought educating patients on built environment is effective disease prevention; 52% considered this a role of family physicians. 78% reported that advocacy for built environment is effective disease prevention; 56% perceived this to be the family physician's role. 59% reported being knowledgeable to discuss how a patient's environment may affect his/her health; 35% reported being knowledgeable to participate in community discussions on built environment. 78% thought education would help with integration into practice. Inadequate time (92%), knowledge (73%), and remuneration (54%) were barriers. Conclusions. While residents perceived value in education and advocacy as disease prevention strategies and acknowledged the importance of a healthy built environment, they did not consider advocacy towards this the family physician's role. Barrier reduction and medical education may contribute to improved advocacy, ultimately improving physical activity levels and patient health outcomes.

Using an intersectional approach to study the impact of social determinants of health for African American mothers living with HIV

Heightened awareness of the social determinants of health by health scientists and clinicians has failed to translate into significant progress in the amelioration of those social determinants contributing to health inequities. The purpose of this article is to broaden the discussion about conceptual approaches nurse scientists can use to address health and health inequities. We will apply an intersectional approach to the study of the social determinants of health for African American mothers living with human immunodeficiency virus and through this explore the utility of an intersectional approach to generate knowledge in nursing.