Urban Health Index Research Articles

Advancing urban health in Portugal: exploring liveability and its association with mental morbidity

Abstract Background As cities face challenges posed by urbanisation, it becomes essential to understand how city planning can contribute to protecting public health. In this study, we aimed to assess the liveability of different areas in Lisbon, Portugal, by developing a liveability index at the parish level. Secondly, we aimed to explore its association with hospitalisation due to mental disorders. Methods The liveability index was built based on the World Health Organisation’s Urban Health Index methodology. We obtained data on liveability related to housing, socio-economic conditions and access to services (e.g. healthcare) from the 2011 census and other open data sources for Lisbon’s parishes (n = 22). Data on hospital admissions due to mental disorders was sourced at the parish level from the national database for hospital morbidity for the period 2013-2016 and sex-age-standardised. Binomial negative regression was employed to estimate the association between the liveability index tertiles and observed hospital admissions. We used the expected number of hospitalisations as the offset variable and tested for spatial autocorrelation among the regression residuals. Results Our analysis showed that living in the most liveable parishes is associated with a significant decrease in the standardised admission ratio due to mental disorders, compared to living in the least liveable areas (Incidence Relative Ratio=0.643; 95% CI: 0.427, 0.967). We did not observe any geographical pattern in the regression residuals (Moran’s I= -0.035, p = 0.427). Conclusions Our findings show disparities in liveability among Lisbon’s parishes and identify a protective association between living in higher liveability areas and hospital admissions due to mental disorders. This work should prompt further studies concerning this subject to inform urban planning policies to improve liveability and equally reduce the risk of mental health-related harm within cities. Key messages • A spatial index to assess liveability in urban areas was developed. The association between the liveability of Lisbon’s parishes and hospital admissions due to mental disorders was explored. • We found a significant protective association between higher liveability and hospital admissions due to mental disorders. This work is relevant to inform the implementation of urban planning policies.

GIS-based assessment of spatial and temporal disparities of urban health index in Shenzhen, China.

To explore the inter-regional health index at the city level to contribute to the reduction of health inequalities. Employed the health determinant model to select indicators for the urban health index of Shenzhen City. Utilized principal component analysis, the weights of these indicators are determined to construct the said health index. Subsequently, the global Moran's index and local Moran's index are utilized to investigate the geographical spatial distribution of the urban health index across various administrative districts within Shenzhen. The level of urban health index in Shenzhen exhibits spatial clustering and demonstrates a positive spatial correlation (2017, Moran's I = 0.237; 2019, Moran's I = 0.226; 2021, Moran's I = 0.217). However, it is noted that this clustering displays a relatively low probability (90% confidence interval). Over the period from 2017 to 2019, this spatial clustering gradually diminishes, suggesting a narrowing of health inequality within economically developed urban areas. Our study reveals the urban health index in a relatively high-income (Shenzhen) in a developing country. Certain spatially correlated areas in Shenzhen present opportunities for the government to address health disparities through regional connectivity.

도시건강 연구의 동향 분석

While more than half of the world’s population lives in urban areas, health disparities across cities remain serious issues. Urban settings are a relatively new phenomenon in human history, and so is urban health. This study aims to figure out the concept of urban health and analyze research trends on urban health through systematic review. Studies published since 2010 either in English or Korean were screened; 31 eligible studies were selected for the review. The contents of the studies were categorized by urban environment, urban planning, urban policy, urban health index and health equity. Taking together urban health and healthy city, there were no significant differences in the concepts; rather, they complement each other to achieve sustainable cities and communities. While there are diverse related studies, urban health remains rare in the field. Therefore, future studies need to focus on urban health topics to resolve health disparities in the urban areas.

Methodological Approach to Compiling a Classifier of Public Health Challenges

Introduction: The dynamics of socio-economic development of the society and emergence of unpredictable large-scale events determine the necessity of creating a classifier of public health challenges. The purpose of the study is to develop a methodological approach to compiling a public health challenge classifier. Materials and methods: We elaborate on our methodological approach to creating a classifier of public health challenges developed through systematization of provisions of GOST R ISO 31000-2019 and “The urban health index: A handbook for its calculation and use” by the World Health Organization. The use of these documents as a basis is justified by the fact that public health challenges entail risks of not achieving strategic targets for maintaining and improving public health. We reviewed 35 scientific papers published in 2002–2023 and found in PubMed, SCOPUS, and eLibrary.ru using the following keywords: risk, public health challenges, and disasters. The method of expert assessments was applied to select indicators of challenge differentiation. Experts were chosen from among public health professionals given established criteria and their opinions were then evaluated for consistency using the coefficient of concordance. The examples of public health challenges were considered based on the reports of the Russian Ministry of Emergency Situations. Results: The classifier of public health challenges implies assignment of challenges to a certain category depending on the level of implementation (occurrence), as well as the expected graveness of consequences. Classification by the level of implementation includes federal, regional, and municipal levels while that by the severity of consequences – high, moderate, and low categories of expected negative consequences. Such classification takes into account the division of powers between the authorities of different levels to ensure feasibility and effectiveness of subsequent application of response tools. Conclusion: The methodological approach considering key characteristics of public health challenges, correct classification of the latter, and timely use of emergency response tools will ensure public health maintenance in the Russian Federation on the federal, regional, and local levels.

Impact of the improvement of living conditions on tuberculosis mortality in Brazil: an ecological study.

The risk of death due to tuberculosis (TB) in Brazil is high and strongly related to living conditions (LC). However, epidemiological studies investigating changes in LC and their impact on TB are lacking. To evaluate the impact of LC on TB mortality in Brazil. This ecological study, using panel data on spatial and temporal aggregates, was conducted in 1,614 municipalities between 2002 and 2015. Data were collected from the Mortality Information System and the Brazilian Institute of Geography and Statistics. The proxy variable used for LC was the Urban Health Index (UHI). Negative binomial regression models were used to estimate the effect of the UHI on TB mortality rate. Attributable risk (AR) was used as an impact measure. From 2002 to 2015, TB mortality rate decreased by 23.5%, and LC improved. The continuous model analysis resulted in an RR = 0.89 (95%CI = 0.82-0.96), so the AR was -12.3%. The categorized model showed an effect of 0.92 (95%CI = 0.83-0.95) in municipalities with intermediate LC and of 0.83 (95%CI = 0.82-0.91) in those with low LC, representing an AR for TB mortality of -8.7% and -20.5%, respectively. Improved LC impacted TB mortality, even when adjusted for other determinants. This impact was greater in the strata of low-LC municipalities.

КОНЦЕПТУАЛЬНЫЕ ОСНОВЫ ОПРЕДЕЛЕНИЯ ДЕТЕРМИНАНТ ОБЩЕСТВЕННОГО ЗДОРОВЬЯ

Significance. Public health is defined as a medical and social resource that ensures national security and potential for socio-economic development of the country. The possibilities of state management of public health as a medical and social resource are limited by the lack of methodology for assessing determinants that affect it. The presented study outlines the conceptual framework for defining determinants of public health from the standpoint of the risk-based approach to its protection, as well as its components of labor, military, reproductive, and reserve resources. Developing a concept of public health management serves as a theoretical justification of public policy measures to develop strategies to control the risks of reducing the quality of public health. The purpose of the study is to develop a conceptual framework for defining determinants of public health. Material and methods. When developing the conceptual framework, the provisions of the following standards have been used: GOST R ISO 31000-2019 standard “Risk management. principles and guidelines”, WHO standard “The urban health index”, GOST R ISO/TS 21667-2009 standard “Health informatics. A conceptual model of health indicators”, as well as “Glossary of health promotion terms”, 2021 by the World Health Organization. The study presents the procedure for identifying risk factors, differentiating them by types of determinants and controlling the risks for the loss of public health under the influence of these determinants. Factors can be identified based on expert assessments, as well as confirmed statistical significance of the factors. Results. The possibilities of public health management are limited by the lack of a comprehensive methodology for measuring determinants of public health. The authors evaluate a set of determinants of public health, including social, biological, behavioral, medical, and environmental determinants. The article has developed a four-stage model for identifying factors that contribute to public health strengthening and risk factors for the loss of public health. A set of unique factors should be identified for each determinant of public health. Conclusion. The developed conceptual framework for defining determinants of public health is focused on the fact that the determinants of public health should be correlated with the components of public health as a medical and social resource that ensures attainment of the strategically important national security goals: national defense capability, viability, reproduction, and protection of society. It is necessary to consider territorial differences in the set of risk factors associated with the causes of loss of public health, as well as changes in their significance depending on the state of determinants, the period of society's life, including the period of pre-crisis, crisis and sustainable development. Scope of application. The determinants of public health should be considered as a methodological basis for the development of strategies to improve public health in the interests of the national security. Developing a list of public health risk factors and a list of factors contributing to its growth plays an essential role in improving effectiveness of strategic planning tools for this resource.

Abstract 14531: Higher Urban Health Index is Associated With Lower Ambulatory Blood Pressure in People Living in Southeast United States

Introduction: Hypertension is common in the Southeastern (SE) United States (US), which increases the risk of heart attack, stroke and other serious health problems. Ambulatory blood pressure (ABP) monitoring is the gold standard for diagnosing hypertension and provides better information on cardio- and cerebrovascular risk than office blood pressure (BP). However, the role of social determinants of health (SDOH) and their influence on BP elevation has been scarcely examined on a neighborhood level. The Urban Health Index (UHI), developed by the World Health Organization, has the potential to measure disparities in SDOH at the small areal level and examine inequalities in health outcomes. Hypothesis: Higher UHI is associated with lower blood pressure. Methods: We analyzed data using a longitudinal cohort established in 1989 with 724 individuals (age 5-16 in 1989, 50.8% females, 47.1% African Americans) from the Central Savannah River Area. A census tract level UHI was calculated using indicators of employment, income, and educational attainment. The UHI is a unitless and continuous measure (between 0 and 1). The relationship between UHI (2000 and 2010 data) and ABP was examined using a linear regression model, adjusted for age, sex, race, and family socioeconomic status. Results: Higher UHI was associated with lower ABP, with a 3.15 mmHg and 2.72 mmHg drop in 24-hour systolic and diastolic ABP with 1 unit increase in UHI, respectively (2000 data; p=0.010; p=0.020). The 2010 data showed similar trends, with an increase in UHI linked to a 2.66 mmHg decrease in mean 24-hour systolic ABP (P=0.042), with the diastolic ABP reduction (1.74 mmHg) in the same direction though not statistically significant (p=0.088). Conclusions: This is one of the first studies to delineate the correlation of ABP with UHI. Our results show that a higher UHI is associated with lower systolic and diastolic ABP, underscoring the influence of aggregate indicators of SDOH on individual health outcomes. Our results support the utility of the UHI as a tool to inform health policymakers on disparities on a sub-county level thereby informing targeted interventions to address these disparities.

Theoretical framework to develop an urban health index using built environment variables: the case of Ferrara, Italy

The quality of our habitat strongly determines the well-being of both our society and us as individuals. The Urban Health (UH) index is an emerging tool for decision-makers to bridge the disparities in the quality of life in cities. Our study assesses the quality of the built environment as a proxy for urban health and proposes a theoretical framework for constructing a UH index. We first conducted a literature review and statistical analyses to select and screen a comprehensive array of urban health indicators, and then used Principal Component Analysis (PCA) to obtain the indicators’ weights and build the UH index. On applying the framework on the city of Ferrara, Italy, we obtained promising results with four interpretable principal components explaining the contextual conditions. The autocorrelation of the UH index (Moran’s I = 0. 795) demonstrated strong clustering, with very healthy urban census tracts located within the city centre and decreasing overall urban health in peripheral census tracts.

Methodological Approach to Assessing the Quality of Public Health

Introduction: The article describes a methodological approach to elaborating the public health quality index used to reflect the true size of the medical and social resource of the society. The method of calculation takes into account both social and medical components. The public health quality index is calculated in accordance with the idea that a certain category of people has more opportunities to perform a social function. The proposed approach makes it possible to move from general assessments of public health to true ones. Objective: To develop a methodological approach to calculating the public health quality index. Materials and methods: To calculate the public health quality index, age ranges of people were selected, considering their physical fitness to perform social functions. To improve the accuracy of the assessment, each social function was weighted by systematizing expert assessments. The calculated Kendall concordance coefficient (0.7) demonstrated a high degree of expert consistency. The index was calculated considering recommendations of “The Urban Health Index: A Handbook for its Calculation and Use” (2014) by the World Health Organization. Results: According to expert opinions, the most significant social function is the ability of fertile women to realize their reproductive function while the least significant is the ability of elderly people to continue working in the next 5 years after retirement. The aspect related to the ability of men to reproduce has been also considered of great importance. Conclusion: During the study, the question was raised about the possibility of clarifying the methodology for calculating the public health index given the goals of public administration. This index should be considered as a monitoring tool available in the current period to counter emerging public health challenges.

The State of Public Health in Constituent Entities of the Russian Federation in Times of a Large-Scale Epidemiological Challenge: The Example of the COVID-19 Pandemic

Introduction: In 2020–2022, Russia, like the rest of the world, faced the COVID-19 pandemic. The necessity to overcome its challenges has led to the expansion of powers of the regions. To improve public policy, it is expedient to evaluate the effectiveness of measures taken by the regions for public health preservation. Such an evaluation is proposed to be carried out using the public health index, which requires the development of appropriate methodological approaches. Objective: To develop and test a methodological approach to analyzing the effectiveness of public policy measures in terms of preserving public health. Materials and methods: This work continues a series of studies on establishing the public health index in the Russian Federation, which has already developed an approach to calculating this indicator in view of medical and social resources of the population. The approach is based on the recommendations of the World Health Organization standard "The Urban Health Index". The evaluation of the effectiveness of public policy measures involves the implementation of several stages for calculating the public health index and the classification of Russian regions depending on the degree of its change for 2019-2022. When performing calculations, correlation analysis is used to identify indicators that do not contradict each other. Through the normalization of indicators, as well as the calculation of average geometric values, the calculation of the public health index is carried out. The data for calculating the public health index are taken from the website of Rosstat and the Ministry of Health of Russia. Results: We established deterioration of public health indicators in most regions. We believe that this finding is primarily related to the COVID-19 pandemic as a large–scale challenge. In 2022, the public health index for the Russian Federation has decreased by 13.15 % compared with 2019. The largest decline has been observed in the Saratov Region (69.14 %). At the same time, an increase in the public health index has been registered in several regions, e.g. by 6 % over the study period in the Tyumen Region. Conclusion: The analysis of the components of the public health index makes it possible to ascertain the cause of public health worsening in the region and to assess its determinants. Having classified the regions, it is important to identify the determinants of public health that can be influenced through public policy instruments.

Ecological–social–economic system health diagnosis and sustainable design of high-density cities: An urban agglomeration perspective

• The ECCDMM was proposed firstly to study the health of HDCs. • In the high-quality development stage of HDCs in developing countries, ecosystem quality remains a decisive factor for HDCs health, while the main influencing factor is social system development level. • In 2018, 50% of the cities in Yangzi River's high-density urban agglomeration are in a healthy state and 50% are in a sub-healthy state. Affected by various urban diseases, the sustainable development of high-density cities (HDCs) is under tremendous pressure. The health evaluation methods of HDCs, such as the emergy method and urban health index evaluation method, have difficulties in reflecting the internal mechanism of the system with non-uniform evaluation indices. The Emergy Coupling Coordination Health Diagnosis Model (ECCHDM) was proposed to study the health of sustainable cities and the design mechanisms. The Yangzi River urban agglomeration is taken as an example for practical research. Results show that: (1) ECCHDM is reliable and reasonable in investigating and evaluating the mechanism and health of urban systems; (2) In the high-quality development stage of HDCs in developing countries, ecosystem quality remains a decisive factor for HDCs health, while the main influencing factor is social system development level. (3) In 2018, 50% of the cities in the Yangzi River urban agglomeration are in a healthy state and 50% are in a sub-health state. The proposed research methods can also be applied in the planning and design of HDCs in other developing countries.

Calculation of the Public Health Index in the Regions of the Russian Federation

Introduction: The COVID-19 pandemic has demonstrated the need to improve methods of public health assessment and approaches to the development of a system for its monitoring in the Russian Federation. Public health represents a sociomedical resource of the society, deterioration of which has a negative effect on the potential of the society to resist emerging threats. Within a series of previous studies, the authors have developed a methodological approach to calculating the public health index, the monitoring of which will facilitate managerial decisions aimed at strengthening of the potential of public health. Objective: To test a methodological approach to calculating the public health index in the regions of the Russian Federation. Materials and methods: To estimate the public health index, we applied an original methodology specially developed with account for strategic goals outlined by the Russian President and provisions of the WHO Handbook for calculation and use of the Urban Health Index. It includes correlation assessment and standardization of parameters. The components of the public health index were selected in view of the requirements established by the presidential decree on preserving the population of the country, developing the human potential, and strengthening national defense capabilities. Results: We calculated Russian regional values of the public health index for the year 2019. The year selection was determined by the absence of significant biological challenges, currently posed by the COVID-19 pandemic, and the aftermath of the pension reform. The estimated mean of the public health index in the Russian Federation in 2019 was 0.238, with extremes established in the Yamalo-Nenets Autonomous Okrug (0.458) and the Kurgan Region (0.036). Conclusions: Public health monitoring involves tracking of achieved values of the public health index and its individual constituents as they allow judgment on the potential of the society to counteract external threats. Further research should be aimed at analyzing changes in the public health index in the regions of Russia during and after large-scale biological and social challenges. It seems expedient to consider the issue of creating a national information portal devoted to public health problems in the country.

Methodological Approach to Organizing Public Health Monitoring in the Russian Federation

Introduction: The World Health Organization has defined the term “public health” as a sociomedical resource and potential of the society but no common methodological approach to its assessment and implementation in the public administration system has been proposed so far. Our study reveals a methodological approach to organizing public health monitoring in the Russian Federation. The relevance of this study is related to the need to focus government regulation on improving the quality of life of citizens, which cannot be achieved without duly monitoring of public health, subsequent managerial decision-making, and ensuring the continuity of health care. Objective: To develop a methodological approach to organization of public health monitoring. Materials and methods: Foreign and Russian experience was reviewed and analyzed based on 37 regulations and scientific papers of foreign and domestic authors published from the year 2008 to the present. We have also systematized guidelines issued by the World Health Organization, the International Organization for Standardization, and the Organization for Economic Cooperation and Development to identify mandatory components of public health monitoring. The OECD “Handbook on Constructing Composite Indicators: Methodology and User Guide” and the WHO “Urban Health Index” are used in determining the procedure for calculating public health indices. Results: We have developed the first methodological approach to constructing monitoring of public health in the Russian Federation that includes criteria of its evaluation as a sociomedical resource, involving calculation of the strategic and operational index of public health status. This approach reveals the order of implementation of organizational and process elements. Organizational elements are related to monitoring administration while process elements reveal the procedure for calculating public health indices. In addition to determining the indicative and critical values of the indices, it also seems appropriate to monitor individual indicators used in calculating the indices, such as the size of “population of pre-reproductive age”, “population under the working age”, “population covered by vaccination”, etc. Conclusion: The implementation of the methodological approach will ensure both the overall control of public health and monitoring of its individual areas. The calculation of the operational index will facilitate adjustment of actions of the authorities on a monthly basis while the assessment of the strategic index will increase the effectiveness of activities implemented within the framework of the strategic planning system.

São Paulo urban health index: measuring and mapping health disparities.

To calculate and map the health inequalities in the city of São Paulo using the Urban Health Index (UHI) methodology. Seven indicators were selected from the Brazilian census: (1) proportion of households with access to sewage systems, (2) proportion of households served by regular waste collection, (3) proportion of households with two or more toilets, (4) proportion of households receiving tap water, (5) average income per household, (6) percentage of white people, and (7) literacy rate. Based on the UHI methodology, all health indicators were standardized and aggregated into a single metric at the census tract level. The UHI scores were ranked and plotted. The disparity ratio and the graph slope were calculated. The correlation between indicators was tested. Results were geocoded to produce a map of health risks. The distribution of index values showed a linear middle section and deviations at each end. The disparity ratio found was 2.95, while the slope was 0.30. All indicators were significantly correlated. The map displayed a typical pattern of health inequality between the downtown and the periphery. The tracts located in the city's downtown had higher UHI values than those on the outskirts. The results of this study presented a visual distribution of health disparities in the city of São Paulo, proving to be a valuable method for identifying areas that require public health attention.

Impact of safe drinking water and clean fuels on health and wellbeing in Pakistan: A spatial analysis

Access to safe drinking water and clean fuels remains a setback for low- and middle-income countries. It has substantially impacted people's health and wellbeing worldwide and its improvement would enhance the economic development of any country. In this study, we constructed four versions of the District Health Index (DHI) each with a different set of indicators by adopting the Urban Health Index (UHI) framework and Geographic Information System (GIS) tools to (i) determine the effect of safe drinking water and clean fuels on districts wellbeing, (ii) measure the impact of safe drinking water and clean fuels on disparities/inequalities (disparity ratios and disparity slopes) concerning DHI scores and, (iii) examine the role of safe drinking water and clean fuels in the spatial relationship among contiguous districts in terms of DHI scores. Results of the study indicated that on average, only 17.72 and 18.29 percent of people in each district had access to safe water and clean fuel respectively. Less accessibility towards these indicators reduced the mean score of the Pakistan district's health from 0.37 to 0.25. The inclusion of safe water widened the disparity ratio and diminished the disparity slope. Spatial analysis revealed that Pakistan's district health status was spatially correlated with contiguous districts. Global Moran's I scores confirmed the declined spatial dependence, when safe drinking water indicator was included in composite index. Most of the districts were concentrated in high-high (HH) and low-low (LL) quadrants. A spatial cluster of low-low (deprived/unhealthy) districts in Baluchistan confirmed that comparatively, Baluchistan is the most deprived province which needs government attention and policy maker's prioritizations.

Spatial index relating urban environment to health lifestyle and obesity risk in men and women from different age groups

The challenge in the search for relationships between urban space, physical mobility, and health status, is detecting indicators able to link the environment with healthy life habits. Therefore, the objective was to design an urban index for the identification of urban environment propensity for physical activity (PA) and to determine how it relates to lifestyle and anthropometric parametrization of obesity. Participants (N = 318-60.4% women and 39.6% men) were recruited from a mid-sized city with epidemiology and morbidity rates below the average for the mid-west region of Brazil. Body mass index (BMI) was measured and a questionnaire was applied to gather information about PA and life habits. The spatial urban health index (SUHI) was designed in a geographic information system using data from demographic, environmental and urban physical features. The relationship between BMI and PA was verified with multiple linear regression, controlled for SUHI levels. Regarding the BMI of the population, 69.5% were classified in the eutrophic or overweight ranges, with no effect of gender and age. The SUHI classified 63.7% of the urban area favorable to PA. The PA routine was adequate (≥3 sessions with ≥1 h each) for ~80% of the population, as well as healthy habits such as non smoking (~94%) and non alcohol abuse (~55%). The SUHI strengthens the relationships of BMI to weekly frequency (r = -0.68; t = -9.4; p<0.001) and session duration (r = -0.66; t = -2.8; p<0.001) for the whole group by improving the explanatory coefficient in ~25% (R2Adj = 0.61 to R2Adj = 0.85). The SUHI indicated that the urban environment is able to promote healthy life habits by diminishing the "obesogenic" features of the city when physical structures are planned to facilitate PA, whatever the gender and age group.

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

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

Improvement of Geographic Disparities: Amelioration or Displacement?

Progression of geographic disparities in social determinants of health is a global concern. Using an Urban Health Index (UHI) approach, we proposed a framework of examining the change of geographic disparities in social determinants in small areas. Using the City of Atlanta in Georgia (USA) as a case study, we standardized six census-based social determinant indicators in 2000 and in 2010, respectively, and calculated their geometric mean to assign each census tract a UHI value for 2000 and for 2010. We then evaluated the temporal change of the UHIs in relation to the demographic changes using spatial and statistical methods. We found that Atlanta experienced an improvement in social determinant status and a reduction of disparities in the 10years. The areas that experienced improvement, however, underwent demographic changes as well. This analysis provides support for displacement, rather than improvement, as the underlying factor for apparent change in geographic disparities. Findings suggest the importance of local evaluation for future policies to reduce disparities in cities.

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

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

A flexible urban health index for small area disparities.

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