From built environment to health inequalities: An explanatory framework based on evidence

[Primary Care Inequalities to the Disadvantage of the Population of Socially Deprived Urban Areas: A Case Study of Essen, Germany]

Background As a large city in the middle of a metropolitan area, the city of Essen is characterized by strong social segregation and a north-south divide in the social status of its population. The conventional demand planning does not take such strong disparities within a planning unit into account. The present study aims to analyze the distribution of primary care structures using the example of two large urban areas within the city of Essen and to identify perspectives for strengthening primary care in disadvantaged urban areas. Methods First, a secondary data analysis was carried out at the district level and the study area Essen North (258,790 residents), consisting of 19 districts, was defined on the basis of two inclusion criteria - 1. location of the district north of the A40 freeway and 2. a mean subsistence rate>17.20 percent (average value of the city of Essen). Subsequently the study area was compared with the rest of the city (332,242 residents) with regard to the indicators a) social status, and b) available general practioners and pediatricians. The data of the selected indicators is based on the social reporting of the city of Essen and the "Online Practice Search" (Online-Praxissuche) of the Association of Statutory Health Insurance Physicians North Rhine. The resulting database (last update: 10/20212) was then evaluated at the district level and the primary care situation of the two urban areas was compared. Results The results revealed a significantly lower primary care coverage in the socially disadvantaged study area Essen North by about 25 percent for general practioners and by almost half for pediatricians. Thus, higher social disadvantage was associated with poorer access to primary care close to home, especially for children and adolescents. Conclusion The distribution of primary care providers in the city of Essen increases the risk of contributing to the manifestation of geographic disparities and health inequalities. The existing planning system in particular is not suitable for addressing the threatening or already existing undersupply of primary health care to the population in disadvantaged urban districts.

Upstream Determinants of Overweight and Obesity in Europe

PURPOSE OF REVIEW

To review the upstream determinants of overweight and obesity in Europe, including food and built environments, and political, commercial, and socioeconomic determinants.

RECENT FINDINGS

Overweight and obesity affect 60% of European adults, and one in three children, and are more common in individuals with low compared to high socioeconomic position (SEP). Individuals in low SEP groups are more exposed to unhealthy built and food environments, including higher exposure to unhealthy food marketing. Industries influencing the food system have much economic power, resulting in ignoring or silencing the role of ultra-processed foods and commercial practices in weight gain. Overall, effective policies to address overweight and obesity have been insufficiently implemented by governments. To accelerate implementation, strengthened political commitment is essential. Policies must also focus on the upstream, structural, and systemic drivers of overweight and obesity; be comprehensive; and target socioeconomic inequalities in diets and physical activity.

[Readiness for Implementation of Prevention and Health Promotion Measures for People in Difficult Living Situations in Deprived Municipalities in Bavaria: A Qualitative Analysis]

OBJECTIVE

The community setting is crucial to improving health equity. To enable the implementation of need-based and target-oriented measures, it is important to understand the challenges and needs of communities. This is highly relevant for deprived communities that have offered hardly any health promotion programs for socially disadvantaged people. The main research question of this study is: "How do deprived communities perceive the need for action and support in connection with the implementation of disease prevention and health promotion measures focused on socially disadvantaged people?"

METHODS

A qualitative, exploratory analysis through semi-structured interviews with experts (n=10) was conducted in five deprived communities in Bavaria. The degree of deprivation was represented by the Bavarian Index of Multiple Deprivation (BIMD, 2010), which shows the extent of lack of resources at the community level. Qualitative analysis of the interviews followed the theoretical framework of qualitative content analysis according to Kuckartz.

RESULTS

Themes arising from the interviews were (1) groups perceived to be in need of support, (2) disease prevention and health promotion assets, and (3) need for action regarding prevention and health promotion. Target groups in need of support were identified in the analyzed communities. Furthermore, it became apparent that in deprived communities there were scarcely resources and structures to address disease prevention and health promotion.

CONCLUSION

This study shows that deprived communities need support to implement need-based and target-oriented prevention and health promotion measures for socially disadvantaged people. However, those communities have limited capacities, and thus should be supported (e. g., through networking).

Associations of the Neighborhood Built Environment with Gestational Weight Gain

OBJECTIVE

This study aimed to determine whether specific factors of the built environment related to physical activity and diet are associated with inadequate and excessive gestational weight gain (GWG).

STUDY DESIGN

This analysis is based on data from the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-To-Be, a prospective cohort of nulliparous women who were followed from the beginning of their pregnancies through delivery. At each study visit, home addresses were recorded and geocoded. Locations were linked to several built-environment characteristics such as the census tract National Walkability Score (the 2010 Walkability Index) and the number of gyms, parks, and grocery stores within a 3-km radius of residential address. The primary outcome of GWG (calculated as the difference between prepregnancy weight and weight at delivery) was categorized as inadequate, appropriate, or excessive based on weight gained per week of gestation. Multinomial regression (generalized logit) models evaluated the relationship between each factor in the built environment and excessive or inadequate GWG.

RESULTS

Of the 8,182 women in the analytic sample, 5,819 (71.1%) had excessive GWG, 1,426 (17.4%) had appropriate GWG, and 937 (11.5%) had inadequate GWG. For the majority of variables examined, built environments more conducive to physical activity and healthful food availability were associated with a lower odds of excessive or inadequate GWG category. For example, a higher number of gyms or parks within 3 km of a participant's residential address was associated with lower odds of having excessive (gyms: adjusted odds ratio [aOR] = 0.93 [0.89-0.96], parks: 0.94 [0.90-0.98]) or inadequate GWG (gyms: 0.91 [0.86-0.96]; parks: 0.91 [0.86-0.97]). Similarly, a higher number of grocery stores was associated with lower odds of having excessive GWG (0.94 [0.91-0.97]).

CONCLUSION

Among a diverse population of nulliparous women, multiple aspects of the built environment are associated with excessive and inadequate GWG.

KEY POINTS

· There are little data on the association between the built environment and pregnancy outcomes.. · Multiple aspects of the built environment are associated with excessive and inadequate GWG.. · These results suggest the role that neighborhood investment may play in improving pregnancy outcomes..

Emergency General Surgery Procedures in Older Adults: Where You Live Matters!

BACKGROUND

Neighborhood location and its built environment are important social determinants of health that impact health outcomes. Older adults (OAs) represent the fastest growing population in the United States with many requiring emergency general surgery procedures (EGSPs). The aim of this study was to evaluate whether neighborhood location, represented by zip code, influences mortality and disposition in OAs undergoing EGSPs in Maryland.

METHODS

A retrospective review was undertaken of hospital encounters in the Maryland Health Services Cost Review Commission from 2014 to 2018 of OAs undergoing EGSPs. Older adults residing in the 50 most affluent (MANs) and 50 least affluent (LANs) neighborhoods based on zip codes were compared. Data collected included demographics, all patient-refined (APR)-severity of illness (SOI), APR-risk of mortality (ROM), Charlson Comorbidity Index, complications, mortality, and discharge to a higher level of care.

RESULTS

Of the 8661 OAs analyzed, 2362 (27.3%) resided in MANs and 6299 (72.7%) in LANs. Older adults in LANs were more likely to undergo EGSPs, had higher APR-SOI and APR-ROM, and experienced more complications, discharge to higher level of care, and mortality. Living in LANs was independently associated with discharge to higher level of care (OR 1.56, 95% CI: 1.38-1.77, P < .001) and increased mortality (OR 1.35, 95% CI: 1.07-1.71, P = .01).

DISCUSSION

Mortality and quality of life in OAs undergoing EGSPs are dependent on environmental factors likely determined by neighborhood location. These factors need to be defined and incorporated in predictive models of outcomes. Public health opportunities to improve outcomes for those who are socially disadvantaged are necessary.

Measuring and modelling perceptions of the built environment for epidemiological research using crowd-sourcing and image-based deep learning models

BACKGROUND

Perceptions of the built environment, such as nature quality, beauty, relaxation, and safety, may be key factors linking the built environment to human health. However, few studies have examined these types of perceptions due to the difficulty in quantifying them objectively in large populations.

OBJECTIVE

To measure and predict perceptions of the built environment from street-view images using crowd-sourced methods and deep learning models for application in epidemiologic studies.

METHODS

We used the Amazon Mechanical-Turk crowdsourcing platform where participants compared two street-view images and quantified perceptions of nature quality, beauty, relaxation, and safety. We optimized street-view image sampling methods to improve the quality and resulting perception data specific to participants enrolled in the Washington State Twin Registry (WSTR) health study. We used a transfer learning approach to train deep learning models by leveraging existing image perception data from the PlacePulse 2.0 dataset, which includes 1.1 million image comparisons, and refining based on new WSTR perception data. Resulting models were applied to WSTR addresses to estimate exposures and evaluate associations with traditional built environment measures.

RESULTS

We collected over 36,000 image comparisons and calculated perception measures for each image. Our final deep learning models explained 77.6% of nature quality, 68.1% of beauty, 72.0% of relaxation, and 64.7% of safety in pairwise image comparisons. Applying transfer learning with the new perception labels specific to the WSTR yielded an average improvement of 3.8% for model performance. Perception measures were weakly to moderately correlated with traditional built environment exposures for WSTR participant addresses; for example, nature quality and NDVI (r = 0.55), neighborhood area deprivation (r = -0.16), and walkability (r = -0.20), respectively.

SIGNIFICANCE

We were able to measure and model perceptions of the built environment optimized for a specific health study. Future applications will examine associations between these exposure measures and mental health in the WSTR.

IMPACT STATEMENT

Built environments influence health through complex pathways. Perceptions of nature quality, beauty, relaxation and safety may be particularly import for understanding these linkages, but few studies to-date have examined these perceptions objectively for large populations. For quantitative research, an exposure measure must be reproducible, accurate, and precise--here we work to develop such measures for perceptions of the urban environment. We created crowd-sourced and image-based deep learning methods that were able to measure and model these perceptions. Future applications will apply these models to examine associations with mental health in the Washington State Twin Registry.

Evaluation of General Health Status of Persons Living in Socio-Economically Disadvantaged Neighborhoods in a Large European Metropolitan City

Background: Living in socio-economically disadvantaged neighborhoods can predispose persons to numerous health conditions. The purpose of this study was to report the general health conditions of persons living in disadvantaged neighborhoods in Rome, Italy, a large European metropolitan city. Participants were reached through the mobile facilities of the primary care services of the Dicastery for the Charity Services, Vatican City. Methods: People living in disadvantaged neighborhoods were reached with mobile medical units by doctors, nurses, and paramedics. Demographic characteristics, degree of social integration, housing conditions, and history of smoking and/or alcohol use were investigated. Unstructured interviews and general health assessments were performed to investigate common acute and/or chronic diseases, and history of positivity to COVID-19. Basic health parameters were measured; data were collected and analyzed. Results: Over a 10-month period, 436 individuals aged 18–95 years were enrolled in the study. Most lived in dormitories, whereas a few lived in unsheltered settings. Most participants (76%) were unemployed. Smoking and drinking habits were comparable to the general population. The most common pathological conditions were cardiovascular diseases in 103 subjects (23.39%), diabetes in 65 (14.9%), followed by musculoskeletal system disorders (11.7%), eye diseases (10.5%), psychiatric conditions such as anxiety and depression (9.2%), and chronic respiratory conditions (8.7%). Conclusions: Subjects in our sample showed several pathologic conditions that may be related to their living conditions, thus encouraging the development of more efficient and effective strategies for a population-tailored diagnosis and treatment.

Selected Research Issues of Urban Public Health

Health is created within the urban settings of people’s everyday lives. In this paper we define Urban Public Health and compile existing evidence regarding the spatial component of health and disease in urban environments. Although there is already a substantial body of single evidence on the links between urban environments and human health, focus is mostly on individual health behaviors. We look at Urban Public Health through a structural lens that addresses health conditions beyond individual health behaviors and identify not only health risks but also health resources associated with urban structures. Based on existing conceptual frameworks, we structured evidence in the following categories: (i) build and natural environment, (ii) social environment, (iii) governance and urban development. We focused our search to review articles and reviews of reviews for each of the keywords via database PubMed, Cochrane, and Google Scholar in order to cover the range of issues in urban environments. Our results show that linking findings from different disciplines and developing spatial thinking can overcome existing single evidence and make other correlations visible. Further research should use interdisciplinary approaches and focus on health resources and the transformation of urban structures rather than merely on health risks and behavior.

Shaping Pathways to Child Health: A Systematic Review of Street-Scale Interventions in City Streets

Street-level built environment factors, for example, walking infrastructure, building density, availability of public transport, and proliferation of fast-food outlets can impact on health by influencing our ability to engage in healthy behaviour. Unhealthy environments are often clustered in deprived areas, thus interventions to improve the built environments may improve health and reduce inequalities. The aim of this review was to identify whether street-level built environment interventions can improve children's health in high income countries. A secondary aim was to describe key built environment elements targeted in interventions and research gaps. A systematic review of published literature was conducted by a multi-disciplinary team. Ten intervention papers were included. Physical activity or play was the only health outcome assessed. Most interventions described temporary changes including closure of streets to traffic (N = 6), which were mainly located in deprived neighbourhoods, or the addition of technology to 'gamify' active travel to school (N = 2). Two studies reported permanent changes to street design. There was limited evidence that closing streets to traffic was associated with increases in activity or play and inconclusive evidence with changes to street design and using technology to gamify active travel. Our ability to draw conclusions was hampered by inadequate study designs. Description of interventions was poor. Rigorous evaluation of built environment interventions remains challenging. We recommend a multi-disciplinary approach to evaluation, explicit reporting of built environment indicators targeted in interventions and offer solutions to others working in this area.

Defining the Exposome Using Popular Education and Concept Mapping With Communities in Atlanta, Georgia

Introduction

The exposome concept provides a framework to better incorporate the environment into the study of health and disease and has been defined by academics to encompass all lifetime exposures including toxicants, diet, and lifestyle choices. However, initial applications of the exposome concept have been less apt at measuring social determinants of health, focusing primarily on conventional environmental exposures and lifestyle choices that do not reflect the complex lived experience of many communities. To bring community voice into the exposome concept, the HERCULES Exposome Research Center and its Stakeholder Advisory Board co-developed the Exposome Roadshow. We present and discuss the resulting community-exposome definition to inform and improve exposome research.

Materials and Methods

Four communities from distinct areas across metro-Atlanta participated in separate 2-day Exposome Roadshow workshops with concept mapping. Aligned with a popular education approach in which community knowledge is used to work collectively for change, concept mapping provided a systematic method to collect and visualize community members' knowledge and create a shared understanding to take action. Community members brainstormed, sorted, and rated their responses to the prompt: "What in your environment is affecting your and your community's health?" Responses were analyzed and visually depicted by concept maps consisting of separate but interrelated clusters of ideas. Community members discussed and validated the maps, selecting a final map illustrating their community's exposome.

Results

A total of 118 community members completed concept mapping. On average communities identified 7 clusters to define their exposome. The resulting concept maps offer a community definition of the exposome. Five major themes arose across all four communities: conventional environmental concerns, built environment, social relationships, crime and safety, and individual health and behaviors.

Discussion

The resulting community-exposome definition demonstrates the importance of expanding the scope of exposures beyond traditional environmental influences to include the lived experience of individuals and communities. While newer exposome definitions align more closely with this community definition, traditional exposome methods do not routinely include these factors. To truly capture the totality of lifetime exposures and improve human health, researchers should incorporate community perspectives into exposome research.

Socioeconomic Disparities in Outdoor Branded Advertising in San Francisco and Oakland, California

Advertising exerts a powerful influence over consumer decision-making, and disproportionate marketing for unhealthy products may contribute to health inequities. The objective of this study was to examine socioeconomic and racial and ethnic disparities in outdoor branded advertising for products harmful to health in San Francisco and Oakland, CA. We collected cross-sectional data on outdoor advertising from 372 blocks with ≥ 1 residential or mixed-residential parcel in SF and Oakland in 2018–2019. Blocks were randomly sampled by city, land use, majority vs. non-majority Black and/or Hispanic composition, and upper and lower tertiles of household income. Advertisements were coded by product, healthfulness, and branding. Exposure variables were neighborhood household median income and percent of residents who were Hispanic of any race, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White. The primary outcome variable was block-level dichotomous presence of any unhealthy branded advertisement for food, beverage, alcohol, or tobacco. Analyses were unadjusted and adjusted for land use and number of total advertisements on each block. Each additional $10,000 in neighborhood household median income was associated with an 11% lower adjusted odds of having any unhealthy branded advertisements on the block (95%CI: 0.80–0.99; P = 0.03). There were no significant associations between neighborhood racial and ethnic composition and presence of unhealthy branded advertisements, but with each 10% higher neighborhood composition of Hispanic residents, there was a borderline significant higher presence of unhealthy branded advertisements (OR = 1.23; 95%CI: 1.00–1.51; P = 0.05). Results indicate that low-income neighborhoods were disproportionately exposed to outdoor branded advertisements for unhealthy products.

Exposome and Social Vulnerability: An Overview of the Literature Review

Background—The exposome concept refers to the totality of exposures from internal and external sources, including chemical and biological agents from conception throughout the lifetime. Exposome is also made up of psychosocial components such as socio-economic status (SES), which will focus on in this review. Despite exposures to the same environmental nuisances, individuals and groups are impacted differently. According to the literature, health inequalities exist among different socioeconomic groups, and SES may influence the association between environmental nuisances and health outcomes. However, the variation of this interaction across ages has rarely been studied. There is a need to adopt a life course approach to understand the history of diseases better. Objective—The main objective of this review is to document how SES could modify the association between environmental nuisances and health outcomes, across different ages, as a first crucial step introducing the emerged concept of social exposome. Methods—The PubMed database was searched from January 2010 to August 2021 for systematic reviews published in English addressing the interaction between SES, environmental nuisances, and health outcomes. Socio-economic indicators considered include education, level of income, neighborhood environment. Environmental nuisances considered many environment nuisances, mainly air pollution and noise. Results—Among 242 literature reviews identified, 11 of them address the question of the effect modification. Overall, our work reveals that environmental nuisances were mostly associated with poorer health outcomes and that SES modified this association, increasing the health risk among the poorest. Very interestingly, our work reports the existence of this interaction across different ages, including pregnancy, childhood, and adulthood, and for various environmental nuisances. Conclusion—In conclusion, our work confirms that we are not all equal to face environmental nuisances. The poorest are more vulnerable to the health effect of environmental nuisances. Policy decisions and interventions should target this high-risk population as a priority. Further investigations are needed to formalize the concept of social exposome more precisely and then communicate about it.

Master-planned communities in the United States as novel contexts for individual and population-level research

It has long been known that social and physical environments can shape individual and population health, for better or worse. Master-planned communities (MPCs) in the US are custom-designed residential neighborhoods with defined boundaries planned and developed under a single, private owner or entity from their inception. Across the US, these vary greatly in scale ranging from 100 to over 50,000 homes, but broadly all provide residents with housing, infrastructure, landscaping, and purpose-built facilities to support socialization. Current research in the urban planning literature suggests that MPCs can influence the health of their residents. However, few studies have examined the use of MPCs as settings to conduct individual or population health research. In this paper, we examine the potential of MPCs as context for observational or intervention studies aimed at understanding individual and population-level health and well-being. We first summarize links between built and social environment and individual and population health research. Next, we describe the history of planned communities in the US. Then, we review specific features of MPCs related to governance, development, design, and social structure. We end by exploring how those specific features may lead to potential opportunities and challenges when using MPCs in health research. Through this discussion, we highlight MPCs as overlooked settings that may offer potential for collaborative, innovative, and socially engaged health research.

Using Satellite Images and Deep Learning to Identify Associations Between County-Level Mortality and Residential Neighborhood Features Proximal to Schools: A Cross-Sectional Study

What is the relationship between mortality and satellite images as elucidated through the use of Convolutional Neural Networks? Background: Following a century of increase, life expectancy in the United States has stagnated and begun to decline in recent decades. Using satellite images and street view images, prior work has demonstrated associations of the built environment with income, education, access to care, and health factors such as obesity. However, assessment of learned image feature relationships with variation in crude mortality rate across the United States has been lacking. Objective: We sought to investigate if county-level mortality rates in the U.S. could be predicted from satellite images. Methods: Satellite images of neighborhoods surrounding schools were extracted with the Google Static Maps application programming interface for 430 counties representing ~68.9% of the US population. A convolutional neural network was trained using crude mortality rates for each county in 2015 to predict mortality. Learned image features were interpreted using Shapley Additive Feature Explanations, clustered, and compared to mortality and its associated covariate predictors. Results: Predicted mortality from satellite images in a held-out test set of counties was strongly correlated to the true crude mortality rate (Pearson r = 0.72). Direct prediction of mortality using a deep learning model across a cross-section of 430 U.S. counties identified key features in the environment (e.g., sidewalks, driveways, and hiking trails) associated with lower mortality. Learned image features were clustered, and we identified 10 clusters that were associated with education, income, geographical region, race, and age. Conclusions: The application of deep learning techniques to remotely-sensed features of the built environment can serve as a useful predictor of mortality in the United States. Although we identified features that were largely associated with demographic information, future modeling approaches that directly identify image features associated with health-related outcomes have the potential to inform targeted public health interventions.

Land use mix and leukocyte telomere length in Mexican Americans

It has been well-known that built environment features influence the risk of chronic diseases. However, the existing data of its relationship with telomere length, a biomarker of biological aging, is still limited, with no study available for Mexican Americans. This study investigates the relationship between several factors of the built environment with leukocyte telomere length among 5508 Mexican American adults enrolled in Mano-A-Mano, the Mexican American Cohort Study (MACS). Based on the quartile levels of telomere length, the study population was categorized into four groups, from the lowest (1st quartile) to the highest telomere length group (4th quartile). For individual built environment factors, their levels did not differ significantly across four groups. However, in the multinominal logistic regression analysis, increased Rundle’s land use mixture (LUM) and Frank’s LUM were found statistically significantly associated with increased odds of having high levels of telomere length (Rundle’s LUM: 2nd quartile: Odds ratio (OR) 1.26, 95% Confidence interval (CI) 1.07, 1.48; 3rd quartile: OR 1.25, 95% CI 1.06, 1.46; 4th quartile: OR 1.19, 95% CI 1.01, 1.41; Frank’s LUM: 2nd quartile: OR 1.34, 95% CI 1.02, 2.63; 3rd quartile: OR 1.55, 95% CI 1.04, 2.91; 4th quartile: OR 1.36, 95% CI 1.05, 2.72, respectively). The associations for Rundle’s LUM remained significant after further adjusting other non-redundant built environment factors. Finally, in stratified analysis, we found the association between Rundle’s LUM and telomere length was more evident among younger individuals (< 38 years old), women, and those with obesity, born in Mexico, having low levels of physical activity, and having low levels of acculturation than their relative counterparts. In summary, our results indicate that land use mixture may impact telomere length in leukocytes in Mexican Americans.

Socioeconomic Inequalities in Physical Activity and Sedentary Behaviour among the Chilean Population: A Systematic Review of Observational Studies

Socioeconomic inequalities in physical (in)activity and sedentary behaviours are key mediators in obesity and health socioeconomic inequalities. Considering the high and uneven obesity rates in Chile, this review aims to systematically assess the socioeconomic inequalities in physical activity (PA) and sedentary behaviour (SB) among the Chilean population from different age groups. Peer-reviewed and grey literature were searched from inception until 31st December 2019 in PubMed, Scopus, PsycINFO, Web of Sciences and LILACS. Publications in English and Spanish, from observational studies that reported the comparison of at least one indicator of PA or SB between at least two groups of different socioeconomic positions (SEP), from the general Chilean population, were included. Data searches, screening, extraction, and quality assessment, using the Newcastle Ottawa Quality Assessment Scale for observational studies, were conducted by two independent researchers. Seventeen articles (from 16 studies) met the inclusion criteria (14 cross-sectional; two cohort). Across these, quality was considered low, medium and high for 19%, 69% and 13%, respectively. Results showed consistent evidence for a lower leisure-time PA and sitting time, and higher physical inactivity among adults from the lower, compared to the highest, SEP groups. Associations between SEP and total PA, moderate-to-vigorous PA, low PA, and transport and work-related PA were inconsistent. These findings provide insights to public health and physical activity researchers and policymakers aiming to reduce socioeconomic inequalities in PA and SB in Chile and other countries.

Does investing in low-income urban neighborhoods improve sleep?

STUDY OBJECTIVES

Neighborhood disadvantage is associated with poor sleep, which may contribute to and exacerbate racial and socioeconomic health disparities. Most prior work has been cross-sectional and thus it has not been possible to estimate causal effects.

METHODS

We leveraged a natural experiment opportunity in two low-income, predominantly African American Pittsburgh, PA neighborhoods, following a randomly selected cohort of households (n = 676) between 2013 and 2016. One of the neighborhoods received substantial public and private investments (housing, commercial) over the study period, while the other socio-demographically similar neighborhood received far fewer investments. Primary analyses used a difference-in-difference analysis based on neighborhood, to examine changes in actigraphy-assessed sleep duration, efficiency, and wakefulness after sleep onset (WASO), and self-reported sleep quality. Secondary analyses examined whether residents' proximity to investments, regardless of neighborhood, was associated with changes in sleep outcomes.

RESULTS

Resident sleep worsened over time in both neighborhoods with no significant differences among residents between the two neighborhoods. Secondary analyses, including covariate adjustment and propensity score weighting to improve comparability, indicated that regardless of neighborhood, those who lived in closer proximity to investments (<0.1 mile) were significantly less likely to experience decreases in sleep duration, efficiency, and quality, or increases in WASO, compared to those who lived farther away.

CONCLUSIONS

While we did not observe sleep differences among residents between neighborhoods, living closer to a neighborhood investment was associated with better sleep outcomes. Findings have relevance for public health and policy efforts focused on investing in historically disinvested neighborhoods.

Temporary Urbanisms as Policy Alternatives to Enhance Health and Well-Being in the Post-Pandemic City

PURPOSE OF REVIEW

While there has been extensive discussion on the various forms of temporary uses in urban settings, little is known on the ways in which temporary and health urbanisms connect. Now, a turning point has been reached regarding the interactions between health and the built environment and the contributions made by urban planning and other built environment disciplines. In the context of the post-pandemic city, there is a need to develop a health-led temporary urbanism agenda than can be implemented in various settings both in the Global South and North.

RECENT FINDINGS

Health-led temporary urbanism requires a reinterrogation of current models of urban development including designing multifunctional spaces in urban environments that provide sites for temporary urbanism-related activities. A healthy city is an adaptable city and one that provides opportunities for citizen-led interventions intended to enhance well-being by blending the temporary with the permanent and the planned with the improvised. Health-led temporary urbanism contributes to the call for more trans- and inter-disciplinary discussions allowing to more thoroughly link urban planning and development with health.

Maternal Ambient Exposure to Atmospheric Pollutants during Pregnancy and Offspring Term Birth Weight in the Nationwide ELFE Cohort

Background: Studies have reported associations between maternal exposure to atmospheric pollution and lower birth weight. However, the evidence is not consistent and uncertainties remain. We used advanced statistical approaches to robustly estimate the association of atmospheric pollutant exposure during specific pregnancy time windows with term birth weight (TBW) in a nationwide study. Methods: Among 13,334 women from the French Longitudinal Study of Children (ELFE) cohort, exposures to PM_2.5, PM₁₀ (particles < 2.5 µm and <10 µm) and NO₂ (nitrogen dioxide) were estimated using a fine spatio-temporal exposure model. We used inverse probability scores and doubly robust methods in generalized additive models accounting for spatial autocorrelation to study the association of such exposures with TBW. Results: First trimester exposures were associated with an increased TBW. Second trimester exposures were associated with a decreased TBW by 17.1 g (95% CI, −26.8, −7.3) and by 18.0 g (−26.6, −9.4) for each 5 µg/m³ increase in PM_2.5 and PM₁₀, respectively, and by 15.9 g (−27.6, −4.2) for each 10 µg/m³ increase in NO₂. Third trimester exposures (truncated at 37 gestational weeks) were associated with a decreased TBW by 48.1 g (−58.1, −38.0) for PM_2.5, 38.1 g (−46.7, −29.6) for PM₁₀ and 14.7 g (−25.3, −4.0) for NO₂. Effects of pollutants on TBW were larger in rural areas. Conclusions: Our results support an adverse effect of air pollutant exposure on TBW. We highlighted a larger effect of air pollutants on TBW among women living in rural areas compared to women living in urban areas.

Relationship between built environments and risks of ischemic stroke based on meteorological factors: A case study of Wuhan's main urban area

Ischemic stroke is one of the most common causes of death worldwide, and uncomfortable meteorological and built environments may increase its risk. Residents in different built environments are exposed to different risks of ischemic stroke in cold and hot weather. By using the data from 3547 patients hospitalized, a distributed lag non-linear model was established to compare the differences in the risk of ischemic stroke in urban areas with respect to different Building Height, Building Density, Normalized Differential Vegetation Index, and Distance to Water under the meteorological condition. The results showed that lower Building Height is related to the negative cold effects in winter, and higher Building Height is related to increased risks at high temperatures. Built environments with Building Heights of 10-15 m in hot weather and above 15 m in cold weather have low risks. Higher Building Density was found to be associated with reduced negative cold effects; however, the negative hot effects increased in summer. Built environments with a Building Density of more than 0.3 showed low risks, regardless of the weather conditions. Increasing NDVI seemed to mitigate negative effects in uncomfortable weather, and built environments with higher NDVI were found to be associated with lower risks of ischemic stroke. Built environments with shorter Distance to Water seemed to pose higher risks in summer, and longer Distance to Water was correlated with higher risks in winter. Built environments with Distance to Water in the range of 0.65-2.30 km showed low risks. The research results could have some implications for urban planners to form reasonable built environments under certain meteorological factors which can be beneficial for the mitigation of incidence of ischemic stroke.

The impact of urban and transport planning on health: Assessment of the attributable mortality burden in Madrid and Barcelona and its distribution by socioeconomic status

BACKGROUND

The population living in urban areas is growing rapidly. The level of exposure to adverse environmental factors is detrimental to human health and is directly related to urban and transport planning practices.

OBJECTIVE

To estimate the premature mortality burden of non-compliance with international exposure guidelines for air pollution, noise, access to green space and heat for Barcelona and Madrid (Spain), and its distribution among the population by the socioeconomic status (SES).

METHODS

The Urban and TranspOrt planning Health Impact Assessment (UTOPHIA) tool was applied and the attributable premature mortality due to non-compliance with recommended exposure levels was estimated. The distribution of the attributable mortality burden among the population by SES was investigated through Generalized Additive Models (GAMs) adjusting for spatial autocorrelation and a cluster analysis was performed to identify attributable mortality hot spots.

RESULTS

Annually, 7.1% and 3.4% of premature mortality in Barcelona and Madrid, respectively, could be attributed to non-compliance with the international exposure recommendations for air pollution, noise, heat and access to green space. In addition, analysis by SES showed that in Barcelona lower SES areas had an overall greater attributable mortality rate, while in Madrid, the distribution of the attributable mortality burden by SES varied by exposure.

CONCLUSION

This study shows the impact of environmental exposures on mortality and highlights the importance of taking integrated actions when designing cities considering the health impacts, but also the specificities of each city such as the socio-demographic context. Moreover, the high precision scale of the analysis enables the identification of environmental hazards and mortality hot spots providing a powerful tool to support priority-setting and guide policymakers towards a healthy, sustainable and just city for all of their residents.

Border Environmental Justice PPGIS: Community-Based Mapping and Public Participation in Eastern Tijuana, México

Community mapping projects have been studied as important contributions to the field of environmental justice and Public Participation Geographic Information Systems (PPGIS). As a collaborative project between the Colectivo Salud y Justicia Ambiental and Red de Ciudadanos por el Mejoramiento de las Comunidades (RECIMEC), the “Mapeo Comunitario de la Zona Alamar” was created as a mechanism for community participation in the urban planning process in Tijuana, México. This paper outlines the project’s community mapping process, including planning, data collection, priority identification, and data submission. Results from this community mapping project are analyzed including the (1) particular environmental risks and goods in this border region, (2) the influence that the project data had on the urban planning process, and (3) the impact that the community mapping process had on community organizing capacity. Our findings point to particular environmental challenges in this border city including clandestine trash dumps, and contaminated water runoff points. The mapping project influenced the land use planning process by identifying the key environmental risks and goods to prioritize in the zoning and ground truthing urban planning data. The community mapping project also had a key impact on community organizing through the fomenting of knowledge and relationships between community members and government representatives at the city’s urban planning agency.

Community-Based Approaches to Reducing Health Inequities and Fostering Environmental Justice through Global Youth-Engaged Citizen Science

Growing socioeconomic and structural disparities within and between nations have created unprecedented health inequities that have been felt most keenly among the world's youth. While policy approaches can help to mitigate such inequities, they are often challenging to enact in under-resourced and marginalized communities. Community-engaged participatory action research provides an alternative or complementary means for addressing the physical and social environmental contexts that can impact health inequities. The purpose of this article is to describe the application of a particular form of technology-enabled participatory action research, called the Our Voice citizen science research model, with youth. An overview of 20 Our Voice studies occurring across five continents indicates that youth and young adults from varied backgrounds and with interests in diverse issues affecting their communities can participate successfully in multiple contributory research processes, including those representing the full scientific endeavor. These activities can, in turn, lead to changes in physical and social environments of relevance to health, wellbeing, and, at times, climate stabilization. The article ends with future directions for the advancement of this type of community-engaged citizen science among young people across the socioeconomic spectrum.

Realtors' Perceptions of Social and Physical Neighborhood Characteristics Associated with Active Living: A Canadian Perspective

Realtors match home-seekers with neighborhoods that have built and social characteristics they desire to pursue active lifestyles. Studies have yet to explore realtors’ perspectives on neighborhood design that supports active living. Using qualitative description, our study was to explore the perceptions and understandings of neighborhood design (walkability, healthy, bike-ability, vibrancy, and livability) among urban residential realtors. Nineteen (6 men; 13 women; average age 48 years) self-identified residential realtors from Calgary, Edmonton, and Lethbridge (Canada) completed semi-structured telephone interviews. Content analysis identified themes from the interview data. Specifically, walkability was described as: perceived preferences, destinations and amenities, and connections; a healthy community was described as: encourages outdoor activities, and promotes social homogeneity; bike-ability was described as: bike-ability attributes, and was controversial; vibrancy was described as: community feel, and evidence of life; and livability was described as: subjective, and preferences and necessities. Our findings can inform the refinement of universal definitions and concepts used to in neighborhood urban design.

Urban Health Multidisciplinary Actions Promoting Health in an Urban Environment

The crisis faced by the Western lifestyle model when dealing with problems associated with climate change and the new roles that cities and buildings must play in a world of globalisation fosters the rise of a new approach that marks a necessary turning point for our civilisation. For decades now, the fight against climate change has seen many of the world’s most important countries committing themselves to agreements—from the Kyoto Protocol of 1992 to the Paris COP21 in 2015—that are gradually getting better at establishing goals, strategies and actions for improving quality of life and protecting the entire planet, even if some venture doubts on the concrete possibility of achieving them.

Neighbourhood built environment and physical function among mid-to-older aged adults: A systematic review

This systematic review included 23 quantitative studies that estimated associations between aspects of the neighbourhood built environment and physical function among adults aged ≥45 years. Findings were analysed according to nine aspects of the neighbourhood built environment: walkability, residential density, street connectivity, land use mix, public transport, pedestrian infrastructure, aesthetics, safety and traffic. Evidence was found for a positive association of pedestrian infrastructure and aesthetics with physical function, while weaker evidence was found for land use mix, and safety from crime and traffic. There was an insufficient number of studies for walkability, residential density, street connectivity and access to public transport.

Research challenges for cultural ecosystem services and public health in (peri-)urban environments

Urbanization is a global trend, and consequently the quality of urban environments is increasingly important for human health and wellbeing. Urban life-style is typically associated with low physical activity and sometimes with high mental stress, both contributing to an increasing burden of diseases. Nature-based solutions that make effective use of ecosystem services, particularly of cultural ecosystem services (CES), can provide vital building blocks to address these challenges. This paper argues that, the salutogenic, i.e. health-promoting effects of CES have so far not been adequately recognised and deserve more explicit attention in order to enhance decision making around health and wellbeing in urban areas. However, a number of research challenges will need to be addressed to reveal the mechanisms, which underpin delivery of urban CES. These include: causal chains of supply and demand, equity, and equality of public health benefits promoted. Methodological challenges in quantifying these are discussed. The paper is highly relevant for policy makers within and beyond Europe, and also serves as a review for current researchers and as a roadmap to future short- and long-term research opportunities.

Iniquidades do ambiente construído relacionado à atividade física no entorno de escolas públicas de Curitiba, Paraná, Brasil

Resumo: O objetivo do estudo foi investigar a associação entre as características do ambiente relacionado à atividade física com a renda em áreas de entorno escolar em Curitiba, Paraná. Foram auditados 888 segmentos de rua com um instrumento de observação sistemática em três seções (Rotas, Segmentos e Cruzamentos) no raio de 500 metros ao redor de 30 escolas públicas. O escore total foi a soma das seções. Dados de renda do entorno escolar foram obtidos do Censo Demográfico de 2010, e a distância linear de cada escola até o centro da cidade foi calculada. Modelos multiníveis (nível um segmento e nível dois escola) foram aplicados na análise, com estimativas de médias ponderadas e correlações intraclasse (ICC). Na análise bruta, a maior variabilidade entre as escolas foi observada na seção Segmentos (ICC = 0,41), e a menor, na seção Rotas (ICC = 0,19). Os segmentos de rua localizados no entorno de escolas do primeiro tercil de renda alcançaram uma média ajustada de 15,6 (IC95%: 13,0-18,3) no escore total, quase metade daqueles de renda maior, que atingiram 30,7 (IC95%: 28,0-33,5) pontos, com diferença significativa entre os tercis (p < 0,001). O escore das áreas mais centrais foi 30,1 (IC95%: 26,9-33,4), significativamente maior (p < 0,001) se comparado àquelas mais periféricas em que a pontuação foi 16,3 (IC95%: 12,8-19,8). As características do ambiente avaliadas nas seções Rotas e Segmentos, além do escore total, mostraram-se associadas com a menor renda. Ambiente de pior qualidade em áreas de menor renda é uma das iniquidades que precisa ser enfrentada nas metrópoles brasileiras e que pode contribuir para a melhoria da saúde das pessoas.

Exploring the experiences of staff working at an opiate assisted treatment clinic: An interpretive descriptive study

There have been many advances in harm reduction over the past three decades. One of the newest approaches is the provision of medical grade heroin to people with opiate addiction, known as opiate assisted treatment (OAT). There is one clinic in North America which provides this service. The goal of this study was to uncover how clinic staff provide care to those who attend this clinic, their perspectives on how the clinic program impacted them and their patients, and their opinions about the program itself. This was a qualitative study with an interpretive descriptive methodology underpinned by critical social theory. Convenience sampling yielded 22 participants - 18 nurses, two social workers and two peer support workers. Thematic analysis was undertaken to identify recurring, converging and contradictory patterns of interaction, key concepts and emerging themes. The study location was the OAT clinic located in the downtown eastside of Vancouver, BC. The findings were organized around the following six themes: from chaos to stability, it's not all roses, a little preparation would be good, putting the patient at the centre, the stigma hasn't gone away, and the clinic is life transforming. Taken together, these themes indicate the complexities of working in this environment. The findings can guide clinic staff, including nurses, in how they provide care to patients with addiction problems and also provide direction for policy makers on harm reduction planning. CONTRIBUTION OF THE PAPER: What is already known about the topic? What does this paper add?

Is the built environment associated with morbidity and mortality? A systematic review of evidence from Germany

The empirical evidence on this relationship mainly comes from Anglo-American countries whereas evidence from Germany is only emerging. Our objective is to provide a narrative overview and critical appraisal of the existing empirical evidence on the relationship between the built environment and morbidity/mortality in Germany. We conducted a systematic literature search where we included all empirical studies that linked the built environment aspects with morbidity or mortality outcomes. Findings were summarized and critically evaluated according to the Newcastle Ottawa Scale. Eighteen studies met the inclusion criteria and underwent in-depth analysis. Findings indicate that traffic exposure and green space tend to be associated with acute respiratory symptoms but not with chronic respiratory conditions. Evidence was inconsistent for the role of infrastructural aspects and urbanicity. Our review confirms the well-established association between traffic and respiratory health. Yet, the consistency between self-reported and objective measures of respiratory health should be investigated in more detail.

Healthy Design and Urban Planning Strategies, Actions, and Policy to Achieve Salutogenic Cities

Starting from a previous experience carried out by the working group "Building and Environmental Hygiene" of the Italian Society of Hygiene and Preventive Medicine (SItI), the aim of the present work is to define new strategic goals for achieving a "Healthy and Salutogenic City", which will be useful to designers, local governments and public bodies, policy makers, and all professionals working at local health agencies. Ten key points have been formulated: 1. climate change and management of adverse weather events; 2. land consumption, sprawl, and shrinking cities; 3. tactical urbanism and urban resilience; 4. urban comfort, safety, and security perception; 5. strengths and weaknesses of urban green areas and infrastructures; 6. urban solid waste management; 7. housing emergencies in relation to socio-economic and environmental changes; 8. energy aspects and environmental planning at an urban scale; 9. socio-assistance and welfare network at an urban scale: importance of a rational and widespread system; and 10. new forms of living, conscious of coparticipation models and aware of sharing quality objectives. Design strategies, actions, and policies, identified to improve public health and wellbeing, underline that the connection between morphological and functional features of urban context and public health is crucial for contemporary cities and modern societies.

Social and Economic Policies Matter for Health Equity: Conclusions of the SOPHIE Project

Since 2011, the SOPHIE project has accumulated evidence regarding the influence of social and economic policies on population health levels, as well as on health inequalities according to socioeconomic position, gender, and immigrant status. Through comparative analyses and evaluation case studies across Europe, SOPHIE has shown how these health inequalities vary according to contexts in macroeconomics, social protection, labor market, built environment, housing, gender equity, and immigrant integration and may be reduced by equity-oriented policies in these fields. These studies can help public health and social justice advocates to build a strong case for fairer social and economic policies that will lead to the reduction of health inequalities that most governments have included among their policy goals. In this article, we summarize the main findings and policy implications of the SOPHIE project and the lessons learned on civil society participation in research and results communication.

Increasing Research Capacity in Underserved Communities: Formative and Summative Evaluation of the Mississippi Community Research Fellows Training Program (Cohort 1)

Background

The Mississippi Community Research Fellows Training Program (MSCRFTP) is a 15-week program conducted in Jackson, MS, USA consisting of training in the areas of evidence-based public health, research methods, research ethics, and cultural competency. The purpose of the program was to increase community knowledge and understanding of public health research, develop community-based projects that addressed health disparity in the participants’ community, increase individual and community capacity, and to engage community members as equal partners in the research process.

Methods

A comprehensive evaluation of the MSCRFTP was conducted that included both quantitative and qualitative methods. All participants were asked to complete a baseline, midterm, and final assessment as part of their program requirements. Knowledge gained was assessed by comparing baseline assessment responses to final assessment responses related to 27 key content areas addressed in the training sessions. Assessments also collected participants’ attitudes toward participating in research within their communities, their perceived influence over community decisions, and their perceptions of community members’ involvement in research, satisfaction with the program, and the program’s impact on the participants’ daily practice and community work.

Results

Twenty-one participants, the majority of which were female and African-American, completed the MSCRFTP. Knowledge of concepts addressed in 15 weekly training sessions improved significantly on 85.2% of 27 key areas evaluated (p < 0.05). Two mini-grant community based participatory research projects proposed by participants were funded through competitive application. Most participants agreed that by working together, the people in their community could influence decisions that affected the community. All participants rated their satisfaction with the overall program as “very high” (76.2%, n = 16) or “high” (23.8%, n = 5).

Conclusion

The evaluation of the MSCRFTP demonstrates that participants have the necessary knowledge to engage as research partners, and the pilot projects provided an opportunity for application of this objective to be realized. Overall, the MSCRFTP was an intervention that assisted community members in identifying their communities’ strengths and weaknesses, interpret knowledge in a meaningful way, and create a self-reflective community of inquiry for change.

The role of the built environment in explaining educational inequalities in walking and cycling among adults in the Netherlands

BACKGROUND

This study examined whether characteristics of the residential built environment (i.e. population density, level of mixed land use, connectivity, accessibility of facilities, accessibility of green) contributed to educational inequalities in walking and cycling among adults.

METHODS

Data from participants (32-82 years) of the 2011 survey of the Dutch population-based GLOBE study were used (N = 2375). Highest attained educational level (independent variable) and walking for transport, cycling for transport, walking in leisure time and cycling in leisure time (dependent variables) were self-reported in the survey. GIS-systems were used to obtain spatial data on residential built environment characteristics. A four-step mediation-based analysis with log-linear regression models was used to examine to contribution of the residential built environment to educational inequalities in walking and cycling.

RESULTS

As compared to the lowest educational group, the highest educational group was more likely to cycle for transport (RR 1.13, 95% CI 1.04-1.23), walk in leisure time (RR 1.12, 95% CI 1.04-1.21), and cycle in leisure time (RR 1.12, 95% CI 1.03-1.22). Objective built environment characteristics were related to these outcomes, but contributed minimally to educational inequalities in walking and cycling. On the other hand, compared to the lowest educational group, the highest educational group was less likely to walk for transport (RR 0.91, 95% CI 0.82-1.01), which could partly be attributed to differences in the built environment.

CONCLUSION

This study found that objective built environment characteristics contributed minimally to educational inequalities in walking and cycling in the Netherlands.

Hispanic health in the USA: a scoping review of the literature

Hispanics are the largest minority group in the USA. They contribute to the economy, cultural diversity, and health of the nation. Assessing their health status and health needs is key to inform health policy formulation and program implementation. To this end, we conducted a scoping review of the literature and national statistics on Hispanic health in the USA using a modified social-ecological framework that includes social determinants of health, health disparities, risk factors, and health services, as they shape the leading causes of morbidity and mortality. These social, environmental, and biological forces have modified the epidemiologic profile of Hispanics in the USA, with cancer being the leading cause of mortality, followed by cardiovascular diseases and unintentional injuries. Implementation of the Affordable Care Act has resulted in improved access to health services for Hispanics, but challenges remain due to limited cultural sensitivity, health literacy, and a shortage of Hispanic health care providers. Acculturation barriers and underinsured or uninsured status remain as major obstacles to health care access. Advantageous health outcomes from the "Hispanic Mortality Paradox" and the "Latina Birth Outcomes Paradox" persist, but health gains may be offset in the future by increasing rates of obesity and diabetes. Recommendations focus on the adoption of the Health in All Policies framework, expanding access to health care, developing cultural sensitivity in the health care workforce, and generating and disseminating research findings on Hispanic health.

Mapping Environmental Inequalities Relevant for Health for Informing Urban Planning Interventions-A Case Study in the City of Dortmund, Germany

Spatial differences in urban environmental conditions contribute to health inequalities within cities. The purpose of the paper is to map environmental inequalities relevant for health in the City of Dortmund, Germany, in order to identify needs for planning interventions. We develop suitable indicators for mapping socioeconomically-driven environmental inequalities at the neighborhood level based on published scientific evidence and inputs from local stakeholders. Relationships between socioeconomic and environmental indicators at the level of 170 neighborhoods were analyzed continuously with Spearman rank correlation coefficients and categorically applying chi-squared tests. Reclassified socioeconomic and environmental indicators were then mapped at the neighborhood level in order to determine multiple environmental burdens and hotspots of environmental inequalities related to health. Results show that the majority of environmental indicators correlate significantly, leading to multiple environmental burdens in specific neighborhoods. Some of these neighborhoods also have significantly larger proportions of inhabitants of a lower socioeconomic position indicating hotspots of environmental inequalities. Suitable planning interventions mainly comprise transport planning and green space management. In the conclusions, we discuss how the analysis can be used to improve state of the art planning instruments, such as clean air action planning or noise reduction planning towards the consideration of the vulnerability of the population.