Confronting the challenges in reconnecting urban planning and public health

Cross-sectional associations between residential environmental exposures and cardiovascular diseases

BACKGROUND

Prior research examining neighbourhood effects on cardiovascular diseases (CVDs) has focused on the impact of neighbourhood socio-economic status or a few selected environmental variables. No studies of cardiovascular disease outcomes have investigated a broad range of urban planning related environmental factors. This is the first study to combine multiple neighbourhood influences in an integrated approach to understanding the association between the built and social environment and CVDs. By modeling multiple neighbourhood level social and environmental variables simultaneously, the study improved the estimation of effects by accounting for potential contextual confounders.

METHODS

Data were collected using a cross-sectional survey (n = 2411) across 87 census tracts (CT) in Toronto, Canada, and commercial and census data were accessed to characterize the residential environment. Multilevel regressions were used to estimate the associations of neighbourhood factors on the risk of CVD.

RESULTS

Exposure to violent crimes, environmental noise, and proximity to a major road were independently associated with increased odds of CVDs (p < 0.05) in the fully adjusted model. While reduced access to food stores, parks/recreation, and increased access to fast food restaurants were associated with increased odds of CVDs in partially adjusted models (p < 0.05), these associations were fully attenuated after adjusting for BMI and physical activity. Housing disrepair was not associated with CVD risk.

CONCLUSIONS

These findings illustrate the importance of measuring and modeling a broad range of neighborhood factors--exposure to violent crimes, environmental noise, and traffic, and access to food stores, fast food, parks/recreation areas--to identify specific stressors in relation to adverse health outcomes. Further research to investigate the temporal order of events is needed to better understand the direction of causation for the observed associations.

Interactive and independent associations between the socioeconomic and objective built environment on the neighbourhood level and individual health: a systematic review of multilevel studies

BACKGROUND

The research question how contextual factors of neighbourhood environments influence individual health has gained increasing attention in public health research. Both socioeconomic neighbourhood characteristics and factors of the built environment play an important role for health and health-related behaviours. However, their reciprocal relationships have not been systematically reviewed so far. This systematic review aims to identify studies applying a multilevel modelling approach which consider both neighbourhood socioeconomic position (SEP) and factors of the objective built environment simultaneously in order to disentangle their independent and interactive effects on individual health.

METHODS

The three databases PubMed, PsycINFO, and Web of Science were systematically searched with terms for title and abstract screening. Grey literature was not included. Observational studies from USA, Canada, Australia, New Zealand, and Western European countries were considered which analysed simultaneously factors of neighbourhood SEP and the objective built environment with a multilevel modelling approach. Adjustment for individual SEP was a further inclusion criterion.

RESULTS

Thirty-three studies were included in qualitative synthesis. Twenty-two studies showed an independent association between characteristics of neighbourhood SEP or the built environment and individual health outcomes or health-related behaviours. Twenty-one studies found cross-level or within-level interactions either between neighbourhood SEP and the built environment, or between neighbourhood SEP or the built environment and individual characteristics, such as sex, individual SEP or ethnicity. Due to the large variation of study design and heterogeneous reporting of results the identification of consistent findings was problematic and made quantitative analysis not possible.

CONCLUSIONS

There is a need for studies considering multiple neighbourhood dimensions and applying multilevel modelling in order to clarify their causal relationship towards individual health. Especially, more studies using comparable characteristics of neighbourhood SEP and the objective built environment and analysing interactive effects are necessary to disentangle health impacts and identify vulnerable neighbourhoods and population groups.

Urban agriculture: long-term strategy or impossible dream?: Lessons from Prospect Farm in Brooklyn, New York

Proponents of urban agriculture have identified its potential to improve health and the environment but in New York City and other densely developed and populated urban areas, it faces huge challenges because of the shortage of space, cost of land, and the lack of contemporary local food production. However, large portions of the city and metropolitan region do have open land and a history of agricultural production in the not-too-distant past. Local food movements and concerns about food security have sparked a growing interest in urban farming. Policies in other sectors to address diet-related illnesses, environmental quality and climate change may also provide opportunities to expand urban farming. Nevertheless, for any major advances in urban agriculture, significant changes in local and regional land use policies are needed. These do not appear to be forthcoming any time soon unless food movements amplify their voices in local and national food policy. Based on his experiences as founder of a small farm in Brooklyn, New York and his engagement with local food movements, the author analyzes obstacles and opportunities for expanding urban agriculture in New York.

Ties that bind: community attachment and the experience of discrimination among Black men who have sex with men

In the USA, the impact of psychological distress may be greater for Black men who have sex with men given that they may experience both racial discrimination in society at large and discrimination due to sexual orientation within Black communities. Attachments to community members may play a role in addressing psychological distress for members of this vulnerable population. This analysis is based on 312 Black men who have sex with men recruited for a behavioural intervention trial in New York City. Analyses were conducted using bivariate and multivariable logistic regression to examine the relationship of discrimination and community attachment to psychological distress. Most participants (63%) reported exposure to both discrimination due to race and sexual orientation. However, a majority of participants (89%) also reported racial and/or sexual orientation community attachment. Psychological distress was significant and negatively associated with older age (40 years and above), being a high school graduate and having racial and/or sexual orientation community attachments. Psychological distress was significantly and positively associated with being HIV-positive and experiencing both racial and sexual orientation discrimination. Similar results were found in the multivariable model. Susceptibility to disparate psychological distress outcomes must be understood in relation to social membership, including its particular norms, structures and ecological milieu.

Multinational corporations and infectious disease: Embracing human rights management techniques

Background

Global health institutions have called for governments, international organisations and health practitioners to employ a human rights-based approach to infectious diseases. The motivation for a human rights approach is clear: poverty and inequality create conditions for infectious diseases to thrive, and the diseases, in turn, interact with social-ecological systems to promulgate poverty, inequity and indignity. Governments and intergovernmental organisations should be concerned with the control and elimination of these diseases, as widespread infections delay economic growth and contribute to higher healthcare costs and slower processes for realising universal human rights. These social determinants and economic outcomes associated with infectious diseases should interest multinational companies, partly because they have bearing on corporate productivity and, increasingly, because new global norms impose on companies a responsibility to respect human rights, including the right to health.

Methods

We reviewed historical and recent developments at the interface of infectious diseases, human rights and multinational corporations. Our investigation was supplemented with field-level insights at corporate capital projects that were developed in areas of high endemicity of infectious diseases, which embraced rights-based disease control strategies.

Results

Experience and literature provide a longstanding business case and an emerging social responsibility case for corporations to apply a human rights approach to health programmes at global operations. Indeed, in an increasingly globalised and interconnected world, multinational corporations have an interest, and an important role to play, in advancing rights-based control strategies for infectious diseases.

Conclusions

There are new opportunities for governments and international health agencies to enlist corporate business actors in disease control and elimination strategies. Guidance offered by the United Nations in 2011 that is widely embraced by companies, governments and civil society provides a roadmap for engaging business enterprises in rights-based disease management strategies to mitigate disease transmission rates and improve human welfare outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/2049-9957-3-39) contains supplementary material, which is available to authorized users.

Healthy Canada by Design CLASP: Lessons learned from the first phase of an intersectoral, cross-provincial, built environment initiative

OBJECTIVES

The Healthy Canada by Design (HCBD) CLASP (Coalitions Linking Action and Science for Prevention) Initiative promotes the building of communities that support health by 1) facilitating the integration of health evidence into built environment decision-making; 2) developing new, cross-sector collaboration models and tools; and 3) fostering a national community of practice.

PARTICIPANTS

A coalition of public health professionals, researchers, professional planners and non-governmental organization (NGO) staff from across Canada developed, implemented and participated in the Initiative.

SETTINGS

In the first phase, HCBD interventions took place for the most part in large urban and suburban settings in Quebec, Ontario and British Columbia. National knowledge transfer and exchange (KTE) activities were delivered both locally and nationally.

INTERVENTION

Project participants developed tools or processes for collaboration between the health and the community planning sectors. These were designed to increase the capacity of the health sector to influence decisions about land use and transportation planning. Tool or process development was accompanied by pilot testing, evaluation, and dissemination of findings and lessons learned. On a parallel track, NGOs involved with HCBD led national KTE interventions.

OUTCOMES

The first phase of HCBD demonstrated the potential for public health organizations to influence the built environment determinants of cancer and chronic diseases. Public health authorities forged relationships with several organizations with a stake in built environment decisions, including municipal and regional planning departments, provincial governments, federal government agencies, researchers, community groups and NGOs. The Initiative accomplished the following: 1) created new relationships across sectors and across health authorities; 2) improved the knowledge and skills for influencing land use planning processes among public health professionals; 3) increased awareness of health evidence and intent to change practice among built environment decision-makers; and 4) facilitated inclusion of health considerations in local plans, policies and decisions.

CONCLUSIONS

The first phase of HCBD engaged built environment stakeholders, including public health professionals, planners, researchers, community groups and NGOs, in ways that would be expected to influence health risk factors and population health outcomes in the long term.

Urban design and health: progress to date and future challenges

Over the last 15 years, a growing body of Australian and international evidence has demonstrated that urban design attributes are associated with a range of health outcomes. For example, the location of employment, shops and services, provision of public and active transport infrastructure and access to open space and recreational opportunities are associated with chronic disease risk factors such as physical activity levels, access to healthy food, social connectedness, and air quality. Despite the growing knowledge base, this evidence is not being consistently translated into urban planning policy and practice in Australia. Low-density neighbourhoods with poor access to public transport, shops and services continue to be developed at a rapid rate in the sprawling outer suburbs of Australian cities. This paper provides an overview of the evidence of the association between the built environment and chronic diseases, highlighting progress and future challenges for health promotion. It argues that health promotion practitioners and researchers need to more closely engage with urban planning practitioners, policymakers and researchers to encourage the creation of healthy urban environments through integrated transport, land use and infrastructure planning. There is also a need for innovative research to evaluate the effectiveness of policy options. This would help evidence to be more effectively translated into policy and practice, making Australia a leader in planning healthy communities.

From Farm to Nuisance: Animal Agriculture and the Rise of Planning Regulation

Municipal ordinances to remove farm animals from city limits played a central part in defining city planning's role in urban ecosystems, economies, and public health. This article examines the regulation of animal agriculture since the eighteenth century in four cities: Baltimore, Boston, Philadelphia, and New York. Across the nineteenth century, municipal ordinances to remove farm animals from city limits set the tone for the planning profession, aligning it with the field of public health in creating a hygienic city. In the efforts to untangle animal agriculture from waste management, public space, and urban food supply, urban authorities employed some of the first land-use regulations in the United States, shaping new planning powers. Ordinances banning slaughterhouses, piggeries, and dairies culminated with zoning as planning became a profession. These regulations ultimately allowed planners to transform cities and their food environments by dismantling a system in which animals and their caretakers among the urban poor had played integral parts in food production, processing, and municipal waste management. Unpacking the objectives, debates, and impacts of these early regulations reveals enduring tensions and challenges as planners today seek to reweave animal agriculture into cities.

Neighborhood alcohol outlets and the association with violent crime in one mid-Atlantic City: the implications for zoning policy

Violent crime such as homicide causes significant excess morbidity and mortality in US urban areas. A health impact assessment (HIA) identified zoning policy related to alcohol outlets as one way to decrease violent crime. The objectives were to determine the relationship between alcohol outlets including off-premise alcohol outlets and violent crime in one urban area to provide local public health evidence to inform a zoning code rewrite. An ecologic analysis of census tracts in Baltimore City was conducted from 2011 to 2012. The data included violent crimes (n = 51,942) from 2006 to 2010, licensed alcohol outlets establishments (n = 1,327) from 2005 to 2006, and data on neighborhood disadvantage, percent minority, percent occupancy, and drug arrests from 2005 to 2009. Negative binomial regression models were used to determine the relationship between the counts of alcohol outlets and violent crimes controlling for other factors. Spatial correlation was assessed and regression inference adjusted accordingly. Each one-unit increase in the number of alcohol outlets was associated with a 2.2 % increase in the count of violent crimes adjusting for neighborhood disadvantage, percent minority, percent occupancy, drug arrests, and spatial dependence (IRR = 1.022, 95 % CI = 1.015, 1.028). Off-premise alcohol outlets were significantly associated with violent crime in the adjusted model (IRR = 1.048, 95 % CI = 1.035, 1.061). Generating Baltimore-specific estimates of the relationship between alcohol outlets and violent crime has been central to supporting the incorporation of alcohol outlet policies in the zoning code rewrite being conducted in Baltimore City.

Sustained impact of community-based physical activity interventions: key elements for success

Background

Compelling evidence supports the cost effectiveness and potential impact of physical activity on chronic disease prevention and health promotion. Quality of evidence is one piece, but certainly not the sole determinant of whether public health interventions, physical activity focused or otherwise, achieve their full potential for impact. Health promotion at both population and community levels must progress beyond health intervention models that isolate individuals from social, environmental, and political systems of influence.

We offer a critical evaluation of lessons learned from two successful research initiatives to provide insights as to how health promotion research contributes to sustained impact. We highlight factors key to success including the theoretical and methodological integration of: i) a social ecological approach; ii) participatory action research (PAR) methods; and iii) an interdisciplinary team.

Methods

To identify and illustrate the key elements of our success we layered an evaluation of steps taken atop a review of relevant literature.

Results

In the school-based case study (Action Schools! BC), the success of our approach included early and sustained engagement with a broad cross-section of stakeholders, establishing partnerships across sectors and at different levels of government, and team members across multiple disciplines. In the neighbourhood built environment case study, the three domains guided our approach through study design and team development, and the integration of older adults’ perspectives into greenway design plans. In each case study we describe how elements of the domains serve as a guide for our work.

Conclusion

To sustain and maximize the impact of community-based public health interventions we propose the integration of elements from three domains of research that acknowledge the interplay between social, environmental and poilitical systems of influence. We emphasize that a number of key factors determine whether evidence from public health interventions in school and built environment settings is applied in practice and policy sectors. These include relationship building at individual, community, and societal levels of the social ecological model, using participatory action research methods, and involving an engaged and committed interdisciplinary team.

Examining the capacities of municipal governments to reduce health inequities: a survey of municipal actors' perceptions in Metro Vancouver

OBJECTIVES

Canada is an increasingly urban nation, with considerable health inequities (HI) within its urban centres. While Canadian municipalities have a range of policy and planning levers that could reduce the burden of HI, little is known about how municipal employees perceive the capacities of municipal governments to address HI within their jurisdictions. This study sought to capture these perceptions through a survey of politicians and senior-level staff working in Metro Vancouver municipalities.

METHODS

The survey was administered by mail to 637 politicians and senior-level staff from 17 municipal governments in Metro Vancouver. The survey captured respondents' perceptions on the responsibilities of, opportunities for, and constraints on, municipal-level action to address HI, as well as respondents' input on existing municipal policies and programs that could reduce HI in their jurisdictions.

RESULTS

Respondents perceived senior governments to bear greater responsibility for reducing HI than municipalities. Investing in "parks &amp; recreation facilities" was considered the most promising policy lever for addressing HI, while "insufficient federal and provincial funding" was perceived to be the greatest constraint on municipal action. "Affordable housing" and "recreational programs" were the most commonly identified existing strategies to address HI in the municipalities sampled.

CONCLUSIONS

Our findings revealed concerns about inter-governmental downloading of responsibilities, and behaviour-based assumptions of disease etiology. To advance an urban health equity agenda, more work is needed to engage and educate municipal actors from a range of departments on the social determinants of health inequities.

Neighborhoods and HIV: a social ecological approach to prevention and care

Neighborhood factors have been linked to HIV risk behaviors, HIV counseling and testing, and HIV medical care. However, the social-psychological mechanisms that connect neighborhood factors to HIV-related behaviors have not been fully determined. In this article we review the research on neighborhood factors and HIV-related behaviors, approaches to measuring neighborhoods, and mechanisms that may help to explain how the physical and social environment within neighborhoods may lead to HIV-related behaviors. We then discuss organizational, geographic, and social network approaches to intervening in neighborhoods to reduce HIV transmission and facilitate HIV medical care with the goal of reducing morbidity and mortality and increasing social and psychological well-being.

Revitalizing communities together: the shared values, goals, and work of education, urban planning, and public health

Inequities in education, the urban environment, and health co-exist and mutually reinforce each other. Educators, planners, and public health practitioners share commitments to place-based, participatory, youth-focused, and equitable work. They also have shared goals of building community resilience, social capital, and civic engagement. Interdisciplinary programs that embody these shared values and work towards these shared goals are emerging, including school-based health centers, full-service community schools, community health centers, Promise Neighborhoods, and Choice Neighborhoods. The intersection of these three fields represents an opportunity to intervene on social determinants of health. More collaborative research and practice across public health, education, and planning should build from the shared values identified to continue to address these common goals.

Exploring a public health perspective on pedestrian planning

A pedestrian plan is a public document that explains a community's vision and goals for future pedestrian activity. This study explored whether involvement by public health professionals in the development of pedestrian plans was associated with certain characteristics of the plan (vision, goals, identified programs, and evaluation). This study identified, collected, and analyzed content of all pedestrian plans in North Carolina through 2008. Among the 46 plans, 39% reported involvement by public health professionals in their development. Overall, 72% of pedestrian plans included a vision statement; health was mentioned four times and quality of life was mentioned five times. Slightly more than half (52%) of the plans included goals to improve public health. Plans that involved public health professionals more often included the type of physical activity, safety, or education program. Only 22% of all pedestrian plans included a proposal to evaluate their implementation. Plans that included public health professionals were less likely to include an evaluation proposal (11%) compared with those that did not involve public health professionals (21%). Public health professionals are encouraged to seek involvement in the pedestrian planning process, particularly in the areas of health program development, implementation, and evaluation.

Associations between the quality of the residential built environment and pregnancy outcomes among women in North Carolina

BACKGROUND

The built environment, a key component of environmental health, may be an important contributor to health disparities, particularly for reproductive health outcomes.

OBJECTIVE

In this study we investigated the relationship between seven indices of residential built environment quality and adverse reproductive outcomes for the City of Durham, North Carolina (USA).

METHODS

We surveyed approximately 17,000 residential tax parcels in central Durham, assessing > 50 individual variables on each. These data, collected using direct observation, were combined with tax assessor, public safety, and U.S. Census data to construct seven indices representing important domains of the residential built environment: housing damage, property disorder, security measures, tenure (owner or renter occupied), vacancy, crime count, and nuisance count. Fixed-slope random-intercept multilevel models estimated the association between the residential built environment and five adverse birth outcomes. Models were adjusted for maternal characteristics and clustered at the primary adjacency community unit, defined as the index block, plus all adjacent blocks that share any portion of a line segment (block boundary) or vertex.

RESULTS

Five built environment indices (housing damage, property disorder, tenure, vacancy, and nuisance count) were associated with each of the five outcomes in the unadjusted context: preterm birth, small for gestational age (SGA), low birth weight (LBW), continuous birth weight, and birth weight percentile for gestational age (BWPGA; sex-specific birth weight distributions for infants delivered at each gestational age using National Center for Health Statistics referent births for 2000-2004). However, some estimates were attenuated after adjustment. In models adjusted for individual-level covariates, housing damage remained statistically significantly associated with SGA, birth weight, and BWPGA.

CONCLUSION

This work suggests a real and meaningful relationship between the quality of the residential built environment and birth outcomes, which we argue are a good measure of general community health.

Toward a research and action agenda on urban planning/design and health equity in cities in low and middle-income countries

The importance of reestablishing the link between urban planning and public health has been recognized in recent decades; this paper focuses on the relationship between urban planning/design and health equity, especially in cities in low and middle-income countries (LMICs). The physical urban environment can be shaped through various planning and design processes including urban planning, urban design, landscape architecture, infrastructure design, architecture, and transport planning. The resultant urban environment has important impacts on the health of the people who live and work there. Urban planning and design processes can also affect health equity through shaping the extent to which the physical urban environments of different parts of cities facilitate the availability of adequate housing and basic infrastructure, equitable access to the other benefits of urban life, a safe living environment, a healthy natural environment, food security and healthy nutrition, and an urban environment conducive to outdoor physical activity. A new research and action agenda for the urban environment and health equity in LMICs should consist of four main components. We need to better understand intra-urban health inequities in LMICs; we need to better understand how changes in the built environment in LMICs affect health equity; we need to explore ways of successfully planning, designing, and implementing improved health/health equity; and we need to develop evidence-based recommendations for healthy urban planning/design in LMICs.

Skewed riskscapes and gentrified inequities: environmental exposure disparities in Seattle, Washington

OBJECTIVES

Few studies have considered the sociohistorical intersection of environmental injustice and gentrification; a gap addressed by this case study of Seattle, Washington. This study explored the advantages of integrating air toxic risk screening with gentrification research to enhance proximity and health equity analysis methodologies. It was hypothesized that Seattle's industrial air toxic exposure risk was unevenly dispersed, that gentrification stratified the city's neighborhoods, and that the inequities of both converged.

METHODS

Spatial characterizations of air toxic pollution risk exposures from 1990 to 2007 were combined with longitudinal cluster analysis of census block groups in Seattle, Washington, from 1990 to 2000.

RESULTS

A cluster of air toxic exposure inequality and socioeconomic inequity converged in 1 area of south central Seattle. Minority and working class residents were more concentrated in the same neighborhoods near Seattle's worst industrial pollution risks.

CONCLUSIONS

Not all pollution was distributed equally in a dynamic urban landscape. Using techniques to examine skewed riskscapes and socioeconomic urban geographies provided a foundation for future research on the connections among environmental health hazard sources, socially vulnerable neighborhoods, and health inequity.

Disproportionate exposures in environmental justice and other populations: the importance of outliers

We examined traditional environmental justice populations and other groups whose exposure to contaminants is often disproportionately high. Risk assessment methods may not identify these populations, particularly if they are spatially dispersed. We suggest using a National Health and Nutrition Examination Survey approach to oversample minority communities and develop methods for assessing exposure at different distances from pollution sources; publishing arithmetic and geometric means and full distributions for minority populations; and paying particular attention to high-end exposures. Means may sufficiently characterize populations as a whole but are inadequate in identifying vulnerable groups and subgroups. The number of individuals above the 95th percentile of any distribution may be small and unrepresentative, but these outliers are the ones who need to be protected.

Pursuing health equity: zoning codes and public health

Health equity can be defined as the absence of disadvantage to individuals and communities in health outcomes, access to health care, and quality of health care regardless of one’s race, gender, nationality, age, ethnicity, religion, and socioeconomic status. Health equity concerns those disparities in public health that can be traced to unequal, systemic economic, and social conditions. Despite significant improvements in the health of the overall population, health inequities in America persist. Racial and ethnic minorities continue to experience higher rates of morbidity and mortality than non-minorities across a range of health issues. For example, African-American children with asthma have a seven times greater mortality rate than Non-Hispanic white children with the illness. While cancer is the second leading cause of death among all populations in the U.S., ethnic minorities are especially burdened with the disease.

Improving the population's health: the Affordable Care Act and the importance of integration

Despite evidence indicating that public health services are the most effective means of improving the population's health status, health care services receive the bulk of funding and political support. The recent passage of the Affordable Care Act, which focused on improving access to health care services through insurance reform, reflects the primacy of health care over public health. Although policymakers typically conceptualize health care and public health as two distinct systems, gains in health status are most effectively and cost-efficiently achieved through their integration into a single health system. The Act does little to compel integration; however, there are numerous opportunities to encourage the coordination of public health and health care in the Act's implementation.

The impact of densification by means of informal shacks in the backyards of low-cost houses on the environment and service delivery in cape town, South Africa

This paper investigates the state-sponsored low cost housing provided to previously disadvantaged communities in the City of Cape Town. The strain imposed on municipal services by informal densification of unofficial backyard shacks was found to create unintended public health risks. Four subsidized low-cost housing communities were selected within the City of Cape Town in this cross-sectional survey. Data was obtained from 1080 persons with a response rate of 100%. Illegal electrical connections to backyard shacks that are made of flimsy materials posed increased fire risks. A high proportion of main house owners did not pay for water but sold water to backyard dwellers. The design of state-subsidised houses and the unplanned housing in the backyard added enormous pressure on the existing municipal infrastructure and the environment. Municipal water and sewerage systems and solid waste disposal cannot cope with the increased population density and poor sanitation behaviour of the inhabitants of these settlements. The low-cost housing program in South Africa requires improved management and prudent policies to cope with the densification of state-funded low-cost housing settlements.

Neighborhood archetypes for population health research: is there no place like home?

This study presents a new, latent archetype approach for studying place in population health. Latent class analysis is used to show how the number, defining attributes, and change/stability of neighborhood archetypes can be characterized and tested for statistical significance. The approach is demonstrated using data on contextual determinants of health for US neighborhoods defined by census tracts in 1990 and 2000. Six archetypes (prevalence 13-20%) characterize the statistically significant combinations of contextual determinants of health from the social environment, built environment, commuting and migration patterns, and demographics and household composition of US neighborhoods. Longitudinal analyses based on the findings demonstrate notable stability (76.4% of neighborhoods categorized as the same archetype ten years later), with exceptions reflecting trends in (ex)urbanization, gentrification/downgrading, and racial/ethnic reconfiguration. The findings and approach is applicable to both research and practice (e.g. surveillance) and can be scaled up or down to study health and place in other geographical contexts or historical periods.

Urban sprawl, smart growth, and deliberative democracy

Urban sprawl is an increasingly common feature of the built environment in the United States and other industrialized nations. Although there is considerable evidence that urban sprawl has adverse affects on public health and the environment, policy frameworks designed to combat sprawl-such as smart growth-have proven to be controversial, making implementation difficult. Smart growth has generated considerable controversy because stakeholders affected by urban planning policies have conflicting interests and divergent moral and political viewpoints. In some of these situations, deliberative democracy-an approach to resolving controversial public-policy questions that emphasizes open, deliberative debate among the affected parties as an alternative to voting-would be a fair and effective way to resolve urban-planning issues.

The role of urban municipal governments in reducing health inequities: A meta-narrative mapping analysis

BACKGROUND

The 1986 Ottawa Charter for Health Promotion coincided with a preponderance of research, worldwide, on the social determinants of health and health inequities. Despite the establishment of a 'health inequities knowledge base', the precise roles for municipal governments in reducing health inequities at the local level remain poorly defined. The objective of this study was to monitor thematic trends in this knowledge base over time, and to track scholarly prescriptions for municipal government intervention on local health inequities.

METHODS

Using meta-narrative mapping, four bodies of scholarly literature - 'health promotion', 'Healthy Cities', 'population health' and 'urban health' - that have made substantial contributions to the health inequities knowledge base were analyzed over the 1986-2006 timeframe. Article abstracts were retrieved from the four literature bodies using three electronic databases (PubMed, Sociological Abstracts, Web of Science), and coded for bibliographic characteristics, article themes and determinants of health profiles, and prescriptions for municipal government interventions on health inequities.

RESULTS

1004 journal abstracts pertaining to health inequities were analyzed. The overall quantity of abstracts increased considerably over the 20 year timeframe, and emerged primarily from the 'health promotion' and 'population health' literatures. 'Healthy lifestyles' and 'healthcare' were the most commonly emphasized themes in the abstracts. Only 17% of the abstracts articulated prescriptions for municipal government interventions on local health inequities. Such interventions included public health campaigns, partnering with other governments and non-governmental organizations for health interventions, and delivering effectively on existing responsibilities to improve health outcomes and reduce inequities. Abstracts originating from Europe, and from the 'Healthy Cities' and 'urban health' literatures, were most vocal regarding potential avenues for municipal government involvement on health inequities.

CONCLUSIONS

This study has demonstrated a pervasiveness of 'behavioural' and 'biomedical' perspectives, and a lack of consideration afforded to the roles and responsibilities of municipal governments, among the health inequities scholarly community. Thus, despite considerable research activity over the past two decades, the 'health inequities knowledge base' inadequately reflects the complex aetiology of, and solutions to, population health inequities.

Are neighborhood-level characteristics associated with indoor allergens in the household?

BACKGROUND

Individual home characteristics have been associated with indoor allergen exposure; however, the influence of neighborhood-level characteristics has not been well studied. We defined neighborhoods as community districts determined by the New York City Department of City Planning.

OBJECTIVE

We examined the relationship between neighborhood-level characteristics and the presence of dust mite (Der f 1), cat (Fel d 1), cockroach (Bla g 2), and mouse (MUP) allergens in the household.

METHODS

Using data from the Puerto Rican Asthma Project, a birth cohort of Puerto Rican children at risk of allergic sensitization (n = 261), we examined associations between neighborhood characteristics (percent tree canopy, asthma hospitalizations per 1,000 children, roadway length within 100 meters of buildings, serious housing code violations per 1000 rental units, poverty rates, and felony crime rates), and the presence of indoor allergens. Allergen cutpoints were used for categorical analyses and defined as follows: dust mite: >0.25 microg/g; cat: >1 microg/g; cockroach: >1 U/g; mouse: >1.6 microg/g.

RESULTS

Serious housing code violations were statistically significantly positively associated with dust mite, cat, and mouse allergens (continuous variables), adjusting for mother's income and education, and all neighborhood-level characteristics. In multivariable logistic regression analyses, medium levels of housing code violations were associated with higher dust mite and cat allergens (1.81, 95%CI: 1.08, 3.03 and 3.10, 95%CI: 1.22, 7.92, respectively). A high level of serious housing code violations was associated with higher mouse allergen (2.04, 95%CI: 1.15, 3.62). A medium level of housing code violations was associated with higher cockroach allergen (3.30, 95%CI: 1.11, 9.78).

CONCLUSIONS

Neighborhood-level characteristics, specifically housing code violations, appear to be related to indoor allergens, which may have implications for future research explorations and policy decisions.

High point walking for health: creating built and social environments that support walking in a public housing community

OBJECTIVES

We implemented and evaluated multiple interventions to increase walking activity at a multicultural public housing site.

METHODS

A community-based participatory research partnership and community action teams assessed assets and barriers related to walking and developed multiple interventions to promote walking activity. Interventions included sponsoring walking groups, improving walking routes, providing information about walking options, and advocating for pedestrian safety. A pre-post study design was used to assess the changes in walking activity.

RESULTS

Self-reported walking activity increased among walking group participants from 65 to 109 minutes per day (P = .001). The proportion that reported being at least moderately active for at least 150 minutes per week increased from 62% to 81% (P = .018).

CONCLUSIONS

A multicomponent intervention developed through participatory research methods that emphasized walking groups and included additional strategies to change the built and social environments increased walking activity at a public housing site in Seattle.

Complexities of holistic community-based participatory research for a low income, multi-ethnic population exposed to multiple built-environment stressors in Worcester, Massachusetts

Low income, multi-ethnic communities in Main South/Piedmont neighborhoods of Worcester, Massachusetts are exposed to cumulative, chronic built-environment stressors, and have limited capacity to respond, magnifying their vulnerability to adverse health outcomes. "Neighborhood STRENGTH", our community-based participatory research (CBPR) project, comprised four partners: a youth center; an environmental non-profit; a community-based health center; and a university. Unlike most CBPR projects that are single topic-focused, our 'holistic', systems-based project targeted five priorities. The three research-focused/action-oriented components were: (1) participatory monitoring of indoor and outdoor pollution; (2) learning about health needs and concerns of residents through community-based listening sessions; (3) engaging in collaborative survey work, including a household vulnerability survey and an asthma prevalence survey for schoolchildren. The two action-focused/research-informed components were: (4) tackling persistent street trash and illegal dumping strategically; and (5) educating and empowering youth to promote environmental justice. We used a coupled CBPR-capacity building approach to design, vulnerability theory to frame, and mixed methods: quantitative environmental testing and qualitative surveys. Process and outcomes yielded important lessons: vulnerability theory helps frame issues holistically; having several topic-based projects yielded useful information, but was hard to manage and articulate to the public; access to, and engagement with, the target population was very difficult and would have benefited greatly from having representative residents who were paid at the partners' table. Engagement with residents and conflict burden varied highly across components. Notwithstanding, we built enabling capacity, strengthened our understanding of vulnerability, and are able to share valuable experiential knowledge.

Environmental contributions to disparities in pregnancy outcomes

One of the most persistent disparities in American health status is the pronounced difference in birth outcomes between non-Hispanic black and non-Hispanic white women. Poor pregnancy outcomes have a substantial impact on mortality, morbidity, and health care costs. Increasing evidence indicates that environmental exposures are associated with poor birth outcomes. This paper reviews the latest research on how environmental exposures affect pregnancy outcomes and then discusses how these exposures may be embedded within a context of significant social and host factor stress. The analysis suggests that environmental, social, and host factors are cumulatively stressing non-Hispanic black women and that this cumulative stress may be a cause of the persistent disparities in pregnancy outcomes.

Public health, the APHA, and urban renewal

Joint efforts by fields of public health in the last decade have advocated use of the built environment to protect health. Past involvement by public health advocates in urban policy, however, has had mixed results. Although public health has significantly contributed to health improvements, its participation in urban renewal activities was problematic. Health advocates and the American Public Health Association produced guidelines that were widely used to declare inner-city areas blighted and provided a scientific justification for demolishing neighborhoods and displacing mostly poor and minority people. Furthermore, health departments failed to uphold their legal responsibility to ensure that relocated families received safe, affordable housing alternatives. These failures have important implications for future health-related work on the built environment and other core public health activities.

Analysis of Individual Social-ecological Mediators and Moderators and Their Ability to Explain Effect of a Randomized Neighborhood Walking Intervention

BACKGROUND

Using data from the SHAPE trial, a randomized 6-month neighborhood-based intervention designed to increase walking activity among older adults, this study identified and analyzed social-ecological factors mediating and moderating changes in walking activity.

METHODS

Three potential mediators (social cohesion, walking efficacy, and perception of neighborhood problems) and minutes of brisk walking were assessed at baseline, 3-months, and 6-months. One moderator, neighborhood walkability, was assessed using an administrative GIS database. The mediating effect of change in process variables on change in brisk walking was tested using a product-of-coefficients test, and we evaluated the moderating effect of neighborhood walkability on change in brisk walking by testing the significance of the interaction between walkability and intervention status.

RESULTS

Only one of the hypothesized mediators, walking efficacy, explained the intervention effect (product of the coefficients (95% CI) = 8.72 (2.53, 15.56). Contrary to hypotheses, perceived neighborhood problems appeared to suppress the intervention effects (product of the coefficients (95% CI = -2.48, -5.6, -0.22). Neighborhood walkability did not moderate the intervention effect.

CONCLUSION

Walking efficacy may be an important mediator of lay-lead walking interventions for sedentary older adults. Social-ecologic theory-based analyses can support clinical interventions to elucidate the mediators and moderators responsible for producing intervention effects.

Homicide and geographic access to gun dealers in the United States

BACKGROUND

Firearms are the most commonly used weapon to commit homicide in the U.S. Virtually all firearms enter the public marketplace through a federal firearms licensee (FFL): a store or individual licensed by the federal government to sell firearms. Whether FFLs contribute to gun-related homicide in areas where they are located, in which case FFLs may be a homicide risk factor that can be modified, is not known.

METHODS

Annual county-level data (1993-1999) on gun homicide rates and rates of FFLs per capita were analyzed using negative binomial regression controlling for socio-demographic characteristics. Models were run to evaluate whether the relation between rates of FFLs and rates of gun homicide varied over the study period and across counties according to their level of urbanism (defined by four groupings, as below). Also, rates of FFLs were compared against FS/S - which is the proportion of suicides committed by firearm and is thought to be a good proxy for firearm availability in a region - to help evaluate how well the FFL variable is serving as a way to proxy firearm availability in each of the county types of interest.

RESULTS

In major cities, gun homicide rates were higher where FFLs were more prevalent (rate ratio [RR] = 1.70, 95% CI 1.03-2.81). This association increased (p < 0.01) from 1993 (RR = 1.69) to 1999 (RR = 12.72), due likely to federal reforms that eliminated low-volume dealers, making FFL prevalence a more accurate exposure measure over time. No association was found in small towns. In other cities and in suburbs, gun homicide rates were significantly lower where FFLs were more prevalent, with associations that did not change over the years of the study period. FFL prevalence was correlated strongly (positively) with FS/S in major cities only, suggesting that the findings for how FFL prevalence relates to gun homicide may be valid for the findings pertaining to major cities but not to counties of other types.

CONCLUSION

Modification of FFLs through federal, state, and local regulation may be a feasible intervention to reduce gun homicide in major cities.

Staying connected: neighbourhood correlates of social participation among older adults living in an urban environment in Montréal, Quebec

Alongside community involvement, promoting social participation has been identified as a key strategy of fostering empowerment, one of the central tenets of the health promotion movement. Engagement in social and productive activities appears to be particularly beneficial to older adults, as it has been found to be associated with positive outcomes on a variety of health indicators. It is therefore critical to identify factors that might lead to greater social participation within these age groups. The objective of this study was to investigate the relationship between perceptions of neighbourhood user-friendliness and social participation while controlling for personal characteristics in a sample of seniors living in an urban environment. A convenience sample of older adults (n = 282) was recruited through community organizations located in high- average- and low-income Montreal neighbourhoods. Data were collected via an interviewer-administered questionnaire assessing social participation and various variables at the neighbourhood level (e.g. housing and social environment, walking environment and transportation, and services and amenities) and at the individual-level (e.g. health status and socio-demographic characteristics). Five variables emerged as independent predictors of social participation. Positive predictors retained in the final regression model included frequent walking episodes (almost every day), higher Vitality and General Health SF-12v2 scores, and perceived accessibility to key resources for older adults. Also included was a negative predictor: age (R2 of the final model = 0.28). Implications of the findings for research and action pertaining to ecological, health promotion interventions for older adults are identified.

A model curriculum for a course on the built environment and public health: training for an interdisciplinary workforce

Despite growing evidence of the direct and indirect effects of the built environment on public health, planners, who shape the built environment, and public health professionals, who protect the public's health, rarely interact. Most public health professionals have little experience with urban planners, zoning boards, city councils, and others who make decisions about the built environment. Likewise, few planners understand the health implications of design, land use, or transportation decisions. One strategy for bridging this divide is the development of interdisciplinary courses in planning and public health that address the health implications of the built environment. Professional networking and Internet-based searches in 2007 led to the identification of six primarily graduate-level courses in the U.S. that address the links between the built environment and public health. Common content areas in most of the identified courses included planning and public health histories, health disparities, interdisciplinary approaches, air and water quality, physical activity, social capital, and mental health. Instructors of these courses collaborated on course content, assignments, and evaluations to develop a model curriculum that follows an active learning-centered approach to course design. The proposed model curriculum is adaptable by both planning and public health departments to promote interdisciplinary learning. Results show that students gain planning and public health perspectives through this instruction, benefiting from active-learning opportunities. Faculty implementation of the proposed interdisciplinary model curriculum will help bridge the divide between the built environment and public health and enable both planners and public health professionals to value, create, and promote healthy environments.

Assessing competencies for obesity prevention and control

Obesity is the result of people consistently consuming more calories than they expend. A complex interaction of social and environmental conditions affects both energy consumption and physical activity levels. These conditions include, but are not limited to the following factors: the availability of affordable and healthy food; price disparities between healthy and less healthy foods; access to or perceived safety of recreation facilities; and the conduciveness of the physical environment to active modes of transportation, such as walking and biking. As outlined in the “Assessing Laws and Legal Authorities for Obesity Prevention and Control” paper in this supplement issue, laws and government policies in the United States influence nearly all of these social and environmental factors.

Creating tools for healthy development: case study of San Francisco's Eastern Neighborhoods Community Health Impact Assessment

The San Francisco Department of Public Health recently completed a 2-year collaborative process, the Eastern Neighborhoods Community Health Impact Assessment (ENCHIA), to evaluate the potential positive and negative health impacts of land use development. ENCHIA resulted in a number of outcomes, including (1) a vision of a healthy San Francisco; (2) community health objectives to reflect the vision; (3) indicators and data to assess and measure the objectives and vision; (4) a menu of urban development strategies to advance the objectives; and (5) the Healthy Development Measurement Tool, an evidence-based tool to support accountable, comprehensive, evidence-based, and health-oriented planning. This case study describes the 18-month ENCHIA process, key outcomes, and lessons learned. The case study also provides an overview of the Healthy Development Measurement Tool and examples of its first applications to urban planning. Given the growing understanding of built environmental influences on health, ENCHIA illustrates the ability of a local public health agency to effectively engage in land use policy as a health promotion strategy.

Advocating for active living on the rural-urban fringe: a case study of planning in the Portland, Oregon, metropolitan area

This case study is about the politics of incorporating active-living elements into a concept plan for a new community of about 68,000 people on the edge of the Portland, Oregon, metropolitan area. Development on the rural-urban fringe is ongoing in metropolitan areas around the United States. In this article, we evaluate the product of the concept-planning process from the standpoint of the extent to which environmental elements conducive to active living were included. We also analyze four issues in which challenges to the incorporation of active-living features surfaced: choices related to transportation facilities, the design and location of retail stores, the location of schools and parks, and the location of a new town center. Overall, the Damascus/Boring Concept Plan positions the area well to promote active living. Analyses of the challenges that emerged yielded lessons for advocates regarding ways to deal with conflicts between facilitating active living and local economic development and related tax-base concerns and between active-living elements and school-district planning autonomy as well as the need for advocates to have the capacity to present alternatives to the usual financial and design approaches taken by private- and public-sector investors.

Achieving Millennium Development Goals for health: building understanding, trust and capacity to respond

Biomedical interventions promise achievement of health-related Millennium Development Goals provided social-, capacity- and knowledge-based constraints to scaling up and reaching marginalized people at risk, are addressed, and balance between prevention and treatment is struck. We argue for a new approach: multi-stakeholder capacity building and learning for empowerment: MuSCLE. MuSCLE is used as a way to frame three systemic weaknesses in traditional health science and policy approaches: (1) a lack of engagement with people at risk to build a collective understanding of the contexts of health problems, including social drivers; (2) a lack of multi-criteria evaluation of alternative interventions; (3) a lack of attention paid to integrated capacity building. The MuSCLE framework responds in three ways: (1) participatory assessment of the ecological, socio-cultural, economic and political contexts of health, identifying priorities using risk and vulnerability science, and modeling drivers; (2) selection among intervention alternatives that makes ecological, socio-cultural, economic and political tradeoffs transparent; (3) integrated capacity building for sustainable and adaptive interventions. Literature and field lessons support the argument, and guidelines are set down. A MuSCLE approach argues for a transformation in health science and policy in order to achieve Millennium Development Goals for health.

The forest for the trees: a systems approach to human health research

We explore the relationship between current research directions in human health and environmental and public health policy. Specifically, we suggest there is a link between the continuing emphasis in biomedical research on individualized, therapeutic solutions to human disease and the increased reliance on individual choice in response to environmental and/or public health threats. We suggest that continued research emphasis on these traditional approaches to the exclusion of other approaches will impede the discovery of important breakthroughs in human health research necessary to understand the emerging diseases of today. We recommend redirecting research programs to interdisciplinary and population-focused research that would support a systems approach to fully identifying the environmental factors that contribute to disease burden. Such an approach would be able to address the interactions between the social, ecological, and physical aspects of our environment and explicitly include these in the evaluation and management of health risks from environmental exposures.

Identifying Streetscape Features Significant to Well-Being

To determine effective relationships between the built environment and health and well-being, a transdisciplinary team of architectural, behavioral and health scientists developed a built environment coding system (UMBECS). They examined the relationship of resulting streetscape features to health and well-being at the block level. The research team conducted studies of the validity of UMBECS focusing on children through school conduct and grades, and on elders through a longitudinal cognitive functioning study. For children, contrary to popularly held views, commercial-residential mix was as effective as a high proportion of residential use in predicting children's school outcomes (i.e., better conduct, achievement, effort, and grades). For elders, modest but statistically significant relationships existed between block-level features, elders' neighboring behaviors, and social support, which in turn were significantly associated with cognitive and affective functioning. These findings suggest the utility of this built environment coding system for examining the relationship of built environment features to residents' health and well-being. UMBECS offers a useful tool for developing a viable transdisciplinary model of the role of the built environment in behavioral and health outcomes.

Health impact assessment and urbanisation. Lessons from the NSW HIA Project

Health impact assessment (HIA) can ensure that health is a core element of sustainable urban planning. Based on the experience of the NSW HIA Project, we discuss the current strengths of HIA and challenges facing it as an urban sustainability tool across five areas: the use of evidence; integrating HIA with environmental impact assessments; including consideration of equity; recognising wider determinants of health; and building capacity.

Neighborhood risk factors for obesity

OBJECTIVE

The goal of this study was to explore neighborhood environmental factors associated with obesity in a sample of adults living in a major U.S. metropolitan area.

RESEARCH METHODS AND PROCEDURES

This was a multi-level study combining data from the U.S. Behavioral Risk Factor Surveillance System with data from the U.S. Census. A total of 15,358 subjects living in 327 zip code tabulation areas were surveyed between 1998 and 2002. The outcome was obesity (BMI >30), and independent variables assessed included individual level variables (age, education, income, smoking status, sex, black race, and Hispanic ethnicity), and zip code level variables (percentage black, percentage Hispanic, percentage with more than a high school education, retail density, establishment density, employment density, population density, the presence of a supermarket, intersection density, median household income, and density of fast food outlets).

RESULTS

After controlling for individual level factors, median household income [relative risk (RR) = 0.992; 95% confidence interval (CI) = 0.990, 0.994], population density (RR = 0.98; 95% CI = 0.972, 0.990), employment density (RR = 1.004; 95% CI = 1.001, 1.009), establishment density (RR = 0.981 95% CI = 0.964, 0.999), and the presence of a supermarket (RR = 0.893; 95% CI = 0.815, 0.978) were associated with obesity risk. Fast food establishment density was poorly associated with obesity risk.

DISCUSSION

Where one lives may affect obesity status. Given the influence of the presence of a supermarket on obesity risk, efforts to address food access might be a priority for reducing obesity.

Protecting health using an environmental impact assessment: a case study of San Francisco land use decisionmaking

Laws and regulations for an environmental impact assessment enable a health impact assessment whenever physical changes in the environment may significantly affect health. In this case study, I describe 2 instances in which a local public health agency used the procedural requirements for an environmental impact assessment to account for societal-level health determinants that are not traditionally evaluated in land-use decisions. These examples show that a public health critique can contribute both to the scope of analysis in an environmental impact assessment and to substantive changes in land-use decisions. I have evaluated this health appraisal approach as a form of a health impact assessment and will make recommendations for law, research, and practice that support its technical, cultural, and political feasibility.

Application of law to the childhood obesity epidemic

Childhood obesity is in important respects a result of legal policies that influence both dietary intake and physical activity. The law must shift focus away from individual risk factors alone and seek instead to promote situational and environmental influences that create an atmosphere conducive to health. To attain this goal, advocates should embrace a population-wide model of public health, and policymakers must critically examine the fashionable rhetoric of consumer choice.