demography today' leisure series on 6th march 2017: urban environmente and cardiovascular...

March 6th. 2017

Fundación BBVA y CSIC

Urban environment and cardiovascular

health: The Heart Healthy Hoods

ERC project

Manuel Franco MD, PhDAssociate Professor

School of Medicine, University of Alcala, Spain

Adjunct Associate Professor

Department of Epidemiology

Johns Hopkins Bloomberg School of Public Health, Baltimore

DEMOGRAPHY TODAY

http://hhhproject.eu

First, some questions

• Let´s think first about the place where you live/work

• Let´s think now about the opportunities for being

physically active and mantain a healthy diet

where you live/work

• Let´s think now about the social norms regarding

physical activity and diet where you live/work


Second, some reflectionsabout Madrid


Second, some reflections

about Madrid

• Opportunities / resources for being

physically active and mantain a healthy diet

in Madrid

• Social norms regarding physical activity

and diet in Madrid


Physical activity environment in

Madrid, HHH study

International Journal of Epidemiology 2015, Franco M

Miguel, 45 years old, lives

in Villaverde, Madrid. Low-

income area.

Miguel goes out for a walk

every afternoon to the

park. “I used to run all the

distance of the bike lane

but I started having knee

problems and now I prefer

walking. When I am in a

good mood I can walk all

the way to the next large

neighbourhood.”


Food environment in Madrid,

HHH study

International Journal of Epidemiology 2015, Franco M

María, 45 ys, resident of

Villaverde. Low-income

area.

María and her friends

meet twice per week to

have a dinner snack at

the Dehesa Boyal park, a

pinewood and main park

in San Cristobal. María

lives in Spain for the last

4 years, unemployed for

the last 8 months, and

she often thinks about

coming back to the

Dominican Republic

where her family lives.


Opportunities for cardiovascular health within

Urban Health Research

• By 2050: 66% of the world population will live in cities

• Challenge of aging and chronic diseases already in our cities

• Social determinants as working conditions, unemployment

and poverty are clearly patent in our cities

• Segregation patterns and health inequality trends are social

phenomena measurable in our cities

• Cities, municipalities, districts, offer great (structural)1

opportunities to improve population health

(1) Franco, Bilal and Diez-Roux, J Epidemiol Comm Health 2015

• New sources and types of health and urban data, allong with

novel methodologies and interdisciplinary teams

• Urban health research is directly linked to action


Cities and Health Inequalities

Life expectancy in high income

neighborhood: 85 years

Life expectancy in low income

neighborhood: 66 years

Baltimore life expectancy gap

by neighbohoods: 18 years

El País, 2015, Franco M, Bilal U, Cooper R


Female life expectancy in high

income neighborhood: 88 years

Female life expectancy in low

income neighborhood: 82 years

Madrid life expectancy gap

by neighbohoods: 6 years

Cities and Health Inequalities

Social and Physical Urban

Environment and CV Health:

The Much Needed

Population Approach

Manuel Franco MD, PhD

Starting Grant 2013

Start Date April 1st 2014

ERC Starting Grants

FUNDING 1.5 million € for 5 years

OBJECTIVE To encourage independent careers of excellent investigators providing enough support in the critical moment (starting to develop their own team).

ELEGIBILITY PI must have a PhD degree in the last 2 to 7 years. Available to non-EU researchers.

REQUISITES At least one relevant publication without his/her thesis advisor

At least 50% effort

PROFILE High potential, project with potential social Impact in Europe.

Presenter’s Name

Date

Physical

Environment

Social

Environment

SOCIAL

EPIDEMIOLOGY

Studies social determinants of disease

Methodologies from Social Sciences and Public Health

Focus on population preventive approach

Addresses growing social inequalities in health

First cause of death in Europe (47% of all deaths in 2010)

Increasing prevalence (50 mill. patients in 2009 in Europe)

Rising social and economic costs (196 billion € in 2009)

Traditional medical preventive approaches are individual

Cardiovascular

Health

Presenter’s Name

Date

Physical

Environment

Social

Environment

Cardiovascular

Health

HEART

HEALTHY

HOODSObesity

Physical

Activity

Diet

Alcohol

Physical Activity

Environment

Food

Environment

CVD

Smoking

Tobacco

Environment

Social and Physical

Environment

Individual

Cardiovascular Health

Alcohol

EnvironmentNe

igh

bo

rho

od

So

cio

ec

on

om

ic S

tatu

s

Unem

plo

ym

ent

–E

ducation –

Povert

y

Imm

igra

tio

n C

om

po

sit

ion

Ind

ivid

ua

l S

ocio

eco

no

mic

Sta

tus

Occupation –

Incom

e –

Education

Gen

der

–Im

mig

rati

on

Heart Healthy Hoods Study

Main Goal


To study the impact of the

social and physical environment in terms of

tobacco, alcohol, food and physical activity

on residents cardiovascular health

Heart Healthy Hoods

Overall Objectives


1. To include a qualitative approach to understand the

context and meanings of the urban environment in

relation to cardiovascular health

2. To develop measurements to characterize the

social and physical urban environments in a

systematic and accurate fashion

3. To understand the already known relation between

the urban environment and cardiovascular health in

the United States with this relation in Europe

Heart Healthy Hoods

Secondary Objectives


To provide scientific evidence to researchers, the

general population and policy makers to intervene at

the population level to prevent the first cause of

death in Europe.

HHH overarching objective

Policy and research implications


Photography

KnowledgeDissemination

Citizen Science

Epidemiology

Health Sociology

University of Salamanca

Johns Hopkins School of Public Health

Geography

University of Alcalá

CRESH Edinburgh

LSHTM

Interdisciplinary team

PI: Social Epidemiology

University of Alcalá

Johns Hopkins School of Public Health


INTERDISCIPLINARY TEAM

https://hhhproject.eu/people/

Madrid Team

International Collaborations

https://hhhproject.eu/people/madrid-team/


HHH Kick off meeting

September 2014


21 Districts

128 Neighborhoods

2.412 Census Sections

(≅1.500 ps)

3,2 Mill. Residents

HHH will analyze the

Integrated Primary Care

Health System Electronic

Health Records Database of

1,4 mill. residents 40-75 ys.

MADRID MUNICIPALITY


HHH Study Design

Baseline VisitCohort

Study

1st Database

MiningWhole

Population

Study4 yr follow up

2,576 participants Final Visit

Final Database

Mining1,4 million people

Environment

Tobacco

Alcohol

Food

Physical Activity

1st Assessment 2nd AssessmentNeighborhoods

Multilevel Association

Analysis


To describe CV profile of adult population (40-75 years)

from the city of Madrid, and to investigate the

association between social and physical features of

the urban environment with populations’ CV health

WHHHole-Population Study

Using…

• Electronic Health Records for CV Health (Almost 1,5

million people).

• Several secondary databases for urban environment.

Overall Objective


Primary Health Care Centers of MadridCohort HHH centers

1 C.S. ADELFAS

2 C.S. ALPES

3 C.S. ANGELA URIARTE

4 C.S. ARTILLEROS

5 C.S. BARAJAS

6 C.S. CARAMUEL

7 C.S. CERRO ALMODOVAR

8 C.S. CIUDAD JARDIN

9 C.S. DAROCA

10 C.S. DR. CASTROVIEJO

11 C.S. ELOY GONZALO

12 C.S. ENTREVIAS

13 C.S. ESPRONCEDA

14 C.S. FEDERICA MONTSENY

15 C.S. FUENCARRAL

16 C.S. GARCIA NOBLEJAS

17 C.S. GENERAL RICARDOS

18 C.S. GUAYABA

19 C.S. IBIZA

20 C.S. LAGASCA

21 C.S. LAS CORTES

22 C.S. LAVAPIES

23 C.S. LOS YEBENES

24 C.S. MAR BALTICO

25 C.S. MONOVAR

26 C.S. PAVONES

27 C.S. SAN ANDRES

28 C.S. SAN FERMIN

29 C.S. TORITO

30 C.S. VALDEBERNARDO

31 C.S. VILLAAMIL


The CoHHHort Study

Main Objective:

To study the association between environment

characteristics and diet, smoking, physical activity,

alcohol consumption, and cardiovascular risk

Target Population:

- Men and women between 40 and 75 years old

- Free of cardiovascular disease

- Residents of Madrid city

- Origin: Ecuador, Colombia, Perú y Bolivia


21 Madrid districts

31 Primary Healthcare centers

Sample size

N=2576

370 Physicians and

nurses trained

The CoHHHort Study


Clinical visit

Telephone

survey

Biological

cardiovascular risk

factors

Behavioral

cardiovascular risk

factors

The CoHHHort Study

Variables:


2017Follow-up

2018

Follow-up

2019

Follow-up

2020

Clinical visit

+

Telephone

survey

Electronic

health

records

CVD

outcomes

Clinical visit

+

Telephone

survey

Electronic

health

records

CVD

outcomes

Cohort Study calendar:

The CoHHHort Study


a) Mixed Methods Exploratory Study in a Median

Area of Madrid (Usama Billal)

b) Results by domains

a) Food

b) Physical Activity

c) Tobacco

d) Alcohol

c) Results by working groups

a) Urban Geography

b) Qualitative Research

HHH Analyses and Results


Mixed Methods Approach


Methods (quantitative)

• Cardiovascular Disease:

– Whole population (>99%) EHR through universal health system.

– Validated (1) data on physician-diagnosed: diabetes, hypertension,

dyslipidemia, smoking and obesity.

• Urban environment

– Food: location and type of food stores and food services, directly

measured healthy food availability (brief NEMS-S)

– Physical activity: SPACES audit tool for walkability and bikeability,

SOPARC audit tool for open spaces.

– Alcohol and tobacco: location and type of retailers

References: (1) de Burgos Lunar et al, BMC Med Res Methodol, 2013.


Methods (qualitative)

• 11 semi-structured interviews with key informants:

4 long-term residents, 2 recent immigrants, 1 teacher,

1 community activist, 1 health care provider, 1 public

health officer, 1 local food store owner

• Questions on health and the environment, focusing

on sociodemographics, food, alcohol, tobacco and

physical activity.

• Analysis by triangulation incorporating an

interpretative phenomenological analysis.


Exploratory Study Sociodemographic Profile

Primary Health Care Records

• Total Pilot Area Population: 15,751

• Population in the Primary Care Health System Geocoded to

census section level: 14,857 (95%)

– Possibility of analyzing data for 1.4 million people

• Population 45-106 ys. old: 7,252

• Diabetes Prevalence: 12%

• Diabetes Control (HbA1c<7): 63%

• Hypertension Prevalence: 34%

• Dyslipidemia, all types: 32%

Measuring neighborhood relevant

cardiovascular health exposures


42 neighborhoods in Madrid

(2 neighborhoods per district selected

according to extreme sociodemographic

characteristics)

In each neighborhood we select the

“median” census track in terms of

educational level, immigration, density of

business and age.

Representative area of the municipality of

Madrid in terms of sociodemographic

characteristics

Measuring neighborhood relevant

cardiovascular health exposures


a) Mixed Methods Exploratory Study in a Madrid Median Area


a) Food (Julia Diez) b) Physical Activity

c) Tobacco

d) Alcohol


a) Urban Geography




Cross-city differences


Walking access to healthy food

MADRID BALTIMORE

Preventive Medicine 2016, Diez J et al.




a) Food

b) Physical Activity (Pedro Gullón) c) Tobacco

d) Alcohol


a) Urban Geography




Urban Environment and active

transportation in Madrid


Madrid Systematic Pedestrian and

Cycling Environment Scan (M-SPACES)

- Function

- Safety

- Aesthetics

- Destinations

M-SPACES AUDIT TOOL

Pedro Gullón et al. September 2015 Journal of Urban Health,


Physical Activity Results

Pedro Gullón et al. September 2015 Journal of Urban Health,

Pedro Gullón, Usama Bilal, Alba Cebrecos, Hannah M. Badland,

Francisco Escobar, Iñaki Galán, Manuel Franco

Under Review: International Journal of Health Geographics

Socioeconomic Determinants of Small-

Area Walkability in a European city like

Madrid: The Heart Healthy Hoods

Project


Figure 1. Spatial distribution of Walkability Index (a)

and Socio-Economic Status Index (b) by deciles in

the census section (N=2415) of the city of Madrid




a) Food


c) Tobacco (Xisca Sureda) d) Alcohol


a) Urban Geography



Tobacco retail environment,

outdoor smoke-free policies

and smoking

HHH Ancillary Study

PI: Xisca Sureda

Co-investigators: M. Franco, U. Bilal, FJ Escobar, A Navas, E. Fernández

Alcalá University, ICO Barcelona, Johns Hopkins Bloomberg School of Public

Health, Columbia University

Funding: European Research Council Starting Grant 2013 HeartHealthyHoods

Agreement n. 336893 and Instituto de Salud Carlos III (PI15/02146)

Tobacco in HHH


1. To describe tobacco environment in neighborhoods in

Madrid city in terms of:

1.1 Tobacco availability (point of sales of tobacco,

volume of sales)

1.2 Signs of tobacco consumption outdoors

(hospitality venues and other public spaces)

1.3 Second-hand smoke (SHS) exposure in terraces of

bars and restaurants

2. To determine differences between tobacco urban

environment, smoking behaviour and SHS exposure


Outdoor tobacco consumption signs




a) Food


c) Tobacco

• Alcohol (Madrid, Barcelona, Edinburgh, Baltimore)

a) Results by working groups

a) Urban Geography

b) Participatory Action Research PHOTOVOICE


Alcohol urban environment,

and the implementation of

regulatory policies

HHH Ancillary Study

PI: Xisca Sureda

Co-investigators: M. Franco, J Pearce, M. Lazo-Elizondo, FJ Escobar,

MV. Sandín

Alcalá University, Johns Hopkins Bloomberg School of Public Health,

University of Edinburgh

Funding: European Research Council Starting Grant 2013 HeartHealthyHoods

Agreement n. 336893 and Plan Nacional sobre Drogas (2016I047)

Alcohol in HHH

Sureda X, Villalbí JR, Espelt A, Franco M. Living under the influence: Normalization of alcohol consumption in our cities. Gac Sanit. 2017; vol31(1): 66-68

1. To describe alcohol environment in in terms of availability,

promotion and signs of consumption.

1.1 To determine possible differences between alcohol

urban environment and alcohol drinking behaviour.

2. To conduct a participatory-action research strategy

(Photovoice) to better understand the attitudes and practices

in relation to alcohol consumption

3. To compare the regulation of the alcohol urban

environment and its implementation in Madrid and Barcelona

and how these policies determine possible differences

OHCITIES instrument

Sureda X, Espelt A, Villalbí JR, Cebrecos A, Baranda L, Pearce J, Franco M. Development and validation of the OHCITIES instrument: Assessing alcohol urban environments in the Heart Healthy Hoods project. (submitted)

OHCITIES Validation Results


53,7% with promotionassociated to the outlet

88,2% with promotionassociated to the outlet

Sureda X, Espelt A, Villalbí JR, Pearce J, Franco M. Alcohol in the city: wherever and whenever. (submitted)




a) Food


c) Tobacco

d) Alcohol (Xisca Sureda)


a) Urban Geography (Alba Cebrecos)




The aim was to design and implement a multicomponent

method based on Geographic Information Systems to

characterize and evaluate environmental correlates of obesity:

the food and the physical activity urban environments.


መf x =1

𝑛ℎ

i=1

n

Kx − Xih

Kernel Density Estimation

(KDE)

WALKABILITY

HFAI

HFAI & WALKABILITY

STUDY AREA

METHODOLOGY


RESULTS




a) Food


c) Tobacco

d) Alcohol


a) Urban Geography

b) Qualitative Research (Paloma Conde)



Neighborhoods under change and residents´ health

perceptions: The HHH qualitative study

Objectives:

• To describe the social and neighborhood changes occurring in a

middle-low socioeconomic area of Madrid according to their residents.

• To explore how these neighborhood changes are connected to

residents’ health perceptions.

Methods:

Exploratory qualitative study within 12 months (from January 2014 to

January 2015) using 16 semi-structured interviews. Residents +

professionals.

Interview Topic guide:

- Neighborhood description

- Uses of the neighborhood

- Health in relation to neighborhood

Conde P, Gutiérrez M, Sandín M, Díez J, Rivera J, Franco M. Neighborhoods under change and residents´

health perceptions: The Heart Healthy Hoods qualitative study (submitted)


Breakdown of

traditional forms vs

Individualism

Rapid pace of life

(-) Lack of time

Change in

gender/age role

Generation

and cultural

fracture

NEIGHBORHOOD

CHANGES

Economic crisis

Impoverishment

and lack of

resources

Long working hours

SOCIAL

CHANGES

New

Demographic

composition

New socio-

cultural

values

Economic

aspects

HHH Qualitative results RESIDENTS’ HEALTH PERCEPTIONS

Loss of trust relationships

(-) Loneliness and lack of social

support

New diet practices

(-) Not very healthy diets

New uses of public spaces

(-) Loss of public space use

Associative networks support

(+) Strengthen self-esteem

(+) Decreases anxiety

(+) Increases social cohesion

Participation of elderly in health

promotion and education programs

(+) Promotes Active ageing

Unemployment and job insecurity

(-) Unhealthy diets

(-) Stress, Anxiety

(+) Intergenerational solidarity


HHH Ancillary Studies

1. Photovoice Villaverde: Neighborhoods and Food

2. Johns Hopkins PhD Retrospective HHH substudy

3. Smoking in the City HHH substudy

4. Qualitative HHH substudy

5. Alcohol in the City HHH substudy


HHH Current

Scientific Achievements

• 8 international papers and 4 book chapters

• 5 funded ancillary studies

• Bilingual photobook and public exhibitions

• 3 Predoctoral and one Erasmus master fellowships

• Intramural: 3 research awards Universidad de Alcalá

• 4 travel grants for US (Joel Gittelsohn and Luisa Borrell)

and UK researchers (Daniel Lewis and Jamie Pearce)


• HHH participants

• HHH Madrid team and collaborators

• Different funding agencies:

• European Research Council

• Ayuntamiento y Comunidad de Madrid

• Fondo de Investigación Sanitaria

• Plan Nacional de Investigación

• Plan Nacional Sobre Drogas

• Fundación Mapfre

• Center for a Livable Future, Johns Hopkins

Acknowledgements


HHH TeamThank you very much !

March 6th. 2017

Fundación BBVA y CSIC

Thank you very much !

Manuel Franco MD, PhDAssociate Professor

School of Medicine, University of Alcala, Spain

Adjunct Associate Professor

Department of Epidemiology

Johns Hopkins Bloomberg School of Public Health, Baltimore

DEMOGRAPHY TODAY

demography today' leisure series on 6th march 2017: urban environmente and cardiovascular...

Health & Medicine