Urban Health Research in Africa: Themes and Priority Research Questions.

Abstract

In Africa, urbanization and urban growth are dramatically restructuring the nature of cities. The growing majority of urban dwellers now live in informal conditions that, without access to basic services or public amenities, expose residents to greater health risk, and health-care systems are unable to provide affordable or comprehensive cover. The differential exposure to these urban conditions is compounded by social and economic vulnerability, resulting in health inequities. Yet despite pressing needs driven by Africa’s considerable and complex burden of disease and high levels of health inequity, urban health and urban health equity have not yet emerged as major research and policy priorities in Africa, and as such South Africa, like many other African countries, lags behind in addressing these issues. This commentary presents a conceptual framework, using a public health approach, for interdisciplinary research aimed at contributing to the understanding and mitigation of urban health issues and challenges in Africa (Fig. 1). This approach identifies downstream and upstream factors, based on published literature, associated with key determinants in each theme. In other words, in addition to the individual level risk factors, the figure summarizes factors associated with each theme at the community, experiential, environmental, and structural policy levels. It represents a collective effort by interdisciplinary academics from public health; anthropology; civil engineering; architecture, planning and geomatics; human biology; psychiatry and mental health; medicine; pathology; and paediatrics, from the Research Initiative for Cities and Health (RICHE), University of Cape Town (UCT), to generate African perspectives on urban health and urban health equity. A workshop to tackle the urban health research agenda in August 2015 was attended by 40 RICHE members with extensive global and local urban health experience. In line with the co-production philosophy advocated for African urban contexts 1, additional contributions came from representatives from the Western Cape Department of Health. The process of identifying themes and gaps was as follows: First existing urban health research in Africa was presented. The workshop participants, who have a wide range of experience in urban health in Africa presented what work was ongoing or planned. Through this iterative process, the key components of research questions identified were then thematically classified into six distinct focus areas. Using a public health, socio-ecological model, these themes were then classified into different levels from the individual to policy levels. Gaps in research were then identified qualitatively by the same iterative process from which unanswered priority research questions were identified. Three cross-cutting principles for African urban health research were also identified in the process, based on methodological and technical requirements for the successful conduct of the proposed research themes (Table ​(Table11). FIG. 1 Conceptual framework of public health approach to urban health research themes in Africa. TABLE 1 Urban health research focus areas and priority research questions Six Focus Area Themes Urban Context as a Tool for Health Promotion and Disease Prevention The health and well-being of urban residents is intricately linked to the natural, built, and institutional elements of the urban context. As such, all dimensions of urbanization and urban living, including socio-environmental determinants of health need to be considered 2. The Commission on the Social Determinants of Health 3 and the Hidden Cities4 reports identify addressing urban health as a key priority in the global South. Thus, investigation of the interaction between health and the urban determinants of health (social and policy environments, health services, the built, physical housing and recreational environments, food systems, crime/security, access to potable water, air quality, transport, vector and pest management, community resilience, psycho-social support structures) is essential 5. Understanding these interactions could facilitate developing, implementing, and evaluating interventions that aim to harness these aspects of the urban context as tools for health promotion and prevention of infectious and vector-borne diseases, non-communicable diseases, and injuries, which in South African cities account for 20 % more mortality than in rural areas 6. This understanding could be gained via research paired with “natural experiments” and randomized evaluations, such as urban upgrades, housing developments, and integrated transport system routes, to assess the impact on health behaviors and health outcomes.