Temporal trends and sex differences in sudden cardiac death in the Copenhagen City Heart Study.

OBJECTIVE: More knowledge about the development of sudden cardiac death (SCD) in the general population is needed to develop meaningful predictors of SCD. Our aim with this study was to estimate the incidence of SCD in the general population and examine the temporal changes, demographics and clinical characteristics. METHODS: All participants in the Copenhagen City Heart Study were followed from 1993 to 2016. All death certificates, autopsy reports and national registry data were used to identify all cases of SCD. RESULTS: A total of 14 562 subjects were included in this study. There were 8394 deaths with all information available, whereof 1335 were categorised as SCD. The incidence of SCD decreased during the study period by 41% for persons aged 40-90 years, and the standardised incidence rates decreased from 504 per 100 000 person-years (95% CI 447 to 569) to 237 per 100 000 person-years (95% CI 195 to 289). The incidence rate ratio of SCD between men and women ≤75 years was 1.99 (95% CI 1.62 to 2.46). The proportion of SCD of all cardiac deaths decreased during the observation period and decreased with increasing age. Men had more cardiovascular comorbidities (OR 1.34, 95% CI 1.07 to 1.68, p<0. 01), and SCD was the first registered manifestation of cardiac disease in 50% of all cases. CONCLUSION: The incidence of SCD in the general population has declined significantly during the study period but should be further investigated for more recent variations as well as novel risk predictors for persons with low to medium risk of SCD.

Infant Mortality in the Metropolitan Region, Chile 2005-2014. / Mortalidad Infantil en las comunas de la Región Metropolitana, periodo 2005-2014.

INTRODUCTION: Infant mortality depends on the economic, social, and cultural level of development of the place of residence. OBJECTIVE: To describe the infant mortality rates (IMR) and the late infant mortality rates (LIMR) of the Metropolitan Region (MR) communes and to evaluate their trend between 2005 and 2014. MATERIAL AND METHOD: Ecological study that describes the rates of the 52 communes of the MR. For the analysis, the IMR and LIMR were elaborated for each year and com mune and were compared using population attributable risk (PAR), attributable risk percent (AR%), and rate ratio (RR). Trends were analyzed through the Prais-Winsten model. A value p < 0.05 was considered a statistically significant trend. RESULTS: The commune 'Independencia' presented the hig hest IMR and LIMR with 12.7 and 4.05 per 1000 live births respectively, 1.75 and 2.05 times more compared with the IMR and LIMR of the MR. The commune 'Las Condes' and 'Vitacura' presented the lowest IMR and LIMR respectively. The IMR trend regarding 2005 increased in Lo Barnechea, Lo Espejo, and Recoleta, and decreased in Las Condes, Macul, Pudahuel and San Bernardo. The LIMR decreased in Peñalolén, Puente Alto, Las Condes, Providencia, San Bernardo, Macul, Pudahuel, Tala- gante, Pedro Aguirre Cerda, and Quilicura, and increased in Peñaflor. CONCLUSION: The regional IMR and LIMR hide the slight increase in rates and the persistence of heterogeneity among communes. This forces us to explore the causes of these inequities through future analytical studies.

Mortalidad Infantil en las comunas de la Región Metropolitana, periodo 2005-2014 / Infant Mortality in the Metropolitan Region, Chile 2005-2014

Resumen: Introducción: La mortalidad infantil depende del nivel de desarrollo económico, social y cultural del área de residencia. Objetivo: Describir las tasas de mortalidad infantil (TMI) y mortalidad infantil tardía (TMIT) de las comunas de la Región Metropolitana (RM) y evaluar su tendencia en el perio do 2005-2014. Material y Método: Estudio ecológico que describe las tasas en las 52 comunas de la Región Metropolitana (RM). Para el análisis se construyó la TMI y TMIT para cada año y comuna y se compararon mediante riesgo atribuible poblacional (RAP), Riesgo atribuible porcentual (RAP%) y razón de tasas (RT). Las tendencias se evaluaron con el modelo Prais-Winsten. Se consideró una tendencia estadísticamente significativa un valor p < 0,05. Resultados: La comuna de Independencia mostró la TMI y TMIT más altas con 12,7 y 4,05 por mil RNV respectivamente; 1,75 y 2,05 veces comparado con la TMI y TMIT de la RM. Las tasas más bajas se observaron en Las Condes (TMI) y en Vitacura (TMIT). La tendencia de la TMI respecto al 2005 aumentó en Lo Barnechea, Lo Espejo y Recoleta y disminuyó en Las Condes, Macul, Pudahuel y San Bernardo. La TMIT disminuyó en Peñalolén, Puente Alto, Las Condes, Providencia, San Bernardo, Macul, Pudahuel, Talagante, Pedro Aguirre Cerda y Quilicura y aumentó en Peñaflor. Conclusión: La TMI y la TMIT regional ocultan el leve incremento de las tasas y la persistencia de la heterogeneidad entre las comunas, lo que obliga a explorar las causas de estas inequidades en estudios analíticos a futuro.

Abstract: Introduction: Infant mortality depends on the economic, social, and cultural level of development of the place of residence. Objective: To describe the infant mortality rates (IMR) and the late infant mortality rates (LIMR) of the Metropolitan Region (MR) communes and to evaluate their trend between 2005 and 2014. Material and Method: Ecological study that describes the rates of the 52 communes of the MR. For the analysis, the IMR and LIMR were elaborated for each year and com mune and were compared using population attributable risk (PAR), attributable risk percent (AR%), and rate ratio (RR). Trends were analyzed through the Prais-Winsten model. A value p < 0.05 was considered a statistically significant trend. Results: The commune 'Independencia' presented the hig hest IMR and LIMR with 12.7 and 4.05 per 1000 live births respectively, 1.75 and 2.05 times more compared with the IMR and LIMR of the MR. The commune 'Las Condes' and 'Vitacura' presented the lowest IMR and LIMR respectively. The IMR trend regarding 2005 increased in Lo Barnechea, Lo Espejo, and Recoleta, and decreased in Las Condes, Macul, Pudahuel and San Bernardo. The LIMR decreased in Peñalolén, Puente Alto, Las Condes, Providencia, San Bernardo, Macul, Pudahuel, Tala- gante, Pedro Aguirre Cerda, and Quilicura, and increased in Peñaflor. Conclusion: The regional IMR and LIMR hide the slight increase in rates and the persistence of heterogeneity among communes. This forces us to explore the causes of these inequities through future analytical studies.

Effect of the recent economic crisis on socioeconomic inequalities in mortality in nine urban areas in Europe.

OBJECTIVE: To analyse socioeconomic inequalities in all-cause mortality among men and women in nine European urban areas during the recent economic crisis, and to compare the results to those from two periods before the crisis. METHOD: This is an ecological study of trends based on three time periods (2000-2003, 2004-2008 and 2009-2014). The units of analysis were the small areas of nine European urban areas. We used a composite deprivation index as a socioeconomic indicator, along with other single indicators. As a mortality indicator, we used the smoothed standardized mortality ratio, calculated using the hierarchical Bayesian model proposed by Besag, York and Mollié. To analyse the evolution of socioeconomic inequalities, we fitted an ecological regression model that included the socioeconomic indicator, the period of time, and the interaction between these terms. RESULTS: We observed significant inequalities in mortality among men for almost all the socioeconomic indicators, periods, and urban areas studied. However, no significant changes occurred during the period of the economic crisis. While inequalities among women were less common, there was a statistically significant increase in inequality during the crisis period in terms of unemployment and the deprivation index in Prague and Stockholm, respectively. CONCLUSIONS: Future analyses should also consider time-lag in the effect of crises on mortality and specific causes of death, and differential effects between genders.

Neighborhood social and economic change and diabetes incidence: The HeartHealthyHoods study.

We studied the association between neighborhood social and economic change and type 2 diabetes incidence in the city of Madrid (Spain). We followed 199,621 individuals living in 393 census tracts for diabetes incidence for 6 years using electronic health records, starting in 2009. We measured neighborhood social and economic change from 2005 to 2009 using a finite mixture model with 16 indicators that resulted in four types of neighborhood change. Adjusted results showed an association between neighborhood change and diabetes incidence: compared to those living in Aging/Stable areas, people living in Declining SES, New Housing and Improving SES areas have an 8% (HR = 0.92, 95% CI 0.87 to 0.99), 9% (HR = 0.91, 95% CI 0.81 to 1.01) and 11% (HR = 0.89, 95% CI 0.81 to 0.98) decrease in diabetes incidence. This evidence can help guide policies for diabetes prevention by focusing efforts on specific urban areas.

Cardiovascular health in urban Chinese children and adolescents.

INTRODUCTION: Cardiovascular diseases remain the leading cause of death and disease burden in China and worldwide. We aimed to evaluate the status of cardiovascular health among urban Chinese children and adolescents. METHODS: We conducted a cross-sectional study comprising 12,618 children and adolescents aged 6-18 years, who were recruited from Chinese urban areas during 2013-2015. The poor, intermediate, and ideal levels of 7 cardiovascular health metrics, including smoking, body mass index, dietary intake, physical activity, blood pressure, blood glucose, and total cholesterol were defined according to revised American Heart Association criteria. RESULTS: Ideal smoking status was the most prevalent health component (overall, 90.7%; males, 86.3% and females, 95.4%), whereas ideal health diet score (overall, 8.7%; males, 9.1% and females, 8.3%) was the least prevalent among urban Chinese children and adolescents. The majority (overall, 84.9%; males, 82.6% and females, 87.4%) of participants had 3-5 ideal metrics. The overall prevalence of ideal cardiovascular health (i.e. meeting all 7 ideal components) was extremely low (overall, 0.5%; males, 0.5% and females, 0.4%). CONCLUSIONS: The prevalence of ideal cardiovascular health in urban Chinese children and adolescents is extremely low, particularly for physical activity and healthy dietary intake. Effective public health interventions are required to improve cardiovascular health in children and adolescents to reduce future cardiovascular risk. Key messages Ideal health diet score was the least prevalent health component among urban Chinese children and adolescents The prevalence of ideal cardiovascular health in urban Chinese children and adolescents was extremely low Effective public health interventions are required to improve cardiovascular health in children and adolescents to reduce future cardiovascular risk.

21st century research in urban WASH and health in sub-Saharan Africa: methods and outcomes in transition.

Tackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue - 58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening. Abbreviations: CBA: Controlled Before and After; GSD: Government Service Delivery; IWDSSD: International Drinking-Water, Supply and Sanitation Decade (IDWSSD); KAP: Knowledge, Attitudes and Practices; IBD: Irritable Bowel Diseases; MDG: Millennium Development Goals; NTD: Neglected Tropical Diseases; PSSD: Private Sector Service Delivery; SDG: Sustainable Development Goals; SSA: Sub Saharan Africa; SODIS: Solar Disinfection System; STH: Soil Transmitted Helminths; RCT: Randomised Control Trial; WASH: Water Sanitation and Hygiene; WHO: World Health Organization.

Is the Urban Child Health Advantage Declining in Malawi?: Evidence from Demographic and Health Surveys and Multiple Indicator Cluster Surveys.

In many developing countries including Malawi, health indicators are on average better in urban than in rural areas. This phenomenon has largely prompted Governments to prioritize rural areas in programs to improve access to health services. However, considerable evidence has emerged that some population groups in urban areas may be facing worse health than rural areas and that the urban advantage may be waning in some contexts. We used a descriptive study undertaking a comparative analysis of 13 child health indicators between urban and rural areas using seven data points provided by nationally representative population based surveys-the Malawi Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Rate differences between urban and rural values for selected child health indicators were calculated to denote whether urban-rural differentials showed a trend of declining urban advantage in Malawi. The results show that all forms of child mortality have significantly declined between 1992 and 2015/2016 reflecting successes in child health interventions. Rural-urban comparisons, using rate differences, largely indicate a picture of the narrowing gap between urban and rural areas albeit the extent and pattern vary among child health indicators. Of the 13 child health indicators, eight (neonatal mortality, infant mortality, under-five mortality rates, stunting rate, proportion of children treated for diarrhea and fever, proportion of children sleeping under insecticide-treated nets, and children fully immunized at 12 months) show clear patterns of a declining urban advantage particularly up to 2014. However, U-5MR shows reversal to a significant urban advantage in 2015/2016, and slight increases in urban advantage are noted for infant mortality rate, underweight, and stunting rate in 2015/2016. Our findings suggest the need to rethink the policy viewpoint of a disadvantaged rural and much better-off urban in child health programming. Efforts should be dedicated towards addressing determinants of child health in both urban and rural areas.

Evaluating gentrification's relation to neighborhood and city health.

Gentrification has been argued to contribute to urban inequalities, including those of health disparities. Extant research has yet to conduct a systematic study of gentrification's relation with neighborhood health outcomes nationally. This gap is addressed in the current study through the utilization of census-tract data from the Center for Disease Control's 500 Cities project, the 2000 Census and the 2010-2014 American Community Survey to examine how gentrification relates to local self-rated physical health in select cities across the United States. We examine gentrification's association with neighborhood rates of poor self-rated physical health. We contextualize this relationship by evaluating gentrification's relation with city-level self-rated health inequalities. We find gentrification was significantly and positively related with self-rated physical neighborhood health outcomes. However, the presence and magnitude of gentrification within a city was not associated with health outcomes for cities overall. Based on these findings, we argue that gentrification's health benefits for cities are limited at best, though gentrification does not appear to be associated with deepening city-level health inequalities, either.

Perception of Urban Environmental Risks and the Effects of Urban Green Infrastructures (UGIs) on Human Well-being in Four Public Green Spaces of Guangzhou, China.

Cities face many challenging environmental problems that affect human well-being. Environmental risks can be reduced by Urban Green Infrastructures (UGIs). The effects of UGIs on the urban environment have been widely studied, but less attention has been given to the public perception of these effects. This paper presents the results of a study in Guangzhou, China, on UGI users' perceptions of these effects and their relationship with sociodemographic variables. A questionnaire survey was conducted in four public green spaces. Descriptive statistics, a binary logistic regression model and cross-tabulation analysis were applied on the data from 396 valid questionnaires. The results show that UGI users were more concerned about poor air quality and high temperature than about flooding events. Their awareness of environmental risks was partly in accordance with official records. Regarding the perception of the impacts of environmental risks on human well-being, elderly and female respondents with higher education levels were the most sensitive to these impacts. The respondents' perceptions of these impacts differed among the different green spaces. The effects of UGIs were well perceived and directly observed by the UGI users, but were not significantly influenced by most sociodemographic variables. Moreover, tourists had a lower perception of the impacts of environmental risks and the effects of UGI than residents did. This study provides strong support for UGIs as an effective tool to mitigate environmental risks. Local governments should consider the role of UGIs in environmental risk mitigation and human well-being with regard to urban planning and policy making.

The air of Europe: where are we going?

Air pollution constitutes one of the main threats to public health in Europe. Significant impacts on the health of Europeans in terms of morbidity and mortality have been observed, even in cases of low exposure and where pollutant levels are within limits set by the European Union (EU). The respiratory system is a primary target of the harmful effects of key air pollutants. Emissions of many air pollutants have decreased substantially over the past decades in Europe, resulting in diminished concentrations and improved air quality. However, in several European cities concentrations still exceed EU reference values and, more often, the stricter World Health Organization air quality guidelines for all regulated air pollutants (particles with 50% cut-off aerodynamic diameters of 10 and 2.5 µm, nitrogen dioxide (NO2), benzo[a]pyrene and ozone (O3)) except sulfur dioxide. In addition, current trends indicate that in the absence of substantial changes, particulate matter, NO2 and O3 will still exceed limits in 2020. Additional efforts must be made to comply with current standards and guidelines. These should include a more accurate and detailed monitoring of air pollutants, reduction of emissions and individual behaviour changes.

Worsening Rural-Urban Gap in Hospital Mortality.

BACKGROUND: One out of every 5 Americans live in rural communities. Rural Americans have higher rates of early and preventable deaths outside of the hospital than their urban counterparts. How rurality relates to hospital mortality is unknown. We sought to determine the association between rural versus urban residence and hospital mortality. METHODS: This is a retrospective observational study of 4,412,942 nonmaternal, nonneonatal hospitalizations in 2008, and 3899,464 nonmaternal, nonneonatal hospitalizations in 2013 using all-payer, all-age data from the National Inpatient Sample of the Health care Cost and Utilization Project. Using multivariable logistic regression, we report the association between rural versus urban location of residence and hospital mortality, adjusting for chronic disease burden, age, income, and insurance status. RESULTS: The unadjusted probability of hospital mortality for urban patients decreased from 2.51% (95% CI, 2.40 to 2.62) in 2008 to 2.27% (95% CI, 2.22 to 2.32) in 2013 (P < .001). Hospital mortality did not change for rural patients over this same time period (2008: 2.66% [95% CI, 2.57 to 2.74], 2013: 2.66% [95% CI, 2.60 to 2.72]; P = .99). Adjusting for covariates accounted for the rural-urban hospital mortality difference in 2008 (rural: 2.13% [95% CI, 2.05 to 2.21], urban: 2.11% [95% CI, 2.02 to 2.20]; P = .67), but did not fully explain the difference in 2013 (rural: 1.92% [95% CI, 1.87 to 1.97]; urban: 1.76% [95% CI, 1.72 to 1.80], P < .001), resulting in 8416 excess deaths among hospitalized patients from rural areas. CONCLUSION AND RELEVANCE: In 2013, patients living in rural areas of the United States had a greater probability of hospital mortality than their urban counterparts. Explaining excess rural hospital deaths will require further attention to the patient, community, and health system factors that distinguish rural from urban populations.

Secular trends in dietary patterns of young children in Brazil from 1996 to 2006.

OBJECTIVE: To describe dietary patterns (DP) from 1996 to 2006 and in the first 5 years of life and to explore individual and contextual characteristics associated with each DP. DESIGN: DP were defined by principal component analysis. The association between DP and individual (sociodemographic, maternal and child) and contextual (geographic regional and year) characteristics was analysed by multilevel analysis. SETTING: Two complex probabilistic Brazilian Demographic and Health Surveys (BDHS 1996, 2006). SUBJECTS: Brazilian children under 5 years of age. RESULTS: DP1 included yoghurt, vegetables, fruits, tubers, red meat. DP2 included liquids, milk, fruits, egg/chicken/fish, red meat, breast milk (negative loading). DP3 included fruit juices, 'papilla', yoghurt, red meat (negative loading). DP4 included formulas, milk, enriched 'papilla', egg/chicken/fish (negative loading). DP prevalence within the age range from 1996 to 2006 remained constant for DP1; increased after 12 and 6 months, respectively, for DP2 and DP3; and decreased for DP4. DP1 was explained by higher maternal education, wealth, lower number of children at home; DP2 by living in rural area and younger mothers; and DP4 by lower maternal education and wealth. The total variance of the model attributable to geographic region was 30·2, 20·7 and 54·2 % for DP2, DP3 and DP4, respectively. CONCLUSIONS: DP trends observed from 1996 to 2006 show positive aspects, such as: maintenance of DP1 as the main DP after 12 months; an increase in the prevalence of DP2 and DP3 followed by a decrease of DP4 after 6 months. DP1 is explained mainly by socio-economic factors, regardless of contextual characteristics, and DP2, DP3, DP4 are partially explained by contextual effects.

Diabetes mellitus mortality in Spanish cities: Trends and geographical inequalities.

AIM: To analyze the geographical pattern of diabetes mellitus (DM) mortality and its association with socioeconomic factors in 26 Spanish cities. METHODS: We conducted an ecological study of DM mortality trends with two cross-sectional cuts (1996-2001; 2002-2007) using census tract (CT) as the unit of analysis. Smoothed standardized mortality rates (sSMR) were calculated using Bayesian models, and a socioeconomic deprivation score was calculated for each CT. RESULTS: In total, 27,757 deaths by DM were recorded, with higher mortality rates observed in men and in the period 1996-2001. For men, a significant association between CT deprivation score and DM mortality was observed in 6 cities in the first study period and in 7 cities in the second period. The highest relative risk was observed in Pamplona (RR, 5.13; 95% credible interval (95%CI), 1.32-15.16). For women, a significant association between CT deprivation score and DM mortality was observed in 13 cities in the first period and 8 in the second. The strongest association was observed in San Sebastián (RR, 3.44; 95%CI, 1.25-7.36). DM mortality remained stable in the majority of cities, although a marked decrease was observed in some cities, including Madrid (RR, 0.67 and 0.64 for men and women, respectively). CONCLUSIONS: Our findings demonstrate clear inequalities in DM mortality in Spain. These inequalities remained constant over time are were more marked in women. Detection of high-risk areas is crucial for the implementation of specific interventions.

Generating global political priority for urban health: the role of the urban health epistemic community.

Over the past decade there has been much discussion of the challenges posed by rapid urbanization in the developing world; yet the health of the urban poor, and especially those residing in low- and middle-income countries, continues to receive little political priority in most developing countries and at the global level. This research applies social science scholarship and a public policy analytical framework to assess the factors that have challenged efforts to make health in urban poor settings a priority. We conducted 19 semi-structured phone interviews with key urban health proponents and experts representing agencies that shape opinions and manage resources in global health. We also conducted a literature review, which included published scholarly literature and reports from organizations involved in urban health provision and advocacy. Utilizing a process-tracing method, we triangulated among these sources of data to create a historical narrative and analyse the factors that shape the global level of attention to and resources for urban health. The urban health agenda continues to be challenged by six factors, three of which concern the political context or characteristics of the issue: long-standing competition with the dominant development agenda that is rural health oriented; limited data and measurement tools that can effectively gauge the extent of the problem; and lack of evidence on how to best to address the issue. The other three factors are directly under the control of the urban health community: the community's ineffective governance; little common understanding among its members of the problem and how to address it; and an unconvincing framing of the issue to the public. The study offers suggestions as to what advocates can do to secure greater attention and resources in order to help address the health needs of the urban poor.

Development of a spatial sampling protocol using GIS to measure health disparities in Bobo-Dioulasso, Burkina Faso, a medium-sized African city.

BACKGROUND: Many cities in developing countries experience an unplanned and rapid growth. Several studies have shown that the irregular urbanization and equipment of cities produce different health risks and uneven exposure to specific diseases. Consequently, health surveys within cities should be carried out at the micro-local scale and sampling methods should try to capture this urban diversity. METHODS: This article describes the methodology used to develop a multi-stage sampling protocol to select a population for a demographic survey that investigates health disparities in the medium-sized city of Bobo-Dioulasso, Burkina Faso. It is based on the characterization of Bobo-Dioulasso city typology by taking into account the city heterogeneity, as determined by analysis of the built environment and of the distribution of urban infrastructures, such as healthcare structures or even water fountains, by photo-interpretation of aerial photographs and satellite images. Principal component analysis and hierarchical ascendant classification were then used to generate the city typology. RESULTS: Five groups of spaces with specific profiles were identified according to a set of variables which could be considered as proxy indicators of health status. Within these five groups, four sub-spaces were randomly selected for the study. We were then able to survey 1045 households in all the selected sub-spaces. The pertinence of this approach is discussed regarding to classical sampling as random walk method for example. CONCLUSION: This urban space typology allowed to select a population living in areas representative of the uneven urbanization process, and to characterize its health status in regards to several indicators (nutritional status, communicable and non-communicable diseases, and anaemia). Although this method should be validated and compared with more established methods, it appears as an alternative in developing countries where geographic and population data are scarce.

Medellín y el sueño de Ciudad Saludable: construcción técnica y colectiva / Medellín and the dream of a healthy city: a technical and collective construction

RESUMEN Objetivo Definir para Medellín el alcance del concepto y de la estrategia de Ciudad Saludable. Material y Métodos Estudio mixto con revisión de literatura, análisis documental y participación de actores. Resultados En la construcción del concepto se llega a "una ciudad para vivir más y mejor" y se identifican quince características atribuidas a Medellín Ciudad Saludable. La población califica la situación actual como regular y da mayor importancia a las características de medio ambiente, seguridad, acceso a servicios de salud, vivienda y empleo. Aun así, la ciudad presenta avances y esfuerzos importantes para ser reconocida como Ciudad Saludable, pues mantiene programas y proyectos en estas y otras características que contribuyen a elevar el estado de salud. Discusión La construcción de una Ciudad Saludable es particular a cada contexto y en cualquier caso demanda la combinación de trabajo técnico y participación ciudadana en aras de elaborar su propio imaginario e identificar prioridades. En el caso de Medellín, es necesario asumir la estrategia de manera sistemática para que se mantenga en el futuro y hacer explícitas metas y acciones a emprender con el concurso de diferentes sectores del desarrollo local.(AU)

ABSTRACT Objective To define the scope and the strategy of the Healthy City concept for Medellín. Material y Methods Mixed study with literature review, document analysis and involvement of actors. Results The construction of the concept leads to "a city to live more and better". Fifteen characteristics were identified and attributed to "Medellín, a Healthy City". The population assesses the current situation as average and gives more importance to the environment, safety, access to health services, housing and employment. In spite of this perception, and due to the programs and projects directed to increase health quality, the city has advanced towards the implementation of efforts to be acknowledged as a Healthy City. Discussion The construction of a Healthy City is specific for each context, and, in any case, it demands a combination of technical work and citizen participation, with the purpose of creating an own imaginary and identifying priorities. In the case of Medellín, assuming the strategy in a systematic manner is necessary to continue in the long term and to propose explicit goals and take actions to work along with different sectors of social development.(AU)

Trends and regional inequalities in mortality from stroke in the context of health care reform in Lithuania.

BACKGROUND AND OBJECTIVE: The objective of the study was to analyze mortality from stroke in Lithuania the context of health care reform with particular interest in urban/rural and regional inequalities. Based on the analysis of trends in mortality, and to detection of break-points over two decades of socioeconomic transition, it focused on the challenges in stroke care provision. MATERIALS AND METHODS: The analysis covered the entire country. Information on deaths from 1991 to 2012 was gathered from death certificates held by the Lithuanian Department of Statistics. The joinpoint analysis was used to identify the best-fitting points, wherever a statistically significant change in mortality occurred. Age-standardized mortality rates were calculated for 60 municipalities of Lithuania. RESULTS: The positive break-points in mortality from stroke were registered in 2007 for females and 2008 for males, when the increasing trends reversed to the declining. More positive changes occurred in urban areas, where stroke mortality is lower compare to rural since 1996. Considerable inequalities were disclosed among administrative regions of Lithuania: ratio between the highest and the lowest rates in different municipalities reached 4.88 for males and 3.35 for females. CONCLUSIONS: There are good reasons to expect the favorable stroke mortality trends observed will follow the same direction in the future. Stroke centers are growing up in their competence while networking is also under the development. The new strategies in stroke care should result not only in the declining mortality rates and numbers of severely handicapped stroke patients, but also in diminishing regional and urban/rural inequalities.