A Mixed Methods Study On Urban Health And

Community Resilience In The Lagos Metropolis.

Ebele Mogo

DrPH Candidate,Community and Behavioural HealthColorado School of Public Health

What are healthy and resilient cities?

●Resilient cities are able to bounce back from stresses (Rockefeller Foundation, 2014)

● Examples of stresses: ebola, shootings, hurricane, cholera outbreak

●e.g ebola outbreak: rapid response, fast containment/quarantine people, spread health information, well-resourced healthcare centers, trained health workers, integrated communities, social capital

What are healthy and resilient cities?●Healthy cities work to improve the physical, social environment and community resources for urban residents (World Health Organization, 2015)

●e.g. infrastructure for walking and cycling, streetlights, noise pollution, air pollution, safety, green spaces

●connected to physical activity, hypertension, cancer, psychological well being etc

Study overview/aims● This study used the Lagos metropolis as a case study for

integrating health and resilience into urban development

●Aim 1: Conduct an archival analysis to understand the government’s strategy for urban development

●Aim 2. Administer built environment audits to quantitatively characterize the urban built environment and assess urban health priorities in Lagos

●Aim 3. Administer interviews to government and civil society groups to understand urban governance priorities

Model

Why The Lagos Metropolis?

● Fastest urbanizing region of the world (Coker et al, 2015)

● Most populous region of Nigeria and 7th fastest growing city in the world (Nigerian Population Commision, 2014)

● Population growth rate of 6-8% (Okunlola, 2015)

Putting it in perspective●Population of 21 million (Ilesanmi, 2015, Nigeria

Population Commission, 2014)●Population density of 20000 people per km squared

(Helsinki University of Technology, 2015)●Compare to Denver: 2.8million people, 1,561

people /square kilometer), population growth rate of about 2.8%●Lagos is relevant globally, and given paucity of

urban research on African cities (African Center for Cities, 2016)

A qualitative study on urban health and resilience governance in metropolitan Lagos

Methodology● Key informant interviews were administered to 16 civil

society and government workers

● These practitioners were chosen due to expertise working on urban health issues such as health, environment, housing and safety

● Questions concerned urban development priorities, the priority accorded to health issues and the key actors for implementing said priorities

● e.g. Are there any documents or frameworks that guide your decision-making processes? If so, please describe.

Themes: Environmental management● motor-vehicle and generator emissions● waste management● enforcement of regulations concerning waste

management● climate change mitigation and adaptation especially

flooding● education of communities

●“The long term goal is to make sure that the environmental situation in Lagos is very convenient to the people living in Lagos, very attractive, and also to make sure that it’s neat, it’s proper and it could be a tourist center for people visiting from all over the world.”

Themes: Housing and Human Settlement

● managing the housing deficit ● residents living in buildings prone to collapse ● enforcing housing regulations● civil society concerns about the exclusion of low income

groups

●“Housing for us is almost like a forerunner of other things. Everything I am telling you about housing is applicable with respect to healthcare…When people’s livelihoods are not settled, when their lived environment is in a state of flux then you cannot even determine how they have access to potable water, other services, schools, healthcare systems and all of that”

●“They are confined to the fringe of the city. They are invisible to the city. They are invisible to planners. They are invisible to budget officials. Whereas in an election year, the same officials who denied their existence who for example will tell you that Makoko is not a fixed address because Makoko is on water but during the election year that Makoko…is like a beehive of political activities”

Themes: population engagement and stewardship of the environment ● poor information/language barrier● spatial exclusion● poor maintenance culture● poverty● mistrust of government and civil society

●“People are not ready to learn. They are just

obstinate”

Theme 4: challenges of overpopulation ● resource constraints● security challenges● mental health and infectious diseases ● noise and air pollution (generators, traffic, wastes)● environmental vulnerability

●“The only way government can face this issue of population is to generate enough revenue and that is what government is doing…It usually means more taxes”

Themes: Partnerships● inter-sectoral partnerships: happened as needed but were

not well-defined● intra-sectoral partnerships: decision making mostly took

place at the higher levels of power● public-private partnerships were growing as a financing

innovation● partnerships with iNGOs to meet technical and financing

needs● partnerships with local civil society to access communities

Priority areas identified for public health● Need for greater inclusion e.g. with regard to housing solutions

● Need to involve communities in planning and implementation

● Need to ensure goal alignment and incentivize long term, systemic and preventive health efforts in PPPs

● Need to incentivize inter-sectoral, intra-sectoral and systemic thinking

● Need to build political will for health as a shared priority between sectors

An audit of urban neighbourhoods in metropolitan Lagos, Nigeria

What is the urban built environment?

● Physical features such as design, land use diversity, urban sprawl, walkability, greenery, active transportation, safety

● They are related to physical activity, obesity, injury, violence, mental health, cardiovascular diseases

●The population growth rate of Lagos is roughly equivalent to rate of slum growth (Clemans, 2015)

●Low and middle income contexts are not well represented in urban public health governance and data collection (Cleman, 2015)

Research goals ● To pilot a neighbourhood audit by Brownson et al, 2004 in

metropolitan Lagos

● To determine the utility of the audit and adapt it to a new context

● To characterize built environment features in this setting

● To yield recommendations for improving the urban built environment for improved urban health

Methodology● Piloted the audit with two assistants until at least 85%

agreement was reached between raters

● Informal features were added to the audit

● okadas (motorcycles)● informal on-street parking● mai-guards (informal security guards) and formal security

guards● molues (informal transport buses)● keke napeps (tricycles)

Methodology●Administered audits in 3 closed segments + 3 open

segments per ward●Audited 4 wards per local government●Audited 1 low income, 1 middle income, 1 high

income local government●(3+3) x 4 x 3 = 72 street segments audited

Methodology●Descriptively analysed the audit data

● means, medians and standard deviations for continuous data

● modes and percentages for categorical data● assessed variability by aggregate income of the local

government● assessed variability by whether the segment was enclosed

or open

Methodology●Calculated Cronbach’s Alpha to measure reliability

of the audit●Used an exploratory factor analysis to investigate

the factor structure

Results ● Built environment features fell into three categories:

● residential destinations e.g single family homes, multiple family homes

● commercial destinations e.g shops, restaurants● few public destinations (mosques, churches, health centres

and schools)

● Primarily informal provision of goods and services, waste management, security, transport and parking

● There was a high level of disorder, poor waste management, inadequate road infrastructure and an absence of active transportation infrastructure in neighbourhoods

Results● Individual attempts to safeguard security through barbed

wires, electric fences, broken glasses and hiring security personnel

● Significant noise pollution with generators contributing to noise

Results●The Cronbach’s alpha of the audit was 0.4584

(moderate significance)●The exploratory factor analysis showed a two factor

structure capturing ● residential locations and community services● commercial services

Key takeaways● The built environment could be characterized into residential,

community and commercial features

● The following intervention areas were identified for public health:

● physical disorder● power supply● security● waste management● neighbourhood governance● road infrastructure● provisions for active transportation

Key takeaways●Auditing efforts in similar settings need to account for

informality ●The neighborhood level built environment is underserved

by government services●Subsequently, it is worthwhile to explore leveraging informal service provision for public health●To improve the built environment, efforts to build

community ownership and participatory governance of neighbourhoods are needed

Is Lagos State planning for urban health and community resilience?

Methodology●Use the Lagos metropolis as a case study on how the health sector can provide a public health perspective for policy

● Integrated three frameworks: the social determinant of health, the resilience framework and the socio-ecological model

● Reviewed government archives to identify key documents

Methodology●Identified documents:

● the Lagos State Development Plan● the 2016 Budget● the 2013 Digest of Statistics ● the Manifesto of Governor Akinwunmi Ambode

Methodology●Carried out a content analysis of the documents

●This involved:

● reading through the documents● noting the categories of information● organizing similar concepts into categories● organizing similar categories into major categories● comparing and the collating categories from each archival

document

Themes● Environment: environmental management, housing, slum

reduction, mortgage provision and enforcement of regulations

● Transport: road infrastructure and diversification of transportation

● Poverty and unemployment: simplify business creation, skills development, power supply, job creation

● Food security: providing farming and fishing estates, incentives to support agro-processing and production, funding for farmers

Theme● Safety: improving the capacity, resources and data of the

police force, and building partnerships with communities, protecting the vulnerable

● Health: improving the quality and affordability of health services, private sector engagement, sector standards, capacity and citizen involvement

● Civic participation : improving inclusion and participation in politics, supporting marginalized groups, closing the wealth gap and ensuring community cohesion

Key takeaways● Priorities showed a focus on issues without a focus on

processes ● There was a top-down transactional relationship

between government and citizens

● Strategic plans need to be supported by locally relevant measures, data and engaged communities

● Surveillance systems needed to be strengthened through strengthened capacity and data disaggregation

Key takeaways● The urban context needs to be a priority intervention area for

public health

● Health priorities need to move beyond from a sole focus on medical institutions to the urban living context as a determinant of health

● In line with this, there is need to strengthen capacity to govern, collect data on and intervene on the urban living environment as a determinant of health

Overview and implications of the project

● This project aimed to contribute a public health lens to urban development of the metropolis and to create preliminary evidence for larger scale studies by:

● using quantitative methods to characterize the built environment features and priority areas for intervention

● using qualitative methods to critically evaluate governance priorities for the metropolis

Recommendations for action● There is need for action on the urban neighbourhood as

a determinant of urban health● This will involve:● a strengthened focus on urban environmental

management● a higher priority on housing as an urban health

determinant● investing in infrastructure maintenance and active

transportation● stronger surveillance systems to inform strategic

action

Recommendations for action●Participatory urban governance needs to be operationalized●This will include:

● leveraging informal service provision arrangements● moving from transactional governance to community

engagement● developing intra and inter-sectoral cooperation

Limitations of this project1. The auditing protocol was subjective although inter-

rater reliability was used to minimize this challenge

2. There was no qualitative survey to understand what

the built environment characteristics observed

meant to residents.

3. Archival analyses are limited by survival bias of data

Room for further research● how to strengthen governance mechanisms for urban health

- public private partnerships, informal sector, civil society

● incentives for sharing power between higher and lower levels of power and strengthening intersectoral cooperation

●rigorous and objective ways of assessing the urban environment in African settings where features are complex, informal and formal overlap

Room for further research●to assess built environment features in African cities to produce a standard set of features, and variations by city.

●test findings on a larger scale and examine the place of health and resilience in other city planning processes in Nigeria and across Africa.

Therefore yielding a regional understanding of challenges and opportunities to improve urban health and resilience.

Room for further research● how to ensure improve governance at the grassroots levels -

neighbourhood domains were poorly maintained and underserved by government resources

● how individuals conceptualize their sphere of responsibility in urban settings and how to expand it

● how to leverage positive social interactions in neighbourhoods for urban health governance

● how to leverage the informal sector for urban health

Thank you●Committee●Professors and administrative staff●Peers●Friends

●Questions?

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+ For more pictures: www.instagram.com/ebyral