Measuring the Impact of Environment on the Health of Large Cities.

The relative significance of indicators and determinants of health is important for local public health workers and planners. Of similar importance is a method for combining and evaluating such markers. We used a recently developed index, the Urban Health Index (UHI), to examine the impact of environmental variables on the overall health of cities. We used the UHI to rank 57 of the world’s largest cities (based on population size) in low- and middle-income countries. We examined nine variables in various combinations that were available from the Demographic and Health Surveys conducted in these countries. When arranged in ascending order, the distribution of UHIs follows the previously described pattern of gradual linear increase, with departures at each tail. The rank order of cities did not change materially with the omission of variables about women’s health knowledge or childhood vaccinations. Omission of environmental variables (a central water supply piped into homes, improved sanitation, and indoor solid fuel use) altered the rank order considerably. The data suggest that environmental indicators, measures of key household level risk to health, may play a vital role in the overall health of urban communities.

Toward "Age-Friendly Slums"? Health Challenges of Older Slum Dwellers in Nairobi and the Applicability of the Age-Friendly City Approach.

A majority of urban residents in sub-Saharan Africa (SSA) and other developing regions live in informal settlements, or slums. Much of the discourse on slum health centres on younger generations, while an intensifying agenda on healthy ageing as yet lacks a systematic focus on slums. Similarly, the global age-friendly cities (AFC) movement does not, thus far, extend to slums. This paper examines the particular challenges that a slum-focused age-friendly initiative in SSA may need to address, and the relevance of present AFC indicators and domains for initiatives to advance the health and well-being of older slum dwellers. The analysis builds on the case of two slum communities in Nairobi, Kenya. It analyzes two bodies of relevant evidence from these settlements, namely on the health and social circumstances of older residents, and on the local application and measurement of AFC indicators. The findings point to a set of unsurprising, but also less obvious, core health and social adversities that an age-friendly initiative in such settlements would need to consider. The findings show, further, that the current AFC domains and indicators framework only partly capture these adversities, but that there is potential for adapting the framework to be meaningful for slum settings. The paper concludes by underscoring the need for, and opportunities inherent in, the pursuit of an "age-friendly slums" initiative going forward.

Metrics in Urban Health: Current Developments and Future Prospects.

The research community has shown increasing interest in developing and using metrics to determine the relationships between urban living and health. In particular, we have seen a recent exponential increase in efforts aiming to investigate and apply metrics for urban health, especially the health impacts of the social and built environments as well as air pollution. A greater recognition of the need to investigate the impacts and trends of health inequities is also evident through more recent literature. Data availability and accuracy have improved through new affordable technologies for mapping, geographic information systems (GIS), and remote sensing. However, less research has been conducted in low- and middle-income countries where quality data are not always available, and capacity for analyzing available data may be limited. For this increased interest in research and development of metrics to be meaningful, the best available evidence must be accessible to decision makers to improve health impacts through urban policies.

Disaggregating health inequalities within Rio de Janeiro, Brazil, 2002-2010, by applying an urban health inequality index.

An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.

Disaggregating health inequalities within Rio de Janeiro, Brazil, 2002-2010, by applying an urban health inequality index / Desagregando desigualdades na saúde no Rio de Janeiro, Brasil, 2002-2010, através da aplicação de um índice urbano de desigualdade de saúde / Disgregando desigualdades en el ámbito de la salud en Río de Janeiro, Brasil, 2002-2010, mediante la aplicación de un índice urbano de desigualdad en salud

Abstract An urban health index (UHI) was used to quantify health inequalities within Rio de Janeiro, Brazil, for the years 2002-2010. Eight main health indicators were generated at the ward level using mortality data. The indicators were combined to form the index. The distribution of the rank ordered UHI-values provides information on inequality among wards, using the ratio of the extremes and the gradient of the middle values. Over the decade the ratio of extremes in 2010 declined relative to 2002 (1.57 vs. 1.32) as did the slope of the middle values (0.23 vs. 0.16). A spatial division between the affluent south and the deprived north and east is still visible. The UHI correlated on an ecological ward-level with socioeconomic and urban environment indicators like square meter price of apartments (0.54, p < 0.01), low education of mother (-0.61, p < 0.01), low income (-0.62, p < 0.01) and proportion of black ethnicity (-0.55, p < 0.01). The results suggest that population health and equity have improved in Rio de Janeiro in the last decade though some familiar patterns of spatial inequality remain.

Resumo Um índice de saúde urbana foi utilizado para quantificar desigualdades na saúde no Rio de Janeiro, Brasil, 2002-2010. Oito indicadores de saúde foram gerados no nível dos bairros utilizando dados de mortalidade. Os indicadores foram combinados para formar o índice. A distribuição ordenada dos valores do índice fornece informações sobre a desigualdade entre os bairros, por meio da relação entre os extremos e o gradiente dos valores médios. Ao longo da década, a proporção dos extremos caiu em 2010 em relação a 2002 (1,57 vs. 1,32), assim como a inclinação dos valores médios (0,23 vs. 0,16). A divisão espacial entre o sul afluente e o norte carente está ainda visível. Os valores do índice correlacionam com indicadores socioeconômicos e urbanos como o preço do metro quadrado de apartamentos (0,54, p < 0,01), baixa escolaridade da mãe (-0,61, p < 0,01), baixa renda (-0,62, p < 0,01) e proporção de pretos étnicos (-0,55, p < 0,01). Os resultados sugerem que a equidade na saúde no nível da população tem melhorado no Rio de Janeiro na última década, embora padrões familiares da desigualdade espacial permaneçam.

Resumen Se utilizó un índice de salud urbana para cuantificar desigualdades en el ámbito de la salud en Río de Janeiro, Brasil, 2002 a 2010. Se han generado ocho indicadores de salud a nivel de barrios, utilizando datos de mortalidad. Los indicadores fueron combinados para formar el índice. La distribución ordenada de los valores del índice ofrece información de la desigualdad, a través de la relación entre los extremos y el gradiente de los valores medios. A lo largo de la década la proporción de los extremos disminuyó en 2010, en comparación con 2002 (1,57 vs. 1,32), al igual que el gradiente de los valores medios (0,23 vs. 0,16). La división espacial entre el opulento sur y el norte desfavorecido es todavía visible. Los valores del índice se correlacionan con los indicadores socioeconómicos y urbanos, como el precio de los apartamentos (0,54, p < 0,01), la baja educación materna (-0.61, p < 0.01), baja renta (-0,62, p < 0,01) y la población afrobrasileña (-0,55, p < 0,01). Los resultados sugieren que la equidad en salud ha mejorado en Río de Janeiro en la última década, aunque los patrones familiares de desigualdad espacial permanecen.

Prioritizing action on health inequities in cities: An evaluation of Urban Health Equity Assessment and Response Tool (Urban HEART) in 15 cities from Asia and Africa.

Following the recommendations of the Commission on Social Determinants of Health (2008), the World Health Organization (WHO) developed the Urban Health Equity Assessment and Response Tool (HEART) to support local stakeholders in identifying and planning action on health inequities. The objective of this report is to analyze the experiences of cities in implementing Urban HEART in order to inform how the future development of the tool could support local stakeholders better in addressing health inequities. The study method is documentary analysis from independent evaluations and city implementation reports submitted to WHO. Independent evaluations were conducted in 2011-12 on Urban HEART piloting in 15 cities from seven countries in Asia and Africa: Indonesia, Iran, Kenya, Mongolia, Philippines, Sri Lanka, and Vietnam. Local or national health departments led Urban HEART piloting in 12 of the 15 cities. Other stakeholders commonly engaged included the city council, budget and planning departments, education sector, urban planning department, and the Mayor's office. Ten of the 12 core indicators recommended in Urban HEART were collected by at least 10 of the 15 cities. Improving access to safe water and sanitation was a priority equity-oriented intervention in 12 of the 15 cities, while unemployment was addressed in seven cities. Cities who piloted Urban HEART displayed confidence in its potential by sustaining or scaling up its use within their countries. Engagement of a wider group of stakeholders was more likely to lead to actions for improving health equity. Indicators that were collected were more likely to be acted upon. Quality of data for neighbourhoods within cities was one of the major issues. As local governments and stakeholders around the world gain greater control of decisions regarding their health, Urban HEART could prove to be a valuable tool in helping them pursue the goal of health equity.

Urban health indicators and indices--current status.

Though numbers alone may be insufficient to capture the nuances of population health, they provide a common language of appraisal and furnish clear evidence of disparities and inequalities. Over the past 30 years, facilitated by high speed computing and electronics, considerable investment has been made in the collection and analysis of urban health indicators, environmental indicators, and methods for their amalgamation. Much of this work has been characterized by a perceived need for a standard set of indicators. We used publication databases (e.g. Medline) and web searches to identify compilations of health indicators and health metrics. We found 14 long-term large-area compilations of health indicators and determinants and seven compilations of environmental health indicators, comprising hundreds of metrics. Despite the plethora of indicators, these compilations have striking similarities in the domains from which the indicators are drawn--an unappreciated concordance among the major collections. Research with these databases and other sources has produced a small number of composite indices, and a number of methods for the amalgamation of indicators and the demonstration of disparities. These indices have been primarily used for large-area (nation, region, state) comparisons, with both developing and developed countries, often for purposes of ranking. Small area indices have been less explored, in part perhaps because of the vagaries of data availability, and because idiosyncratic local conditions require flexible approaches as opposed to a fixed format. One result has been advances in the ability to compare large areas, but with a concomitant deficiency in tools for public health workers to assess the status of local health and health disparities. Large area assessments are important, but the need for small area action requires a greater focus on local information and analysis, emphasizing method over prespecified content.

A flexible urban health index for small area disparities.

Available urban health metrics focus primarily on large area rankings. Less has been done to develop an index that provides information about level of health and health disparities for small geographic areas. Adopting a method used by the Human Development Index, we standardized indicators for small area units on a (0, 1) interval and combined them using their geometric mean to form an Urban Health Index (UHI). Disparities were assessed using the ratio of the highest to lowest decile and measurement of the slope of the eight middle deciles (middle; 80 %) of the data. We examined the sensitivity of the measure to weighting, to changes in the method, to correlation among indicators, and to substitution of indicators. Using seven health determinants and applying these methods to the 128 census tracts in the city of Atlanta, USA, we found a disparity ratio of 5.92 and a disparity slope of 0.54, suggesting substantial inequality and heterogeneity of risk. The component indicators were highly correlated; their systematic removal had a small effect on the results. Except in extreme cases, weighting had a little effect on the rankings. A map of Atlanta census tracts exposed a swath of high disparity. UHI rankings, ratio, and slope were resistant to alteration in composition and to non-extreme weighting schemes. This empirical evaluation was limited to a single realization, but suggests that a flexible tool, whose method rather than content is standardized, may be of use for local evaluation, for decision making, and for area comparison.

Linking evidence to action on social determinants of health using Urban HEART in the Americas / De la evidencia a la acción sobre los determinantes sociales de la salud mediante el instrumento Urban HEART en la Región de las Américas

OBJECTIVE: To evaluate the experience of select cities in the Americas using the Urban Health Equity Assessment and Response Tool (Urban HEART) launched by the World Health Organization in 2010 and to determine its utility in supporting government efforts to improve health equity using the social determinants of health (SDH) approach METHODS: The Urban HEART experience was evaluated in four cities from 2010-2013: Guarulhos (Brazil), Toronto (Canada), and Bogotá and Medellín (Colombia). Reports were submitted by Urban HEART teams in each city and supplemented by first-hand accounts of key informants. The analysis considered each city's networks and the resources it used to implement Urban HEART; the process by which each city identified equity gaps and prioritized interventions; and finally, the facilitators and barriers encountered, along with next steps RESULTS: In three cities, local governments spearheaded the process, while in the fourth (Toronto), academia initiated and led the process. All cities used Urban HEART as a platform to engage multiple stakeholders. Urban HEART's Matrix and Monitor were used to identify equity gaps within cities. While Bogotá and Medellín prioritized among existing interventions, Guarulhos adopted new interventions focused on deprived districts. Actions were taken on intermediate determinants, e.g., health systems access, and structural SDH, e.g., unemployment and human rights CONCLUSIONS: Urban HEART provides local governments with a simple and systematic method for assessing and responding to health inequity. Through the SDH approach, the tool has provided a platform for intersectoral action and community involvement. While some areas of guidance could be strengthened, Urban HEART is a useful tool for directing local action on health inequities, and should be scaled up within the Region of the Americas, building upon current experience.

OBJETIVO: Evaluar la experiencia de determinadas ciudades de la Región de las Américas mediante el empleo del instrumento de evaluación y respuesta en materia de equidad en salud en medios urbanos (Urban HEART), introducido por la Organización Mundial de la Salud en el 2010, y determinar su utilidad para apoyar las iniciativas de los gobiernos para incrementar la equidad en salud utilizando el enfoque de los determinantes sociales de la salud (DSS). MÉTODOS: Se evaluó la experiencia de Urban HEART en cuatro ciudades: Guarulhos (Brasil), Toronto (Canadá), y Bogotá y Medellín (Colombia). Los equipos de Urban HEART de cada ciudad presentaron informes y estos fueron complementados por las explicaciones directas de informantes clave. El análisis tuvo en cuenta las redes y los recursos de cada ciudad utilizados para implantar el Urban HEART, el proceso mediante el cual cada ciudad determinó las brechas en materia de equidad y las intervenciones prioritarias y, por último, las barreras y los factores favorecedores detectados, así como las medidas a adoptar RESULTADOS: En tres ciudades, los gobiernos locales lideraron el proceso, mientras que en la cuarta (Toronto), este fue iniciado y conducido por la comunidad académica. Todas las ciudades utilizaron Urban HEART como una plataforma para hacer participar a múltiples interesados directos. Se utilizaron las herramientas Matriz y Monitor de Urban HEART para determinar las brechas de equidad en las ciudades. Mientras Bogotá y Medellín establecieron prioridades entre las intervenciones ya existentes, Guarulhos adoptó nuevas intervenciones centradas en los distritos desprotegidos. Se adoptaron medidas en materia de determinantes intermedios, por ejemplo, el acceso a los sistemas de salud, y los DSS estructurales, tales como el desempleo y los derechos humanos CONCLUSIONES: El instrumento Urban HEART proporciona a los gobiernos locales un método sencillo y sistemático para evaluar y responder a la inequidad en salud. Mediante el enfoque de los DSS, esta herramienta ha proporcionado una plataforma para la acción intersectorial y la participación comunitaria. Aunque podrían fortalecerse algunos aspectos relacionados con la provisión de directrices, Urban HEART constituye una herramienta útil para dirigir la acción local sobre las inequidades en salud y debe extenderse a toda la Región de las Américas aprovechando la experiencia actual.

Inequalities in noncommunicable disease mortality in the ten largest Japanese cities.

The burden of noncommunicable diseases and social inequalities in health among urban populations is becoming a common problem around the world. This phenomenon is further compounded by population aging. Japan faces the task of maintaining its high level of population health while dealing with these challenges. This study focused on the ten largest cities in Japan and, using publicly available administrative data, analyzed standardized mortality ratios to examine inequalities in relative mortality levels due to major noncommunicable disease at both city and subcity levels. On average, the ten major cities had excess mortality due to cancer and lower mortality due to heart disease and cerebrovascular disease compared to the country as a whole. Substantial inequalities in relative mortality were observed both between and within cities, especially for heart disease and cerebrovascular disease among men. Inequalities in relative mortality levels within cities appear to be increasing over time even while relative mortality levels are decreasing overall. The widely observed health inequalities signal the need for actions to ensure health equity while addressing the burden of noncommunicable diseases. Increasingly, more countries will have to deal with these challenges of inequity, urbanization, aging, and noncommunicable diseases. Local health governance informed by locally specific data on health determinants and outcomes is essential for developing contextualized interventions to improve health and health equity in major urban areas.

Linking evidence to action on social determinants of health using Urban HEART in the Americas.

OBJECTIVE: To evaluate the experience of select cities in the Americas using the Urban Health Equity Assessment and Response Tool (Urban HEART) launched by the World Health Organization in 2010 and to determine its utility in supporting government efforts to improve health equity using the social determinants of health (SDH) approach. METHODS: The Urban HEART experience was evaluated in four cities from 2010-2013: Guarulhos (Brazil), Toronto (Canada), and Bogotá and Medellín (Colombia). Reports were submitted by Urban HEART teams in each city and supplemented by first-hand accounts of key informants. The analysis considered each city's networks and the resources it used to implement Urban HEART; the process by which each city identified equity gaps and prioritized interventions; and finally, the facilitators and barriers encountered, along with next steps. RESULTS: In three cities, local governments spearheaded the process, while in the fourth (Toronto), academia initiated and led the process. All cities used Urban HEART as a platform to engage multiple stakeholders. Urban HEART's Matrix and Monitor were used to identify equity gaps within cities. While Bogotá and Medellín prioritized among existing interventions, Guarulhos adopted new interventions focused on deprived districts. Actions were taken on intermediate determinants, e.g., health systems access, and structural SDH, e.g., unemployment and human rights. CONCLUSIONS: Urban HEART provides local governments with a simple and systematic method for assessing and responding to health inequity. Through the SDH approach, the tool has provided a platform for intersectoral action and community involvement. While some areas of guidance could be strengthened, Urban HEART is a useful tool for directing local action on health inequities, and should be scaled up within the Region of the Americas, building upon current experience.

Communicating actionable risk for terrorism and other hazards.

We propose a shift in emphasis when communicating to people when the objective is to motivate household disaster preparedness actions. This shift is to emphasize the communication of preparedness actions (what to do about risk) rather than risk itself. We have called this perspective "communicating actionable risk," and it is grounded in diffusion of innovations and communication theories. A representative sample of households in the nation was analyzed using a path analytic framework. Preparedness information variables (including content, density, and observation), preparedness mediating variables (knowledge, perceived effectiveness, and milling), and preparedness actions taken were modeled. Clear results emerged that provide a strong basis for communicating actionable risk, and for the conclusion both that information observed (seeing preparedness actions that other have taken) and information received (receiving recommendations about what preparedness actions to take) play key, although different, roles in motivating preparedness actions among the people in our nation.

Desire for more children, contraceptive use and unmet need for family planning in a remote area of Bali, Indonesia.

Exploring fertility preferences in relation to contraceptive use can increase the understanding of future reproductive behaviour and unmet family planning needs. This knowledge can help assist women in meeting their reproductive goals. The influences on the desire for more children and current contraceptive use were examined among 1528 married women of reproductive age in an isolated community in Bali, Indonesia, using multivariate logistic regression analysis. Women who were younger, had fewer living children, had given birth in the past year and had regular access to health services were more likely to desire children. Being older, having fewer living children, not having regular access to health services, having given birth in the past year and having the desire for more children were associated with a lower likelihood of using contraception. Women with regular access to health care are more likely to desire more children, probably because they are confident in their ability to have successful birth outcomes. However, specialized clinics or family planning outreach workers may be required to reduce barriers to service utilization among some groups. The findings of this study identify key target populations for family planning, including older women and postpartum women--groups that may not perceive themselves to be at risk for unintended pregnancy. Meeting unmet need for family planning among these groups could help women meet their fertility goals, as well as reduce maternal morbidity and mortality.

First-aid training and capabilities of the lay public: a potential alternative source of emergency medical assistance following a natural disaster.

Basic first-aid skills can be useful in treating minor injuries that commonly result from natural disasters in the United States. Yet there has been insufficient research on training and competence in first-aid skills among community residents. This study utilises panel data for 414 adults in Los Angeles, California, who were interviewed within three years of the 1994 Northridge earthquake and re-interviewed in 1999 after the El Ninõ winter of 1997-98. Descriptive, bivariate and multivariate analyses were performed. Results showed that 24 percent of the members of the sample had received first-aid training since their Northridge earthquake interview. First-aid training, particularly recent training, was associated with greater perceived first-aid skills, as well as with increased expected and actual employment of those skills. With the appropriate training and skill retention, lay members of the public can potentially contribute to a post-disaster medical response.