Multisectoral interventions for urban health in Africa: a mixed-methods systematic review.

Increasing evidence suggests that urban health objectives are best achieved through a multisectoral approach. This approach requires multiple sectors to consider health and well-being as a central aspect of their policy development and implementation, recognising that numerous determinants of health lie outside (or beyond the confines of) the health sector. However, collaboration across sectors remains scarce and multisectoral interventions to support health are lacking in Africa. To address this gap in research, we conducted a mixed-method systematic review of multisectoral interventions aimed at enhancing health, with a particular focus on non-communicable diseases in urban African settings. Africa is the world's fastest urbanising region, making it a critical context in which to examine the impact of multisectoral approaches to improve health. This systematic review provides a valuable overview of current knowledge on multisectoral urban health interventions and enables the identification of existing knowledge gaps, and consequently, avenues for future research. We searched four academic databases (PubMed, Scopus, Web of Science, Global Health) for evidence dated 1989-2019 and identified grey literature from expert input. We identified 53 articles (17 quantitative, 20 qualitative, 12 mixed methods) involving collaborations across 22 sectors and 16 African countries. The principle guiding the majority of the multisectoral interventions was community health equity (39.6%), followed by healthy cities and healthy urban governance principles (32.1%). Targeted health outcomes were diverse, spanning behaviour, environmental and active participation from communities. With only 2% of all studies focusing on health equity as an outcome and with 47% of studies published by first authors located outside Africa, this review underlines the need for future research to prioritise equity both in terms of research outcomes and processes. A synthesised framework of seven interconnected components showcases an ecosystem on multisectoral interventions for urban health that can be examined in the future research in African urban settings that can benefit the health of people and the planet.Paper ContextMain findings: Multisectoral interventions were identified in 27.8% of African countries in the African Union, targeted at major cities with five sectors present at all intervention stages: academia or research, agriculture, government, health, and non-governmental.Added knowledge: We propose a synthesised framework showcasing an ecosystem on multisectoral interventions for urban health that can guide future research in African urban settings.Global health impact for policy and action: This study reveals a crucial gap in evidence on evaluating the long-term impact of multisectoral interventions and calls for partnerships involving various sectors and robust community engagement to effectively deliver and sustain health-promoting policies and actions.

The Urban Environment and Cardiometabolic Health.

Urban environments contribute substantially to the rising burden of cardiometabolic diseases worldwide. Cities are complex adaptive systems that continually exchange resources, shaping exposures relevant to human health such as air pollution, noise, and chemical exposures. In addition, urban infrastructure and provisioning systems influence multiple domains of health risk, including behaviors, psychological stress, pollution, and nutrition through various pathways (eg, physical inactivity, air pollution, noise, heat stress, food systems, the availability of green space, and contaminant exposures). Beyond cardiometabolic health, city design may also affect climate change through energy and material consumption that share many of the same drivers with cardiometabolic diseases. Integrated spatial planning focusing on developing sustainable compact cities could simultaneously create heart-healthy and environmentally healthy city designs. This article reviews current evidence on the associations between the urban exposome (totality of exposures a person experiences, including environmental, occupational, lifestyle, social, and psychological factors) and cardiometabolic diseases within a systems science framework, and examines urban planning principles (eg, connectivity, density, diversity of land use, destination accessibility, and distance to transit). We highlight critical knowledge gaps regarding built-environment feature thresholds for optimizing cardiometabolic health outcomes. Last, we discuss emerging models and metrics to align urban development with the dual goals of mitigating cardiometabolic diseases while reducing climate change through cross-sector collaboration, governance, and community engagement. This review demonstrates that cities represent crucial settings for implementing policies and interventions to simultaneously tackle the global epidemics of cardiovascular disease and climate change.

Assessment of urban ecosystem health and its influencing factors: a case study of Zibo City, China.

Urban ecosystem health is the foundation of sustainable urban development. It is important to know the health status of urban ecosystem and its influencing factors for formulating scientific urban development planning. Taking Zibo city as the study area, the indicators were selected from five aspects: ecosystem vigor, structure, resilience, service function and population health to establish an assessment index system of urban ecosystem health. The health level of urban ecosystem was assessed, and its changing trend was analyzed from 2006 to 2018 in Zibo. Furthermore, obstacle degree analysis and sensitivity analysis were used to quantitatively analyze the main obstacle factors and sensitivity factors affecting urban ecosystem health, so as to provide references for improving urban ecosystem health. The results showed that the health level of urban ecosystem in Zibo showed an upward trend from 2006 to 2018. The poor structure and ecological environment quality were the main obstacle factors to urban ecosystem health. The impact of changes in a single indicator on urban ecosystem health gradually decreased, but the sensitivity index of indicators had obvious differences. Urban ecosystem health was sensitive to changes in ecosystem structure and resilience. In the future, Zibo should strengthen ecological construction, optimize the industrial structure, and develop green economy to promote urban ecosystem healthy.

Community perceptions of community health worker effectiveness: Contributions to health behaviour change in an urban health district in South Africa.

BACKGROUND: Community health worker (CHW) programmes contribute towards strengthening adherence support, improving maternal and child health outcomes and providing support for social services. They play a valuable role in health behaviour change in vulnerable communities. Large-scale, comprehensive CHW programmes at health district level are part of a South African (SA) strategy to re-engineer primary healthcare and take health directly into communities and households, contributing to universal health coverage. OBJECTIVE: These CHW programmes across health districts were introduced in SA in 2010 - 11. Their overall purpose is to improve access to healthcare and encourage healthy behaviour in vulnerable communities, through community and family engagements, leading to less disease and better population health. Communities therefore need to accept and support these initiatives. There is, however, inadequate local evidence on community perceptions of the effectiveness of such programmes. METHODS: A cross-sectional descriptive study to determine community perceptions of the role and contributions of the CHW programme was conducted in the Ekurhuleni health district, an urban metropolis in SA. Members from 417 households supported by CHWs were interviewed in May 2019 by retired nurses used as fieldworkers. Frequencies and descriptive analyses were used to report on the main study outcomes of community acceptance and satisfaction. RESULTS: Nearly all the study households were poor and had at least one vulnerable member, either a child under 5, an elderly person, a pregnant woman or someone with a chronic condition. CHWs had supported these households for 2 years or longer. More than 90% of households were extremely satisfied with their CHW; they found it easy to talk to them within the privacy of their homes and to follow the health education and advice given by the CHWs. The community members highly rated care for chronic conditions (82%), indicated that children were healthier (41%) and had safer pregnancies (6%). CONCLUSION: As important stakeholders in CHW programmes, exploring community acceptance, appreciation and support is critical in understanding the drivers of programme performance. Community acceptance of the CHWs in the Ekurhuleni health district was high. The perspective of the community was that the CHWs were quite effective. This was demonstrated when they reported changes in household behaviour with regard to improved access to care through early screening, referrals and improved management of chronic and other conditions.

Identifying childhood malaria hotspots and risk factors in a Nigerian city using geostatistical modelling approach.

Malaria ranks high among prevalent and ravaging infectious diseases in sub-Saharan Africa (SSA). The negative impacts, disease burden, and risk are higher among children and pregnant women as part of the most vulnerable groups to malaria in Nigeria. However, the burden of malaria is not even in space and time. This study explores the spatial variability of malaria prevalence among children under five years (U5) in medium-sized rapidly growing city of Akure, Nigeria using model-based geostatistical modeling (MBG) technique to predict U5 malaria burden at a 100 × 100 m grid, while the parameter estimation was done using Monte Carlo maximum likelihood method. The non-spatial logistic regression model shows that U5 malaria prevalence is significantly influenced by the usage of insecticide-treated nets-ITNs, window protection, and water source. Furthermore, the MBG model shows predicted U5 malaria prevalence in Akure is greater than 35% at certain locations while we were able to ascertain places with U5 prevalence > 10% (i.e. hotspots) using exceedance probability modelling which is a vital tool for policy development. The map provides place-based evidence on the spatial variation of U5 malaria in Akure, and direction on where intensified interventions are crucial for the reduction of U5 malaria burden and improvement of urban health in Akure, Nigeria.

Citizen science and social innovation as citizen empowerment tools to address urban health challenges: The case of the urban health citizen laboratory in Barcelona, Spain.

Urban health faces significant challenges due to the rapid growth of cities and the concentration of population in urban settings that have a strong impact on people's health. The approach to characterize and address these challenges requires increased societal involvement and interdisciplinary solutions to ensure their effectiveness and democratic nature. With this purpose, it is necessary to explore methodologies for citizen participation that foster a critical understanding of the environment and promote their active role in generating scientific knowledge and change. This article describes the creation of a collaborative space for experimentation and learning that, through the intersection of citizen science and social innovation, aims to engage citizens in the research and diagnosis of their local environment, as well as in the design and implementation of local solutions, while raising awareness about the main challenges to urban health. Through a collaborative and participatory framework, the community identified relevant challenges to urban health they wanted to investigate, co-designed and developed the methodology for data collection and analysis, and ultimately, they devised, designed, and implemented innovative solutions based on the scientific evidence obtained. The framework and results of this project hold potential interest for the scientific community, facilities, institutions, and society by offering an innovative and participatory approach to addressing the present and future urban health challenges.

How do urban green spaces influence heat-related mortality in elderly? A realist synthesis.

BACKGROUND: An important consequence of climate change for urban health is heat-related mortality. Vulnerable groups, especially elderly, will be the most affected. A solution put forward in many reports and policy documents is the introduction or expansion of urban green spaces. While they have a proven effect in decreasing the ambient temperature and reducing heat related mortality, the causal pathways are far from clear. Moreover, results vary for different contexts, population types and characteristics of green spaces as they are 'complex systems thrusted into complex systems'. To our knowledge, there is no systematic synthesis of the literature that examines the mechanisms by which and the circumstances under which green spaces work to decrease heat-related mortality for elderly. METHODS: We performed a realist synthesis- a theory-driven review method- to develop a complexity- and context-sensitive program theory. As a first step, a causal loop diagram was constructed which describes the possible pathways through which urban green spaces influence heat-related mortality in elderly. In a second step, one of the pathways - how they may lead to a reduction of heat-related mortality by increasing social capital - was further explored for underlying mechanisms, the context in which they work and the differentiated patterns of outcomes they generate. Literature was searched for evidence supporting or contradicting the initial programme theory, resulting in a refined theory. RESULTS: Results show how urban green space can impact on heat-related mortality in elderly by its influence on their exposure to outdoor and indoor heat, by improving their resilience as well as by affecting their access to treatment. Urban green spaces and their interactions with social capital affect the access to health information, social support, and the capacity for effective lobbying. Several mechanisms help to explain these observed demi-regularities, among others perceived behavioural control, perceived usefulness, receptiveness, ontological security, and self-interest. If and how they are triggered depends on the characteristics of the urban green space, the population, and other contextual factors. CONCLUSION: Looking into the impact of urban green spaces on heat-related mortality in elderly, researchers and policy makers should take interest in the role of social capital.

Assessing the contributions of an urban population health initiative to shift political priority towards cardiovascular health: three case studies from Brazil, Mongolia and Senegal.

BACKGROUND: The urban population health initiative was designed as a multidisciplinary, multisector programme to address cardiovascular (CV) disease, specifically hypertension and its underlying causes in the cities of Ulaanbaatar, Mongolia; Dakar, Senegal; and São Paulo, Brazil. This article aims to provide an overview of the history and dynamics of CV disease policy making in the three countries, to present the policy reform contributions of the initiative and its role in the policy agenda-setting framework/process in each country and to identify the enablers and challenges to the initiative for doing so. METHODS: A qualitative case study was conducted for each setting from November 2020 to January 2021, comprised of a document review, semi-structured in-depth interviews and unstructured interviews with stakeholders involved in the initiative. The literature review included documents from the initiative and the peer-reviewed and grey literature with a total of 188 documents screened. Interviews were conducted with 21 stakeholders. Data collection and thematic analysis was guided by (i) the Kingdon multiple streams conceptual framework with the main themes being CV disease problems, policy, politics and the role of policy entrepreneurs; and (ii) the study question inquiring on the role of the urban population health initiative at the CV disease policy level and enabling and challenging factors to advancing CV disease policy. Data were thematically analysed using the Framework Method. RESULTS: Each setting was characterized by a high hypertension and CV disease burden combined with an aware and proactive political environment. Policy outcomes attributed to the initiative were updating the guidelines and/or algorithms of care for hypertension and including revised physical and nutritional education in school curricula, in each city. Overall, the urban health initiative's effects in the policy arena, were most prominent in Mongolia and Senegal, where the team effectively acted as policy entrepreneur, promoting the solutions/policies in alignment with the most pressing local problems and in strong involvement with the political actors. The initiative was also involved in improving access to CV disease drugs at primary health levels. Its success was influenced by the local governance structures, the proximity of the initiative to the policy makers and the local needs. In Brazil, needs were expressed predominantly in the clinical practice. CONCLUSIONS: This multi-country experience shows that, although the policy and political environment plays its role in shaping initiatives, often the local priority needs are the driving force behind wider change.

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh.

INTRODUCTION: Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake. METHODS: This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA. RESULTS: Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process. CONCLUSION: While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system.

This retrospective chart review examined care coordination among pediatric patients with varying levels of medical complexity who received care in a rural-urban health system. Care coordination utilization across patient acuity levels was examined for meaningful differences in frequency and duration of care coordination services. Results indicated that patients with more severe medical complexity had increased frequency and duration of care coordination services, as well as different patterns of care coordination activity utilization. This model of pediatric outpatient care coordination provides a flexible and highly targeted approach for stratification of care and services based on the needs of the individual patient.

Food environment of bus terminals in the Rio de Janeiro metropolitan region / Ambiente alimentar de terminais rodoviários da região metropolitana do Rio de Janeiro

ABSTRACT PURPOSE To describe and analyze the healthiness of formal and informal food establishments in bus terminals of the metropolitan region of the state of Rio de Janeiro. METHOD An audit was conducted in 156 formal and 127 informal food establishments located in 14 bus terminals of the five most populous cities of the metropolitan region of Rio de Janeiro. Proportions of types of establishments and means (95%CI) of food availability indicators in formal and informal settings were calculated. For the formal setting, prices, proportions of accepted payment methods, days and hours of operation, and food categories with displayed advertising were described. RESULTS The healthiness of food establishments in bus terminals was low (less than 36%). On average, ultra-processed food subgroups were 250% more available for purchase than fresh or minimally processed food. Purchasing food at these places was convenient because several forms of payment were available, and the opening hours of the establishments followed the peaks of movement. In addition, 73.3% of the advertising referred to ultra-processed drinks, and the cost-benefit of buying ultra-processed food was better than fresh or minimally processed food. CONCLUSION The food environment of bus terminals in the metropolitan region of Rio de Janeiro promotes unhealthy eating. Regulatory public policies should focus on initiatives to limit the wide availability and advertising of ultra-processed food in spaces of great circulation of people.

RESUMO OBJETIVO Descrever e analisar a saudabilidade dos estabelecimentos com venda formal e informal de alimentos em terminais rodoviários da região metropolitana do Rio de Janeiro. MÉTODOS Realizou-se auditoria em 156 estabelecimentos formais e 127 pontos informais de venda de alimentos localizados em 14 terminais rodoviários das cinco cidades mais populosas da região metropolitana do Rio de Janeiro. Foram calculadas proporções de tipos de estabelecimentos e médias (IC95%) de indicadores de disponibilidade de alimentos nos ambientes formal e informal. Para o ambiente formal, foram descritos preços, proporções das formas de pagamento aceitas, dias e horários de funcionamento e categorias de alimentos com propaganda exposta. RESULTADOS A saudabilidade dos pontos de venda de alimentos nos terminais rodoviários era baixa (inferior a 36%). Em média, estavam disponíveis para compra 250% mais subgrupos de alimentos ultraprocessados do que in natura ou minimamente processados. Adquirir comida nesses locais era conveniente porque diversas formas de pagamento estavam disponíveis e os horários de funcionamento dos estabelecimentos acompanhavam os picos de movimentação. Além disso, 73,3% das propagandas se referiam a bebidas ultraprocessadas e o custo-benefício da compra de alimentos ultraprocessados era melhor que o de alimentos in natura ou minimamente processados. CONCLUSÃO O ambiente alimentar dos terminais rodoviários da região metropolitana do Rio de Janeiro promove uma alimentação não saudável. Políticas públicas de regulação devem se concentrar em iniciativas que limitem a ampla disponibilidade e publicidade de alimentos ultraprocessados nesses espaços de grande circulação de pessoas.

A Survey on Factors Affecting Knowledge and Satisfaction with Care Among Persons with Diabetes Mellitus in an Urban Health Centre and its Outreach Clinics in South India.

Objective: To determine the level of knowledge and factors affecting knowledge and satisfaction with diabetes care among persons with diabetes at urban health centre (UHC) and community health worker (CHW)-led outreach clinics (ORC) in South India. Methodology: A cross-sectional study was carried out using a structured questionnaire. One hundred patients at the UHC and 200 patients at the ORC were included. Results: Patients with DM of more than eight years, with co-morbidities and maintained on insulin had good knowledge at the UHC. At the ORC, participants who received education beyond the primary level and belonging to non - Hindu religion had higher knowledge. Patients at the ORC experienced better satisfaction in terms of waiting time for appointments, consultation, registration system and counselling. At the UHC, those who received primary education or those with lower educational attainment had better satisfaction. Overall, knowledge (p = 0.03) and satisfaction (p = 0.00001) of diabetes care was better at the ORC than at the UHC. Conclusions: Our study found better knowledge and satisfaction with diabetes care at the ORC than at the UHC. Whether or not the difference can be attributed to CHW-based clinics in the community needs to be further elucidated.

A participatory system map of the adverse influence of urban environments on population health: integrating urban development and preventive health expertise.

OBJECTIVES: A growing number of urban development and public health professionals are developing expertise in how urban environments influence population health to support preventive health (PH) planning, implementation and outcomes. This study aimed to address the growing interest among these experts in Sydney, Australia, to move beyond silo-based approaches to PH planning and urban development by developing a preliminary mapping of the complex adaptive system. This is a network of agents and parts that collectively relate and interact, where they seek to intervene by meshing the disparate knowledge of their multidisciplinary expertise. This mapping will help experts to better integrate PH approaches by linking primordial and primary prevention within urban environments, collectively prioritising areas for intervention within the complex adaptive system, and developing a better understanding of relations between multiple factors at play within it. METHODS: The system map was developed using a unique participatory system-mapping (PSM) process involving a modified Delphi technique consisting of three rounds between October 2019 and August 2020 and 15 urban development and public health experts engaged in PH in Sydney's urban environment. RESULTS: The final system map encompassed features of the local environment, determinants of health and wellbeing in urban environments, pre-clinical health and wellbeing impacts, and clinical health outcomes, providing a comprehensive map of the adverse effects of urban environments on population health. There was a high level of agreement among experts on the final system map. While experts from different disciplines generally agreed on priority areas for intervention, consensus was higher among those from similar disciplinary backgrounds. CONCLUSIONS: The study highlights how the collective intelligence of experts from diverse disciplines can generate PSM. Furthermore, it illustrates how using systems mapping can help experts interested in complex public health problems to take a broader view of the complex adaptive system for PH planning, support collaborative prioritisation, and offer valuable insights for targeted interventions.

Helicobacter pylori infection prevalence declined among an urban health check-up population in Chengdu, China: a longitudinal analysis of multiple cross-sectional studies.

Objectives: The efficacy of updated health policy in improving the generalization of Helicobacter pylori screening and eradication in southwest China was assessed in a longitudinal analysis of multiple cross-sectional studies from an institution. Methods: In the periods 2009-2010, 2013-2014, and 2019-2021, 8,365, 16,914, and 18,281 urban observations from health check-ups at West China Hospital were analyzed, respectively. The 14C-urea or 13C-urea breath test was consistently used for H. pylori detection. The protocol has been reported elsewhere (PROSPERO Registration number: CRD42019120764). Results: The overall prevalence of H. pylori dramatically decreased from 53.1% to 30.7% over the past decade (OR = 0.39, 95% CI 0.37-0.41), with a similar decline in all sex-specific and age-specific subgroups. The age-specific prevalence consistently increased before 40 years of age and always peaked at 50-59 years. Longitudinal clearance increased along with aging, and prevalence dropped to 22.6%, 25.1%, and 23.6% in the 40-49, 50-59, and 60-69 years initial age groups, respectively. Conclusion: The generalization of H. pylori screening and eradication could greatly contribute to the control of H. pylori infection among urban health check-up populations and lower gastric cancer incidence.

Empowering Participatory Research in Urban Health: Wearable Biometric and Environmental Sensors for Activity Recognition.

Participatory exposure research, which tracks behaviour and assesses exposure to stressors like air pollution, traditionally relies on time-activity diaries. This study introduces a novel approach, employing machine learning (ML) to empower laypersons in human activity recognition (HAR), aiming to reduce dependence on manual recording by leveraging data from wearable sensors. Recognising complex activities such as smoking and cooking presents unique challenges due to specific environmental conditions. In this research, we combined wearable environment/ambient and wrist-worn activity/biometric sensors for complex activity recognition in an urban stressor exposure study, measuring parameters like particulate matter concentrations, temperature, and humidity. Two groups, Group H (88 individuals) and Group M (18 individuals), wore the devices and manually logged their activities hourly and minutely, respectively. Prioritising accessibility and inclusivity, we selected three classification algorithms: k-nearest neighbours (IBk), decision trees (J48), and random forests (RF), based on: (1) proven efficacy in existing literature, (2) understandability and transparency for laypersons, (3) availability on user-friendly platforms like WEKA, and (4) efficiency on basic devices such as office laptops or smartphones. Accuracy improved with finer temporal resolution and detailed activity categories. However, when compared to other published human activity recognition research, our accuracy rates, particularly for less complex activities, were not as competitive. Misclassifications were higher for vague activities (resting, playing), while well-defined activities (smoking, cooking, running) had few errors. Including environmental sensor data increased accuracy for all activities, especially playing, smoking, and running. Future work should consider exploring other explainable algorithms available on diverse tools and platforms. Our findings underscore ML's potential in exposure studies, emphasising its adaptability and significance for laypersons while also highlighting areas for improvement.