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

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

Building a Methodological Foundation for Impactful Urban Planetary Health Science.

Anthropogenic environmental change will heavily impact cities, yet associated health risks will depend significantly on decisions made by urban leaders across a wide range of non-health sectors, including transport, energy, housing, basic urban services, and others. A subset of planetary health researchers focus on understanding the urban health impacts of global environmental change, and how these vary globally and within cities. Such researchers increasingly adopt collaborative transdisciplinary approaches to engage policy-makers, private citizens, and other actors in identifying and evaluating potential policy solutions that will reduce environmental impacts in ways that simultaneously promote health, equity, and/or local economies-in other words, maximising 'co-benefits'. This report presents observations from a participatory workshop focused on challenges and opportunities for urban planetary health research. The workshop, held at the 16th International Conference on Urban Health (ICUH) in Xiamen, China, in November 2019, brought together 49 participants and covered topics related to collaboration, data, and research impact. It featured research projects funded by the Wellcome Trust's Our Planet Our Health (OPOH) programme. This report aims to concisely summarise and disseminate participants' collective contributions to current methodological practice in urban planetary health research.

Correction to: Extending Data for Urban Health Decision-Making: a Menu of New and Potential Neighborhood-Level Health Determinants Datasets in LMICs.

Readers should note an additional Acknowledgment for this article: Dana Thomson is funded by the Economic and Social Research Council grant number ES/5500161/1.

Extending Data for Urban Health Decision-Making: a Menu of New and Potential Neighborhood-Level Health Determinants Datasets in LMICs.

Area-level indicators of the determinants of health are vital to plan and monitor progress toward targets such as the Sustainable Development Goals (SDGs). Tools such as the Urban Health Equity Assessment and Response Tool (Urban HEART) and UN-Habitat Urban Inequities Surveys identify dozens of area-level health determinant indicators that decision-makers can use to track and attempt to address population health burdens and inequalities. However, questions remain as to how such indicators can be measured in a cost-effective way. Area-level health determinants reflect the physical, ecological, and social environments that influence health outcomes at community and societal levels, and include, among others, access to quality health facilities, safe parks, and other urban services, traffic density, level of informality, level of air pollution, degree of social exclusion, and extent of social networks. The identification and disaggregation of indicators is necessarily constrained by which datasets are available. Typically, these include household- and individual-level survey, census, administrative, and health system data. However, continued advancements in earth observation (EO), geographical information system (GIS), and mobile technologies mean that new sources of area-level health determinant indicators derived from satellite imagery, aggregated anonymized mobile phone data, and other sources are also becoming available at granular geographic scale. Not only can these data be used to directly calculate neighborhood- and city-level indicators, they can be combined with survey, census, administrative and health system data to model household- and individual-level outcomes (e.g., population density, household wealth) with tremendous detail and accuracy. WorldPop and the Demographic and Health Surveys (DHS) have already modeled dozens of household survey indicators at country or continental scales at resolutions of 1 × 1 km or even smaller. This paper aims to broaden perceptions about which types of datasets are available for health and development decision-making. For data scientists, we flag area-level indicators at city and sub-city scales identified by health decision-makers in the SDGs, Urban HEART, and other initiatives. For local health decision-makers, we summarize a menu of new datasets that can be feasibly generated from EO, mobile phone, and other spatial data-ideally to be made free and publicly available-and offer lay descriptions of some of the difficulties in generating such data products.

Systems approaches for localising the SDGs: co-production of place-based case studies.

BACKGROUND: Localisation is a pervasive challenge in achieving sustainable development. Contextual particularities may render generalized strategies to achieve the Sustainable Development Goals (SDGs) unfeasible, impractical, or ineffective. Furthermore, many localities are resource- and data-poor, limiting applicability of the global SDG indicator framework. Tools to enable local actors to make sense of complex problems, communicate this understanding, and act accordingly hold promise in their ability to improve results. AIM: Systems approaches can help characterise local causal systems, identify useful leverage points, and foster participation needed to localise and catalyse development action. Critically, such efforts must be deeply rooted in place, involving local actors in mapping decision-processes and causation within local physical, social and policy environments. Given that each place has a unique geographical or spatial extent and therein lies its unique characters and problems, we term these activities "placially explicit." We describe and reflect on a process used to develop placially explicit, systems-based (PESB) case studies on issues that intersect with and impact urban health and wellbeing, addressing the perspectives of various actors to produce place-based models and insights that are useful for SDG localisation. METHODS: Seven case studies were co-produced by one or more Partners with place-based knowledge of the case study issue and a Systems Thinker. In each case, joint delineation of an appropriate framing was followed by iterative dialogue cycles to uncover key contextual factors, with attention to institutional and societal structures and paradigms and the motivations and constraints of other actors. Casual loop diagrams (CLDs) were iteratively developed to capture complex narratives in a simple visual way. RESULTS: Case study development facilitated transfer of local knowledge and development of systems thinking capacity. Partners reported new insights, including a shifting of problem frames and corresponding solution spaces to higher systems levels. Such changes led partners to re-evaluate their roles and goals, and thence to new actions and strategies. CLD-based narratives also proved useful in ongoing communications. CONCLUSION: Co-production of PESB case studies are a useful component of transdisciplinary toolsets for local SDG implementation, building the capacity of local actors to explore complex problems, identify new solutions and indicators, and understand the systemic linkages inherent in SDG actions across sectors and scales.

Recent acquisition of Helicobacter pylori by Baka pygmies.

Both anatomically modern humans and the gastric pathogen Helicobacter pylori originated in Africa, and both species have been associated for at least 100,000 years. Seven geographically distinct H. pylori populations exist, three of which are indigenous to Africa: hpAfrica1, hpAfrica2, and hpNEAfrica. The oldest and most divergent population, hpAfrica2, evolved within San hunter-gatherers, who represent one of the deepest branches of the human population tree. Anticipating the presence of ancient H. pylori lineages within all hunter-gatherer populations, we investigated the prevalence and population structure of H. pylori within Baka Pygmies in Cameroon. Gastric biopsies were obtained by esophagogastroduodenoscopy from 77 Baka from two geographically separated populations, and from 101 non-Baka individuals from neighboring agriculturalist populations, and subsequently cultured for H. pylori. Unexpectedly, Baka Pygmies showed a significantly lower H. pylori infection rate (20.8%) than non-Baka (80.2%). We generated multilocus haplotypes for each H. pylori isolate by DNA sequencing, but were not able to identify Baka-specific lineages, and most isolates in our sample were assigned to hpNEAfrica or hpAfrica1. The population hpNEAfrica, a marker for the expansion of the Nilo-Saharan language family, was divided into East African and Central West African subpopulations. Similarly, a new hpAfrica1 subpopulation, identified mainly among Cameroonians, supports eastern and western expansions of Bantu languages. An age-structured transmission model shows that the low H. pylori prevalence among Baka Pygmies is achievable within the timeframe of a few hundred years and suggests that demographic factors such as small population size and unusually low life expectancy can lead to the eradication of H. pylori from individual human populations. The Baka were thus either H. pylori-free or lost their ancient lineages during past demographic fluctuations. Using coalescent simulations and phylogenetic inference, we show that Baka almost certainly acquired their extant H. pylori through secondary contact with their agriculturalist neighbors.

Implementing "from here to there": A case study of conceptual and practical challenges in implementation science.

There is a significant challenge in global health and development research that pivots on the difficulties of delivering (cost-)effective treatments or interventions that are scalable andtransferable across settings. That is, how does one deliver "true effects", proven treatments, into new settings? This is often addressed in pragmatic trials or implementation research in which one makes adjustments to the delivery of the treatment to ensure that it works here and there. In this critical analytical review, we argue that the approach mis-characterises the cause-effect relationship and fails to recognise the local, highly contextual nature of what it means to say an intervention "works". We use an ongoing randomised controlled trial (RCT)-an informal settlement redevelopment intervention in Indonesia and Fiji to reduce human exposure to pathogenic faecal contamination-as a vehicle for exploring the ideas and implications of identifying interventions that work in global health and development. We describe the highly contextualised features of the research and the challenges these would pose in attempts to generalise the results. In other words, we detail that which is frequently elided from most RCTs. As our critical lens, we us the work of American philosopher, Nancy Cartwright, who argued that research produces dappled regions of causal insights-lacunae against a backdrop of causal ignorance. Rather than learn about a relationship between a treatment and an outcome, we learn that in the right sort of context, a treatment reliably produces a particular outcome. Moving a treatment from here to there becomes, therefore, something of an engineering exercise to ensure the right factors (or "shields") are in place so the cause-effect is manifest. As a consequence, one cannot assume that comparative effectiveness or cost-effectiveness would be maintained.

Supporting a Healthy Planet, Healthy People and Health Equity through Urban and Territorial Planning.

The form of human settlements impacts on planetary health, population health and health equity. Yet goals for urban and territorial planning are only tangentially linked to public health outcomes. The WHO and UN-Habitat support actions to bring health to the fore in planning and design of human settlements, recently publishing 'Integrating Health in Urban and Territorial Planning: a sourcebook' focusing on 'why' action is needed, 'how' to initiate it; and curating several existing resources on 'what' to do. Recommendations for research, policy and practice include calls for rapid development of closer relationships between public health and spatial planning.

Healthy cities initiative in China: Progress, challenges, and the way forward.

China implemented the first phase of its National Healthy Cities pilot program from 2016-20. Along with related urban health governmental initiatives, the program has helped put health on the agenda of local governments while raising public awareness. Healthy City actions taken at the municipal scale also prepared cities to deal with the COVID-19 pandemic. However, after intermittent trials spanning the past two decades, the Healthy Cities initiative in China has reached a crucial juncture. It risks becoming inconsequential given its overlap with other health promotion efforts, changing public health priorities in response to the pandemic, and the partial adoption of the Healthy Cities approach advanced by the World Health Organization (WHO). We recommend aligning the Healthy Cities initiative in China with strategic national and global level agendas such as Healthy China 2030 and the Sustainable Development Goals (SDGs) by providing an integrative governance framework to facilitate a coherent intersectoral program to systemically improve population health. Achieving this alignment will require leveraging the full spectrum of best practices in Healthy Cities actions and expanding assessment efforts. Funding: Tsinghua-Toyota Joint Research Fund "Healthy city systems for smart cities" program.

A Novel International Partnership for Actionable Evidence on Urban Health in Latin America: LAC-Urban Health and SALURBAL.

This article describes the origins and characteristics of an interdisciplinary multinational collaboration aimed at promoting and disseminating actionable evidence on the drivers of health in cities in Latin America and the Caribbean: The Network for Urban Health in Latin America and the Caribbean and the Wellcome Trust funded SALURBAL (Salud Urbana en América Latina, or Urban Health in Latin America) Project. Both initiatives have the goals of supporting urban policies that promote health and health equity in cities of the region while at the same time generating generalizable knowledge for urban areas across the globe. The processes, challenges, as well as the lessons learned to date in launching and implementing these collaborations, are described. By leveraging the unique features of the Latin American region (one of the most urbanized areas of the world with some of the most innovative urban policies), the aim is to produce generalizable knowledge about the links between urbanization, health, and environments and to identify effective ways to organize, design, and govern cities to improve health, reduce health inequalities, and maximize environmental sustainability in cities all over the world.

A census-weighted, spatially-stratified household sampling strategy for urban malaria epidemiology.

BACKGROUND: Urban malaria is likely to become increasingly important as a consequence of the growing proportion of Africans living in cities. A novel sampling strategy was developed for urban areas to generate a sample simultaneously representative of population and inhabited environments. Such a strategy should facilitate analysis of important epidemiological relationships in this ecological context. METHODS: Census maps and summary data for Kisumu, Kenya, were used to create a pseudo-sampling frame using the geographic coordinates of census-sampled structures. For every enumeration area (EA) designated as urban by the census (n = 535), a sample of structures equal to one-tenth the number of households was selected. In EAs designated as rural (n = 32), a geographically random sample totalling one-tenth the number of households was selected from a grid of points at 100 m intervals. The selected samples were cross-referenced to a geographic information system, and coordinates transferred to handheld global positioning units. Interviewers found the closest eligible household to the sampling point and interviewed the caregiver of a child aged < 10 years. The demographics of the selected sample were compared with results from the Kenya Demographic and Health Survey to assess sample validity. Results were also compared among urban and rural EAs. RESULTS: 4,336 interviews were completed in 473 of the 567 study area EAs from June 2002 through February 2003. EAs without completed interviews were randomly distributed, and non-response was approximately 2%. Mean distance from the assigned sampling point to the completed interview was 74.6 m, and was significantly less in urban than rural EAs, even when controlling for number of households. The selected sample had significantly more children and females of childbearing age than the general population, and fewer older individuals. CONCLUSION: This method selected a sample that was simultaneously population-representative and inclusive of important environmental variation. The use of a pseudo-sampling frame and pre-programmed handheld GPS units is more efficient and may yield a more complete sample than traditional methods, and is less expensive than complete population enumeration.

Quantitative urban classification for malaria epidemiology in sub-Saharan Africa.

BACKGROUND: Although sub-Saharan Africa (SSA) is rapidly urbanizing, the terms used to classify urban ecotypes are poorly defined in the context of malaria epidemiology. Lack of clear definitions may cause misclassification error, which likely decreases the accuracy of continent-wide estimates of malaria burden, limits the generalizability of urban malaria studies, and makes identification of high-risk areas for targeted interventions within cities more difficult. Accordingly, clustering techniques were applied to a set of urbanization- and malaria-related variables in Kisumu, Kenya, to produce a quantitative classification of the urban environment for malaria research. METHODS: Seven variables with a known or expected relationship with malaria in the context of urbanization were identified and measured at the census enumeration area (EA) level, using three sources: a) the results of a citywide knowledge, attitudes and practices (KAP) survey; b) a high-resolution multispectral satellite image; and c) national census data. Principal components analysis (PCA) was used to identify three factors explaining higher proportions of the combined variance than the original variables. A k-means clustering algorithm was applied to the EA-level factor scores to assign EAs to one of three categories: "urban," "peri-urban," or "semi-rural." The results were compared with classifications derived from two other approaches: a) administrative designation of urban/rural by the census or b) population density thresholds. RESULTS: Urban zones resulting from the clustering algorithm were more geographically coherent than those delineated by population density. Clustering distributed population more evenly among zones than either of the other methods and more accurately predicted variation in other variables related to urbanization, but not used for classification. CONCLUSION: Effective urban malaria epidemiology and control would benefit from quantitative methods to identify and characterize urban areas. Cluster analysis techniques were used to classify Kisumu, Kenya, into levels of urbanization in a repeatable and unbiased manner, an approach that should permit more relevant comparisons among and within urban areas. To the extent that these divisions predict meaningful intra-urban differences in malaria epidemiology, they should inform targeted urban malaria interventions in cities across SSA.

Urban tinkering.

Cities are currently experiencing serious, multifaceted impacts from global environmental change, especially climate change, and the degree to which they will need to cope with and adapt to such challenges will continue to increase. A complex systems approach inspired by evolutionary theory can inform strategies for policies and interventions to deal with growing urban vulnerabilities. Such an approach would guide the design of new (and redesign of existing) urban structures, while promoting innovative integration of grey, green and blue infrastructure in service of environmental and health objectives. Moreover, it would contribute to more flexible, effective policies for urban management and the use of urban space. Four decades ago, in a seminal paper in Science, the French evolutionary biologist and philosopher Francois Jacob noted that evolution differs significantly in its characteristic modes of action from processes that are designed and engineered de novo (Jacob in Science 196(4295):1161-1166, 1977). He labeled the evolutionary process "tinkering", recognizing its foundation in the modification and molding of existing traits and forms, with occasional dramatic shifts in function in the context of changing conditions. This contrasts greatly with conventional engineering and design approaches that apply tailor-made materials and tools to achieve well-defined functions that are specified a priori. We here propose that urban tinkering is the application of evolutionary thinking to urban design, engineering, ecological restoration, management and governance. We define urban tinkering as:A mode of operation, encompassing policy, planning and management processes, that seeks to transform the use of existing and design of new urban systems in ways that diversify their functions, anticipate new uses and enhance adaptability, to better meet the social, economic and ecological needs of cities under conditions of deep uncertainty about the future.This approach has the potential to substantially complement and augment conventional urban development, replacing predictability, linearity and monofunctional design with anticipation of uncertainty and non-linearity and design for multiple, potentially shifting functions. Urban tinkering can function by promoting a diversity of small-scale urban experiments that, in aggregate, lead to large-scale often playful innovative solutions to the problems of sustainable development. Moreover, the tinkering approach is naturally suited to exploring multi-functional uses and approaches (e.g., bricolage) for new and existing urban structures and policies through collaborative engagement and analysis. It is thus well worth exploring as a means of delivering co-benefits for environment and human health and wellbeing. Indeed, urban tinkering has close ties to systems approaches, which often are recognized as critical to sustainable development. We believe this concept can help forge much-closer, much-needed ties among engineers, architects, evolutionary ecologists, health specialists, and numerous other urban stakeholders in developing innovative, widely beneficial solutions for society and contribute to successful implementation of SDG11 and the New Urban Agenda.

Sustainable, healthy cities: making the most of the urban transition.

The world is undergoing a massive urban transition, which is now both the greatest driver of global environmental change and the most significant influence on human health. Cities offer real opportunities for improving health, but managed poorly, they can also create or reinforce significant health deficits while putting severe stresses on the natural systems which support human civilization. Management of urban problems is rarely straightforward, as complexity across scales and sectors, in causal structures, actors and incentives, can lead to ineffective policies and unintended consequences. Systems thinking offers a promising way forward in its ability to deal with non-linear relationships and simultaneous actions and outcomes. Encompassing, on the one hand, analytic frameworks and methods that can provide important causal insights and a test bed for urban policy, and on the other, broad processes of inter- and trans-disciplinary engagement to better define problems and feasible solutions, systems approaches are critical to the current and future design and management of sustainable healthy cities.

A role for low-order system dynamics models in urban health policy making.

Cities are complex adaptive systems whose responses to policy initiatives emerge from feedback interactions between their parts. Urban policy makers must routinely deal with both detail and dynamic complexity, coupled with high levels of diversity, uncertainty and contingency. In such circumstances, it is difficult to generate reliable predictions of health-policy outcomes. In this paper we explore the potential for low-order system dynamics (LOSD) models to make a contribution towards meeting this challenge. By definition, LOSD models have few state variables (≤5), illustrate the non-linear effects caused by feedback and accumulation, and focus on endogenous dynamics generated within well-defined boundaries. We suggest that experience with LOSD models can help practitioners to develop an understanding of basic principles of system dynamics, giving them the ability to 'see with new eyes'. Because efforts to build a set of LOSD models can help a transdisciplinary group to develop a shared, coherent view of the problems that they seek to tackle, such models can also become the foundations of 'powerful ideas'. Powerful ideas are conceptual metaphors that provide the members of a policy-making group with the a priori shared context required for effective communication, the co-production of knowledge, and the collaborative development of effective public health policies.