Urban Place and Health Equity: Critical Issues and Practices

Associations between environmental perception and self-rated health in the city hierarchy of China: Findings from a national cross-sectional survey

Identifying environmental determinants of health and clarifying their variations is crucial for health promotion in different cities by providing tailored intervention strategies. Although the association between perceived urban environment and health (e.g., self-rated health) has been repeatedly explored, most studies have focused on cities of a specific size, and it is still unknown whether either significant environment variables or the magnitude of the association would vary across different-sized cities. This study investigated how perceived urban environment variables significantly associated with individuals' self-rated health varied from small cities to mega cities in China, based on a national survey including 5963 valid respondents. The results showed that the relationship between self-rated health and city size was U-shaped, with respondents in medium and large cities reporting a low-level self-rated health. Perceived greenness, public facilities, housing supply, and medical services were positively and significantly associated with self-rated health, with the odds ratio (OR) of 1.37 (95%CI: 1.29-1.46), 1.27 (95%CI: 1.19-1.35), 1.14 (95%CI: 1.09-1.20), and 1.17 (95%CI: 1.10-1.24), respectively. Furthermore, the magnitude of the association was significantly larger in mega cities. These findings provide useful evidence for promoting public health in cities of different sizes for achieving health equity and indicate that smaller cities and their health-supportive environment need further attention.

A Co-Created Assessment Framework to Measure Inclusive Health and Wellbeing in a Vulnerable Context in the South of Europe

Rapid urbanisation exacerbates health and wellbeing disparities in vulnerable contexts and underscores the imperative need to develop innovative and participatory co-creation approaches to understand and address the specificities of these contexts. This paper presents a method to develop an assessment framework that integrates top-down dimensions with bottom-up perspectives to monitor the impact of inclusive health and wellbeing interventions tailored to the neighbourhood's needs in Las Palmeras, a vulnerable neighbourhood in Cordoba (Spain). Drawing upon studies in the literature examining urban health and wellbeing trends, it delineates a participatory and inclusive framework, emphasising the need for context-specific indicators and assessment tools. Involving diverse stakeholders, including residents and professionals, it enriches the process and identifies key indicators and assessment methods. This approach provides valuable insights for managing innovative solutions, aligning them with local expectations, and measuring their impact. It contributes to the discourse on inclusive urban health by advocating for participatory, context-specific strategies and interdisciplinary collaboration. While not universally applicable, the framework offers a model for health assessment in vulnerable contexts, encouraging further development of community-based tools for promoting inclusive wellbeing.

'That is because we are alone': A relational qualitative study of socio-spatial inequities in maternal and newborn health programme coverage in rural Uttar Pradesh, India

This qualitative study was conducted in Uttar Pradesh state, India to explore how interrelated socio-economic position and spatial characteristics of four diverse villages may have influenced equity in coverage of community-based maternal and newborn health (MNH) services. We conducted social mapping and three focus group discussions in each village, among women of lower and higher socio-economic position who recently gave birth, and with community health workers (n = 134). Data were analysed in NVivo 11.0 using thematic framework analysis. The extent of socio-economic hierarchies and spatial disparateness within the village, combined with distance to larger centers, together shaped villages' level of socio-spatial remoteness. Disadvantaged socio-economic groups expressed being more often spatially isolated, with less access to infrastructure, resources or services, which was heightened if the village was physically distant from larger centers. In more socio-spatially remote villages, inequities in coverage of MNH services that disadvantaged lower socio-economic position groups were compounded as these groups more often experienced ASHA vacancies, as well as greater distance to and poorer perceived quality of health services nearest the village. The results inform a conceptual framework of 'socio-spatial remoteness' that can guide public health research and programmes to more comprehensively address health inequities within India and beyond.

[Urban Epidemiology as an Integrative Approach to Sustainable and Healthy Urban Development]

Understanding the complex relationships between the physical and social environment and health in urban areas is essential for the development of appropriate measures of health promotion, disease prevention, and health protection. This article aims to characterize the comparatively new approach of urban epidemiology with its relevance for research and practice of urban health. Research in urban epidemiology provides important data and methodological foundations for integrated reporting, health impact assessments, and evaluation of interventions. Current challenges and solutions are outlined and initial recommendations for research, practice, and education and training are presented for discussion. Methods and findings of urban epidemiology can contribute in many ways to health-promoting, sustainable urban development.

The Impact of Health Geography on Public Health Research, Policy, and Practice in Canada

The link between geography and health means that the places we occupy-where we are born, where we live, where we work, and where we play-have a direct impact on our health, including our experiences of health. A subdiscipline of human geography, health geography studies the relationships between our environments and the impact of factors that operate within those environments on human health. Researchers have focused on the social and physical environments, including spatial location, patterns, causes of disease and related outcomes, and health service delivery. The work of health geographers has adopted various theories and philosophies (i.e., positivism, social interactionism, structuralism) and methods to collect and analyze data (i.e., quantitative, qualitative, spatial analysis) to examine our environments and their relationship to health. The field of public health is an organized effort to promote the health of its population and prevent disease, injury, and premature death. Public health agencies and practitioners develop programs, services, and policies to promote healthy environments to support and enable health. This commentary provides an overview of the recent landscape of health geography and makes a case for how health geography is critically important to the field of public health, including examples from the field to highlight these links in practice.

Vulnerability, neglect, and collectivity in Brazilian favelas: Surviving the threats of the COVID-19 pandemic and the state's necropolitics

The COVID-19 pandemic has deepened existing inequities and injustices in Brazil, seen in the disproportionately detrimental impacts on favelas. State policy responses to the pandemic have disregarded favela residents' experiences. Recommendations such as 'shelter-in-place' ignore the reality of over 11.4 million favela residents who cannot work from home or afford to stop working, nor practise physical distancing from others. This study investigates the discourse of community organisations in favelas as they respond to the threats of the COVID-19 pandemic and the state's necropolitics. Community organisations in favelas have taken action to protect their residents from the virus, unemployment and hunger. I assess organisations' (1) justification to act as a collective in their communities, and (2) stances about the government's responses to the crisis. Through content analysis of social media, websites and media appearances of eight favela organisations and collectives in São Paulo and Rio de Janeiro, this study finds three main themes through which organisations justify their actions: vulnerability, neglect, and collectivity and care. More than survival strategies, the actions of favela organisations are counter-political acts as they oppose the decrepit necropolitics of the state by collectively enduring in the Brazilian context of the COVID-19 pandemic. Understanding favela organisations' actions in response to the pandemic is fundamental. It further illuminates the impact of public health emergencies in the lives of informal settlements' residents and the governance of public health emergencies in these communities.

Governing public health emergencies during the coronavirus disease outbreak: Lessons from four Chinese cities in the first wave

The ongoing coronavirus disease (COVID-19) pandemic has had a far-reaching impact on urban living, prompting emergency preparedness and response from public health governance at multiple levels. The Chinese government has adopted a series of policy measures to control infectious disease, for which cities are the key spatial units. This research traces and reports analyses of those policy measures and their evolution in four Chinese cities: Zhengzhou, Hangzhou, Shanghai and Chengdu. The theoretical framework stems from conceptualisations of urban governance and its role in public health emergencies, wherein crisis management and emergency response are highlighted. In all four cities, the trend curves of cumulative diagnosed cases, critical policies launched in key time nodes and local governance approaches in the first wave were identified and compared. The findings suggest that capable local leadership is indispensable for controlling the coronavirus epidemic, yet local governments' approaches are varied, contributing to dissimilar local epidemic control policy pathways and positive outcomes in the fight against COVID-19. The effectiveness of disease control is determined by how local governments' measures have adapted to geospatial and socioeconomic heterogeneity. The coordinated actions from central to local governments also reveal an efficient, top-down command transmission and execution system for coping with the pandemic. This article argues that effective control of pandemics requires both a holistic package of governance strategies and locally adaptive governance measures/processes, and concludes with proposals for both a more effective response at the local level and identification of barriers to achieving these responses within diverse subnational institutional contexts.

Structural vulnerability as a conceptual framework for transgender health research: findings from a community needs assessment of transgender women of colour in Detroit

The concept of structural vulnerability explains how systems of oppression drive health inequities by reducing access to survival resources (e.g. food, housing) for marginalised populations. Indicators of structural vulnerability such as housing instability, violent victimisation and poverty are often interconnected and result from intersectional oppression. We sought to demonstrate the utility of the structural vulnerability framework for transgender health research by examining patterns of structural vulnerability indicators among transgender women of colour in Detroit. We conducted latent class analysis and tested associations between classes and mental health and substance use outcomes. Membership to the Lowest Vulnerability class was negatively associated with post-traumatic stress disorder (PTSD) (aOR = 0.10, 95% CI: 0.02-0.59). High Economic Vulnerability membership was associated with daily marijuana use (aOR = 4.61, 95% CI: 1.31-16.16). Complex Multi-Vulnerability membership was associated with PTSD (aOR = 9.75, 95% CI: 2.55-37.29), anxiety (aOR = 4.12, 95% CI: 1.22-13.97), suicidality (aOR = 6.20, 95% CI: 1.39-27.70), and club drug use (aOR = 4.75, 95% CI: 1.31-17.29). Substantively different findings emerged when testing relationships between each indicator and each outcome, highlighting the value of theoretically grounded quantitative approaches to understanding health inequities. Community-driven interventions and policy changes that reduce structural vulnerability may improve mental health and substance use outcomes among structurally vulnerable trans women of colour.

Physical Activity and Depression and Anxiety Disorders in Australia: A Lifetable Analysis

Introduction

Mental disorders, in particular, depressive and anxiety disorders, are a leading cause of disability in Australia and globally. Physical activity may reduce the incidence of anxiety and depression, and this supports the inclusion of physical activity in strategies for the prevention of mental ill health. Policy makers need to know the potential impact and cost savings of such strategies. We aimed to quantify the impact of changes in physical activity on the burden of anxiety and depression and healthcare costs in Australia.

Methods

We used a proportional multistate lifetable model to estimate the impact of changes in physical activity levels on anxiety and depression burdens for the 2019 Australian population (numbering 24.6 million) over their remaining lifetime. The changes in physical activity were modeled through 3 counterfactual scenarios informed by policy targets: attainment of the Australian Physical Activity Guidelines and achievement of the WHO Global Action Plan on Physical Activity targets of a 10% relative reduction in the prevalence of insufficient physical activity by 2025 and a 15% relative reduction by 2030.

Results

If all Australians adhered to the recommended minimum physical activity levels, in 25 years' time, the burden of anxiety could be reduced by up to 6.4% (95% uncertainty intervals=2.5, 10.6), and that of depression could be reduced by 4.4% (95% uncertainty intervals=2.3, 6.5). Over the lifetime of the 2019 Australian population, the gains could add up to 640,592 health-adjusted life years for anxiety (26 health-adjusted life years per 1,000 persons), 523,717 health-adjusted life years for depression (21 health-adjusted life years per 1,000 persons), and healthcare cost savings of 5.4 billion Australian dollars for anxiety (220 Australian dollars per capita) and 5.8 billion for depression (237 Australian dollars per capita).

Conclusions

Adherence to the Australian physical activity guidelines and achievement of the 2025 and 2030 global physical activity targets could lead to a substantial reduction of the burden of anxiety and depression. This study provides empirical support for the inclusion of physical activity in strategies for the prevention of mental ill health. Future studies should also assess the size and distribution of the benefits for different socioeconomic and ethnic groups.

Placemaking and infrastructure through the lens of levelling up for health equity: A scoping review

The planning and delivery of infrastructure influences how places create health equity. The scholarship on place and health has recently been developed into 'levelling up' principles for equity focussed policy and planning. We conducted a scoping review of the literature on infrastructure through urban regeneration and placemaking interventions. We interrogated the 15 final selected articles for their use of one or more of the five 'levelling' up principles. No article encompassed all five principles. It was most common to find two or three principles in action. Reviewing the articles against the principles allows a deeper explanation of how infrastructure planning practice can positively impact on health equity. We conclude that applying all the principles in standard infrastructure planning practice has great potential for creating places that are positive for health equity.

Our Voice NOLA: Leveraging a Community Engaged Citizen Science Method to Contextualize the New Orleans Food Environment

OBJECTIVE

We employed the Our Voice citizen scientist method using a mobile application (app) to identify and contextualize neighborhood-level features influencing food access and wellbeing in New Orleans, Louisiana.

DESIGN

A three-phase, multi-method study comprised of: (1) a researcher-assisted tag-a-long neighborhood walk (referred to as a 'journey') with the Discovery Tool (DT) app to document neighborhood-level features via geo-coded photos and audio-recorded narratives; (2) a post-journey interview to enable citizen scientists to share their lived experiences; and (3) a community meeting with citizen scientists and local stakeholders.

SETTING

Various neighborhoods in New Orleans, Louisiana, USA.

PARTICIPANTS

Citizen Scientists (i.e., residents) aged 18 years and older.

MAIN OUTCOME MEASURE(S)

Features that influence food access and health behaviors.

ANALYSIS

Descriptive statistics and a thematic content analysis were conducted to assess survey and app data.

RESULTS

Citizen scientists (N = 14) captured 178 photos and 184 audio narratives. Eight major themes were identified: safety; walkability; aesthetics; amenities; food; health services; neighborhood changes; and infrastructure/city planning. The post-journey interview provided insights around the abovementioned themes. The community meeting demonstrated the willingness of citizen scientists and stakeholders to convene and discuss issues and relevant solutions.

CONCLUSIONS AND IMPLICATIONS

Findings demonstrate the ability of technology and citizen science to help better understand the complexities of New Orleans' past, present and distinct culture-and implications for food access and wellbeing in the context of trauma in an urban ecosystem.

Cancer disparities related to poverty and rurality for 22 top cancers in Florida

We aimed to examine poverty and rurality as potential predictors of cancer health disparities. This cross-sectional study used data from the Florida Cancer Data System on all cancer diagnoses in the years 2014-2018 to determine age-adjusted incidence and mortality (per 100,000 population) for the 22 most common cancer sites within rural and urban counties, and high poverty and low poverty communities. Rural/urban and high/low poverty related cancer disparities were tested for statistical significance using the Rate Ratio statistical test. Overall cancer incidence was significantly lower in rural areas than in urban, but significantly higher in high poverty communities. Rurality and poverty were both associated with disparity in cancer incidence risk for tobacco-related cancers. The overall mortality was 22% higher in high poverty areas compared to low poverty areas. Ten cancer sites had mortality disparity from 83% to 17% higher in high poverty areas. Only three cancer sites, all tobacco-related, had higher mortality in rural areas than urban areas, demonstrating the intersectional nature of inhaled and smokeless tobacco use in rural low-income communities. Cancer and mortality rates in rural and urban areas may be largely driven by poverty. The high disparities related to high poverty areas reflects poor access to preventative care and treatment. Low income communities, rural or urban, will require focused efforts to address challenges specific to each population.

COVID-19: Evaluation of Fever Clinic and Fever Sentinel Configuration—A Case Study of Harbin, China

The COVID-19 pandemic has placed the inequalities in health services in countries around the world under severe pressure. As crucial pillars in the prevention and control of COVID-19, fever clinics and fever sentinels are important sites for the screening, diagnosis, and isolation of patients. This study comprehensively evaluated the spatial-layout characteristics, configuration quantity, and service capacity of 42 fever clinics and 418 fever sentinels in Harbin from the perspective of supply by using GIS spatial-analysis methods such as kernel density analysis. From the perspective of demand, we evaluated the accessibility of fever clinics with the modified two-step floating catchment area (2SFCA) method; the OD cost matrix method and Voronoi diagram method were used to evaluate the accessibility and service pressure of fever sentinels. This study found that a monocentric clustering characterizes the spatial layout of fever clinics, and the design of fever clinics in new urban areas and marginal rural areas is relatively lacking. The spatial layout of fever sentinels includes blank areas, and the service pressure in the central city area is relatively high. Combined with the assessment results, the study discussed optimization strategies and implementation paths for improving the public health and epidemic prevention system for COVID-19 in terms of four aspects: the transformation of governance practice, the spatial-planning response, the digital infrastructure response, and guarantees of policies and regulations.

The Transition of Cities towards Innovations in Mobility: Searching for a Global Perspective

The growing concentration of the population in urban areas presents great challenges for sustainability. Within this process, mobility emerges as one of the main generators of externalities that hinder the achievement of the Sustainable Development Goals. The transition of cities towards innovations in sustainable mobility requires progress in different dimensions, whose interaction requires research. Likewise, it is necessary to establish whether the experiences developed between cities with different contexts can be extrapolated. Therefore, the purpose of this study was to identify how the conditions that determine a city’s readiness to implement urban mobility innovations could be combined. For this, qualitative comparative analysis was applied to a model developed using the multi-level perspective, analyzing 60 cities from different geographical areas and with a different gross domestic product per capita. The R package Set Methods was used. The explanation of the readiness of cities to implement mobility innovations is different to the explanation of the readiness negation. While readiness is explained by two solutions, in which only regime elements appear, the negation of readiness is explained by five possible solutions, showing the interaction between the landscape and regimen elements and enacting the negation of innovations as a necessary condition. The cluster analysis shows us that the results can be extrapolated between cities with different contexts.

Urban Climate Justice, Human Health, and Citizen Science in Nairobi’s Informal Settlements

Urban informal settlements or slums are among the most vulnerable places to climate-change-related health risks. Yet, little data exist documenting environmental and human health vulnerabilities in slums or how to move research to action. Citizen science, where residents co-define research objectives with professionals, collect and analyze data, and help translate findings into ameliorative actions, can help fill data gaps and contribute to more locally relevant climate justice interventions. This paper highlights a citizen-science, climate justice planning process in the Mukuru informal settlement of Nairobi, Kenya. We describe how residents, non-governmental organizations and academics partnered to co-create data-gathering processes and generated evidence to inform an integrated, climate justice strategy called the Mukuru Special Planning Area, Integrated Development Plan. The citizen science processes revealed that <1% of residents had access to a private in-home toilet, and 37% lacked regular access to safe and affordable drinking water. We found that 42% of households were subject to regular flooding, 39% reported fair or poor health, and 40% reported a child in the household was stunted. These and other data were used in a community planning process where thousands of residents co-designed improvement and climate change adaptation strategies, such as flood mitigation, formalizing roads and pathways with drainage, and a water and sanitation infrastructure plan for all. We describe the participatory processes used by citizen scientists to generate data and move evidence into immediate actions to protect human health and a draft a long-range, climate justice strategy. The processes used to create the Mukuru Special Planning Area redevelopment plan suggest that participatory, citizen-led urban science can inform local efforts for health equity and global goals of climate justice.

West Oakland's Experience in Building Community Power to Confront Environmental Injustice Through California's Assembly Bill 617

We explored how air quality management processes associated with Assembly Bill 617 (AB 617) in West Oakland, California, represent a shift in power relationships between government agencies and communities toward the goal of addressing legacies of environmental injustice. We drew from a statewide assessment of community engagement in AB 617's first year, and an analysis of the West Oakland AB 617 process. The first comprised 2 statewide surveys (n = 102 and n = 106), 70 key informant interviews, observation of all AB 617 first-year sites, and analysis of related planning documents. The second comprised 2 rounds of interviews (n = 22 and n = 23, with a total of 19 individuals) and extensive participant observation. Several factors are necessary for pursuing environmental justice: (1) invest in community partnerships and collaborations, (2) honor community knowledge and data, (3) ensure that community constituents share power in environmental governance, and (4) adopt explicit racial justice frameworks. Although still a work in progress, AB 617 offers important lessons for community and policy organizations nationwide engaged in environmental justice. (Am J Public Health. 2022;112(2):262-270. https://doi.org/10.2105/AJPH.2021.306592).

City deals and health equity in Sydney, Australia

'City Deals' are new governance instruments for urban development. Vast evidence exists on the relationship between urban factors and health equity, but little research applies a health equity lens to urban policy-making. This paper does precisely that for the Western Sydney City Deal (WSCD) in Australia. We conducted a critical discourse analysis of publicly available documents and interviews with the WSCD's main architects, applying insights from relevant theories. We find 'pro-growth' discourse to encourage economic investment dominates any references to disadvantage. Interviewees maintained the WSCDs fundamental purpose is to rebalance urban investment toward the historically disadvantaged West. However, the WSCD makes limited reference to health and none to equity. Institutionalised governance practices that favour private investments in infrastructure remain the dominant force behind the WSCD. We document how a shift to 'place-based' infrastructure has promise for equity but struggles to overcome institutionalised approaches to urban investments.

Assessing Inequalities in Wellbeing at a Neighbourhood Scale in Low-Middle-Income-Country Secondary Cities and Their Implications for Long-Term Livability

To ensure future sustainability, cities need to consider concepts of livability and resident wellbeing alongside environmental, economic and infrastructure development equity. The current rapid urbanization experienced in many regions is leading to sustainability challenges, but also offers the opportunity to deliver infrastructure supporting the social aspects of cities and the services that underpin them alongside economic growth. Unfortunately, evidence of what is needed to deliver urban wellbeing is largely absent from the global south. This paper contributes to filling this knowledge gap through a novel interdisciplinary mixed methods study undertaken in two rapidly changing cities (one Thai and one Kenyan) using qualitative surveys, subjective wellbeing and stress measurements, and spatial analysis of urban infrastructure distribution. We find the absence of basic infrastructure (including waste removal, water availability and quality) unsurprisingly causes significant stress for city residents. However, once these services are in place, smaller variations (inequalities) in social (crime, tenure) and environmental (noise, air quality) conditions begin to play a greater role in determining differences in subjective wellbeing across a city. Our results indicate that spending time in urban greenspaces can mitigate the stressful impacts of city living even for residents of informal neighborhoods. Our data also highlights the importance of places that enable social interactions supporting wellbeing-whether green or built. These results demonstrate the need for diversity and equity in the provision of public realm spaces to ensure social and spatial justice. These findings strengthen the need to promote long term livability in LMIC urban planning alongside economic growth, environmental sustainability, and resilience.

Unhealthy lifestyles, environment, well-being and health capability in rural neighbourhoods: a community-based cross-sectional study

BACKGROUND

Non-communicable diseases are a leading cause of health loss worldwide, in part due to unhealthy lifestyles. Metabolic-based diseases are rising with an unhealthy body-mass index (BMI) in rural areas as the main risk factor in adults, which may be amplified by wider determinants of health. Changes in rural environments reflect the need of better understanding the factors affecting the self-ability for making balanced decisions. We assessed whether unhealthy lifestyles and environment in rural neighbourhoods are reflected into metabolic risks and health capability.

METHODS

We conducted a community-based cross-sectional study in 15 Portuguese rural neighbourhoods to describe individuals' health functioning condition and to characterize the community environment. We followed a qualitatively driven mixed-method design to gather information about evidence-based data, lifestyles and neighbourhood satisfaction (incorporated in eVida technology), within a random sample of 270 individuals, and in-depth interviews to 107 individuals, to uncover whether environment influence the ability for improving or pursuing heath and well-being.

RESULTS

Men showed to have a 75% higher probability of being overweight than women (p-value = 0.0954); and the reporting of health loss risks was higher in women (RR: 1.48; p-value = 0.122), individuals with larger waist circumference (RR: 2.21; IC: 1.19; 4.27), overweight and obesity (RR: 1.38; p-value = 0.293) and aged over 75 years (RR: 1.78; p-value = 0.235; when compared with participants under 40 years old). Metabolic risks were more associated to BMI and physical activity than diet (or sleeping habits). Overall, metabolic risk linked to BMI was higher in small villages than in municipalities. Seven dimensions, economic development, built (and natural) environment, social network, health care, demography, active lifestyles, and mobility, reflected the self-perceptions in place affecting the individual ability to make healthy choices. Qualitative data exposed asymmetries in surrounding environments among neighbourhoods and uncovered the natural environment and natural resources specifies as the main value of rural well-being.

CONCLUSIONS

Metabolic risk factors reflect unhealthy lifestyles and can be associated with environment contextual-dependent circumstances. People-centred approaches highlight wider socioeconomic and (natural) environmental determinants reflecting health needs, health expectations and health capability. Our community-based program and cross-disciplinary research provides insights that may improve health-promoting changes in rural neighbourhoods.

Community empowerment for health promotion in slums areas: A narrative review with emphasis on challenges and interventions

Community empowerment has been proposed since the 1980s as a way to increase people's power to influence social determinants of health. However, community empowerment for health promotion in urban slums still faces challenges. The present study examined interventions, challenges, actors, scopes, and the consequences mentioned in various studies and with emphasizing interventions and executive challenges tried to create a clear understanding of empowerment programs in slums and improving their health. Narrative review method was used to conduct the study. Databases including PubMed, Scopus, Embase, Web of Science, and Cochrane were searched. The selection of studies was done according to the "community empowerment" defined by the World Health Organization, the concept of bottom-up approach for health promotion of Laverack and Labonte's study and definition of slums by UN-HABITAT. Finally, Hare and Noblit's meta-synthesis was used to analyze the studies. From 15 selected studies, the most intervention proposed for empowerment was identified to be "residents' participation in expressing problems and solutions." The challenge of "creating a sense of trust and changing some attitudes among residents" was the greatest challenge in the studies. Moreover, "improving living conditions and health services" were the most important outcomes, "slum residents" and "governments" were the most important actors, and "sanitation" was the most important scope among the studies. Having a comprehensive view to the health and its determinants and attention to the factors beyond neighborhood and health sector would lead to fewer implementation challenges and better intervention choices to health promotion of slum dwellers.

Stakeholders' Perspectives on the Unmet Needs and Health Priorities of the Urban Poor in South-East Nigeria

Relatively little is known about readiness of urban health systems to address health needs of the poor. This study explored stakeholders' perception of health needs and strategies for improving health of the urban poor using qualitative analysis. Focus group discussions (n = 5) were held with 26 stakeholders drawn from two Nigerian states during a workshop. Urban areas are characterised by double burden of diseases. Poor housing, lack of basic amenities, poverty, and poor access to information are determinants of health of the urban poor. Shortage of health workers, stock-out of medicines, high cost of care, lack of clinical practice guidelines, and dual practice constrain access to primary health services. An overarching strategy, that prioritises community-driven urban planning, health-in-all policies, structured linkages between informal and formal providers, financial protection schemes, and strengthening of primary health care system, is required to address health needs of the urban poor.

How Do Urban Environments Affect Young People's Mental Health? A Novel Conceptual Framework to Bridge Public Health, Planning, and Neurourbanism

Childhood and adolescence are crucial periods for mental and social development. Currently, mental illness among young people is a global epidemic, and rates of disorders such as depression and anxiety are rising. Urban living, compared with rural living, is linked with a higher risk of serious mental illness, which is important because the world is urbanizing faster than ever before. Urban environments and their landscapes, designs, and features influence mental health and well-being. However, no conceptual frameworks to date have detailed the effect of urban environments on young people's mental health, and few studies have considered the growing role of digital and social media in this relationship, leading to calls for the development of holistic approaches to describe this relationship. This article synthesizes existing knowledge on urban places (both built and natural environments) and mental health in the public health and urban planning literature and examines the emerging field of neurourbanism (a multidisciplinary study of the effect of urban environments on mental health and brain activity) to enhance current practice and research. We developed 2 novel conceptual frameworks (1 research-oriented, 1 practice-oriented), adapted from Bronfenbrenner's socioecological model, that focus on the relationship between urban environments and young people's mental health. We added a digital and social media contextual level to the socioecological model, and we applied a multilayer concept to highlight potential cross-field interactions and collaborations. The proposed frameworks can help to guide future practice and research in this area.

Assessing Urban Health Inequities through a Multidimensional and Participatory Framework: Evidence from the EURO-HEALTHY Project

Urban health inequities often reflect and follow the geographic patterns of inequality in the social, economic and environmental conditions within a city-the so-called determinants of health. Evidence of patterns within these conditions can support decision-making by identifying where action is urgent and which policies and interventions are needed to mitigate negative impacts and enhance positive impacts. Within the scope of the EU-funded project EURO-HEALTHY (Shaping EUROpean policies to promote HEALTH equitY), the City of Lisbon was selected as a case study to apply a multidimensional and participatory assessment approach of urban health whose purpose was to inform the evaluation of policies and interventions with potential to address local health gaps. In this paper, we present the set of indicators identified as drivers of urban health inequities within the City of Lisbon, exploring the added value of using a spatial indicator framework together with a participation process to orient a place-based assessment and to inform policies aimed at reducing health inequities. Two workshops with a panel of local stakeholders from health and social care services, municipal departments (e.g. urban planning, environment, social rights and education) and non-governmental and community-based organizations were organized. The aim was to engage local stakeholders to identify locally critical situations and select indicators of health determinants from a spatial equity perspective. To support the analysis, a matrix of 46 indicators of health determinants, with data disaggregated at the city neighbourhood scale, was constructed and was complemented with maps. The panel identified critical situations for urban health equity in 28 indicators across eight intervention axes: economic conditions, social protection and security; education; demographic change; lifestyles and behaviours; physical environment; built environment; road safety and healthcare resources and performance. The geographical distribution of identified critical situations showed that all 24 city neighbourhoods presented one or more problems. A group of neighbourhoods systematically perform worse in most indicators from different intervention axes, requiring not only priority action but mainly a multi- and intersectoral policy response. The indicator matrices and maps have provided a snapshot of urban inequities across different intervention axes, making a compelling argument for boosting intersectoral work across municipal departments and local stakeholders in the City of Lisbon. This study, by integrating local evidence in combination with social elements, pinpoints the importance of a place-based approach for assessing urban health equity.

The Association between Material Deprivation and Avoidable Mortality in Lisbon, Portugal

There is considerable evidence pointing to the existence of a socioeconomic gradient in mortality, which tends to be steeper in urban areas. Similar to other European cities, Lisbon is far from homogeneous since considerable geographical inequalities exist between the more advantaged and the more deprived neighborhoods. The main goals of this study are to describe the geographical pattern of premature deaths (before 65 years old), avoidable deaths (preventable and amenable to healthcare) and cause-specific mortality (HIV/AIDS and suicide) in Lisbon, at the lower administrative level (civil parish, in Portuguese: Freguesia), and analyze the statistical association between mortality risk and deprivation, before (1999–2003) and during the economic crisis (2008–2012). Smoothed Standardized Mortality Ratios (sSMR) and Relative Risk (RR) with 95% credible intervals were calculated to identify the association between mortality and deprivation. The analysis of the geographical distribution of cause-specific mortality reveals that civil parishes with high sSMR in the first period continued to present higher mortality rates in the second. Moreover, a significant statistical association was found between all the causes of death and deprivation, except suicide. These findings contribute to understanding how social conditions influence health outcomes and can offer insights about potential policy directions for local government.

Neighborhood change and psychotic experiences in a general population sample

Social stress caused by the neighborhood environment may be a risk factor for psychotic experiences (PEs). However, little information is available on the effect of the perception of the neighborhood in relation to PEs. In a general population study in the United States (N = 974), we examined the relationship between PEs and neighborhood disruption/gentrification. When adjusted for age, sex, race, income, nativity, city, marital status, and common mental disorders, higher disruption scores were significantly associated with higher odds for any PE (odds ratio = 1.09, 95% CI = 1.05-1.12). The same pattern of associations was observed for individual PEs including delusional mood, delusion of reference and persecution, delusion of control, and hallucination. This study suggests that subjectively perceived neighborhood change may be a factor contributing to the occurrence of PEs. There was no significant relationship between PE and gentrification. Having a low income and racial minority status did not modify this association. Future studies can employ comparative longitudinal analyses of individuals/neighborhoods/cities, geographical information systems, and ethnography, to examine the impact of neighborhood change on mental health.

Analysis of the Local Agenda 21 in Madrid Compared with Other Global Actions in Sustainable Development

Over the last two decades, numerous towns have been involved in the Local Agenda 21 program in Spain, which is founded on social participation. In the wake of this initiative, the recent promotion of the new Spanish Urban Agenda by the national government seeks to implement the 2030 Agenda in municipalities nationwide. This research aims to examine the Local Agenda 21 process by using Madrid as a case study to determine the lessons learned to enable the effective application of the new Spanish Urban Agenda. A total of 3712 activities included in the action plans of the 21 districts of Madrid were analyzed to identify linkages with the Sustainable Development Goals and the targets of Sustainable Development Goal # 11 (“Sustainable cities and communities”). Methodologies used were solely oriented to develop an ad hoc Local Agenda 21 plan for each district, hindering the comparison of schemes and findings. Social, institutional, economic, and environmental dimensions of sustainable development were not equally considered by the plans, being the first two aspects the most predominant. Social engagement hardly reached 0.44% of the registered population. The contribution of all action plans to the sustainable development of Madrid was not assessed due to the absence of indicators in the program.

Is cancer prevention influenced by the built environment? A multidisciplinary scoping review

The built environment is a significant determinant of human health. Globally, the growing prevalence of preventable cancers suggests a need to understand how features of the built environment shape exposure to cancer development and distribution within a population. This scoping review examines how researchers across disparate fields understand and discuss the built environment in primary and secondary cancer prevention. It is focused exclusively on peer-reviewed sources published from research conducted in Australia, Canada, Ireland, New Zealand, the United Kingdom, and the United States from 1990 to 2017. The review captured 9958 potential results in the academic literature, and this body of results was scoped to 268 relevant peer-reviewed journal articles indexed across 13 subject databases. Spatial proximity, transportation, land use, and housing are well-understood features of the built environment that shape cancer risk. Built-environment features predominantly influence air quality, substance use, diet, physical activity, and screening adherence, with impacts on breast cancer, lung cancer, colorectal cancer, and overall cancer risk. The majority of the evidence fails to provide direct recommendations for advancing cancer prevention policy and program objectives for municipalities. The expansion of interdisciplinary work in this area would serve to create a significant population health impact.

The impact and importance of place on health for young people of Pasifika descent in Queensland, Australia: a qualitative study towards developing meaningful health equity indicators

Background

Health equity is a priority in the global sustainable development agenda. Available health equity indicators often focus on health outcomes, access to healthcare, risk factors and determinants such as income, education, and gender. Less attention has been given to other social determinants, including those related to place and ethnicity. Measures such as income, education, and gender, however, may not provide policy-makers with sufficient information to redress inequities. In this paper, we begin to develop health equity indicators for young Pasifika peoples in Logan, Queensland, Australia. While health data on Pasifika young people in Queensland is scant, available data suggests significant inequalities. The purpose of the study was to develop an understanding of the drivers of these disparities through the lens of the social determinants of health, to create health equity indicators.

Methods

Following meetings with community stakeholders to develop respectful and collaborative partnership processes, we took a youth participatory action research approach. Six peer researchers (3 male, 3 female) were recruited from the Logan area for the project. Following training, the peer researchers undertook 31 qualitative interviews with young Pasifika (16–24 years old). Data was manually analysed, coded and grouped into themes to develop the draft indicators. Interviews used the culturally appropriate Talanoa storytelling approach.

Results

Six key themes were identified from the interviews and were used to develop example indicators related to: spiritual and socio-cultural dimensions, place, access to culturally responsive services, economic and material dimensions and political dimensions. The results demonstrate health inequities experienced by Pasifika populations are strongly linked to place and their economic, social and cultural position.

Conclusions

This study emphasises the need to understand the multiplicity of place-based factors that interact in complex ways to shape health inequities for young Pasifika peoples. It highlights health equity indicators must go beyond healthcare services, outcomes and a limited number of objective determinants, to include a more holistic focus. Starting to measure health and wellbeing via the lens of the social determinants of health will help to identify where policy-makers and programmes can intervene to begin to more adequately address inequities.

Demographic Inequities in Health Outcomes and Air Pollution Exposure in the Atlanta Area and its Relationship to Urban Infrastructure

Environmental burdens such as air pollution are inequitably distributed with groups of lower socioeconomic statuses, which tend to comprise of large proportions of racial minorities, typically bearing greater exposure. Such groups have also been shown to present more severe health outcomes which can be related to adverse pollution exposure. Air pollution exposure, especially in urban areas, is usually impacted by the built environment, such as major roadways, which can be a significant source of air pollution. This study aims to examine inequities in prevalence of cardiovascular and respiratory diseases in the Atlanta metropolitan region as they relate to exposure to air pollution and characteristics of the built environment. Census tract level data were obtained from multiple sources to model health outcomes (asthma, chronic obstructive pulmonary disease, coronary heart disease, and stroke), pollution exposure (particulate matter and nitrogen oxides), demographics (ethnicity and proportion of elderly residents), and infrastructure characteristics (tree canopy cover, access to green space, and road intersection density). Conditional autoregressive models were fit to the data to account for spatial autocorrelation among census tracts. The statistical model showed areas with majority African-American populations had significantly higher exposure to both air pollutants and higher prevalence of each disease. When considering univariate associations between pollution and health outcomes, the only significant association existed between nitrogen oxides and COPD being negatively correlated. Greater percent tree canopy cover and green space access were associated with higher prevalence of COPD, CHD, and stroke. Overall, in considering health outcomes in connection with pollution exposure infrastructure and ethnic demographics, demographics remained the most significant explanatory variable.

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.

Strategies of Dyadic Coping and Self-Regulation in the Family Homes of Chronically Ill Persons: A Qualitative Research Study Using the Emotional Map of the Home Interview Method

Environmental and emotional self-regulation skills play a critical role in promoting well-being of individuals and in encouraging healthy relationships. However, occurrence of chronic illness in one family member complicates routine dyadic coping processes for the couple. Additionally, according to environmental psychologists, self-regulation processes are influenced by individuals' perceptions of their socio-physical environments, and during times of chronic illness, the family home is frequently the primary site of dyadic coping. To date, few researchers have investigated the complex relationship among dyadic coping, the family home, and self-regulation processes in the context of chronic illness. The purpose of this paper is to report the results of qualitative research conducted to explore these relationships by analyzing participants' emotionally significant experiences within the family home. We purposively sampled and conducted in depth semi-structured interviews with 23 adults representing 10 families with one chronically ill adult family member. Representative illnesses included epilepsy (4) and chronic back pain (6). We used the Emotional Map of the Home Interview method (EMHI), an elicitation process in which participants are initially asked to place predefined positive and negative experiences on drawn diagrams of their homes. We analyzed the data through grounded theory coding methods, including open, axial and selective coding. Results of data analysis suggest that the family home operated as a critical socio-physical environment and had a profound impact on environmental and emotional self-regulation as well as on dyadic coping when one partner experienced chronic illness. Key selective codes derived from the data that reflect the variation and nuance within this impact included: "stress communication through the home space," "coping by spatial separation" and "coping by joint striving for at-homeness." These results reveal formerly hidden aspects of dyadic coping with chronic illness: the role of environmental cues, represented by the family home in this study, in perceptions of stress; the coordinated use of spatial-environmental contexts to engage the appropriate self-regulatory strategies for coping with illness-related stress. These findings demonstrate the utility of EMHI as an assessment tool and provide meaningful theoretical and practical information about dyadic coping among couples living with chronic disease.

Implementation of Urban Health Equity Assessment and Response Tool: a Case of Matsapha, Swaziland

Equity in health implies that ideally everyone could attain their full health potential and that no one should be disadvantaged from achieving this potential because of their social position or other socially determined circumstances. Making cities and human settlements inclusive, safe, resilient and sustainable contributes towards ensuring healthy lives and promoting well-being for all at all ages in dignity, equality and in a healthy environment. This paper illustrates a case of applying the Urban Health Equity Assessment and Response Tool (Urban HEART) in a small town in Africa. It describes the process followed, facilitating factors and challenges faced. A descriptive single-case study design using qualitative research methods was adopted to collect data from purposively selected respondents. The study revealed that residents of the Matsapha peri-urban informal settlements faced challenges with conditions of daily living which impacted negatively on their health. There were health equity gaps. The application of the tools was facilitated by the formation of an all-inclusive team, intersectoral collaboration and incorporating strategies for improving urban health equity into existing programmes and projects. Urban HEART is a simple and easy to use valuable tool for pursuing the goal of health equity towards attaining sustainable development through evidence-based approaches for intersectoral action and community involvement.

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.

Towards environmental health equity in health impact assessment: innovations and opportunities

OBJECTIVES

As global environmental change drives inequitable health outcomes, novel health equity assessment methodologies are increasingly required. We review literatures on equity-focused HIA to clarify how equity is informing HIA practice, and to surface innovations for assessing health equity in relation to a range of exposures across geographic and temporal scales.

METHODS

A narrative review of the health equity and HIA literatures analysed English articles published between 2003 and 2017 across PubMed, PubMed Central, Biomed Central and Ovid Medline. Title and abstract reviews of 849 search results yielded 89 articles receiving full text review.

RESULTS

Considerations of equity in HIA increased over the last 5 years, but equity continues to be conflated with health disparities rather than their root causes (i.e. inequities). Lessons from six literatures to inform future HIA practice are described: HIA for healthy cities, climate change vulnerability assessment, cumulative health risk assessment, intersectionality-based policy analysis, corporate health impact assessment and global health impact assessment.

CONCLUSIONS

Academic reporting on incorporating equity in HIA practice has been limited. Nonetheless, significant methodological advancements are being made to examine the health equity implications of multiple environmental exposures.

Poverty, Transportation Access, and Medication Nonadherence

BACKGROUND AND OBJECTIVES

Variability in primary medication nonadherence (PMN), or failure to fill a new prescription, influences disparities and widens equity gaps. This study sought to evaluate PMN across 1 metropolitan area and assess relationships with underlying zip code-level measures.

METHODS

This was a retrospective observational study using data extracted from 1 regional community pharmacy market-share leader (October 2016-April 2017). Data included patient age, sex, payer, medication type, and home zip code. This zip code was connected to US census measures enumerating poverty and vehicle access, which were treated as continuous variables and within quintiles. The prescription-level outcome was whether prescriptions were not filled within 30 days of reaching the pharmacy. The ecological-level outcome was PMN calculated for each zip code (numerator, unfilled prescriptions; denominator, received prescriptions).

RESULTS

There were 213 719 prescriptions received by 54 included pharmacies; 12.2% were unfilled. Older children, boys, and those with public insurance were more likely to have prescriptions not filled. Prescriptions originating from the highest poverty quintile were significantly more likely to not be filled than those from the lowest poverty quintile (adjusted odds ratio 1.60; 95% confidence interval 1.52-1.69); a similar pattern was noted for vehicle access (adjusted odds ratio 1.77; 95% confidence interval 1.68-1.87). At the ecological level, there were significant, graded relationships between PMN rates and poverty and vehicle access (both P < .0001); these gradients extended across all medication classes.

CONCLUSIONS

Poverty and vehicle access are related to significant differences in prescription- and ecological-level PMN across 1 metropolitan area. Pharmacists and pharmacies can be key partners in population health efforts.

Urban Green Space and the Pursuit of Health Equity in Parts of the United States

Research has demonstrated that inequitable access to green space can relate to health disparities or inequalities. This commentary aims to shift the dialogue to initiatives that have integrated green spaces in projects that may promote health equity in the United States. Specifically, we connect this topic to factors such as community revitalization, affordable housing, neighborhood walkability, food security, job creation, and youth engagement. We provide a synopsis of locations and initiatives in different phases of development along with characteristics to support effectiveness and strategies to overcome challenges. The projects cover locations such as Atlanta (GA), Los Angeles (CA), the District of Columbia (Washington D.C.), South Bronx (NY), and Utica (NY). Such insight can develop our understanding of green space projects that support health equity and inform the dialogue on this topic in ways that advance research and advocacy.

Increasing the Use of Urban Greenways in Developing Countries: A Case Study on Wutong Greenway in Shenzhen, China

Given the benefits of urban greenways on the health and well-being of urban populations, the increased use of urban greenways has garnered increasing attention. Studies on urban greenways, however, have been mostly conducted in Western countries, whereas there is limited knowledge on greenway use in urban areas in developing countries. To address this shortcoming, the present study selected Wutong Greenway in Shenzhen, China, as a case study and focused on the use pattern and factors that influence the frequency and duration of urban greenway use in developing countries. An intercept survey of greenway users was conducted, and 1257 valid questionnaires were obtained. Multiple logistic regression analysis was used to examine the relationship between potential predictors and greenway use. Results showed that visitors with a varied sociodemographic background use Wutong Greenway with high intensity. Various factors affect the use of urban greenways, including individual and environmental factors and greenway use patterns. Unlike previous studies, we found that accommodation type, length of stay at present residence and mode of transportation to the greenway are important factors that affect greenway use. In contrast with studies conducted in Western countries, less-educated and low-income respondents visit the Wutong greenway even more frequently than others. Thus, the greenway is an important public asset that promotes social equity and that all residents can freely use. To better serve citizens, we suggest that the greenway network should be extended to other areas and that its environmental quality should be improved.