Urban issues in health promotion strategies

Psychological distress and social support among conflict refugees in urban, semi-rural and rural settlements in Uganda: burden and associations

BACKGROUND

Recent research shows that psychological distress is on the rise globally as a result of the COVID-19 pandemic and restrictions imposed on populations to manage it. We studied the association between psychological distress and social support among conflict refugees in urban, semi-rural and rural settlements in Uganda during the COVID-19 pandemic.

METHODS

Cross-sectional survey data on psychological distress, social support, demographics, socio-economic and behavioral variables was gathered from 1014 adult refugees randomly sampled from urban, semi-rural and rural refugee settlements in Uganda, using two-staged cluster sampling. Data was analyzed in SPSS-version 22, and statistical significance was assumed at p < 0.05.

RESULTS

Refugees resident in rural/semi-rural settlements exhibited higher levels of psychological distress [F(2, 1011) = 47.91; p < 0.001], higher availability of social interaction [F(2, 1011) = 82.24; p < 0.001], lower adequacy of social interaction [F(2, 1011) = 54.11; p < 0.001], higher availability of social attachment [F(2, 1011) = 47.95; p < 0.001], and lower adequacy of social attachment [F(2, 1011) = 50.54; p < 0.001] than peers in urban settlements. Adequacy of social interaction significantly explained variations in psychological distress levels overall and consistently across settlements, after controlling for plausible confounders. Additionally, adequacy of social attachment significantly explained variations in psychological distress levels among refugees in rural settlements, after controlling for plausible confounders.

CONCLUSION

There is a settlement-inequality (i.e. rural vs. urban) in psychological distress and social support among conflict refugees in Uganda. To address psychological distress, Mental Health and Psychosocial Support Services (MHPSS) should focus on strategies which strengthen the existing social networks among refugees. Variations in social support are a key predictor of distress which should guide tailored need-adapted interventions instead of duplicating similar and generic interventions across diverse refugee settlements.

Conditions for the Successful Integration of an eHealth Tool "StopBlues" Into Community-Based Interventions in France: Results From a Multiple Correspondence Analysis

Background

For over a decade, digital health has held promise for enabling broader access to health information, education, and services for the general population at a lower cost. However, recent studies have shown mixed results leading to a certain disappointment regarding the benefits of eHealth technologies. In this context, community-based health promotion represents an interesting and efficient conceptual framework that could help increase the adoption of digital health solutions and facilitate their evaluation.

Objective

To understand how the local implementation of the promotion of an eHealth tool, StopBlues (SB), aimed at preventing psychological distress and suicide, varied according to local contexts and if the implementation was related to the use of the tool.

Methods

The study was nested within a cluster-randomized controlled trial that was conducted to evaluate the effectiveness of the promotion, with before and after observation (NCT03565562). Data from questionnaires, observations, and institutional sources were collected in 27 localities where SB was implemented. A multiple correspondence analysis was performed to assess the relations between context, type of implementation and promotion, and use of the tool.

Results

Three distinct promotion patterns emerged according to the profiles of the localities that were associated with specific SB utilization rates. From highest to lowest utilization rates, they are listed as follows: the privileged urban localities, investing in health that implemented a high-intensity and digital promotion, demonstrating a greater capacity to take ownership of the project; the urban, but less privileged localities that, in spite of having relatively little experience in health policy implementation, managed to implement a traditional and high-intensity promotion; and the rural localities, with little experience in addressing health issues, that implemented low-intensity promotion but could not overcome the challenges associated with their local context.

Conclusions

These findings indicate the substantial influence of local context on the reception of digital tools. The urban and socioeconomic status profiles of the localities, along with their investment and pre-existing experience in health, appear to be critical for shaping the promotion and implementation of eHealth tools in terms of intensity and use of digital communication. The more digital channels used, the higher the utilization rates, ultimately leading to the overall success of the intervention.

International Registered Report Identifier (IRRID)

RR2-10.1186/s13063-020-04464-2

Structural Interventions for HIV Prevention and Care Among US Men Who Have Sex with Men: A Systematic Review of Evidence, Gaps, and Future Priorities

The preponderance of HIV interventions have been behavioral, targeting individual, dyadic, or group dynamics. However, structural-level interventions are required to decrease HIV transmission and increase engagement in care, especially for men who have sex with men (MSM), particularly Black and Latinx MSM. A systematic literature review was conducted to assess the current state of structural interventions; only two studies detailing structural interventions related to HIV for Black and Latinx MSM in the US were identified. An additional 91 studies which discussed structural-level barriers to optimal HIV outcomes among MSM, yet which did not directly evaluate a structural intervention, were also identified. While this paucity of findings was discouraging, it was not unexpected. Results of the systematic review were used to inform guidelines for the implementation and evaluation of structural interventions to address HIV among MSM in the U.S. These include deploying specific interventions for multiply marginalized individuals, prioritizing the deconstruction of structural stigma, and expanding the capacity of researchers to evaluate “natural” policy-level structural interventions through a standardization of methods for rapid evaluative response, and through universal application of sex, sexual orientation, and gender identity demographic measures.

Effectiveness of Community-Based Health Promotion Interventions in Urban Areas: A Systematic Review

Over the past few decades, a community-based approach was seen to be the "gold standard" for health promotion and disease prevention, especially in the field of socially deprived neighborhoods in urban areas. Up to the beginning of the 2000s, earlier reviews provide valuable information on activities in this context. However, in their conclusions they were limited to North America and Europe. Therefore, we conducted a systematic literature review on community-based health promotion and prevention programs worldwide. The Pubmed and PsycINFO databases were screened for relevant articles published between January 2002 and December 2018, revealing 101 potentially eligible publications out of 3646 hits. After a systematic review process including searching the reference lists, 32 papers met the inclusion criteria and were included in the review. Twenty-four (75.0%) articles reported improvements in at least one health behavior, health service access, health literacy, and/or a range of health status outcomes. Large-scale community-based health promotion programs, however, often resulted in limited or missing population-wide changes. Possible reasons are methodological limitations, concurrent context effects, and limitations of the interventions used. Our results confirm that community-based interventions are promising for health promotion and disease prevention but so far their potential is not fully realized. For the future, such interventions should aim at proximal outcomes and invest in community capacity building.

Geospatial perspectives on health: The PrEP4Love campaign and the role of local context in health promotion messaging

Pre-exposure prophylaxis (PrEP) remains one of the most effective biomedical interventions for the prevention of HIV transmission. However, uptake among populations most impacted by the HIV epidemic remains low. La rge-scale awareness and mobilization campaigns have sought to address gaps in knowledge and motivation in order to improve PrEP diffusion. Such campaigns must be cognizant of the historical, physical, and structural contexts in which they exist. In urban contexts, neighborhood segregation has the potential to impact health outcomes and amplify disparities. Therefore, we present novel geospatial approaches to the evaluation of a Chicago-based PrEP messaging campaign (PrEP4Love) in a 2018 cohort of men who have sex with men and transgender women, contextualizing results within the localized infrastructure and public health landscape, and examining associations between geographic location and campaign efficacy. Results revealed notable variance in rates of PrEP uptake associated with campaign exposure by Chicago planning area, which are likely explained by the historical and contemporary impacts of racist structures on physical environment and city infrastructure. Findings have important implications for the evaluation and implementation of future messaging campaigns, which should take the unique historical, structural, and geospatial factors of their particular settings into account in order to achieve maximum impact.

Community-Based Interventions to Reduce Alcohol Consumption and Alcohol-Related Harm in Adults

Alcohol consumption was associated with 3 million deaths worldwide in 2016. Although community action has proven to be effective and has become a priority area of the global strategy to reduce alcohol consumption, there is a gap in the knowledge of community interventions to reduce alcohol use among adults. This study aims to analyze the evidence on effective community-based interventions to reduce alcohol consumption and harm among adults and to identify their components and underlying theories. Search strategy involved five databases (January 2000-March 2020). We included multicomponent, evaluated, and community interventions addressing to adults in urban settings of high-income countries. Furthermore, two conceptual frameworks were adapted to identify the social determinants of alcohol related harms and modifiable factors through community interventions. The initial search yielded 164 articles. The final sample included eight primary studies. Six of them were effective and shared three components (community mobilization; law enforcement and media campaigns), they combined approaches at individual and environmental levels addressing structural determinants of health and some cultural aspects related to consumption. Health outcomes focused mainly on reducing consumption, modifying patterns and acute effects on health. Few studies addressed social problems arising from harmful consumption. This review has identified several effective community-based interventions to reduce harmful use of alcohol among adults as well as some mechanisms and theories supporting them. It also provides a framework to guide new designs, with potential evidence of factors, as well as possible combinations of methods to improve health at community level across different settings and contexts.

Urbanicity, biological stress system functioning and mental health in adolescents

Growing up in an urban area has been associated with an increased chance of mental health problems in adults, but less is known about this association in adolescents. We examined whether current urbanicity was associated with mental health problems directly and indirectly via biological stress system functioning. Participants (n = 323) were adolescents from the Dutch general population. Measures included home and laboratory assessments of autonomic nervous system and hypothalamic-pituitary-adrenal axis functioning, neighborhood-level urbanicity and socioeconomic status, and mother- and adolescent self-reported mental health problems. Structural equation models showed that urbanicity was not associated with mental health problems directly. Urbanicity was associated with acute autonomic nervous system and hypothalamic-pituitary-adrenal axis reactivity such that adolescents who lived in more urban areas showed blunted biological stress reactivity. Furthermore, there was some evidence for an indirect effect of urbanicity on mother-reported behavioral problems via acute autonomic nervous system reactivity. Urbanicity was not associated with overall autonomic nervous system and hypothalamic-pituitary-adrenal axis reactivity or basal hypothalamic-pituitary-adrenal axis functioning. Although we observed some evidence for associations between urbanicity, biological stress reactivity and mental health problems, most of the tested associations were not statistically significant. Measures of long-term biological stress system functioning may be more relevant to the study of broader environmental factors such as urbanicity.

Association between community characteristics and implementation of community programmes and policies addressing childhood obesity: the Healthy Communities Study

BACKGROUND

Little is known about whether characteristics of communities are associated with differential implementation of community programmes and policies to promote physical activity and healthy eating. This study examines associations between community characteristics (e.g. region and race/ethnicity) and the intensity of community programmes and policies implemented to prevent childhood obesity. It explores whether community characteristics moderate the intensity of community efforts to prevent childhood obesity.

OBJECTIVE

The objective of this study is to investigate associations between community characteristics and the intensity of community policies and programmes to prevent childhood obesity documented in the Healthy Communities Study that engaged a diverse sample of US communities.

METHOD

Programmes and policies were documented in 130 communities across the USA, reporting over 9000 different community programmes and policies to prevent obesity among children ages 4-15. We examined associations between community characteristics and the intensity of community programmes and policies implemented (i.e. their amount and reach, duration and strength of change strategy).

CONCLUSION

Community characteristics explain 25% of the variability in the intensity of community programmes and policies implemented in communities. Particular characteristics - urbanicity, region, being a large county and the per cent of African-Americans in a community - contributed to more (over 18% of the 25%) of the observed variability.

Quantifying collaboration using Himmelman ' s strategies for working together

Purpose

– Coordinated school health programs (CSHPs), a type of health promoting school (HPS) program adopted by Canada and the USA, were developed to provide a comprehensive approach to school health in the USA. Community partnerships are central to CSHP and HPS efforts, yet the quality of collaboration efforts is rarely assessed. The purpose of this paper is to use Himmelman’s strategies for working together to assess the types of partnerships that are being formed by CSHPs and to explore the methodological usefulness of this framework. The Himmelman methodology describes four degrees of partnering interaction: networking, coordinating, cooperating, and collaborating, with each degree of interaction signifying a different level of partnership between organizations.

Design/methodology/approach

– Data were collected as part of the 2008-2009 and 2009-2010 CSHP annual Requests for Proposal from all 131 public school systems in Tennessee. Thematic analysis methods were used to assess partnerships in school systems. Descriptive analyses were completed to calculate individual collaboration scores for each of the eight CSHP components (comprehensive health education, physical education/activity, nutrition services, health services, mental health services, student, family, and community involvement, healthy school environment, and health promotion of staff) during the two data collection periods. The level of collaboration was assessed based on Himmelman’s methodology, with higher scores indicating a greater degree of collaboration. Scores were averaged to obtain a mean score and individual component scores were then averaged to obtain statewide collaboration index scores (CISs) for each CSHP component.

Findings

– The majority of CSHPs partnering activities can be described as coordination, level two in partnering interaction. The physical activity component had the highest CISs and scored in between coordinating and cooperating (2.42), while healthy school environment had the lowest score, scoring between networking and coordinating (1.93), CISs increased from Year 1 to Year 2 for all of the CSHP components. Applying the theoretical framework of Himmelman’s methodology provided a novel way to quantify levels of collaboration among school partners. This approach offered an opportunity to use qualitative and quantitative methods to explore levels of collaboration, determine current levels of collaboration, and assess changes in levels of collaboration over the study period.

Research limitations/implications

– This study provides a framework for using the Himmelman methodology to quantify partnerships in a HPS program in the USA. However, the case study nature of the enquiry means that changes may have been influenced by a range of contextual factors, and quantitative analyses are solely descriptive and therefore do not provide an opportunity for statistical comparisons.

Practical implications

– Quantifying collaboration efforts is useful for HPS programs. Community activities that link back to the classroom are important to the success of any HPS program. Himmelman’s methodology may be useful when applied to HPSs to assess the quality of existing partnerships and guide program implementation efforts.

Originality/value

– This research is the first of its kind and uses a theoretical framework to quantify partnership levels in school health programs. In the future, using this methodology could provide an opportunity to develop more effective partnerships in school health programs, health education, and public health.

An Exploratory Study of Internal Migration and Substance Use Among an Indigenous Community in Southern Mexico

The primary aim of this study was to explore the association between internal migration experience within Mexico and lifetime substance use among a sample of 442 indigenous persons from Yucatan, Mexico. Adjusting for potential confounding, correlates of lifetime substance use were assessed among participants with and without internal migration experience. Internal migration to a tourist destination was independently associated with higher odds (adjusted odds ratio: 2.1; 95% confidence interval: 1.3-3.4) of reporting lifetime substance use. Findings suggest that environmental contexts of internal migration may be of importance in shaping vulnerability to substance use.

Design and preliminary results of a metropolitan lifestyle intervention program for people with metabolic syndrome in South Korea

INTRODUCTION

The Seoul Metabolic Syndrome Management (SMESY) project, a metropolitan lifestyle intervention program aimed at decreasing the risk of metabolic syndrome to the residents of the city, has recently been implemented in 2011.

METHODS

Our target population consisted of residents of Seoul who were 30-64 years old. Subjects visiting a Public Health Center were screened for five risk factors for metabolic syndrome and then divided into three groups according to the number of the risk factors: active counseling, for having more than three risk factors; motivational guide, for having one or two; and information support for having none. Members of the active counseling group, the main target of the project, were provided with monthly in-person counseling on health-related lifestyle choices, as well as a follow-up examination every 3 months during the 12-month program.

RESULTS

In the active counseling group, subjects showed statistically significant improvements in all five risk factors and the average number of retained risk factors decreased from 3.5 to 2.7. However, the percentage of active counseling group members who attended at least 3 out of the 4 sessions provided was only 11.3%. As for the motivational guide group and the information support group, clinically significant improvements were not observed and the percentage of members who attended all sessions were 10.4% and 11.8%, respectively.

CONCLUSIONS

Increased public participation for the ongoing project is expected to lead to great positive changes in the health of people with metabolic syndrome.

Urbanisation, urbanicity, and health: a systematic review of the reliability and validity of urbanicity scales

Background

Despite a plethora of studies examining the effect of increased urbanisation on health, no single study has systematically examined the measurement properties of scales used to measure urbanicity. It is critical to distinguish findings from studies that use surrogate measures of urbanicity (e.g. population density) from those that use measures rigorously tested for reliability and validity. The purpose of this study was to assess the measurement reliability and validity of the available urbanicity scales and identify areas where more research is needed to facilitate the development of a standardised measure of urbanicity.

Methods

Databases searched were MEDLINE with Full Text, CINAHL with Full Text, and PsycINFO (EBSCOhost) as well as Embase (Ovid) covering the period from January 1970 to April 2012. Studies included in this systematic review were those that focused on the development of an urbanicity scale with clearly defined items or the adoption of an existing scale, included at least one outcome measure related to health, published in peer-reviewed journals, the full text was available in English and tested for validity and reliability.

Results

Eleven studies met our inclusion criteria which were conducted in Sri Lanka, Austria, China, Nigeria, India and Philippines. They ranged in size from 3327 to 33,404 participants. The number of scale items ranged from 7 to 12 items in 5 studies. One study measured urban area socioeconomic disadvantage instead of urbanicity. The emerging evidence is that increased urbanisation is associated with deleterious health outcomes. It is possible that increased urbanisation is also associated with access and utilisation of health services. However, urbanicity measures differed across studies, and the reliability and validity properties of the used scales were not well established.

Conclusion

There is an urgent need for studies to standardise measures of urbanicity. Longitudinal cohort studies to confirm the relationship between increased urbanisation and health outcomes are urgently needed.

Roundtable on Urban Living Environment Research (RULER)

For 18 months in 2009-2010, the Rockefeller Foundation provided support to establish the Roundtable on Urban Living Environment Research (RULER). Composed of leading experts in population health measurement from a variety of disciplines, sectors, and continents, RULER met for the purpose of reviewing existing methods of measurement for urban health in the context of recent reports from UN agencies on health inequities in urban settings. The audience for this report was identified as international, national, and local governing bodies; civil society; and donor agencies. The goal of the report was to identify gaps in measurement that must be filled in order to assess and evaluate population health in urban settings, especially in informal settlements (or slums) in low- and middle-income countries. Care must be taken to integrate recommendations with existing platforms (e.g., Health Metrics Network, the Institute for Health Metrics and Evaluation) that could incorporate, mature, and sustain efforts to address these gaps and promote effective data for healthy urban management. RULER noted that these existing platforms focus primarily on health outcomes and systems, mainly at the national level. Although substantial reviews of health outcomes and health service measures had been conducted elsewhere, such reviews covered these in an aggregate and perhaps misleading way. For example, some spatial aspects of health inequities, such as those pointed to in the 2008 report from the WHO's Commission on the Social Determinants of Health, received limited attention. If RULER were to focus on health inequities in the urban environment, access to disaggregated data was a priority. RULER observed that some urban health metrics were already available, if not always appreciated and utilized in ongoing efforts (e.g., census data with granular data on households, water, and sanitation but with little attention paid to the spatial dimensions of these data). Other less obvious elements had not exploited the gains realized in spatial measurement technology and techniques (e.g., defining geographic and social urban informal settlement boundaries, classification of population-based amenities and hazards, and innovative spatial measurement of local governance for health). In summary, the RULER team identified three major areas for enhancing measurement to motivate action for urban health-namely, disaggregation of geographic areas for intra-urban risk assessment and action, measures for both social environment and governance, and measures for a better understanding of the implications of the physical (e.g., climate) and built environment for health. The challenge of addressing these elements in resource-poor settings was acknowledged, as was the intensely political nature of urban health metrics. The RULER team went further to identify existing global health metrics structures that could serve as platforms for more granular metrics specific for urban settings.

Lifting boats without closing gaps: child health outcomes in distressed US cities from 1992-2002

OBJECTIVES

We compared cause-specific mortality and birth rates for children and youths aged younger than 18 years in 100 US cities from 1992 through 2002.

METHODS

We used 5 census indicators to categorize the 100 most populous US cities in 1990 as economically distressed or nondistressed. We used Poisson regression to calculate rate ratios for cause-specific mortality and birth rates, comparing distressed cities to nondistressed cities overall and by race/ethnicity from 1992 through 2002. We also calculated rates of change in these variables within each city over this period.

RESULTS

Despite improvements in health for the study population in all cities, disparities between city groups held steady or widened over the study period. Gaps in outcomes between Whites and Blacks persisted across all cities. Living in a distressed city compounded the disparities in poor outcomes for Black children and youths.

CONCLUSIONS

A strong national economy during the study period may have facilitated improvements in health outcomes for children and youths in US cities, but these benefits did not close gaps between distressed and nondistressed cities.

The role of community resource assessments in the development of 15 adolescent health community-researcher partnerships

BACKGROUND

Connect to Protect (C2P): Partnerships for Youth Prevention Interventions is an initiative that alters the community's structural elements to reduce youth HIV rates.

OBJECTIVES

This study details a community resource assessment and describes how resources were evaluated in the context of local needs.

METHODS

Fifteen sites developed a community resource list, conducted a brief survey, created a youth service directory, and mapped where disease prevalence and community resources intersected. Sites also completed a survey to review and verify local site findings.

RESULTS

On average, sites identified 267 potential community resources. Sites narrowed their resource list to conduct a brief survey with 1,162 agencies; the site average was 78. Final products of this process included maps comparing resources with risk data.

CONCLUSIONS

The evaluation of local resources is an important initial step in partnership development and is essential for the success of health promotion and disease prevention interventions that target adolescents.

Poverty and elimination of urban health disparities: challenge and opportunity

The aim of this article is to examine the intersection of race and poverty, two critical factors fueling persistent racial and ethnic health disparities among urban populations. From the morass of social determinants that shape the health of racial and ethnic communities in our urban centers, we will offer promising practices and potential solutions to eliminating racial and ethnic health disparities.

A Lay Health Advisor Program to Promote Community Capacity and Change Among Change Agents

The Charlotte REACH 2010 project focuses on cardiovascular disease and diabetes among African Americans in a geographically defined community. The goal of the project is to create changes in individual behaviors, community capacity, change agents, and systemic policies and actions that will result in the reduction of health disparities related to cardiovascular disease and diabetes. The project consists of three main components: lay health advisors as change agents, targeted interventions (exercise, nutrition, smoking cessation, primary care), and environmental and systemic interventions. The purpose of this article is to describe the lay health advisor intervention using qualitative methodologies that were developed to document changes in community capacity and change among change agents. Lay health advisors report that they have internalized their role as a community advocate and have made positive changes in their own personal health behavior. Their understanding of the underlying causes of poor health has expanded to include social and institutional factors and they have begun to shift their emphasis toward advocacy for social and institutional change.

Urban as a determinant of health

Cities are the predominant mode of living, and the growth in cities is related to the expansion of areas that have concentrated disadvantage. The foreseeable trend is for rising inequities across a wide range of social and health dimensions. Although qualitatively different, this trend exists in both the developed and developing worlds. Improving the health of people in slums will require new analytic frameworks. The social-determinants approach emphasizes the role of factors that operate at multiple levels, including global, national, municipal, and neighborhood levels, in shaping health. This approach suggests that improving living conditions in such arenas as housing, employment, education, equality, quality of living environment, social support, and health services is central to improving the health of urban populations. While social determinant and multilevel perspectives are not uniquely urban, they are transformed when viewed through the characteristics of cities such as size, density, diversity, and complexity. Ameliorating the immediate living conditions in the cities in which people live offers the greatest promise for reducing morbidity, mortality, and disparities in health and for improving quality of life and well being.

Urbanization and tropical health--then and now

Since the launch of the Annals of Tropical Medicine and Parasitology 100 years ago, the percentage of the world's population living in urban settings has more than tripled and is now approaching 50%. Urbanization will continue at a high pace, particularly in the less developed regions of Africa and Asia. The profound demographic, ecological and socio-economic transformations that accompany the process of urbanization have important impacts on health and well-being. In industrialized countries, urbanization led to the so-called 'epidemiological transition', from acute infectious and deficiency diseases to chronic non-communicable diseases, many decades ago. In the developing world, surprisingly little research has been carried out on the health-related aspects of urbanization. In a temporal analysis of publications in the Annals of Tropical Medicine and Parasitology, for example, in which the first volume in every decade from 1907 was examined, only 16 (2.6%) of the 604 articles investigated focused on epidemiological and/or public-health issues in urban tropical settings. This review begins with the question 'what is urban?' and then provides a summary of the trends seen in urbanization, and its impacts on human health, over the past century, on both a global and regional scale. For the main tropical diseases, estimates of the at-risk populations and the numbers of cases are updated and then split into urban and non-urban categories. The inhabitants of urban slums are particularly vulnerable to many of these diseases and require special attention if internationally-set targets for development are to be met. Heterogeneity, a major feature of urban settings in the tropics that complicates all efforts at health improvement, is demonstrated in an exploration of a densely populated municipality of a large West African town. Urban planners, public-health experts and other relevant stakeholders clearly need to make much more progress in alleviating poverty and enhancing the health and well-being of urban residents, in an equity-effective and sustainable manner.

Social influences, social context, and health behaviors among working-class, multi-ethnic adults

Little research has explored the relationship between social influences (e.g., social networks, social support, social norms) and health as related to modifying factors that may contribute to health disparities. This is a cross-sectional analysis of fruit and vegetable intake and physical activity, using baseline data from two cancer prevention studies with working-class, multi-ethnic adults. Several social influence and social contextual variables were associated with fruit and vegetable intake and physical activity in both samples. Fruit and vegetable consumption was associated with social norms and social networks, although different contextual variables also were related to intake across the two samples. Physical activity was associated with social networks, social norms, and competing demands. By examining how key social influence and contextual mediating variables relate to health behaviors, we can learn more about the types of interventions that might be needed to promote sustained health behavior change in this population.

Laying the foundation for Connect to Protect: a multi-site community mobilization intervention to reduce HIV/AIDS incidence and prevalence among urban youth

Despite the considerable resources that have been dedicated to HIV prevention interventions and services over the past decade, HIV incidence among young people in the United States remains alarmingly high. One reason is that the majority of prevention efforts continue to focus solely on modifying individual behavior, even though public health research strongly suggests that changes to a community's structural elements, such as their programs, practices, and laws or policies, may result in more effective and sustainable outcomes. Connect to Protect is a multi-city community mobilization intervention that focuses on altering or creating community structural elements in ways that will ultimately reduce youth HIV incidence and prevalence. The project, which spans 6 years, is sponsored by the Adolescent Medicine Trials Network for HIV/AIDS Interventions at multiple urban clinical research sites. This paper provides an overview of the study's three phases and describes key factors in setting a firm foundation for the initiation and execution of this type of undertaking. Connect to Protect's community mobilization approach to achieving structural change represents a relatively new and broad direction in HIV prevention research. To optimize opportunities for its success, time and resources must be initially placed into laying the groundwork. This includes activities such as building a strong overarching study infrastructure to ensure protocol tasks can be met across sites; tapping into local site and community expertise and knowledge; forming collaborative relationships between sites and community organizations and members; and fostering community input on and support for changes at a structural level. Failing to take steps such as these may lead to insurmountable implementation problems for an intervention of this kind.

Laying the foundation for Connect to Protect: a multi-site community mobilization intervention to reduce HIV/AIDS incidence and prevalence among urban youth

Despite the considerable resources that have been dedicated to HIV prevention interventions and services over the past decade, HIV incidence among young people in the United States remains alarmingly high. One reason is that the majority of prevention efforts continue to focus solely on modifying individual behavior, even though public health research strongly suggests that changes to a community's structural elements, such as their programs, practices, and laws or policies, may result in more effective and sustainable outcomes. Connect to Protect is a multi-city community mobilization intervention that focuses on altering or creating community structural elements in ways that will ultimately reduce youth HIV incidence and prevalence. The project, which spans 6 years, is sponsored by the Adolescent Medicine Trials Network for HIV/AIDS Interventions at multiple urban clinical research sites. This paper provides an overview of the study's three phases and describes key factors in setting a firm foundation for the initiation and execution of this type of undertaking. Connect to Protect's community mobilization approach to achieving structural change represents a relatively new and broad direction in HIV prevention research. To optimize opportunities for its success, time and resources must be initially placed into laying the groundwork. This includes activities such as building a strong overarching study infrastructure to ensure protocol tasks can be met across sites; tapping into local site and community expertise and knowledge; forming collaborative relationships between sites and community organizations and members; and fostering community input on and support for changes at a structural level. Failing to take steps such as these may lead to insurmountable implementation problems for an intervention of this kind.

Cities and population health

A majority of the world's population will live in urban areas by 2007 and cities are exerting growing influence on the health of both urban and non-urban residents. Although there long has been substantial interest in the associations between city living and health, relatively little work has tried to understand how and why cities affect population health. This reflects both the number and complexity of determinants and of the absence of a unified framework that integrates the multiple factors that influence the health of urban populations. This paper presents a conceptual framework for studying how urban living affects population health. The framework rests on the assumption that urban populations are defined by size, density, diversity, and complexity, and that health in urban populations is a function of living conditions that are in turn shaped by municipal determinants and global and national trends. The framework builds on previous urban health research and incorporates multiple determinants at different levels. It is intended to serve as a model to guide public health research and intervention.

Age differences in health effects of stressors and perceived control among urban African American women

A conceptual model of the stress process has been useful in examining relationships among a variety of stressors, health status, and protective factors that modify the health-stress relationship. The model can contribute to an understanding of variations in health among people living in urban environments experiencing high degrees of stress. This study examines social contextual stressors in the neighborhood, health outcomes, and perceived control at multiple levels beyond the individual as a protective factor, among a random sample (N = 679) of predominantly low-income African American women who reside on Detroit's east side. Findings suggest that although stress has a consistently negative impact on health, perceived control may buffer against the deleterious effects of stress. The buffering role of perceived control, however, depends on age, the type of stressor examined, and the context or level at which perceived control is assessed (e.g., organizational, neighborhood, beyond the neighborhood). For young women, perceived control was found to be health protective. Among older women, perceived control in the face of stressors was inversely related to health. These findings suggest the need for health and social service programs and policy change strategies to both increase the actual influence and control of women living in low-income urban communities and to reduce the specific social contextual stressors they experience.

Overcoming the hurdles to providing urban health care in the 21st century

The delivery of health care services to urban populations in the United States is a system of rapidly increasing complexity. With the emergence of superspecialized physicians, a scientific approach to disease management has received great emphasis. Those providing health care at the population level may also apply this evidence-based approach. Analysis of the process of health care delivery in its entirety is complicated, confusing, and may be fraught with bias. In this article, a powerful instrument for providing a scientific approach to urban health care health policy development is introduced. This tool allows for analysis and assessment of hurdles to health care delivery to urban populations by dividing the process into elements of "administration," "provision," and "utilization" (APU). This APU triangle model, while intuitive, also allows a more definitive analysis by parts than would be possible to make of the whole. Using this model, the authors explore some of the hurdles faced by each element as well as some potential solutions. Although this model is presented in the context of urban hurdles to health care, it is equally applicable to rural environments or other service-delivery systems. In conclusion, this article discusses the emergence of the role of the public health department as the facilitator and manager between sectors of the community not traditionally connected in a collaborative health care model. Thus, the urban public health department coordinates efforts to surmount the hurdles and provides the venue for analysis, development, and employment of successful strategies.

Reaching low-income families: Focus group results provide direction for a behavioral approach to WIC services

Supplemental Nutrition Program for Women, Infants, and Children (WIC) families were asked to identify motivators and barriers to health behavior change and preferred approaches to nutrition education in WIC. Six focus groups involved a total of 41 English-speaking WIC participants and addressed parenting, family meals, food preparation, and physical activity. The discussions were audiotaped, transcribed, and analyzed using NUD*IST software (Non-Numerical Unstructured Data Indexing, Searching, and Theorizing, version 4.0. Thousand Oaks, CA: Sage Publications Software, 1997). Key barriers to behavior change included inadequate parenting skills, lack of knowledge, unhealthy social environments, lack of time, and lack of social or financial support. Key motivators included feelings of responsibility, concern for child health and development, and positive social support. Participants identified facilitated discussions, support groups, cooking classes, and a WIC Web site as preferred methods of nutrition education. Results provided the foundation for the Healthy Habits nutrition education modules implemented in the Washington State WIC program and can be used to improve future nutrition education in WIC.

The urban safety net: can it keep people healthy and out of the hospital?

There is much discussion and debate over the relative vulnerability and capacity of the health care safety net to care for the growing numbers of uninsured and disenfranchised persons in urban poor communities. In this study, we present findings from a community-based survey of 248 adults identified at eight safety net provider sites in Baltimore, Maryland, to contextualize recent findings that described Baltimore's safety net capacity as having more hospital- and intensive service-based interventions, with higher proportions of the population reportedly unable to get care when needed compared with other cities. The average age of respondents was 41.2 years, most (87.3%) were African American, unemployed (75.8%), homeless (57.0%), and with at least one chronic medical problem (77.8%). Almost one half (47.6%) also reported a chronic mental health condition, and 51.2% reported having difficulty accessing health care services in the past. Overall, 76.9% reported accessing additional community sites for daily sustenance needs, with most of these sites community non-profit or faith-based organizations. In the multiple logistic regression model, only individuals with chronic mental health conditions were significantly more likely to report difficulties accessing health care. The lack of a Community Access Program or other structured efforts to facilitate integration of services among providers in Baltimore and an "all-payer" system that reimburses uncompensated care only for hospital admissions are postulated as two structural elements that may contribute to these findings.

Metropolitan-area estimates of binge drinking in the United States

OBJECTIVES

We estimated adult binge drinking prevalence in US metropolitan areas.

METHODS

We analyzed 1997 and 1999 Behavioral Risk Factor Surveillance System data for 120 metropolitan areas in 48 states and the District of Columbia.

RESULTS

The prevalence of binge drinking varied substantially across metropolitan areas, from 4.1% in Chattanooga, Tenn, to 23.9% in San Antonio, Tex, (median = 14.5%). Seventeen of the 20 metropolitan areas with the highest estimates were located in the upper Midwest, Texas, and Nevada. In 13 of these areas, at least one third of persons aged 18 to 34 years were binge drinkers. There were significant intrastate differences for binge drinking among metropolitan areas in New York, Tennessee, and Utah.

CONCLUSIONS

Metropolitan-area estimates can be used to guide local efforts to reduce binge drinking.

Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations

BACKGROUND

This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations.

METHODS

The Harvard Cancer Prevention Program Project Includes Three Studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design.

RESULTS

Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities.

CONCLUSIONS

By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

Is the promise of cancer-screening programs being compromised? Quality of follow-up care after abnormal screening results

Cancer screening has increased dramatically in the United States, yet in some populations, particularly racial minorities or the poor, advanced disease at diagnosis remains high. One potential explanation is that follow-up of abnormal tests is suboptimal, and the benefits of screening are not being realized. The authors used a conceptual model of access to care and integrated constructs from models of provider and patient health behaviors to review published literature on follow-up care. Most studies reported that fewer than 75 percent of patients received some follow-up care, indicating that the promise of screening may be compromised. They identified pervasive barriers to follow-up at the provider, patient, and health care system levels. Interventions that address these barriers appear to be effective. Improvement of data infrastructure and reporting will be important objectives for policy makers, and further use of conceptual models by researchers may improve intervention development and, ultimately, cancer control.

Cancer screening estimates for U.S. metropolitan areas

OBJECTIVES

To provide estimates of breast, cervical, and colorectal cancer screening for metropolitan areas in the United States.

METHODS

Behavioral Risk Factor Surveillance System (BRFSS) data from 1997 to 1999 were reweighted and analyzed for 69 U.S. metropolitan areas for the receipt of a Papanicolaou (Pap) test (ages > or =18 years); mammography (ages > or =40 years); fecal occult blood testing and sigmoidoscopy (ages > or =50 years). Stratified analyses by demographics were performed for 25 metropolitan areas with populations of > or =1.5 million.

RESULTS

Metropolitan estimates ranged from 64.6% to 82.0% for mammography and from 77.2% to 91.7% for Pap tests. There was much greater variability in estimates for colorectal cancer screening, with a 3.6-fold difference in the range of estimates for fecal occult blood testing (9.9% to 35.2%) and a 2.5-fold difference for sigmoidoscopy (17.3% to 43.3%). In the 25 largest areas, prevalence of cancer screening was generally lower for persons with a high school education or less and for those without health insurance. Compared with women aged 50 to 64 years, mammography estimates were lower for women aged 40 to 49 years in 13 of the 25 metropolitan areas. Pap testing was less common among women aged > or =65 years, and colorectal cancer screening was less common for persons aged 50 to 64 years.

CONCLUSIONS

Estimates of cancer screening varied substantially across metropolitan areas. Increased efforts to improve cancer screening are needed in many urban areas, especially for colorectal cancer screening. The BRFSS is a useful, inexpensive, and timely resource for providing metropolitan-area cancer screening estimates and may be used in the future to guide local or county-level screening efforts.

Methodological, practical, and ethical challenges to inner-city health research

Inner-city health research can be challenging because it deals with vulnerable populations and sometimes puts investigators in difficult situations. Some challenges are methodological, including selecting the optimal research design, implementing effective methods of recruitment and retention, and determining the best approach to data analysis. Other issues are practical, including addressing potential biases in social research; dealing with conflicting research agendas among investigators, community agencies, and funding agencies; and disseminating research findings effectively. Another set of issues relates to the ethical conduct of research, including ensuring privacy, maintaining confidentiality, and obtaining consent that is informed, not coerced, and not influenced by undue inducements. Throughout the research endeavor, the inner-city health researcher must carefully balance the roles of investigator, advocate, activist, and caregiver.

Neighbourhood socioeconomic context and self reported health and smoking: a secondary analysis of data on seven cities

OBJECTIVE

Many studies have shown that poor health status and harmful health behaviour occur more frequently in deprived neighbourhoods. Most studies show modest associations between area level socioeconomic factors, the neighbourhood context, and health outcomes. However, estimates for the contextual effects vary. It is unclear if this variation is attributable to differences in methodology. This study examines whether contextual neighbourhood differences in health outcomes really vary between cities or that differences in methodology may account for these differences.

DESIGN

Secondary analysis of data from health interview surveys in seven large Dutch cities in the 1990s comprising 23 269 residents of 484 neighbourhoods, using multilevel logistic models.

SETTING

General population aged 16 and over.

MAIN OUTCOME MEASURES

Self reported health, smoking of cigarettes.

MAIN RESULTS

The socioeconomic context of neighbourhoods is associated with health outcomes in all large Dutch cities. The strength of the association varies between cities, but variation is much smaller in the age group 25-64. Furthermore, neighbourhood differences vary in size between native and other residents. Contextual neighbourhood differences are about two times larger for self reported health than for the smoking of cigarettes, but for native Dutch people they are of similar size.

CONCLUSIONS

A comparatively large improvement in health may be gained in deprived neighbourhoods, because of the poorer health status to which the context of these neighbourhoods also contributes. Health promoting interventions should be aimed at the residents and at the context of deprived neighbourhoods, taking differences between ethnic groups and age groups into account.

A population health framework for inner-city mental health

Dealing with mental health problems in the inner city presents a major challenge to planners and service providers. Traditional mental health service-oriented interventions often prove ineffective due to the complexity of individuals' needs. This article argues that a population health framework can be used to identify critical risk and protective factors and facilitate more effective, upstream, population-based interventions for mental health problems in the inner city. A community report card is seen as a useful measure of key indicators at any point in time and of changes over time at the community or neighborhood level. A number of issues with regard to report card development are identified and discussed, as is the process of creating a report card, including key domains and the organization of findings.

Urbanization, urbanicity, and health

A majority of the world's population will live in urban areas by 2007. The most rapidly urbanizing cities are in less-wealthy nations, and the pace of growth varies among regions. There are few data linking features of cities to the health of populations. We suggest a framework to guide inquiry into features of the urban environment that affect health and well-being. We consider two key dimensions: urbanization and urbanicity. Urbanization refers to change in size, density, and heterogeneity of cities. Urbanicity refers to the impact of living in urban areas at a given time. A review of the published literature suggests that most of the important factors that affect health can be considered within three broad themes: the social environment, the physical environment, and access to health and social services. The development of urban health as a discipline will need to draw on the strengths of diverse academic areas of study (e.g., ecology, epidemiology, sociology). Cross-national research may provide insights about the key features of cities and how urbanization influences population health.

The social ecology of child health and well-being

The term social ecology refers to the nested arrangement of family, school, neighborhood, and community contexts in which children grow up. In this chapter, new directions in public health science as reflected in the theoretical and methodological implications of the concept are explored. The contributions of this ecologically oriented approach to child health practice, designed as it is from a health promotions perspective, are considered. A critique of the term social capital is also presented because of its growing popularity in matters of child health. The point is made that application of this vague term carries the serious risk of misspecifying social phenomena. Future trends in the promotion of child well-being are in a position to flourish given the confluence of advances in theory, methods, and analytical capacity. The capacity to benefit children is also enhanced as public health science aims to translate the principles of child rights into health practice and policy.