An analysis of health levels and various indicators of urban environments for Healthy Cities projects

Evaluating urban environmental quality using multi criteria decision making

In the urban environment, the quality refers to the capacity that provides and fulfills the material and spiritual needs of inhabitants. In order to improve the quality of urban life and standard of living for their citizens, planners and managers strive to raise Urban Environmental Quality. The objective of this study is to evaluate the quality of urban environment through the spatial analysis of a multi-criteria decision making (MCDM) method utilizing CRITIC. This research is conducted in district 4 and district 2 of the Tabriz Metropolis Municipality. In order to determine the quality of an urban environment, air pollution, vegetation coverage, land surface temperature, production of waste, population density, noise pollution, health care per capita, green spaces per capita, recreational spaces per capita, and distance from fault lines are used. After evaluating and producing environmental quality maps in two separate districts, 10 indicators were tested for significance and a comparative evaluation of two districts was conducted in order to determine which district was in better condition based on a statistical analysis of the T-test results. In accordance with the CRITIC method, there are significant differences between averages of waste production, population density, noise pollution, distance from fault lines, Land Surface Temperature, Normalized difference vegetation index, and distance from fault lines between the two districts. It appears that recreational space, air pollution, health care per capita, and green space per capita are not meaningfully different on averages. The preparation of environmental quality maps reveals the importance of meaningful indicators at the neighborhood level in two urban districts. In both districts by strengthening the continuity of the landscape through the development of ecological corridors and an increase in per capita can contribute to the improvement of the quality of the urban environment.

An Innovative Index for Evaluating Urban Vulnerability on Pandemic Using LambdaMART Algorithm

The COVID-19 pandemic has significantly changed urban life and increased attention has been paid to the pandemic in discussions of urban vulnerability. There is a lack of methods to incorporate dynamic indicators such as urban vitality into evaluations of urban pandemic vulnerability. In this research, we use machine learning to establish an urban Pandemic Vulnerability Index (PVI) that measures the city’s vulnerability to the pandemic and takes dynamic indicators as an important aspect of this. The proposed PVI is constructed using 140 statistic variables and 10 dynamic variables, using data from 47 prefectures of Japan. Factor Analysis is used to extract factors from variables that may affect city vulnerability, and the LambdaMART algorithm is used to aggregate factors and predict vulnerability. The results show that the proposed PVI can predict the relative seriousness of the COVID-19 pandemic in two weeks with a precision of more than 0.71, which is meaningful for taking controlling measures in advance and shaping the society’s response. Further analysis revealed the key factors affecting urban pandemic vulnerability, including city size, transit station vitality, and medical facilities, emphasizing precautions for public transport systems and new planning concepts such as the compact city. This research explores the application of machine learning techniques in the indicator establishment and incorporates dynamic factors into vulnerability assessments, which contribute to improvements in urban vulnerability assessments and the planning of sustainable cities while facing the challenges of the COVID-19 pandemic.

Healthy cities and self-reported health: evidence from Israel

The World Health Organization's Healthy Cities Network (HCN) enlists community stakeholders (residents, businesses, non-governmental organizations and municipal governments) to promote health, quality of life and sustainable development in urban settings. The project, now three decades old, involves thousands of municipalities globally, including 52 in Israel. However, there is very little evidence regarding the effects of joining the HCN. This study examines whether HCN membership affects residents' self-reported health (SRH). Social survey data for Israel's 13 largest cities in 2005-2017 were analyzed using difference-in-differences and event study research designs. We use the gradual entry of cities to the HCN to compare SRH before and after network entry. Examined variables include municipal spending on health and duration of the city's participation in the network. Data were analyzed through multivariate linear regression with fixed effects at the city and year levels. Joining the HCN does not have an immediate effect on SRH. SRH increases with the duration of the city's participation in the network, but this result is only marginally statistically significant. Municipal health spending mildly increases with membership duration. A weak negative association was found between municipal health spending and SRH. Duration of a city's membership in the HCN is positively associated with residents' SRH; this association is not explained by an increase in municipal health spending. Identifying a mechanism for this improvement is beyond the scope of this study and is left for future research.

Development of the Korean Community Health Determinants Index (K-CHDI)

This study developed and validated a Korean community health determinants index (K-CHDI), which can be used to assess the health status of the community. To develop composite indicators, we followed the guidelines of the Joint Research Centre of the Organization for Economic Cooperation and Development. We reviewed previous studies and formed a theoretical framework to systematize our domains and indicators, which were decided through a Delphi survey of healthcare experts. Data on indicators were obtained from the Korean Statistics and Community Health Survey. We applied the Min-Max normalization method and measured weights by the analytic hierarchy process. Health outcomes were estimated using mortality, years of life lost, years lived with disability, and disability-adjusted life years by standardizing sex and age. The value of the index is between 0 and 1; higher values indicate more positive health determinants. K-CHDI for 250 subnational regions (cities, counties, and districts, or Si·Gun·Gu) were correlated with health outcomes. The correlation coefficient was stronger in large cities than in medium-sized areas and small areas, and the higher the K-CHDI group, the higher the coefficient. The K-CHDI represents a reference standard for estimating health status using health determinants as composite indicators at the subnational level.

Subnational Burden of Disease According to the Sociodemographic Index in South Korea

The sociodemographic index (SDI), a composite index per capita income, educational attainment, and total fertility rate in a country, can indicate whether the country's burden of disease varies depending upon its level of socioeconomic development. This study identified the subnational SDI and disease burden of South Korea based on the country's overall SDI, using national representative data. The burden of disease was measured using disability-adjusted life years (DALY) with an incidence-based approach. We used National Health Insurance Services claims data to estimate the years lived with disability (YLD) and cause-of-death statistics to estimate the years of life lost (YLL). Indicators of subnational SDI were also extracted. The Korean subnational SDIs for 250 regions were correlated with YLL, YLD, and DALY for the year 2016. The correlation between SDI and YLL was stronger in big cities than in medium areas and small areas. Moreover, the higher the SDI, the higher the coefficient. The SDI should be used as a standard for interpreting and comparing regions' disease burden at the subnational level.

Perceptions of barriers and levers of health-enhancing physical activity policies in mid-size French municipalities

Background

Policy is one of the levers for initiating structural change to foster the promotion of health-enhancing physical activity (HEPA). To this end, policy-makers have to deal with complex ecosystems embedded in specific contexts. However, limited research has been conducted on this topic at the local level. The purpose of this study was to identify the perceived barriers and levers of HEPA policies according to department heads and elected officials across various sectors in mid-size French municipalities.

Methods

This study used a mixed method primarily based on an adaptation of the concept mapping approach. A list of statements completing the sentence: ‘In a mid-size municipal context, to develop HEPA policies, it is necessary to …’ was submitted to key informants of 17 mid-sized French cities. Key informants in each municipality first rated the importance of each statement without considering their local context; they then rated the feasibility of each statement given their local context. In both cases, they used a Likert scale ranging from 1 to 6.

Results

A total of 23 municipal department heads and 10 elected officials from the sport (n = 14), health (n = 10) and social (n = 9) sectors in 11 mid-size French cities participated in this study. A list of 84 statements, sorted into 16 categories, was rated by participants according to their importance (M = 4.52, SD = 0.86) and their feasibility (M = 3.77, SD = 0.74). Potential barriers to (n = 10) and levers of (n = 38) HEPA policy development were identified. These results varied according to the position and sector of the participants.

Conclusions

The results suggest that local contextual factors can affect the development of HEPA policies in mid-size French municipalities. The different perceptions of the potential levers and barriers according to sector might affect intersectoral collaboration. This study contributes by enhancing understanding of how local HEPA policies are developed in the French context.

Developing an Indicator System for a Healthy City: Taking an Urban Area as a Pilot

PURPOSE

The Healthy Cities Project is an important strategy for global health. This study aimed to develop a scientific and appropriate indicator system for the evaluation of a Healthy City in Chongqing, China.

METHODS

Data were collected via a review of government documents, focus group discussions, and in-depth interviews. A total of 34 government documents were reviewed to build the indicator database based on our previous studies. The first round of focus group discussions, which involved eight health-related experts, was conducted to form the indicator system framework. In-depth interviews with 15 experts from government departments were conducted to design the improved indicator system. The second round of focus group discussions, which featured four experts, was conducted to obtain the final recommended list of indicators. A thematic framework was used to analyze the detailed interview notes.

RESULTS

The indicator system for the Healthy City consisted of 5 first-level indicators, 21 second-level indicators (e.g., health literacy), 73 third-level indicators (e.g., incidence of myopia), and three characteristic indicators. This indicator system spanned the scope of the environment, society, health services, healthy people, and health behaviors.

CONCLUSION

This indicator system was based on the current status of the construction of the Healthy City in the pilot district. The indicator system could be dynamically adjusted according to the development of the Healthy City in the pilot district. Government departments play an important decision-making role in the development process of this indicator system.

Effects of the Health Promotion Programs on Happiness

The Healthy City program is a comprehensive health promotion program implemented by local governments to improve citizens’ health. The Healthy City program aims to improve citizens’ quality of life through health promotion activities in daily life. It also improves health by eliminating health risk factors and increasing citizens’ happiness. Therefore, this study investigated the effects of the Healthy City program on the happiness index of local residents and the correlation between the Healthy City program and the happiness index using quality of life as a parameter. We conducted a questionnaire survey of residents of Seoul, where Healthy City networks are actively promoted. A total of 392 responses were obtained. Structural equations were used to analyze the collected data. The Healthy City program had positive effects on the happiness index. In other words, it increased the happiness index by improving the health of the local residents. Relevant policy efforts are also being made to advance health services through Healthy City programs. For an effective Healthy City program, it is necessary to implement policies regarding health equity, to expand Healthy City programs based on a settings approach, and to implement a sustainable Healthy City program through the establishment of Healthy City governance.

Population Health Inequalities Across and Within European Metropolitan Areas through the Lens of the EURO-HEALTHY Population Health Index

The different geographical contexts seen in European metropolitan areas are reflected in the uneven distribution of health risk factors for the population. Accumulating evidence on multiple health determinants point to the importance of individual, social, economic, physical and built environment features, which can be shaped by the local authorities. The complexity of measuring health, which at the same time underscores the level of intra-urban inequalities, calls for integrated and multidimensional approaches. The aim of this study is to analyse inequalities in health determinants and health outcomes across and within nine metropolitan areas: Athens, Barcelona, Berlin-Brandenburg, Brussels, Lisbon, London, Prague, Stockholm and Turin. We use the EURO-HEALTHY Population Health Index (PHI), a tool that measures health in two components: Health Determinants and Health Outcomes. The application of this tool revealed important inequalities between metropolitan areas: Better scores were found in Northern cities when compared with their Southern and Eastern counterparts in both components. The analysis of geographical patterns within metropolitan areas showed that there are intra-urban inequalities, and, in most cities, they appear to form spatial clusters. Identifying which urban areas are measurably worse off, in either Health Determinants or Health Outcomes, or both, provides a basis for redirecting local action and for ongoing comparisons with other metropolitan areas.

Urban Health Indicator Tools of the Physical Environment: a Systematic Review

Urban health indicator (UHI) tools provide evidence about the health impacts of the physical urban environment which can be used in built environment policy and decision-making. Where UHI tools provide data at the neighborhood (and lower) scale they can provide valuable information about health inequalities and environmental deprivation. This review performs a census of UHI tools and explores their nature and characteristics (including how they represent, simplify or address complex systems) to increase understanding of their potential use by municipal built environment policy and decision-makers. We searched seven bibliographic databases, four key journals and six practitioner websites and conducted Google searches between January 27, 2016 and February 24, 2016 for UHI tools. We extracted data from primary studies and online indicator systems. We included 198 documents which identified 145 UHI tools comprising 8006 indicators, from which we developed a taxonomy. Our taxonomy classifies the significant diversity of UHI tools with respect to topic, spatial scale, format, scope and purpose. The proportions of UHI tools which measure data at the neighborhood and lower scale, and present data via interactive maps, have both increased over time. This is particularly relevant to built environment policy and decision-makers, reflects growing analytical capability and offers the potential for improved understanding of the complexity of influences on urban health (an aspect noted as a particular challenge by some indicator producers). The relation between urban health indicators and health impacts attributable to modifiable environmental characteristics is often indirect. Furthermore, the use of UHI tools in policy and decision-making appears to be limited, thus raising questions about the continued development of such tools by multiple organisations duplicating scarce resources. Further research is needed to understand the requirements of built environment policy and decision-makers, public health professionals and local communities regarding the form and presentation of indicators which support their varied objectives.

The importance of green spaces to public health: a multi-continental analysis

As green spaces are a common feature of liveable cities, a detailed understanding of the benefits provided by these areas is essential. Although green spaces are regarded as a major contribution to the human well-being in urbanized areas, current research has largely focused on the cities in developed countries and their global importance in terms of public health benefits remains unclear. In this study, we performed a multiple linear regression using 34 cities in different regions across the globe to investigate the relationship between green spaces and public health. Our analysis suggested that for richer cities, green spaces were associated with better public health; whereas a greater area of green spaces was associated with reduced public health in the poorest cities. In contrast to previous studies, which typically found positive relationships between green spaces and health benefits, we demonstrate that health benefits of green spaces could be context dependent.

Socio-demographic factors and the prevalence of burns in children: an overview of the literature

BACKGROUND

In most countries, socio-demographic factors influence the incidence of burns in children. The aims of this literature review were therefore to identify which of those factors are linked to an increase in the prevalence and identify ways of enhancing burn prevention programmes and preventing practices which play a role in the occurrence of burns in children.

METHOD

A comprehensive search (no time limit) of primary studies, titles and abstracts was undertaken in the following electronic databases; MEDLINE, CINAHL, ERIC, Cochrane Library, PsychInfo and Google Scholar.

RESULTS

Socio-demographic factors which were linked to an increased incidence of burns include low household income, living in deprived areas, living in rented accommodation, young mothers, single-parent families and children from ethnic minorities. The level of parental education, parental occupation, and the type and size of accommodation were also cited.

CONCLUSION

A range of socio-demographic factors result in an increase in the prevalence of burns, and the risk is even greater in children who are exposed to a number of these factors. Such information will be useful for planning prevention strategies and identifying further research questions that need to be answered.

Socioeconomic status, comorbidity, activity limitation, and healthy life expectancy in older men and women: a 6-year follow-up study in Japan

This study aimed to explore the structural contributions of socioeconomic status (SES), comorbidity, and activity limitation to the healthy life expectancy (HALE) of Japanese suburban elderly. A questionnaire survey was distributed to all residents aged 65 years and older in Tama City, Tokyo, in 2001; a follow-up study was conducted in 2004; and individual vital status data from the municipal residents' registry were tracked until 2007. In all, 7,905 respondents were included for analysis. Data analysis was performed by structural equation modeling (SEM). The data were well fit by the models, and HALE was found to be well explained by SES, comorbidity, and activity limitation (R (2) = .59 for men and R (2) = .71 for women). In conclusion, elderly people with higher SES were more likely to live longer with good self-rated health, via living with less chronic diseases and better performance in daily living activities, especially for elderly women.

Urban ecosystem health assessment: perspectives and Chinese practice

The concept of ecosystem health is a way to assess the holistic operations and development potential of urban ecosystems. Accelerated by the practical need for integrated ecosystem management, assessment of urban ecosystem health has been greatly developed and extensively applied in urban planning and management. Development is aimed at comprehensively evaluating the performance of urban ecosystems, identifying the limiting factors, and providing suggestions for urban regulation. The time has come for reviewing and establishing an instructional framework for urban ecosystem health assessment to shed light on certain essential issues of urban ecosystem health. Based on literature reviews and series of practice, a holistic framework of urban ecosystem health assessment is proposed. The framework covers the essential elements of urban ecosystem health and integrates three dimensions: theoretical foundation, assessment method, and practical application. Concrete assessment methods are also established, focusing on both external performance and internal metabolic processes. The practice of urban ecosystem health assessment in China is illustrated to briefly demonstrate the application of the established framework and methods. Some prospects are discussed for urban ecosystem health assessment and its application in urban planning and management.

Health and environment in the context of urbanization

This paper introduces a series of research projects designed to fulfill the societal role of environmental health studies by investigating (1) the dynamic and complex relationships between environmental conditions and (2) health in an urban setting. Research in this first category has revealed the existence of the combined influence of multiple physical environmental factors on health and its mechanisms. In the second category, there have been a number of studies of the integrated influence of social environmental factors on health employing an aggregate modeling of multiple determinants of health and studies of individual topics related to social determinants of health. These research projects have contributed to the formulation of specific remedies and the development of comprehensive health policies. Participatory approaches have been used to enhance capacity building opportunities and to ensure that research results reflect the actual conditions in urban societies. Healthy Cities projects and programs have been developed in close collaboration with this type of research. Urban societies have become interdependent and share the same issues globally. Further research into the relationships between health and the environment in the context of urbanization will expand the base of evidence applicable to the complex realities in modern societies.

Area-level social fragmentation and walking for exercise: cross-sectional findings from the Quebec Adipose and Lifestyle Investigation in Youth Study

OBJECTIVES

We determined whether social fragmentation, which is linked to the concept of anomie (or normlessness), was associated with a decreased likelihood of willingness to walk for exercise.

METHODS

Data were collected from mothers and fathers of 630 families participating in the Quebec Adipose and Lifestyle Investigation in Youth Cohort, an ongoing longitudinal study investigating the natural history of obesity and insulin resistance in children. Social fragmentation was defined as the breakdown of social bonds between individuals and their communities. We used log-binomial multiple regression models to estimate the association between social fragmentation and walking for exercise.

RESULTS

Higher social fragmentation was associated with a decreased likelihood of walking for exercise among women but not men. Compared with women living in neighborhoods with the lowest social fragmentation scores (first quartile), those living in neighborhoods in the second (relative risk [RR] = 0.91; 95% confidence interval [CI] = 0.78, 1.05), third (RR = 0.83; 95% CI = 0.70, 1.00), and fourth (RR = 0.80; 95% CI = 0.65, 0.99) quartiles were less likely to walk for exercise (P = .02).

CONCLUSIONS

Social fragmentation is associated with reduced walking among women. Increasing neighborhood stability may increase walking behavior, especially among women.

Out of our inner city backyards: re-scaling urban environmental health inequity assessment

In this paper, we report the results of a three-year research project (2008-2011) that aimed to identify urban environmental health inequities using a photography-mediated qualitative approach adapted for comparative neighbourhood-level assessment. The project took place in Vancouver, Toronto, and Winnipeg, Canada and involved a total of 49 inner city community researchers who compared environmental health conditions in numerous neighbourhoods across each city. Using the social determinants of health as a guiding framework, community researchers observed a wide range of differences in health-influencing private and public spaces, including sanitation services, housing, parks and gardens, art displays, and community services. The comparative process enabled community researchers to articulate in five distinct ways how such observable conditions represented system level inequities. The findings inform efforts to shift environmental health intervention from constricted action within derelict urban districts to more coordinated mobilization for health equity in the city.

Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuan earthquake

Major earthquakes often result in incalculable environmental damage, loss of life, and threats to health. Tremendous progress has been made in response to many medical challenges resulting from earthquakes. However, emergency medical rescue is complicated, and great emphasis should be placed on its organisation to achieve the best results. The 2008 Wenchuan earthquake was one of the most devastating disasters in the past 10 years and caused more than 370,000 casualties. The lessons learnt from the medical disaster relief effort and the subsequent knowledge gained about the regulation and capabilities of medical and military back-up teams should be widely disseminated. In this Review we summarise and analyse the emergency medical rescue efforts after the Wenchuan earthquake. Establishment of a national disaster medical response system, an active and effective commanding system, successful coordination between rescue forces and government agencies, effective treatment, a moderate, timely and correct public health response, and long-term psychological support are all crucial to reduce mortality and morbidity and promote overall effectiveness of rescue efforts after a major earthquake.

Public health status and influence factors after 2008 Wenchuan earthquake among survivors in Sichuan province, China: cross-sectional trial

OBJECTIVES

On 12 May 2008, an earthquake with a magnitude of 8.0 on the Richter scale struck in Sichuan province, China. After the disaster, approximately 5 million people were living in temporary shelters. The objectives of this study were: (1) to provide the basic information on public health outcomes among the survivors; (2) to compare these outcomes between counties affected to differing extents by the earthquake; and (3) to identify important policies and programmes associated with public health outcomes.

STUDY DESIGN

Cross-sectional multicluster sample surveys were employed using data collected from two counties.

METHODS

Cross-sectional surveys were conducted in August 2008 in two counties in Sichuan province. The study outcomes [physical component summary (PCS) and mental component summary (MCS)] were measured using Short Form-12. Independent demographic, socio-economic and trauma exposure variables were also measured. Multivariate regression analysis was conducted to investigate associations between the independent variables and PCS and MCS outcomes.

RESULTS

In total, 3862 interviews were completed in the two counties. The mean PCS score was 37.6 [95% confidence interval (95% CI 35.13-41.97) in Beichuan county and 45.4 (95% CI 44.30-45.95) in Langzhong county. MCS scores were 36.8 (95% CI 33.61-40.71) in Beichuan county and 49.6 (95% CI 49.69-50.01) in Langzhong county, well below the instrument norm of 50. Variables with negative associations with physical or mental health included: female gender, living in a temporary shelter, higher income, deaths among family/friends, family property damaged and illness within the past 2 weeks. Higher frequencies of trauma exposure (more than six trauma exposure events) showed a strong significant negative association with PCS and MCS in both counties.

CONCLUSIONS

Interventions should be designed to focus on people without a household income (or a lower income), living in shelters or temporary houses. Governments should support income-generating activities and improve living conditions and public health status.

Constructing area-level indicators of successful ageing in Taiwan

We constructed area-level indicators of successful ageing in Taiwan. Area-level successful ageing was defined as follows: the living environment in a community/city is beneficial for physical, psychological and social health, and the people living in the area are well informed about the issues that pertain to maintaining health and behave in ways that promote their health. A modified Delphi method and analytical hierarchy process were used, with eight experts completing three successive rounds of questionnaires to determine the appropriate dimensions and indicators. In total, 65 indicators of area-level successful ageing were suggested. The weights of the six dimensions of the area indicators were determined as follows: health status (0.273), health lifestyle (0.182), social participation (0.166), health-care resources and utilisation (0.164), social environment (0.113) and natural environment (0.102). Nationwide survey data and government statistics were used to describe the profiles of 23 cities and counties in Taiwan with respect to successful ageing. Degree of ageing and geographic location were not related significantly to the total successful ageing scores of the cities/counties. However, urbanisation was correlated negatively to the total score (Spearman's rho = -0.43), the dimensions health status (rho = -0.54), health lifestyle (rho = -0.52), and natural environment (rho = -0.43), and degree of ageing was related moderately and negatively to health lifestyle (rho = -0.39). There were significant differences in health lifestyle and natural environment according to geographic location. These area indicators will be helpful to local governments for monitoring and improving successful ageing within their communities.

Health-care provision factors associated with child immunization coverage in a city centre and a rural area in Kabul, Afghanistan

A total of 1327 households were surveyed in Kabul province, Afghanistan to evaluate child immunization coverage and its association with distance to health facilities, attendance at antenatal care, the place of delivery and contact by outreach activity. The proportion of fully immunized children, those who had received at least 1 dose of BCG, 3 doses of DPT, and 1 dose of measles vaccine, was 84.5% in the city centre and 60.7% in the rural area. Fully immunized status was positively associated with close proximity to a health facility (odds ratio [OR]=1.92, [95%CI, 1.08, 3.39]), and attendance at antenatal care (OR=1.39, [95%CI, 1.00, 1.93]) in the city centre, and outreach contact (OR=11.6, [95%CI, 6.92, 19.4]) in the rural area after adjustment for demography, socio-economic factors, participation in health education and experiences of hardship. Attendance at antenatal care in the rural area (OR=1.91, [95%CI, 1.35, 2.72]), and institutional delivery in the city centre and rural area (OR=2.83, [95%CI, 1.20, 6.71]; OR=2.17, [95%CI, 1.01, 4.64], respectively) were positively associated with antigen specific coverage. Improving multiple community conditions including health-care provision and socio-economic factors through close partnership among various sectors promotes the immunization program.

Rural-urban differences in health and health behaviour: a baseline description of a community health-promotion programme for the elderly

STUDY OBJECTIVE

To (1) describe the setting and design of the Good Ageing in Lahti Region (GOAL) programme; (2) by using the baseline results of the GOAL cohort study, to examine whether living in urban, semi-urban, or rural communities is related to risk factors for chronic diseases and functional disability in ageing individuals.

DESIGN

The baseline data of a cohort study of ageing individuals living in three community types (urban, semi-urban, rural). Data were collected by two questionnaires and laboratory assessments.

SETTING

Fourteen municipalities in the Lahti region (Päijät-Häme County) in Finland.

PARTICIPANTS

A regionally and locally stratified random sample of men and women born in 1946-50, 1936-40, and 1926-30. A total of 4,272 were invited and 2,815 (66%) participated.

MAIN RESULTS

Elevated serum cholesterol, obesity, disability, sedentary lifestyle (<2 times/week walking), and high fat intake were more prevalent in rural vs. urban and semi-urban communities. After adjustment for sex, age, education, obesity, diet, physical activity, smoking, and alcohol use, rural communities remained the only community type with increased (p<0.05) probability for high BMI (OR 1.33) and high waist circumference (OR 1.43).

CONCLUSIONS

The unfavourable health and lifestyle profile, together with an old population, makes health promotion for elderly citizens a special challenge for rural communities such as those in Päijät-Häme County, Finland. Most, if not all, of the differences in health between the three community types were explained by educational background, physical activity, and smoking.

Calculation of prefectural disability-adjusted life expectancy (DALE) using long-term care prevalence and its socioeconomic correlates in Japan

OBJECTIVES

The objectives of this study were: (1) to determine the disability weight, "utility", for calculation of disability-adjusted life expectancy (DALE) using the prevalence of long-term care; (2) to calculate prefectural DALE; and (3) to clarify the relation between DALE and area socioeconomic conditions in Japan.

METHODS

Disability utility by care level (support and levels I-V) of long-term care insurance was determined by a survey of 236 professionals with four standard utility measures: EuroQol-5D, time trade-off, standard gamble, and visual analogue scale. DALE at age 65 (DALE65) and age-adjusted weighted disability prevalence (WDP) of 47 prefectures were calculated using the determined utilities, prevalence of long-term care, and life tables. The relationships of DALE and WDP to mortality from major causes and socioeconomic indicators were examined by correlation analysis.

RESULTS

The determined utilities were: support, 0.78; level I, 0.68; level II, 0.64; level III, 0.44; level IV, 0.34; and level V, 0.21. The prefectural DALE65 ranged from 17.11 to 15.29 years for men and from 20.21 to 18.42 years for women. Strong correlations were found between DALE65 and mortality for both sexes. Male DALE65 was correlated with no socioeconomic indicators, while female DALE65 was correlated with some indicators. WDP was positively associated with indicators representing socioeconomic disadvantage, such as unemployment rate and percentage of elderly single households.

CONCLUSIONS

The socioeconomic correlates of DALE and WDP suggested that favorable socioeconomic policies, in addition to a decrease in mortality from major causes, will contribute to significant extension of the independence period in the elderly. The method proposed here encourages the practical use of health expectancy in health policy, especially at local and regional levels.

Harboring illnesses: on the association between disease and living conditions in a Palestinian refugee camp in Lebanon

This research examined the association between the domestic built environment in a Palestinian refugee camp in Beirut, Lebanon, and the presence of illness among household members. Data on the domestic built environment, socio-demographics and health were collected in 860 households. The association between the presence of illness among household members and three environmental indices, namely infrastructure and services, housing conditions, and crowding was evaluated. These indices were based on a number of items that reflected the existing problems in the domestic built environment. The main finding was the positive association between poor housing conditions and the presence of illness among household members. Households with 8 - 15 housing problems were twice more likely to report the presence of illness than those with less than four housing problems (OR=2.08, 95% CI=1.40 - 3.11). This research contributes to the understanding of the influence of the built environment on the health of a refugee population.

Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincial-territorial level

BACKGROUND

Since, at the health system level, there is little research into the possible interrelationships among the various indicators of health, healthcare performance, non-medical determinants of health, and community and health system characteristics, we conducted this study to explore such interrelationships using the Canadian Health Indicators Framework.

METHODS

We conducted univariate correlational analyses with health and healthcare performance as outcomes using recent Canadian data and the ten Canadian provinces and three territories as units of the analyses. For health, 6 indicators were included. Sixteen healthcare performance indicators, 12 non-medical determinants of health and 16 indicators of community and health system characteristics were also included as independent variables for the analysis. A set of decision rules was applied to guide the choice of what was considered actual and preferred performance associations.

RESULTS

Health (28%) correlates more frequently with non-medical determinants than healthcare does (12%), in the preferred direction. Better health is only correlated with better healthcare performance in 13% of the cases in the preferred direction. Better health (24%) is also more frequently correlated with community and health system characteristics than healthcare is (13%), in the preferred direction.

CONCLUSION

Canadian health performance is a function of multiple factors, the most frequent of which may be the non-medical determinants of health and the community characteristics as against healthcare performance. The contribution of healthcare to health may be limited only to relatively small groups which stand to benefit from effective healthcare, but its overall effect may be diluted in summary measures of population health. Interpreting multidimensional, multi-indicator performance data in their proper context may be more complex than hitherto believed.

Variation of health status among people living on boats in Hue, Vietnam

OBJECTIVES

To examine patterns of disease and injury in people living on boats in Hue City, Vietnam, and their relations to socioeconomic conditions, sanitary practices, disease prevention proficiency, and people's preference to continued living on boats.

METHODS

The subjects were 3737 people aged 5 years and over living on boats in Hue City, Vietnam. Diseases and injuries were diagnosed according to ICD-10. The associations between disease/injury and socioeconomic conditions, sanitary practices, disease prevention proficiency, and preference to continued living on boats were analysed by logistic regression.

MAIN RESULTS

The prevalence rates of certain infectious and parasitic diseases, diseases of the respiratory system, diseases of the skin and subcutaneous tissue, diseases of the digestive system, and injuries were 85.3%, 78.0%, 51.2%, 15.4%, and 13.2%, respectively. Various associations were seen between diseases/injuries and socioeconomic conditions. Patterns of disease were strongly influenced by sanitary practices. Better disease prevention proficiency was significantly related to lower prevalence of the first three categories of diseases/injuries regardless of sex, age, or socioeconomic status (p < 0.05, p < 0.001, p < 0.001, respectively). Diseases were more prevalent among people who preferred not to continue living on boats.

CONCLUSIONS

This large scale comprehensive field study illustrated major diseases and injuries among people living on boats. Variations in health status showed a web-like relation of socioeconomic conditions, sanitary practices, disease prevention proficiency, and preference to continued living on boats. Measures to develop disease prevention proficiency reduce the risk of disease and injury.

Variations in societal characteristics of spatial disease clusters: examples of colon, lung and breast cancer in Japan

Background

Spatial analyses and ecological studies are essential for epidemiology and public health. The present study combining these two methods was performed to identify spatial clusters of selected types of cancer in Japan and to determine their societal characteristics focusing on homogeneity among clusters.

Results

Spatial clusters of high mortality rates of male colon and lung cancer and of female breast cancer were identified by the spatial scan statistic using Japanese municipal data (N = 3360) from 1993 to 1998 and also municipalities were divided into four societal clusters based on socioeconomic indicators and population density (urban-rich, suburban, rural-poor, and clutter). Five, seven, and four mortality clusters were identified for lung, colon and breast cancer, respectively. For colon and breast cancer, most municipalities of all except one cluster were included in a single societal cluster (urban-rich). The municipalities associated with mortality clusters for lung cancer belonged to various societal clusters.

Conclusion

Increased mortality rates of colon and breast cancer can be explained by homogenous societal characteristics related to urbanisation, although there were exceptional areas with higher mortality rates. The regional variation in lung cancer mortality rate appeared to be due to heterogeneous factors. These findings and the analysis performed in the present study will contribute to both nationwide and region-specific cancer prevention strategies.

Improvement in maternal health literacy among pregnant women who did not complete compulsory education: policy implications for community care services

This paper examined factors that influence the improvement in maternal health literacy among pregnant women in Paraguay, including those who did not complete compulsory education but participated in a community-based antenatal care program. Structured interviews were conducted to evaluate the pregnant women's maternal health literacy during their first, second, and third visits to the program in the Caazapa Region. The associations between individual maternal health knowledge scores and its gains, healthcare personnel capabilities, available health facility equipment, community social network, and living environment were analyzed by multiple regression analysis. The mean maternal health knowledge score from 124 women who completed three-consecutive assessments increased between the first and third interviews. Higher capabilities of healthcare personnel and better living environment were significantly related to gains in the maternal health knowledge score (p<0.01). Wider application of a community-based antenatal care program to meet the needs of those who are functionally illiterate in the standard language of the country, training for community healthcare personnel to improve capabilities, and resources for social network in the community would contribute to the improvement in maternal health literacy.

Municipal socioeconomic status and mortality in Japan: sex and age differences, and trends in 1973-1998

The purpose of this study was to examine the sex and age differences and the time trends in the association between municipal socioeconomic status (SES) and all-cause mortality across Japan from 1973 to 1998. Sex-specific mortality of municipalities (N=3319 in 1995) by age groups (total, under 75-year, and over 75-year populations) was linked to municipal SES indicators related to income, education, unemployment and living space, and two SES composite indices formulated by principle component analysis (Index 1 related to lower income and education, and Index 2 related to unemployment and overcrowding). The relation was assessed using mortality gradients by SES quintiles and Bayesian hierarchical Poisson regression. The results showed that a lower SES was related to higher mortality for all SES indicators and composite indices. The mortality gradient was steeper for the under 75-year population than the total and over 75-year populations, and the relation between mortality and income- and education-related indicators/index was stronger for males than for females. The time trend showed an increase in the relation for Index 2, while a decrease for Index 1. This study demonstrated that lower municipal SES had an adverse influence on population health, and the influence was marked for males and premature death. Although a substantial health disadvantage still remained in lower SES areas, the impact of SES factors on geographical health variation changed over time; the association with mortality has weakened for income and education, while it has strengthened for unemployment and living space.

The relationship between housing and health: children at risk

In November 2002, the National Center for Healthy Housing convened a 2-day workshop to review the state of knowledge in the field of healthy housing. The workshop, supported with funds from the U.S. Centers for Disease Control and Prevention's National Center for Injury Prevention and Control and National Center for Environmental Health, was unique in that it focused solely on the effect of housing on children's health and the translation of research findings into practical activities in home construction, rehabilitation, and maintenance. Participants included experts and practitioners representing the health, housing, and environmental arenas. Presentations by subject-matter experts covered four key areas: asthma, neurotoxicants, injury, and translational research. Panel discussions followed the presentations, which generated robust dialogue on potential future research opportunities and overall policy gaps. Lack of consensus on standard measurements, incomplete understanding about the interaction of home hazards, inadequate research on the effectiveness of interventions, and insufficient political support limit current efforts to achieve healthy housing. However, change is forthcoming and achievable. Key words: asthma, childhood exposure, environmental toxicants, healthy housing, lead poisoning.

Increased excess deaths in urban areas: quantification of geographical variation in mortality in Japan, 1973-1998

To quantify the magnitude of geographical health inequality by sex and age group, and to observe the change in regional distribution of health disadvantage, this study estimated excess deaths attributable to the mortality variation among municipalities across Japan from 1973 through 1998. The municipalities (N = 3340 in 1995) were divided into quintiles according to standardized mortality ratio (SMR). Using the mortality of the lowest SMR quintile as the standard, the number of excess deaths (ED) and its ratio to observed deaths (EDR) were estimated by sex, age group (total population and under 65-year population) and regional block in 1973-1977, 1978-1982, 1983-1987, 1988-1992 and 1993-1998. Total annual ED in 1993-1998 was estimated as 47,124 for males and 46,562 for females, representing EDR of 9.9 and 11.6%, respectively. The under 65-year population had a higher EDR than the total population. Rural regions showed a marked decrease in EDR in contrast to the increase in urban regions over time. The present study suggests that the reduction of a large number of deaths, especially premature deaths, is expected by elimination of geographical health inequality, and that health policies for urban residents are prioritized.

Visual localisation of community health needs to rational decision-making in public health services

The objectives were to visualise the locations of community health needs and to develop a community health needs assessment geographic information system (GIS) for rational decision-making in public health services. We compiled census data, digital data of basic planning maps, digital data of topographic maps, contents of registers of medical and welfare facilities, and statistics of establishments into a geographical database; visualised geographical distributions of specific community health needs by integrating sets of indicators to reflect individual needs; and quantified their clustering by the nearest neighbour method. The database aggregated 3400 items of demographic, life and environmental factors. Thematic maps and clustering values showed different patterns of geographical distribution of the individual community needs. Means to match needs with services in smaller geographical units were discussed. This GIS will support appropriate resource allocation, intersectoral collaboration and greater transparency in planning and implementing services, by visualising locations of community health needs.

Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces

STUDY OBJECTIVES

To study the association between greenery filled public areas that are nearby a residence and easy to walk in and the longevity of senior citizens in a densely populated, developed megacity.

DESIGN

Cohort study.

METHODS

The authors analysed the five year survival of 3144 people born in 1903, 1908, 1913, or 1918 who consented to a follow up survey from the records of registered Tokyo citizens in relation to baseline residential environment characteristics in 1992.

MAIN RESULTS

The survival of 2211 and the death of 897 (98.9% follow up) were confirmed. The probability of five year survival of the senior citizens studied increased in accordance with the space for taking a stroll near the residence (p<0.01), parks and tree lined streets near the residence (p<0.05), and their preference to continue to live in their current community (p<0.01). The principal component analysis from the baseline residential environment characteristics identified two environment related factors: the factor of walkable green streets and spaces near the residence and the factor of a positive attitude to a person's own community. After controlling the effects of the residents' age, sex, marital status, and socioeconomic status, the factor of walkable green streets and spaces near the residence showed significant predictive value for the survival of the urban senior citizens over the following five years (p<0.01).

CONCLUSIONS

Living in areas with walkable green spaces positively influenced the longevity of urban senior citizens independent of their age, sex, marital status, baseline functional status, and socioeconomic status. Greenery filled public areas that are nearby and easy to walk in should be further emphasised in urban planning for the development and re-development of densely populated areas in a megacity. Close collaboration should be undertaken among the health, construction, civil engineering, planning, and other concerned sectors in the context of the healthy urban policy, so as to promote the health of senior citizens.

Urban residential environments and senior citizens' longevity in megacity areas: the importance of walkable green spaces

STUDY OBJECTIVES

To study the association between greenery filled public areas that are nearby a residence and easy to walk in and the longevity of senior citizens in a densely populated, developed megacity.

DESIGN

Cohort study.

METHODS

The authors analysed the five year survival of 3144 people born in 1903, 1908, 1913, or 1918 who consented to a follow up survey from the records of registered Tokyo citizens in relation to baseline residential environment characteristics in 1992.

MAIN RESULTS

The survival of 2211 and the death of 897 (98.9% follow up) were confirmed. The probability of five year survival of the senior citizens studied increased in accordance with the space for taking a stroll near the residence (p<0.01), parks and tree lined streets near the residence (p<0.05), and their preference to continue to live in their current community (p<0.01). The principal component analysis from the baseline residential environment characteristics identified two environment related factors: the factor of walkable green streets and spaces near the residence and the factor of a positive attitude to a person's own community. After controlling the effects of the residents' age, sex, marital status, and socioeconomic status, the factor of walkable green streets and spaces near the residence showed significant predictive value for the survival of the urban senior citizens over the following five years (p<0.01).

CONCLUSIONS

Living in areas with walkable green spaces positively influenced the longevity of urban senior citizens independent of their age, sex, marital status, baseline functional status, and socioeconomic status. Greenery filled public areas that are nearby and easy to walk in should be further emphasised in urban planning for the development and re-development of densely populated areas in a megacity. Close collaboration should be undertaken among the health, construction, civil engineering, planning, and other concerned sectors in the context of the healthy urban policy, so as to promote the health of senior citizens.

Age-adjusted mortality and its association to variations in urban conditions in Shanghai

The objective of this study was to explore the association between health and urbanization in a megacity, Shanghai, by calculating the age-adjusted mortality ratio by ward-unit of Shanghai and by examining relationships between mortalities and urban indicators. Crude mortality rates and age-adjusted mortality ratios by ward-unit were calculated. Demographic, residential environment, healthcare, and socioeconomic indicators were formulated for each of the ward-units between 1995 and 1998. Correlation and Poisson regression analyses were performed to examine the association between urban indicators and mortalities. The crude mortality rate by ward-unit in 1997 varied from 6.3 to 9.4 deaths per 1000 population. The age-adjusted mortality ratio in 1997 by ward-units as reference to the average mortality of urban China varied from 57.8 to 113.3 within Shanghai. Age-adjusted mortalities were inversely related with indicators of a larger floor space of dwellings per population, a larger proportion of parks, gardens, and green areas to total land area; a greater number of health professionals per population; and a greater number of employees in retail business per population. Spacious living showed independent association to a higher standard of community health in Shanghai (P < 0.05). Consequences of health policy and the developments of urban infrastructural resources from the viewpoint of the Healthy Cities concept were discussed.

The national financial adjustment policy and the equalisation of health levels among prefectures

STUDY OBJECTIVES

The objectives of this study were to examine (1) trends concerning financial assistance from the national government to local governments, (2) trends regarding death rates and life expectancies among prefectures, and (3) the effect of the national financial adjustment policy in equalising both the revenues of local governments and variations in the health levels among prefectures in terms of death rates and life expectancies.

DESIGN

The study analysed prefectural income, the amount of national taxes collected, financial assistance from the national government to local governments, and age adjusted death rates and life expectancies of all of the prefectures in Japan during the period from 1965 through 1995.

MAIN RESULTS

(1) Under the financial adjustment policy, financial assistance from the national government to the local governments, which consists of the sum of the local allocation tax and treasury disbursements, increased from 1831 billion yen in 1965 to 31 116 billion yen in 1995. (2) During the same period, the age adjusted death rate per 100 000 people decreased from 1168.9 (1965) to 545.3 (1995). The range of variation in the age adjusted death rate among prefectures diminished as the coefficient of variation of the death rate declined from 0.060 in 1965 to 0.043 in 1995. (3) There was a significant statistical correlation between higher prefectural incomes and lower mortality rates during from 1965 until 1975 (p < 0.05), whereas this correlation was indistinct in the 1980s and has not been observed since 1990. (4) The relative health level of Tokyo has declined in terms of its ranking among all the prefectures with regard to life expectancy, from being the best in 1965 to below average in 1995.

CONCLUSIONS

The national financial adjustment policy to balance the revenues of local governments has increased the health levels of rural prefectures. It is probable that the policy reduced the disparity in death rates and life expectancies among prefectures throughout the country. However, the policy has precluded the nation's capital city from applying its economic resources as local government expenditures to deal with the megacity issues affecting health.