The three paradigms on urban health

Background

While public health and urban planning share a historical connection in the mid-19th century, when public health and sanitation became a key guiding principle for urban planning, the two disciplines evolved in separate ways after major technological and social developments such as the development of germ theory and the ascent of biomedicine. Recently, urban planners and public health experts globally are calling for a reconnection between the health and urban planning spheres. However, there are different schools of thought around how to address health in the urban context that originates from different worldviews and epistemological traditions of the disciplines.

Methods

This study is a narrative review that explores the core beliefs and assumptions of the different research traditions that are observed around health in the urban context.

Results

The study identifies three main traditions. The 'urban health science' tradition is characterized by the pathogenic and epidemiological analysis of urban problems, suggesting predominantly technological solutions to these issues. Scholars of this tradition emphasize that urban health requires straight Cartesian causal thinking to inform interventions to promote the health of urban populations. The 'healthy cities movement' tradition is based on the principles of the Ottawa Charter for Health Promotion with strong roots in social movements, and takes a value-based approach to solutions that embraces the principles of solidarity, equity, sustainability and empowerment. While these two traditions originate from the discipline of public health, the third 'healthy urban planning' tradition emerged from the urban planning discipline and proposes to include health as objectives in the spatial development of cities.

Conclusions

This study identifies the core beliefs and assumptions of the paradigms of urban health and highlights areas where beliefs and assumptions epistemologically or practically overlap and interface.

Key messages

Scholars from different epistemological traditions possess different worldview on the problem definition and solution to urban health. The three paradigms on urban health are not mutually exclusive, rather each could learn from each other to promote the health of urban citizens.

Housing, health and master planning: rules of engagement

OBJECTIVES

Knowledge about health focussed policy collaboration to date has been either tactical or technical. This article focusses on both technical and tactical issues to describe the experience of cross-sectoral collaboration between health and housing stakeholders across the life of a housing master plan, including but not limited to a health impact assessment (HIA).

STUDY DESIGN

A single explanatory case study of collaboration on a master plan to regenerate a deprived housing estate in Western Sydney was developed to explain why and how the collaboration worked or did not work.

METHODS

Data collection included stakeholder interviews, document review, and reflections by the health team. Following a realist approach, data was analysed against established public policy theory dimensions.

RESULTS

Tactically we did not know what we were doing. Despite our technical knowledge and skills with health focussed processes, particularly HIA, we failed to appreciate complexities inherent in master planning. This limited our ability to provide information at the right points. Eventually however the HIA did provide substantive connections between the master plan and health. We use our analysis to develop technical and tactical rules of engagement for future cross-sectoral collaboration.

CONCLUSIONS

This case study from the field provides insight for future health focussed policy collaboration. We demonstrate the technical and tactical requirements for future intersectoral policy and planning collaborations, including HIAs, with the housing sector on master planning. The experience also suggested how HIAs can be conducted flexibly alongside policy development rather than at a specific point after a policy is drafted.

Parental perspectives on caring for a child with chronic kidney disease: an in-depth interview study

BACKGROUND

Children diagnosed with chronic kidney disease (CKD) depend on their parents for complex, continuous and intensive support. The study aimed to explore the experiences of parents who have children with CKD.

METHODS

Parents of 20 children with CKD, recruited from two paediatric hospitals in Australia, participated in an in-depth interview, qualitative study.

RESULTS

Four major themes were identified: (1) absorbing the clinical environment: parents struggled to accept the diagnosis and permanence of CKD, felt traumatized watching their child undergo invasive clinical procedures, battled to meet appointments, negotiated with staff for their child's needs and felt disempowered; (2) medicalizing parenting: parents became caregivers, a role which was stressful, exhausting and overwhelming. Dialysis was unrelenting and consumed the time, thoughts and energy of parents who felt at fault if their child developed infections and other complications. Parents struggled with their child's psychological problems and episodic aggressive behaviour; (3) disrupting family norms: CKD caused spousal tension, sibling neglect and influenced family planning; (4) coping strategies and support structures: Parents depended on support from their health care providers and valued meeting and learning from other parents of CKD children. Parents also expressed information needs and suggested methods of communicating information.

CONCLUSIONS

Despite facing profound and pervasive difficulties, parents strived to fulfil their dual parental and health care provider responsibilities. Parents appear to need better support structures to help them cope with the difficulties encountered during all stages of their child's illness.

Improving services for people with a psychotic disorder and problematic substance use: a multifaceted approach to project evaluation

OBJECTIVE

The objective of this study was to conduct a multifaceted formative evaluation of the Central Sydney Area Health Service (CSAHS) Psychosis and Substance Use Project.

METHOD

Four evaluative methods were used: (i) description and interpretation of the Project's documented processes and outcomes; (ii) a benchmark comparison of the Project processes and outcomes against three of the 11 National Standards for Mental Health Services; (iii) a survey of the Project's key stakeholders; and (iv) interviews with 12 purposefully sampled key informants.

RESULTS

The Project achieved its aim to develop a strategy to improve services for people with comorbid psychosis and problematic substance use. Three of the five Project objectives were fully achieved: examination of current clinical services, development of a clinical services plan, and development of a staff education programme. The Project partially achieved two objectives: development of an information system, and a research agenda. The Project and CSAHS performed well when measured against three of the National Mental Health Standards. Project participants perceived the Project to have been successful and worth continuing, identified some shortcomings and made recommendations for the second phase.

CONCLUSIONS

The participatory approach to the Project and the evaluation was successful. With some improvements the Project is worth continuing into a second phase. A multifaceted approach and qualitative research methods are useful for formative evaluation of health service programmes.

Divisions of population health: quantum leap forward or rearranging the deckchairs?

OBJECTIVES

To describe the reasons for the formation of divisions of population health in NSW, their functional units, how they might be evaluated, and some future challenges; to stimulate critical appraisal of the divisions.

METHODS

Personal observation; review of documentation and organisational charts.

RESULTS

Area health services (AHSs) were established in NSW in 1986; there are now 17. Divisions of population health attempt to overcome the marginalisation and fragmentation that often characterise population health workers within AHSs. Divisions aim to strengthen an AHS's capacity to meet its legislated responsibility to protect and promote the health of the local population. Each of the 13 divisions established since 1994 contains a different mix of services. Public health, health promotion and health services planning units are most commonly included in divisions. Formal evaluations of organisational structures are not common in health services. Evaluations of divisions of population health should focus on their success at creating organisational structures and processes which are conducive to the implementation of population health strategies; improving health outcomes; and improving the personal, social and environmental preconditions for health.

CONCLUSIONS

Establishing divisions of population health has highlighted the lack of evidence regarding the effectiveness of different organisational structures for delivering population health services.

IMPLICATIONS

Greater effort is needed to evaluate existing organisational structures and to develop and implement optimal structures for population health services.

Industrial atmospheric pollution, historical land use patterns and mortality

BACKGROUND

The measurement of atmospheric pollution for epidemiological studies is problematic. This study presents a new proxy measure of atmospheric pollution of industrial origin and uses it to determine, at electoral ward level, the relationship between atmospheric pollution and all-cause mortality.

METHODS

All-cause Standardized Mortality Ratios (SMR), all ages, and for persons under 65 years for the period 1984-1988, proportions of land in each ward utilized by industrial works (the proxy for atmospheric pollution) and levels of socioeconomic deprivation of the ward residents were compared in 104 electoral wards.

RESULTS

The all-age SMR in the 22 wards containing the largest proportions of industrial land (113) was 9.7 per cent higher than the SMR (103) in the 60 wards with no industrial land. The under 65 years SMR in the 22 highly industrialized wards (120) was 22.4 per cent higher than the SMR (98) in the wards with no industrial land. After matching the levels of deprivation, the all-age SMR in the 15 wards containing over 10 per cent industrial land (116) was significantly higher than the SMR in 15 wards containing no industrial land (108); corresponding figures for the under 65 years SMR were 135 and 118.

CONCLUSIONS

A greater proportion of industrial land in a ward is associated with a higher mortality of the ward residents, even after controlling for the level of socio-economic deprivation of the residents. The association between deprivation and mortality is stronger than the association between atmospheric pollution and mortality. There is an urgent need for better measures of atmospheric pollution which are usable in epidemiological studies.

An outcomes approach to population health at the local level in NSW: practical problems and potential solutions

While a health outcomes approach has the potential to improve the health status of Australians as well as health service efficiency, such a policy will be successful only if practice at the local level follows suit. This paper briefly reviews the health outcomes approach and describes how the Central Sydney Area Health Service has established a Needs Assessment & Health Outcomes Unit to help improve health outcomes. The paper discusses issues in working with population health outcomes at the local level, such as the usefulness and limitations of routinely collected data for planning and managing health services, problems of small area data, gaps in the documentation of national health goals and targets, problems of attribution of improved outcomes to specific interventions, and definition of responsibilities for action at the local level. It offers some potential solutions relevant at the local level.

Estimating suicide risk among attempted suicides: I. The development of new clinical scales

A discriminant function analysis was carried out to separate a sample of 75 suicides from a sample of 146 attempted suicides, on which comprehensive clinical and social data were recorded on an identical schedule. Two sets of discriminating items (with 18 and 6 variables) correctly classified 91 per cent and 83 per cent of the two samples in their respective groups. The results provide a basis for examining the usefulness of these variables as predictors of future suicide in people who have attempted suicide.

The accuracy of officially reported suicide statistics for purposes of epidemiological research

Suicide is underreported for a number of reasons and the reliability of the official rates is subject to error from variation in defining and reporting cases--the kind of inaccuracies encountered when ascertaining cases in studies of mortality from any cause. Nevertheless, the evidence from studies designed to see whether these sources of error invalidate the differences reported between cultural and social groups indicate that they are randomised, at least to an extent that allows epidemiologists to compare rates between countries and districts within them, between demographic groups, and over time.

An Ultrasound technique for the measurement of tardive dyskinesia

A simple and portable ultrasound system, using a transducer attached to a pair of spectacles, to measure disorders of facial movement is described and applied to the measurement of tardive dyskinesia. Product-moment coefficients of correlation for the split-half and test-retest assessments of reliability in 20 patients were 0.96 and 0.93 respectively. Concurrent validity was confirmed by assessing the consistency between ultrasound scores and time-sampled scores based on video films (Pearson r = 0.86). Serial measurements of tardive dyskinesia over five months revealed striking individual consistency.

Measuring gesture: its cultural and clinical correlates

An ultrasonic system for measuring psychomotor behaviour is described, and then applied to compare the extent to which English and French students gesticulate. The findings supported the hypotheses that: (1) French students gesticulate more than the English both when using descriptive speech and when discussing their feelings; (2) descriptive speech elicits more gesture then affectively-toned speech; (3) when verbal expression is more difficult the use of gesture increases; (4) individuals tend to maintain a characteristic level of gesturing. We concluded the ultrasonic system provides a reliable and sensitive method for measuring gesture activity and can be applied clinically to the study of psychomotor behaviour.

The value of assessing intent in attempted suicide

Suicidal intent was assessed in a sample of 151 admissions to a general hospital for self-poisoning or self-inflicted injury. Severity of intent was associated with the act's medical seriousness and with the risk of suicide derived from a validated risk scale. Although high and low intent cases were comparable in respect of precipitating factors, patients rated high on suicidal intent were more likely to have experienced depressive symptoms in the previous month.

Incidence of referred mental illness in Chichester and Salisbury

The annual rates of referral to two differently organized comprehensive psychiatric services in separate but demographically similar areas are presented for various demographic social and clinical categories. In Part 1 the rates are examined for similarities both between the two areas and with findings from other studies in order to obtain pointers to factors affecting the inception of psychiatric disorders. In Part 2 an attempt is made to evaluate an aspect of the community service. Differences between the rates in the two areas are discussed with a view to identifying those variables that selectively affect referral to a community service.

A hundred cases of suicide: clinical aspects

Historically, doctors have not always acknowledged that they have an obligation to prevent suicide, partly because they shared the prevalent idea that most suicides were caused by moral crises, no concern of theirs—and indeed suicide was a criminal matter until quite recently; but more, perhaps, because a fatalism has characterized their attitudes to its prevention, even where the suicide was clearly suffering from mental illness. Yet two recent American studies have shown more than 90 per cent of suicides to be mentally ill before their death (17, 8); this finding and the familiar clinical observation that suicidal thoughts disappear when the illness is successfully treated provide a strong case for a medical policy of prevention.

Medical Research Council Clinical Psychiatry Unit

The Clinical Research Department was started at Graylingwell Hospital, Chichester, Sussex, by Dr. J. Carse in 1947, when the hospital was administered by Sussex County Council. The first director was Dr. (now Professor) E. Stengel, and he undertook the first systematic follow-up of leucotomized patients. From 1950 to 1955 the director was Dr. Martin Roth; his studies on the psychoses of old age, and especially those delineating depressive psychoses, are now a landmark in clinical research. At about this time, the means by which clinical research in the National Health Service hospitals should be administered was reviewed and a policy evolved whereby departments in which clinical research was prospering and whose further development would make financial demands beyond those available to the regional hospital boards would be considered for support by the Medical Research Council.

The effects that patients have on their families in a community care and a control psychiatric service--a two year follow-up

The effects that mentally ill people have on their families have been more commented upon than studied. The currently favoured practice of community care has increased the need for a systematic attempt to evaluate the families' problems, and an opportunity to do this occurred when a community psychiatric service was introduced in Chichester in 1958, while the neighbouring Salisbury district continued with a conventional hospital-based service. The Medical Research Council's Clinical Psychiatry Research Unit has been evaluating the new service to find out how it affects referral and admission rates; how it influences social and clinical outcome, and the effect it has on the community itself. As the patient's family is the sector of the community most closely concerned in any extension of the extra-mural care of patients, we began by assessing the effects on them. The present paper therefore describes the assessments we made of the burden the patients' families carried in the Chichester Community Care Service and compares their burden with that experienced by families in Salisbury, where admission to hospital was more commonly practised. The comparison is made in terms of the relief that was afforded the two groups of families over a period of two years.

Physiological assessment of anxiety: psychomotor measures

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