Examining the Urban and Rural Healthcare Progress in Big Cities of China: Analysis of Monitoring Data in Dalian from 2008 to 2017

Efficiency evaluation, regional technological heterogeneity and determinant of total factor productivity change in China's healthcare system

Enhancing efficiency and productivity in countries' healthcare systems is a global challenge. The Chinese government invested huge resources to improve the efficiency and productivity of the healthcare system across the country. To assess the success of the mission above, this research utilized DEA-SBM Meta frontier analysis alongside the Malmquist Productivity Index. These methodologies were employed to gauge Efficiency, production technology heterogeneity, and productivity of healthcare systems change across 31 mainland Chinese provinces and four distinct geographical regions throughout the study period spanning from 1997 to 2022. Results revealed that the mean efficiency score of China's healthcare system is 0.7672. It indicates a growth potential of 23.28 percent in the operational efficiency of healthcare systems. The eastern region's efficiency level (0.86917) is higher among all four regions. Zhejiang, Shandong, and Guangdong are the top three healthcare-efficiency performers. The technology gap ratio indicates that eastern regions witnessed a high TGR (0.9909), showing the country's attainment of superior healthcare technologies. Beijing, Guangdong, Shanghai, Tianjin, and Zhejiang witnessed higher TGR values among all 31 mainland Chinese provinces. The total factor productivity index of the healthcare system witnessed a slight growth of 0.33%, with an average MI score of 1.0033. Efficiency change (EC) was found to be the main determinant of TFPC as technology change TC is less than EC. Moreover, the MI score of the Western region (1.033) is higher than the corresponding Eastern, northeastern, and central regions. Guizhou, Anhui, and Yunnan were found to be the top three performers in TFPC growth. Finally, the Kruskal-Wallis test confirmed the statistically significant difference among 4 Chinese regions for the healthcare system's efficiency, TFPC, and TGR.

Spatial effects of township health centers' health resource allocation efficiency in China

Introduction

China is a large agricultural nation with the majority of the population residing in rural areas. The allocation of health resources in rural areas significantly affects the basic rights to life and health for rural residents. Despite the progress made by the Chinese government in improving rural healthcare, there is still room for improvement. This study aims to assess the spatial spillover effects of rural health resource allocation efficiency in China, particularly focusing on township health centers (THCs), and examine the factors influencing this efficiency to provide recommendations to optimize the allocation of health resources in rural China.

Methods

This study analyzed health resource allocation efficiency in Chinese rural areas from 2012 to 2021 by using the super-efficiency SBM model and the global Malmquist model. Additionally, the spatial auto-correlation of THC health resource allocation efficiency was verified through Moran test, and three spatial econometric models were constructed to further analyze the factors influencing efficiency.

Results

The key findings are: firstly, the average efficiency of health resource allocation in THCs was 0.676, suggesting a generally inefficient allocation of health resources over the decade. Secondly, the average Malmquist productivity index of THCs was 0.968, indicating a downward trend in efficiency with both non-scale and non-technical efficient features. Thirdly, Moran's Index analysis revealed that efficiency has a significant spatial auto-correlation and most provinces' values are located in the spatial agglomeration quadrant. Fourthly, the SDM model identified several factors that impact THC health resource allocation efficiency to varying degrees, including the efficiency of total health resource allocation, population density, PGDP, urban unemployment rate, per capita disposable income, per capita healthcare expenditure ratio, public health budget, and passenger traffic volume.

Discussion

To enhance the efficiency of THC healthcare resource allocation in China, the government should not only manage the investment of health resources to align with the actual demand for health services but also make use of the spatial spillover effect of efficiency. This involves focusing on factors such as total healthcare resource allocation efficiency, population density, etc. to effectively enhance the efficiency of health resource allocation and ensure the health of rural residents.

Prevalence of Polypharmacy in Elderly Population Worldwide: A Systematic Review and Meta-Analysis

BACKGROUND

Polypharmacy (PP) is common in elderly population and associated with some adverse clinical outcomes and increases healthcare burdens. We performed this systemic review and meta-analysis to estimate worldwide prevalence of PP and explore associated factors in the elderly.

METHODS

The PubMed, Web of Science, Cochrane Library, and Ovid EMBASE databases were searched for studies published until May 30, 2022. We included observational studies representative of general patients aged ≥60 in which PP was defined as multiple drugs ≥5. Studies were excluded if only a particular group of the elderly population (e.g., with diabetes) were included. The primary outcome was the prevalence of PP. Random-effect models were employed to estimate the overall or variable-specific pooled estimates of PP. Secondary outcomes were hyperpolypharmacy (HPP, defined as multiple drugs ≥10) and PP prevalence based on different study years, genders, locations, populations, and so forth.

RESULTS

We included 122 original observational studies with an overall population of 57 328 043 individuals in the meta-analysis. The overall prevalence of PP and HPP in the elderly population worldwide was 39.1% (95% confidence interval [CI], 35.5%-42.7%) and 13.3% (95% CI, 10.4%-16.5%), respectively. The prevalence of PP in Europe, Oceania, North America, Asia, and South America was 45.8% (95% CI, 41.5%-50.2%), 45.5% (95% CI, 26.7%-64.3%), 40.8% (95% CI, 29.8%-51.6%), 29.0% (95% CI, 20.0%-38.0%), and 28.4% (95% CI, 24.0%-32.8%), respectively (p < 0.01). Multivariate meta-regressions showed geographical regions of Europe or North America, age ≥70, and residence from nursing homes were independently associated with higher PP prevalence.

CONCLUSIONS

Nearly 40% of the elderly population is exposed to PP. The prevalence of PP is significantly higher in elderly individuals aged 70 or older, in developed regions and in nursing homes. It is important to focus on avoiding inappropriate PP in this population to address the growing burden of PP.

Effectiveness of hierarchical medical system and economic growth: based on China's urban vs. rural health perspectives

Background

The hierarchical medical system is an important measure to promote equitable healthcare and sustain economic development. As the population's consumption level rises, the demand for healthcare services also increases. Based on urban and rural perspectives in China, this study aims to investigate the effectiveness of the hierarchical medical system and its relationship with economic development in China.

Materials and methods

The study analyses panel data collected from Chinese government authorities, covering the period from 2009 to 2022. According to China's regional development policy, China is divided into the following regions: Eastern, Middle, Western, and Northeastern. Urban and rural component factors were downscaled using principal component analysis (PCA). The factor score formula combined with Urban-rural disparity rate (ΔD) were utilized to construct models for evaluating the effectiveness of the hierarchical medical system from an urban-rural perspective. A Vector Autoregression model is then constructed to analyze the dynamic relationship between the effects of the hierarchical medical system and economic growth, and to predict potential future changes.

Results

Three principal factors were extracted. The contributions of the three principal factors were 38.132, 27.662, and 23.028%. In 2021, the hierarchical medical systems worked well in Henan (F = 47245.887), Shandong (F = 45999.640), and Guangdong (F = 42856.163). The Northeast (ΔDmax = 18.77%) and Eastern region (ΔDmax = 26.04%) had smaller disparities than the Middle (ΔDmax = 49.25%) and Western region (ΔDmax = 56.70%). Vector autoregression model reveals a long-term cointegration relationship between economic development and the healthcare burden for both urban and rural residents (βurban = 3.09, βrural = 3.66), as well as the number of individuals receiving health education (β = -0.3492). Both the Granger causality test and impulse response analysis validate the existence of a substantial time lag between the impact of the hierarchical medical system and economic growth.

Conclusion

Residents in urban areas are more affected by economic factors, while those in rural areas are more influenced by time considerations. The urban rural disparity in the hierarchical medical system is associated with the level of economic development of the region. When formulating policies for economically relevant hierarchical medical systems, it is important to consider the impact of longer lags.

Knowledge, attitude, and practice toward postoperative self-management among patients after percutaneous coronary intervention: A structural equation modeling analysis

OBJECTIVE

The knowledge, attitude, and practice (KAP) toward post-percutaneous coronary intervention (PCI) self-management among Chinese patients remains unknown. This study investigated the KAP toward postoperative self-management among patients after PCI.

HYPOTHESIS

Patients exhibit poor knowledge, attitudes, and practices regarding post-PCI self-management, requiring enhanced education strategies.

METHODS

This cross-sectional study recruited patients after PCI at Jishuitan Hospital, Beijing, between November 2022 and May 2023. Inclusion criteria comprised patients 1-3 months post-PCI, those capable of self-care, and those willingly participating. The questionnaire (49 items) was designed with reference to current guidelines (the Cronbach α = .829). The final questionnaire included four dimensions with 49 items. The Pearson correlation analysis and structural equation modeling (SEM) were used to determine the relationship among knowledge, attitude, and practice.

RESULTS

A total of 476 valid questionnaires were included. The knowledge, attitude, and practice scores were 8.24 ± 2.78 (possible range: 0-12), 21.61 ± 3.15 (possible range: 9-45), and 32.62 ± 3.75 (possible range: 10-50). The Pearson correlation analysis showed only knowledge scores were correlated with the attitude scores (r = .446, p < .001). The SEM showed that knowledge directly affects attitude (β = .616, p < .001) but had no influence on practice (β = .119, p = .155); attitude had no influence on practice (β = .015, p = .809).

CONCLUSION

This study indicated that patients had poor knowledge, unfavorable attitudes, and unsatisfied practice toward post-PCI self-management. Strengthening patient health education through diverse approaches is imperative.

Impact of the National Nursing Development Plan on nursing human resources in China: An interrupted time series analysis for 1978-2021

BACKGROUND

Shortages of nurses and unequal distribution of nursing staff have been huge challenges for global health services.

OBJECTIVES

The aim of our study was to evaluate the impact of the National Nursing Development Plan on nursing human resources in China.

METHODS

An interrupted time series design was used in this study. The data for this study were extracted from the National Health Statistics Yearbook from 1978 to 2021. The Ministry of Health issued the National Nursing Development Plan (2005-2010) in July 2005. Subsequently, the strategic plan was issued every 5 years: the National Nursing Development Plan (2011-2015), the National Nursing Development Plan (2016-2020), and the National Nursing Development Plan (2021-2025). This study used five indicators including 1) the number of registered nurses (RNs) in China, 2) the number of RNs per 1000 population in China, 3) the proportion of RNs in health technical personnel in China, 4) the doctor-nurse ratio and 5) the number of nurses working in primary medical institutions to evaluate the changing trend of nursing human resources in China from 1978 to 2021.

RESULTS

Interrupted time series analysis showed that after the implementation of the National Nursing Development Plan (2005-2010), the building of nurses in China was gradually strengthening, and the number of RNs in China increased by 0.198 million per year (95%CI 0.174-0.223; P < 0.001); the number of RNs per 1000 population (Coefficient = 0.139; 95%CI 0.123-0.154; P < 0.001); the proportion of RNs in the total number of health professionals in China has increased from 29.6 % to 44.6 % (Coefficient = 0.010; 95%CI 0.009-0.010; P < 0.001); in China, the doctor-nurse ratio increased by 0.024 (95%CI 0.019-0.029; P < 0.001). In 2021, the number of RNs working in primary medical institutions increased by approximately 0.86 million compared with that in 2005, and the proportion of RNs in the country increased by 1.4 %. The development of nurses is especially tilted to the primary level to meet the health and nursing needs of the primary level.

CONCLUSIONS

The implementation of the National Nursing Development Plan has greatly expanded the scale of nursing human resources in China and significantly optimized the efficiency of allocation. The implementation of the National Nursing Development Plan (2011-2015) and the National Nursing Development Plan (2016-2020) well continued the strategic plan from 2005 to 2010, further expanded the nursing workforce and further optimized the allocation efficiency.

TWEETABLE ABSTRACT

The implementation of the National Nursing Development Plan has greatly expanded the scale of nursing human resources in China and significantly optimized the efficiency of allocation.

Mapping stunted children in Ethiopia using two decades of data between 2000 and 2019. A geospatial analysis through the Bayesian approach

BACKGROUND

Childhood stunting is a major public health problem globally, resulting in poor cognition and educational performance, low adult wages, low productivity, and an increased risk of nutrition-related chronic diseases in adulthood life. Accurate and reliable data on the prevalence of stunting over time with a sub-national estimate are scarce in Ethiopia.

OBJECTIVE

Our objective was to investigate the spatiotemporal distributions and ecological level drivers of stunting among under-five children over time in Ethiopia.

METHODS

A geospatial analysis using the Bayesian framework was employed to map the spatial variations of stunting among children aged less than five years. The data for the primary outcome were obtained from the Ethiopian Demographic and Health Surveys (2000-2019) and covariates data were accessed from different publicly available credible sources. The spatial binomial regression model was fitted to identify drivers of child stunting using the Bayesian approach.

RESULT

The national prevalence of stunting was 47.9 in 2000, 43.3 in 2005, 37.3 in 2011, 36.6 in 2016, and 35.9 in 2019, with a total reduction rate of 25%. Substantial spatial clustering of stunting was observed in the Northern (Tigray), Northcentral (Amhara), and Northwestern (Amhara) parts of Ethiopia. Temperature (mean regression coefficient (β): -0.19; 95% credible interval (95% CrI): -0.25, -0.12) and population density (β: -0.012; 95% CrI: -0.016, -0.009) were negatively associated with stunting, whereas travel time to the nearest cities (β: 0.12; 95% CrI: 0.064, 0.17) was positively associated with child stunting in Ethiopia.

CONCLUSION

The prevalence of stunting varied substantially at subnational and local levels over time. Clustering of stunted children were observed in the Northern parts of Ethiopia. Temperature, population density and travel time to the nearest cities were identified as the drivers of stunting in children. Improving community awareness of child nutrition through community health extension programs should be strengthened.

User Experience of Symptom Checkers: A Systematic Review

This review reports the user experience of symptom checkers, aiming to characterize users studied in the existing literature, identify the aspects of user experience of symptom checkers that have been studied, and offer design suggestions. Our literature search resulted in 31 publications. We found that (1) most symptom checker users are relatively young; (2) eight relevant aspects of user experience have been explored, including motivation, trust, acceptability, satisfaction, accuracy, usability, safety/security, and functionality; (3) future symptom checkers should improve their accuracy, safety, and usability. Although many facets of user experience have been explored, methodological challenges exist and some important aspects of user experience remain understudied. Further research should be conducted to explore users' needs and the context of use. More qualitative and mixed-method studies are needed to understand actual users' experiences in the future.

Analysing the global and local spatial associations of medical resources across Wuhan city using POI data

BACKGROUND

There is a sharp contradiction between the supply and demand of medical resources in the provincial capitals of China. Understanding the spatial patterns of medical resources and identifying their spatial association and heterogeneity is a prerequisite to ensuring that limited resources are allocated fairly and optimally, which, along with improvements to urban residents' quality of life, is a key aim of healthy city planning. However, the existing studies on medical resources pattern mainly focus on their spatial distribution and evolution characteristics, and lack the analyses of the spatial co-location between medical resources from the global and local perspectives. It is worth noting that the research on the spatial relationship between medical resources is an important way to realize the spatial equity and operation efficiency of urban medical resources.

METHODS

Localized colocation quotient (LCLQ) analysis has been used successfully to measure directional spatial associations and heterogeneity between categorical point data. Using point of interest (POI) data and the LCLQ method, this paper presents the first analysis of spatial patterns and directional spatial associations between six medical resources across Wuhan city.

RESULTS

(1) Pharmacies, clinics and community hospitals show "multicentre + multicircle", "centre + axis + dot" and "banded" distribution characteristics, respectively, but specialized hospitals and general hospitals present "single core" and "double core" modes. (2) Overall, medical resources show agglomeration characteristics. The degrees of spatial agglomeration of the five medical resources, are ranked from high to low as follows: pharmacy, clinic, community hospital, special hospital, general hospital and 3A hospital. (3) Although pharmacies, clinics, and community hospitals of basic medical resources are interdependent, specialized hospitals, general hospitals and 3A hospitals of professional medical resources are also interdependent; furthermore, basic medical resources and professional medical resources are mutually exclusive.

CONCLUSIONS

Government and urban planners should pay great attention to the spatial distribution characteristics and association intensity of medical resources when formulating relevant policies. The findings of this study contribute to health equity and health policy discussions around basic medical services and professional medical services.

Equity and efficiency of medical and health service system in China

BACKGROUND

Equity and efficiency are basic value dimensions to evaluate the effectiveness of China's medical and health service system (MHS) reform and development. Coordinated development of equity and efficiency is necessary to realize high-quality development of medical and health services. This study aims to evaluate the equity, efficiency, and combined efforts in coordinating the MHS during 1991-2020 reform.

METHODS

Data on China's MHS were obtained from the China Statistical Yearbook 1992-2021. Ratios of urban to rural residents' medical expenditure and number of medical professionals per 10,000 people were employed to evaluate MHS's equity. The data envelopment analysis-Malmquist model was employed to evaluate MHS's efficiency. We constructed a combined-efforts-in-coordination model to examine the coordination degree between equity and efficiency.

RESULTS

Equity of medical expenditure burden significantly improved from during 1991-2007. Urban residents' 1991 medical expenditure burden was 87.8% of that of rural residents, which increased to 100.1% in 2007. Urban areas' mean medical expenditure burden was 105.94% of that in rural areas during 1991-2007. The gap in equity of medical expenditure burden between urban and rural areas slowly widened after 2007, with urban areas' mean burden being 68.52% of that in rural areas during 2007-2020. Medical and health resources allocation shows an alarming inequity during this period, with mean number of medical professionals per 10,000 people in urban areas being 238.30% of that in rural areas. Efficiency experienced several fluctuations before 2008. Since 2008, efficiency was high (0.915) and remained stable, except in 2020. The combined-efforts-in-coordination score for medical expenditure burden was less than 0.2 for 80% of the years, while that for in medical and health resources was more than 0.5 for 99.67% of the years.

CONCLUSIONS

MHS inequity remains between urban and rural China, primarily because of disproportionate allocation of medical and health resources. The government should enhance rural medical professionals' salary and welfare and provide medical subsidies for rural residents to adjust resource allocation levels in urban and rural areas, control differences in medical expenditure burden between urban and rural residents to a reasonable range, and continuously improve urban and rural residents' equity level.

Exacerbation in patients with stable COPD in China: analysis of a prospective, 52-week, nationwide, observational cohort study (REAL)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) management in China is inadequate and there is a need to improve care and outcomes for patients nationwide.

OBJECTIVES

The REAL study was designed to generate reliable information on COPD management from a representative sample of Chinese patients with COPD. Here, we present study outcomes related to acute exacerbations.

DESIGN

A 52-week, multicentre, prospective, observational study.

METHODS

Outpatients (aged ⩾ 40 years) enrolled from 25 tertiary and 25 secondary hospitals across six geographic regions in China were followed for 12 months. Risk factors for COPD exacerbation and disease severity by exacerbation were assessed using multivariate Poisson and ordinal logistic regression models, respectively.

RESULTS

Between June 2017 and January 2019, 5013 patients were enrolled, with 4978 included in the analysis. Mean (standard deviation) age was 66.2 (8.9) years. More patients presented with exacerbations in secondary versus tertiary hospitals (59.4% versus 40.2%) and in rural versus urban areas (53.2% versus 46.3%). Overall exacerbation rates differed across regions (range: 0.27-0.84). Patients from secondary versus tertiary hospitals had higher rates of overall exacerbation (0.66 versus 0.47), severe exacerbation (0.44 versus 0.18) and exacerbation that resulted in hospitalisation (0.41 versus 0.16). Across regions and hospital tiers, the rates of overall exacerbation and exacerbations that resulted in hospitalisation were highest in patients with very severe COPD (based on the severity of airflow limitation or GOLD 2017 combined assessment). Strong predictors of exacerbation included demographic and clinical characteristics, modified Medical Research Council scores, mucus purulence, exacerbation history and the use of maintenance mucolytic treatment.

CONCLUSION

COPD exacerbation rates varied across regions and were higher in secondary compared with tertiary hospitals in China. Understanding the factors associated with COPD exacerbation may facilitate improved management of COPD exacerbations in China.

REGISTRATION

The trial was registered on 20 March 2017 (ClinicalTrials.gov: NCT03131362; https://clinicaltrials.gov/ct2/show/NCT03131362).

PLAIN LANGUAGE SUMMARY

Exacerbations in patients with chronic obstructive pulmonary disease in ChinaBackground: Chronic obstructive pulmonary disease (COPD) causes progressive and irreversible airflow limitation. As the disease progresses, patients often experience a flare up of symptoms referred to as an exacerbation. There is inadequate management of COPD in China and, therefore, there is a need to improve care and outcomes for patients across the country.Objective: This study aimed to generate reliable information on exacerbations among Chinese patients with COPD to help inform future management strategies.Study design and methods: Patients (aged ⩾ 40 years) were enrolled from 25 secondary and 25 tertiary hospitals across six regions of China. Physicians collected data over 1 year during routine outpatient visits.Results: There were more patients who experienced an exacerbation in secondary versus tertiary hospitals (59% versus 40%) and in rural versus urban areas (53% versus 46%). Patients in different geographic regions experienced varying frequencies of exacerbations over 1 year. Compared with patients from tertiary hospitals, patients from secondary hospitals experienced exacerbations (including exacerbations that were severe and those that resulted in hospitalisation) at a higher frequency over 1 year. Patients with very severe disease experienced exacerbations (including exacerbations that resulted in hospitalisation) at the highest frequency over 1 year, regardless of the patient's geographic region or hospital tier. Patients who had certain characteristics and symptoms, had exacerbation(s) over the previous year, or received medication that aids in the clearance of mucus were more likely to experience exacerbations.Conclusion: The frequency of exacerbations among Chinese patients with COPD varied between patients living in different geographic regions and between patients presenting to different hospital tiers. Understanding the factors related to the occurrence of an exacerbation may help physicians better manage the disease.

How Does Smart Healthcare Service Affect Resident Health in the Digital Age? Empirical Evidence From 105 Cities of China

With the emergence of the digital age, smart healthcare services based on the new generation of information technologies play an increasingly important role in improving the quality of resident health. This study empirically examined the impact of regional smart healthcare services on resident health as well as the underlying mechanism by employing a two-way fixed effects model. We constructed a Regional Smart Healthcare Service Development Index and matched it with survey data from the China Health and Retirement Longitudinal Study to validate the model. The results showed that (1) smart healthcare services have a significant positive impact on resident health. (2) The availability of outpatient services and inpatient services plays a mediating role in the relationship between regional smart healthcare services and resident health. (3) The influence of regional smart healthcare services on resident health is heterogeneous among different regions. Specifically, the effect of smart healthcare services on resident health is significant in the eastern regions, while it is not significant in the central, western, and northeastern regions. The effect of smart healthcare services on resident health is significant in rural regions but not in urban regions. This study enriches the nascent research stream of smart healthcare services. This study offers useful insights for practitioners and the government to guide them in formulating smart healthcare strategies.

An integrated model for evaluation of maternal health care in China

In recent years, in the context of China’s continuous medical and health reforms, the health status of Chinese women and children has been significantly improved through the continuous efforts of staff at all levels of maternal and child health care institutions. Many indicators in maternal health care have improved significantly, but the speed and magnitude of changes have varied. The purpose of this study is to evaluate the dynamic changes in China’s maternal health status from 2004 to 2018, in order to determine whether China’s medical and health reform measures in recent years have improved maternal health. A total of 6 evaluation indicators from the data of China Health Statistics Yearbook 2019 were selected. Then, based on the multi-criteria decision-making (MCDA) methodology, the entropy weighted technique for order preference by similarity to an ideal solution (TOPSIS), entropy weighted rank-sum ratio (RSR) method and the fuzzy comprehensive evaluation were employed in this study. In addition, sensitivity analysis was engaged to validate the stability and accuracy of the achieved results. The study results shows the ranking values of various methods were not exactly the same, but the overall trend was consistent. Overall, the maternal health care in China improved from 2004 to 2018 year by year, of which the top four were ranked from 2015 to 2018, and relatively poor from 2004 to 2006. This means that the policies and measures implemented in China’s medical and health reform in the past few decades have effectively promoted China’s maternal health care, and this will also provide a theoretical basis for future decisions to promote maternal health care.

Selecting Indicators to Monitor and Assess Environmental Health in a Portuguese Urban Setting: A Participatory Approach

Environmental health (EH) is influenced by complex interactions between health and the built and natural environments, there being little research on its specificities in urban settings. The use of suitable indicators to monitor and assess EH is fundamental in informing evidence-based interventions at the local level. A participatory approach to selecting indicators to inform the monitoring and assessment of EH in Lisbon is herein considered. Evidence derived from a systematic review of literature and data from Lisbon and Portuguese databases were analyzed by 12 Portuguese experts in individual semi-structured interviews. The interviews aimed at identifying relevant indicators and important emerging issues in the Lisbon urban setting. The outputs from the interviews were validated by a two-round Web-Delphi process in which panelists (22 experts) from different areas of expertise expressed their views regarding the relevance of the indicators for the analysis of EH in urban settings. Seventeen indicators were validated in the Web-Delphi process. High participation achieved along this process supports the view that this participatory approach was useful for validation. Results from the adopted participatory approach point out gaps in the collection of noise and mobility indicators data and raise emerging issues on housing indicators that require further research. The results also suggest the need for local action to improve indicators and tools in order to help the monitorization of EH in urban contexts. The adopted participatory approach can be replicated for other Portuguese and European urban settings.