Urban upgrading and its impact on health: a "quasi-experimental" mixed-methods study protocol for the BH-Viva Project

Research Translation to Promote Urban Health in Latin America: The SALURBAL Experience

In highly urbanized and unequal Latin America, urban health and health equity research are essential to effective policymaking. To ensure the application of relevant and context-specific evidence to efforts to reduce urban health inequities, urban health research in Latin America must incorporate strategic research translation efforts. Beginning in 2017, the Urban Health in Latin America (SALURBAL) project implemented policy-relevant research and engaged policymakers and the public to support the translation of research findings. Over 6 years, more than 200 researchers across eight countries contributed to SALURBAL's interdisciplinary network. This network allowed SALURBAL to adapt research and engagement activities to local contexts and priorities, thereby maximizing the policy relevance of research findings and their application to promote policy action, inform urban interventions, and drive societal change. SALURBAL achieved significant visibility and credibility among academic and nonacademic urban health stakeholders, resulting in the development of evidence and tools to support urban policymakers, planners, and policy development processes across the region. These efforts and their outcomes reveal important lessons regarding maintaining flexibility and accounting for local context in research, ensuring that resources are dedicated to policy engagement and dissemination activities, and recognizing that assessing policy impact requires a nuanced understanding of complex policymaking processes. These reflections are relevant for promoting urban health and health equity research translation across the global south and worldwide. This paper presents SALURBAL's strategy for dissemination and policy translation, highlights innovative initiatives and their outcomes, discusses lessons learned, and shares recommendations for future efforts to promote effective translation of research findings.

Temporal trends of dengue cases and deaths from 2007 to 2020 in Belo Horizonte, Brazil

Dengue, a disease with multifactorial determinants, is linked to population susceptibility to circulating viruses and the extent of vector infestation. This study aimed to analyze the temporal trends of dengue cases and deaths in Belo Horizonte, Minas Gerais, Brazil, from 2007 to 2020. Data from the Notifiable Diseases Information System (Sinan) were utilized for the investigation. To assess the disease's progression over the study period and predict its future incidence, time series analyses were conducted using a generalized additive model (GAM) and a seasonal autoregressive integrated moving average (SARIMA) model. Over the study period, a total of 463,566 dengue cases and 125 deaths were reported. Notably, there was an increase in severe cases and deaths, marking hyperendemics characterized by simultaneous virus circulation (79.17% in 2016-50% in 2019). The generalized additive model revealed a non-linear pattern with epidemic peaks in 2010, 2013, 2016, and 2019, indicating an explosive pattern of dengue incidence. The SARIMA (3,1,1) (0,0,0)12 model was validated for each year (2015 to 2019). Comparing the actual and predicted numbers of dengue cases, the model demonstrated its effectiveness for predicting cases in the municipality. The rising number of dengue cases emphasizes the importance of vector surveillance and control. Enhanced models and predictions by local health services will aid in anticipating necessary control measures to combat future epidemics.

Determining the relationship between dengue and vulnerability in a Brazilian city: a spatial modeling analysis

Dengue is a viral infection transmitted by the Aedes aegypti mosquito. This study aimed to assess the distribution of cases and deaths from dengue and severe dengue, and its relationship with social vulnerability in Belo Horizonte, State of Minas Gerais, Brazil, from 2010 to 2018. The incidence and lethality rates of dengue and their relationship with sex, age, education, skin color, and social vulnerability were studied using chi-square tests, Ordinary Least Squares (OLS), and Geographically Weighted Regression (GWR) analyses. The number of cases of dengue in Belo Horizonte during the study period was 324,044 dengue cases, with 1,334 cases of severe dengue and 88 deaths. During the past few decades, the incidence rate of both dengue and severe cases varied, with an average incidence rate of respectively 1515.5 and 6.2/100,000 inhabitants. The increase in dengue cases was directly related to areas with higher social vulnerability areas and more working-age people. Also, the disease is more severe in people self-declared as black, elderly, and male. The findings of this study might provide relevant information for health services in the organization of control and prevention policies for this problem, emphasizing the most vulnerable urban areas and categories.

Evolution of fruit and vegetable intake among health promotion service participants in a Brazilian metropolis: 48-month follow-up of a randomized controlled community trial

OBJECTIVE

To assess longitudinal effects of a nutrition intervention on fruit and vegetable (F&V) intake among Primary Health Care (PHC) service participants in Belo Horizonte, Brazil.

METHODS

Demographics and health data on 3414 PHC service participants were collected at baseline in 2013-2014. F&V intake was assessed at baseline, 12, 36, and 48 months until 2017-2018. Services were randomized to control (CG, usual care) or intervention (IG, usual care and a Transtheoretical Model-based intervention to increase F&V intake). We performed difference-in-differences (DiD) analysis to identify intervention effects on F&V intake, and sensitivity analyses of participants observed at all timepoints.

RESULTS

Participants were mostly middle-aged, low-income women. Mean baseline intakes were 168.7 g of fruit, 202.0 g of vegetables, and 370.7 g of F&V, with lower fruit in the IG (164.1 g) than the CG (172.3 g). At 12 months, the intervention increased fruit intake in the IG and fruit and F&V intake among individuals with low baseline F&V intake. Fruit intake remained higher at 36 months in the IG. No effect on vegetable intake was identified. According to sensitivity analyses, effects on fruit intake among the complete sample did not remain significant at 36 months, and an effect on fruit intake at 36 months was identified among those with adequate baseline F&V intake. Reductions in F&V intake did not remain significant.

CONCLUSIONS

At 12 months, a TTM-based intervention increased fruit intake in the overall sample, and fruit and F&V intake among individuals with low baseline intakes. Repeated interventions may be needed over time.

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["My life will be much better than before": a qualitative study on the relationship between renewal of public housing, quality of life, and health]

The objective was to understand the link between housing, health and quality of life in a context of social housing regeneration, through the experiences and perceptions of its inhabitants, exploring the mechanisms that sustain this link before regeneration, and those elements derived from housing regeneration that result in improvements in quality of life and potentially in health. Between 1980 and the 2000s, Chile faced a massive quantitative housing deficit through a policy that delivered more than 120,000 low-cost social housing apartments. Today, thousands present severe habitability problems, generating negative consequences for their inhabitants, their health and well-being. Seeking to solve the deterioration of housing and neighborhoods, the Chilean Ministry of Housing and Urbanism developed the Housing Complex Regeneration Program. The RUCAS project seeks to evaluate the effects of the program on health and to assess the impact of interventions such as these on vulnerable populations in Latin America. We present results of 8 interviews and 2 focus groups conducted in a social housing complex in process of intervention in Viña del Mar. Using discursive content analysis, results show that the poor material quality of housing is perceived as harmful to health. Regenerated housing, on the other hand, promotes the recovery and re-appropriation of spaces and their uses, sociability, new healthy practices, positive feelings and psychological well-being, bringing to the fore the psychosocial component of people's relationship with their house. It is concluded that housing regeneration has the potential to benefit physical and mental health through both direct mechanisms, derived from the renovated materiality, and indirect mechanisms related to the practices and experiences of the lived space.

[Developing tools to study the health impact of urban transformations in high vulnerability contexts: the RUCAS study]

This article describes the design and characteristics of a questionnaire and an intradomiciliary observation tool developed to assess the housing-neighborhood-health relationship both cross-sectionally and longitudinally in the context of urban transformations carried out in populations of high socio-territorial vulnerability. The instruments were developed for the multi-method longitudinal study RUCAS (Urban Regeneration, Quality of Life and Health), a natural experiment aiming to assess the quality of life and health impact of a comprehensive Urban Regeneration Program in two social housing complexes in Chile. The design of the instruments followed four main stages: (1) narrative review of the literature to define the dimensions of the study, and of existing measurement instruments to identify appropriate items for measuring them; (2) content validation with experts; (3) pre-test; and (4) pilot study. The resulting questionnaire, composed of 262 items, considers the different stages of the life course and gender issues. The intradomiciliary observation tool (77 items) is applied by the interviewer. The instruments assess (i) characteristics of the current residential situation that are known to affect health and will be intervened by the program; (ii) dimensions of health potentially affected by the residential situation and/or by the intervention within the time frame of the study (4 years); (iii) other health and health-related conditions that are relevant, even if changes will not be modified within the time frame of the study; and (iv) relevant socioeconomic, occupational and demographic dimensions. The instruments have shown to be capable of addressing the multidimensionality of urban transformation processes in contexts of urban poverty in formal housing.

Disentangling associations between vegetation greenness and dengue in a Latin American city: Findings and challenges

Being a Re-Emerging Infectious Disease, dengue causes 390 million cases globally and is prevalent in many urban areas in South America. Understanding the fine-scale relationships between dengue incidence and environmental and socioeconomic factors can guide improved disease prevention strategies. This ecological study examines the association between dengue incidence and satellite-based vegetation greenness in 3826 census tracts nested in 474 neighborhoods in Belo Horizonte, Brazil, during the 2010 dengue epidemic. To reduce potential bias in the estimated dengue-greenness association, we adjusted for socioeconomic vulnerability, population density, building height and density, land cover composition, elevation, weather patterns, and neighborhood random effects. We found that vegetation greenness was negatively associated with dengue incidence in a univariate model, and this association attenuated after controlling for additional covariates. The dengue-greenness association was modified by socioeconomic vulnerability: while a positive association was observed in the least vulnerable census tracts, the association was negative in the most vulnerable areas. Using greenness as a proxy for vegetation quality, our results show the potential of vegetation management in reducing dengue incidence, particularly in socioeconomically vulnerable areas. We also discuss the role of water infrastructure, sanitation services, and tree cover in lowering dengue risk.

The Regeneración Urbana, Calidad de Vida y Salud - RUCAS project: a Chilean multi-methods study to evaluate the impact of urban regeneration on resident health and wellbeing

BACKGROUND

The available evidence of the health effects of urban regeneration is scarce In Latin America, and there are no studies focused on formal housing that longitudinally evaluate the impact of housing and neighborhood interventions on health. The "Regeneración Urbana, Calidad de Vida y Salud" (Urban Regeneration, Quality of Life, and Health) or RUCAS project is a longitudinal, multi-method study that will evaluate the impact of an intervention focused on dwellings, built environment and community on the health and wellbeing of the population in two social housing neighborhoods in Chile.

METHODS

RUCAS consists of a longitudinal study where inhabitants exposed and unexposed to the intervention will be compared over time within the study neighborhoods (cohorts), capitalizing on interventions as a natural experiment. Researchers have developed a specific conceptual framework and identified potential causal mechanisms. Proximal and more distal intervention effects will be measured with five instruments, implemented pre- and post-interventions between 2018 and 2021: a household survey, an observation tool to evaluate dwelling conditions, hygrochrons for measuring temperature and humidity inside dwellings, systematic observation of recreational areas, and qualitative interviews. Survey baseline data (956 households, 3130 individuals) is presented to describe sociodemographics, housing and health characteristics of both cohorts, noting that neighborhoods studied show worse conditions than the Chilean population.

DISCUSSION

RUCAS' design allows for a comprehensive evaluation of the effects that the intervention could have on various dimensions of health and health determinants. RUCAS will face some challenges, like changes in the intervention process due to adjustments of the master plan, exogenous factors -including COVID-19 pandemic and associated lockdowns- and lost to follow-up. Given the stepped wedge design, that the study capitalizes on within household changes over time, the possibility of adjusting data collection process and complementarity of methods, RUCAS has the flexibility to adapt to these circumstances. Also, RUCAS' outreach and retention strategy has led to high retention rates. RUCAS will provide evidence to inform regeneration processes, highlighting the need to consider potential health effects of regeneration in designing such interventions and, more broadly, health as a key priority in urban and housing policies.

Evaluating the health effects of place-based slum upgrading physical environment interventions: A systematic review (2012-2018)

Rapid urbanization in low- and middle-income countries (LMIC) is associated with increasing population living in informal settlements. Inadequate infrastructure and disenfranchisement in settlements can create environments hazardous to health. Placed-based physical environment upgrading interventions have potential to improve environmental and economic conditions linked to health outcomes. Summarizing and assessing evidence of the impact of prior interventions is critical to motivating and selecting the most effective upgrading strategies moving forward. Scientific and grey literature were systematically reviewed to identify evaluations of physical environment slum upgrading interventions in LMICs published between 2012 and 2018. Thirteen evaluations that fulfilled inclusion criteria were reviewed. Quality of evaluations was assessed using an adapted Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Findings were then pooled with those published prior to 2012. Narrative analysis was performed. Of thirteen evaluations, eight used a longitudinal study design (“primary evaluations”). All primary evaluations were based in Latin America and included two housing, two transportation, and four comprehensive intervention evaluations. Three supporting evaluations assessed housing interventions in Argentina and South Africa; two assessed a comprehensive intervention in India. Effects by intervention-type included improvements in quality of life and communicable diseases after housing interventions, possible improvements in safety after transportation and comprehensive interventions, and possible non-statistically significant effects on social capital after comprehensive interventions. Effects due to interventions may vary by regional context and intervention scope. Limited strong evidence and the diffuse nature of comprehensive interventions suggests a need for attention to measurement of intervention exposure and analytic approaches to account for confounding and selection bias in evaluation. In addition to health improvements, evaluators should consider unintended health consequences and environmental impact. Understanding and isolating the effects of place-based interventions can inform necessary policy decisions to address inadequate living conditions as rapid urban growth continues across the globe.

Homicídios em Belo Horizonte, MG: um retrato das iniquidades nas cidades

Resumo Os homicídios no Brasil são um dos indicadores mais sensíveis da desigualdade social nas cidades. Assim, políticas de proteção social integradas nos territórios podem impactar esse evento em saúde. Este artigo objetiva descrever os homicídios em Belo Horizonte à luz de um modelo conceitual, parte de um processo avaliativo de um projeto de reurbanização na cidade. A partir da revisão da literatura, construiu-se um modelo conceitual para a compreensão dos homicídios e sua vinculação com o viver nas cidades. Realizou-se um estudo descritivo dos homicídios a partir de dados do Sistema de Informação sobre Mortalidade (SIM) relativos ao período de 2002 a 2012. O modelo conceitual reforça que os homicídios encontram nas cidades seus mais expressivos determinantes vinculados à desigualdade e à exclusão, junto a valores de uma cultura de força e preconceitos. Os homicídios em Belo Horizonte apresentam taxas elevadas na cidade formal, sendo de três a seis vezes maiores nas favelas. Morrem mais negros, jovens homens, de baixa escolaridade, nas vias públicas e nos territórios vulneráveis. Os homicídios são a síntese das desvantagens urbanas, especialmente em tais áreas. Retrata-se em Belo Horizonte o que se vê no Brasil, denunciando a desigualdade e sua perversidade no viver e morrer nas cidades.

Mortality from Homicides in Slums in the City of Belo Horizonte, Brazil: An Evaluation of the Impact of a Re-Urbanization Project

Background: Homicide rates in Brazil are among the highest worldwide. Although not exclusive to large Brazilian cities, homicides find their most important determinants in cities' slums. In the last decade, an urban renewal process has been initiated in the city of Belo Horizonte, in Brazil. Named Vila Viva project, it includes structuring urban interventions such as urban renewal, social development actions and land regularization in the slums of the city. This study evaluates the project's effect on homicide rates according to time and interventions. Methods: Homicide rates were analyzed comparing five slums with interventions (S1⁻S5) to five grouped non-intervened slums (S0), with similar socioeconomic characteristics from 2002 to 2012. Poisson regression model estimates the effect of time of observation and the effect of time of exposure (in years) to a completed intervention, besides the overall risk ratio (RR). Results: Using the time of observation in years, homicide rates decreased in the studied period and even more if considered cumulative time of exposure to a completed intervention for S1, S2, S3 and S4, but not for S5. Conclusions: Although the results of the effect of the interventions are not repeated in all slums, a downward trend in homicide rates has been found, which is connected to the interventions. New approaches could be necessary in order to verify the nexus between slum renewal projects and the reduction of homicide rates.

Cause and context: place-based approaches to investigate how environments affect mental health

OBJECTIVES

Our surroundings affect our mood, our recovery from stress, our behavior, and, ultimately, our mental health. Understanding how our surroundings influence mental health is central to creating healthy cities. However, the traditional observational methods now dominant in the psychiatric epidemiology literature are not sufficient to advance such an understanding. In this essay we consider potential alternative strategies, such as randomizing people to places, randomizing places to change, or harnessing natural experiments that mimic randomized experiments.

METHODS

We discuss the strengths and weaknesses of these methodological approaches with respect to (1) defining the most relevant scale and characteristics of context, (2) disentangling the effects of context from the effects of individuals' preferences and prior health, and (3) generalizing causal effects beyond the study setting.

RESULTS

Promising alternative strategies include creating many small-scale randomized place-based trials, using the deployment of place-based changes over time as natural experiments, and using fluctuations in the changes in our surroundings in combination with emerging data collection technologies to better understand how surroundings influence mood, behavior, and mental health.

CONCLUSIONS

Improving existing research strategies will require interdisciplinary partnerships between those specialized in mental health, those advancing new methods for place effects on health, and those who seek to optimize the design of local environments.

Temporal and Spatial Trends in Childhood Asthma-Related Hospitalizations in Belo Horizonte, Minas Gerais, Brazil and Their Association with Social Vulnerability

INTRODUCTION

Asthma is a multifactorial disease and a serious public health problem. Environmental factors and poverty are the main determinants of this disease.

OBJECTIVE

To describe the spatial and temporal distribution of asthma-related hospitalizations and identify the areas with the highest prevalence of and vulnerability to severe asthma in a major Brazilian city.

METHODS

An ecological study of hospitalizations for asthma from 2002 to 2012, in children and adolescents under 15 years of age, living in Belo Horizonte, Southeast Brazil. All events were geocoded by residence address using Hospital Information System data. The socioeconomic vulnerability of residence address was ranked using the Health Vulnerability Index. Raster surfaces were generated and time-series plots were constructed to determine spatial and time trends in the frequency of asthma-related hospitalizations, respectively.

RESULTS

Asthma-related hospitalization rates were highest in children aged 0-4 years and in boys. There was a decreasing trend in the number of asthma-related hospitalizations across the study period. Approximately 48% of all hospitalizations were children living in health vulnerable areas. Seasonal trends showed a hospitalization peak in March, April, and May, coinciding with the post-rainy period.

CONCLUSION

Our findings suggest that social and environmental factors may be determinants of disparities in severe asthma.