18/02/2020

SH7003N HEALTH IN THE CITY

Session 3
Analysing Determinants of Health and Health
Inequalities in City Settings

Livingstone Musoro
l.musoro@londonmet.ac.uk
BEU1-07

Session Plan
Lecture
Cities and the urban environment – importance of
understanding determinants of health in cities
Conceptual frameworks of health determinants in cities
Health determinants and inequalities in health in cities

Seminar Activities
Health profiles and tackling inequalities in health

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What are Determinants of Health

 “The determinants of health are a range of

interacting factors that shape health and
wellbeing and are underpinned by social and
economic inequalities

 These determinants include: material

circumstances, the social environment,
psychosocial factors, behaviours and biological
factors” (Marmot Review, 2010; cited in HSE,
2011: 8)

Cities and the Urban Environment - importance of

this study
 The ‘urban’ as a determinant of health
 The complexity of the urban environment (Vlavov et al, 2007)

 The influence of urbanization on determinants of health

 Living and working conditions in cities
 Areas of concentrated disadvantage and health inequalities
 The ‘health system’ in cities
 Determinants and outcomes of health and a complex web of activities that link them

 Viewing health determinants in cities in multi-level and multi-

sectoral dimensions
 Whilst may be different in emphasis between the global south
and global north, the ‘urban’ impacts on health in a similar
way

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Conceptual Frameworks of Health Determinants in

Cities - the multi-sectoral dimension

 The Lalonte Report (1974) and the ‘upstream’

approaches to health particularly in cities

 In practice, selective / horizontal primary health care is

the norm
 Answer- need to expand planning and action from health services to an
inclusive public health.
 But even broader public health interventions alone are insufficient – give
examples from the global north and global south

 A need for ‘joined-up governance’ and a comprehensive

place-based strategy like the HCP of the WHO

Conceptual Frameworks of Health Determinants in

Cities - the multi-sectoral dimension
Impact of broader determinants of health, %

social circumstances and

environmental exposure
Health care

health behaviour patterns

*Source: PHE

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Conceptual Frameworks of Health Determinants

in Cities - the multi-sectoral dimension
“An overall inference that can be suggested from these
simple analyses is as follows: while cities are associated
with development (and development with positive health
outcomes), areas of concentrated disadvantage in cities
show worse outcomes irrespective of level of
development. Replacing GNI with GDP demonstrated
similar results” (Vlahov et al, 2007: i19)
 Four broad categories to help frame the analysis of
determinants of health in cities:
 Population composition
 The physical environment
 The social environment, and
 Availability of and access to health and social services

Conceptual Frameworks of Health Determinants in

Cities - the multi-sectoral dimension
Inadequate
Rural to urban
health
migration
knowledge
Poor life styles
Poor (smoking,
environmental alcohol,
and housing drugs)
conditions
Health
outcomes Violence and
social
Restricted access disorganisation
to health care
services
Poor or heavily
congested
Poor transport
neighbourhood networks
satisfaction Informal conditions Restricted access
(working, housing, to information
health care use) (mass media)

*Adopted from Kramer A, Khan M H and Kraas F (2011) (eds) Health in Megacities and Urban Areas. New York:
Springer Physica-Verlag HD; p11. Available Online.

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Conceptual Frameworks of Health Determinants in Cities -

the multi-sectoral dimension

*Source: Rydin et al (2012) Shaping cities for health: complexity and the planning of urban environments in the 21st
century. In Lancet 2012; 379: 2079–108.

Conceptual Frameworks of Health Determinants in

Cities - the multi-level dimension

 The shortfalls of traditional focus on individual

characteristics as health determinants

 More useful to understand the impact on health of

‘place’, or community-level factors and beyond
 Adding ‘geography’ to health
 Adding ‘multi-spaces’ to health

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Conceptual Frameworks of HD in Cities - the multi-

level dimension
Macro (city, regional, national and global) level

Neighbourhood level

Household level

Individual level

Health
outcome

Personal characteristics and behaviours

Housing, socio-economic and environmental factors

Social, cultural, political, environmental and institutional factors

Climate change, global health policies/declarations, economy, health facilities and public-private
partnerships

*Adopted from Kramer A, Khan M H and Kraas F (2011) (eds) Health in Megacities and Urban Areas. New York: Springer Physica -
Verlag HD; p11. Available Online.

Conceptual Frameworks of Health Determinants in

Cities - the multi-sectoral and multi-level dimension
Major Global Urban Living &
Municipal Level
Trends and Working Outcomes
Determinants
Dynamics Conditions

• Populations
• Immigration •Local (demographics, pop
Government subgroups)
• Globalisation Policies • Physical
Health and
Environment (built
Non-health
•Suburbanisation • Markets environment)
Outcomes
• Social Environment
• Changing role of •Civil Society • Food Environment
government (voluntary sectors •Service
organisations) Environment (health
and social services )

UNDERLYING FACTORS: Government, Culture, Social & Economic

Systems, Geography (Place & Location) & Political Factors

*Adopted from Galea et al (2006)

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The Dalhgren and Whitehead-Barton and Grant Model: the

multi-sectoral and multi-level dimensions

*Source: Health Service Executive (2011) The Health Promotion Strategic Framework. Dublin: HSE National Health Promotion Office.

Urban Form and Population Health

 Material infrastructure (urban form) and collective social
functioning
 physical features of the environment shared by all residents;
 home, work and recreational environments that are conducive
to health;
 services provided, publicly or privately to support people in
their daily lives;
 the socio‐cultural features of a neighbourhood; and
 the reputation of an area
 (Macintyre et al, 2002, cited by McDonald et al, 2008: 3)

 Three characteristics of an urban environment that

influence health ‐ place, space and people
 (Travaglia et al, 2002).

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Example of Broad Intervention - The Healthy Cities

Project
The Healthy City Project’s (HCP) (WHO, 1995) objectives are :
1. Political mobilisation and community participation in preparing and
implementing a municipal health plan.

2. Increased awareness of health issues in urban development efforts by

municipal and national authorities, including non-health ministries and
agencies.

3. Creation of increased capacity of municipal government to manage urban

problems and formation of partnerships with communities and
community-based organizations (CBOs) in improving living conditions in
poor communities.

4. Creation of a network of cities that provides information exchange and

technology transfers.
UK Healthy Cities Network

Health Determinants and Inequalities in Health in

Cities

 Health Inequities - are socially produced

 Inequalities in Health – “group differences in health that

are unnecessary, preventable and unjust” (Braveman,
2006, cited in Whitman et al, 2011: 8)

 As urban living expands, there is likely to be growing

levels of inequities across a wide range of social and
health dimensions

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Health Determinants and Inequalities in Health in

Cities
 “The poor health of the poor, the social gradient in health
within countries, and the marked health inequities between
countries are caused by the unequal distribution of power,
income, goods, and services, globally and nationally, the
consequent unfairness in the immediate, visible
circumstances of peoples lives – their access to health care,
schools, and education, their conditions of work and leisure,
their homes, communities, towns, or cities – and their
chances of leading a flourishing life...Together, the structural
determinants and conditions of daily life constitute the social
determinants of health and are responsible for a major part of
health inequities between and within countries”
(Commission on Social Determinants of Health, 2008; cited in HSE, 2011: 8)

 PHE (Online) Wider Determinants OF Health

in London and beyond

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Determinants of Health in London-What is Being

Done?
Many initiatives such as:
 Focusing on BEMs (skills and training, living wage, immigration)

 Inequalities in health (Mayoral Strategy, 2010 with updates)

 Key public health problems e.g. CHO, cancers, diabetes and

CVD)
 Transforming the physical environment to promote physical
activeness, e.g. cycling – the ‘Boris bikes’
 Promoting and expanding traditional activities e.g. urban
agriculture – growing of vegetables
 Promoting and supporting life skills, e.g. cooking skills

 Changing lifestyles – reducing inactiveness and social

exclusion, e.g. gym parks and dance clubs

Readings and References

Galea S and Vlahov D (eds) (2005) Handbook of Urban Health: Populations, Methods and Practice. New York: Springer.
Galea S, Freudenburg N and Vlahov D (2006) A Framework for the Study of Urban Health. In Freudenberg N, Galea S and Vlahov
D (eds) Cities and the Health of the Public. Vanderbilt University Press
Kjellstrom, T (2007) Our cities, our health, our future: Acting on social determinants for health equity in urban settings. Kobe, Japan:
WHO Centre for Health Development. [Online] Available as PDF file [70p.] at:
McDonald J, Wise M & Harris P (2008) The Health Impacts of the Urban Form: A Review of Reviews. Sydney: Centre for Health
Equity Training, Research and Evaluation, part of the Research Centre for Primary Health Care and Equity, University of New South
Wales.
Motavalli, J, Abhat, J, Dineen, S (2005) Cities of the Future. E Magazine: The Environmental Magazine; Sep/Oct2005, 16 (5): 26-
36.
National Research Council (2003) Cities transformed: Demographic change and its implications in the Developing World.
Washington, DC: National Academic Press.
Rydin Y, Bleahu A, Davies M, Dávila JD, Friel S, De Grandis D, Groce N, Hallal PC, Hamilton I, Howden-Chapman P, Lai KM, Lim
CJ, Martins J, Osrin D, Ridley I, Scott I, Taylor M, Wilkinson P, and Wilson J (2012) Shaping cities for health: complexity and the
planning of urban environments in the 21st century. In Lancet 2012; 379: 2079–108
Seager JR (1995) Research on urban health - priorities and approaches. In: Harpham T, Tanner M, eds. Urban health in developing
countries: progress and prospects ; 64-81. London: Earthscan.
Travaglia J, Harris E, et al. (2002). Locational Disadvantage: focussing on place to improve health. Sydney, Centre for Health
Equity Training Research and Evaluation (CHETRE), UNSW.
UN HABITAT (2010) Hidden Cities: Unmasking and overcoming health inequities in urban settings. Geneva: UN HABITAT and
WHO. [Online] Available at:
Vlahov D, Freudenberg N, Proietti F, Ompad D, Quinn A, Nandi V, and Galea S (2007) Urban as a Determinant of Health. In Journal
of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 1: i16-i24. Available Online
WHO-Europe (2012) Addressing the social determinants of health: the urban dimension and the role of local government.
Copenhagen: WHO-Regional Office for Europe

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