Urban Health Final Exam

case study: asthma in the bronx

On the following slides, we will take a closer look at the problem of asthma in the Bronx It is a much discussed case study Over time there has been progress in addressing underlying environmental injustice issue, but some aspects of it remain highly controversial Key theme: Addressing environmental justice concerns is also tied to creating more desirable neighborhoods, and may have unintended consequences like gentrification The Bronx is home to more than 1.3 million people Poorest of NY City's 5 boroughs, among the most poor urban counties in the U.S. Highest percent black and Latino populations (85.5%) Fewest high school graduates (62.3%) Highest poverty rate is in the South Bronx, with the lowest median income and highest proportion of children living in poverty Was the Bronx always home to so much pollution? No Two key events contributed: 1970s to 1990s: historic zoning changes in NYC While other areas of NYC were rezoning from industrial to residential, many acres in the Bronx were rezoned from residential to industrial use Light industrial use changed to heavy industrial use, too Fresh Kills Landfill in Staten Island closes Handled all NYC trash, finally closed in 1998 after mounting concerns and higher fees for waste disposal So, where did NYC's trash end up? Some 85 new waste transfer stations established in Brooklyn and Bronx to handle trash to ship it out of state Established in areas where land was cheapest and zoning permitted them 70% of all putrescible waste (i.e., subject to decay) is now sent through transfer stations in those areas, which were in and near low-income communities This increased heavy truck traffic and particulates, noise, and fumes Also increased odors, pests and vermin The Bronx in particular became home to many new noxious facilities including waste transfer stations and hazardous materials storage centers Zoning changes may not have been malicious or racist in intent, but resulted in disproportionate burden of pollutants for Blacks and Latinos Weak regulations had no effect on concentration of sites 1990s: environment justice movement in N.Y. emerged Identified a public health crisis: asthma in children is a top concern Highest child hospitalization rates were in low-income neighborhoods in South Bronx Harlem (northern Manhattan) and Central Brooklyn also identified as problem areas In general, there has been an asthma epidemic in many low-income urban areas in U.S. since 1980s Leading cause of hospitalizations of children over one year in age Multiple triggers of asthma, including indoor and outdoor air pollution, pollen, allergies, exposure to second-hand smoke Major air pollutants, such as particulate matter, sulfur dioxide, ozone, etc. linked to asthma Proximity to roadways and type of traffic play a role In the Bronx, neighborhood activists made connections between high asthma rates and concentrations of noxious facilities, including waste transfer stations, bus depots and dense highway networks Operations at these facilities exacerbate asthma because of increased truck traffic, odors, noise and vermin These facilities provide citywide and regional services to 8 million people Necessary to address broader relationship of Bronx to NYC in order to get an effective solution WE ACT: Organization gathered additional data Asthma hospitalization rates by ZIP code and neighborhood for children 0-14 years old in New York City in 2000 Highest rates in the boroughs are in the Bronx (darkest red) Important findings about asthma hospitalization rates for children: In the Bronx, the rates doubled between 1988 and 1997 Compared to New York City as a whole, Bronx rates were 70% higher 200% higher in Mott's Haven/Hunt's Point sections Compared with New York state (excluding NYC), Bronx rates were 700% higher The Bronx has the highest asthma hospitalization rates for children in the nation Historic moment for EJ: In 2006, NYC council approved an updated solid waste management plan for city's 5 boroughs: Includes retrofitting existing marine transfer stations by revitalizing unused garbage transfer stations Would reduce trash hauled to other boroughs for processing Barges will be used to reduce truck traffic in getting the waste to out-of-state landfills The retrofitted 91st Street Waste Transfer station in Manhattan has been VERY controversial A very wealthy neighborhood that includes Gracie Mansion Strong community protest and litigation has slowed down the 91st street station. Currently, it is projected to open in 2016 It will take time to evaluate the result of these initiatives in terms of childhood asthma rates, but declines in the Bronx are expected 2008, Mayor Bloomberg released the "South Bronx Initiative" (SBI) Plan to attract private investment and promote the creation of affordable housing, retail, and office space in the South Bronx Create new construction as well as permanent jobs and lay the groundwork for additional, sustainable growth Utilize existing mass transit access as well as exciting highways - Major Deegan and Cross Bronx Expressways

limiting greenhouse gas emissions

Policies and programs try to reduce the emissions of carbon dioxide, methane and other greenhouse gases Requires action at so many levels to be effective International - Kyoto protocol - U.S. did not sign it and those that did are not all meeting their obligations National: Federal government has set higher fuel efficiency standards for cars, but hard to predict effect; Will take longer to create an economic incentive for reductions in emissions, such as a cap-and-trade systems for carbon dioxide Local policies in terms of land use can have a large impact, especially those that might increase automobile use and single-family homes, which increase fossil fuel consumption Planning for global climate change Rising temperatures pose a number of potential problems Weather events, rising sea levels, etc. Impact of disasters on elderly and other vulnerable populations discussed in previous lectures Need to address and protect public health Requires planning and financial resources Many major U.S. coastal cities are vulnerable Similar issues in seaside resort communities Individuals can also help - their decisions matter Changing diets, recycling, where to live, how to commute, etc.

ideas and theories: early 20th century

City living still perceived to be bad for mental health, but changing ideas as to why Acculturation Formally studies since at least 1918, used in fields of sociology, anthropology and psychology Key concept: Individuals adapt by shifting to cultural values and social norms of new country Part of this entails loosing the health practices and beliefs of their prior country This shift may also expose immigrants to new risks. Discrimination More recent view: acculturation less of a factor in a globalized world It is the influence of discrimination that leads to adverse health outcomes Biophilia - The hypothesis that people have an innate attraction to or need for nature Key proponents: Eric Fromm, psychologist (c. 1964) and later E.O. Wilson (c. 1984), from environmental movement Some research supports this: Patients with views of nature recovered quicker than those looking at brick walls Other studies measuring biological responses to pictures of open space: looking at nature lowered heart rate, blood pressure Chicago public housing study: residents with access to landscaped areas reported better mental health outcomes than those who looked at parking lots and other hard surfaces

Assessment/information tools and sustainability

Communities, urban planners and public health professionals want tools to evaluate proposals, programs and policies But, every tool has its limitations These tools are not decision-making tools themselves The proper use is in informing decision-making Care should be taken not to rely on a tool that doesn't have the capability of doing what it is asked to do Some tools are tied to more formal process (i.e., assessment tools), while others are may be used more generally

Rural living in the US

Cons: Greater social isolation Greater widespread, overall rates of poverty Hospitals, supermarkets are much further away Rural residents tend to walk less than urban residents Higher rates of motor vehicle accidents May have greater water pollution than urban areas Pros: Benefits of natural views, peacefulness Less air pollution than urban areas

urban residence

Despite the large numbers of immigrants in U.S. urban areas, relatively little is known about the relationship of urban residence to health status What's known is that immigrants: Confront difficulties due to language barriers, lack of physician training for relevant health issues, lack of insurance Experience difficulties exacerbated by laws that require or threaten to report immigration status to authorities, or prohibit the provision of care to those without documentation May delay seeking care - this can have consequences Can result in reduced health status, poor health outcome Communicable diseases of particular concern in dense urban areas

information tools

Developed to assess or provide information on specific places or issues Often results in gathering of new information and data Undertaken by researchers, community groups, government agencies, foundations or anybody who has a particular issue with the built environment Results can be incorporated into EISs or HIAs or stand alone activities Or, data may be important, but not incorporated into a new development or policy proposal Data is available that can be used to help assess issues on built environment Varies in terms of accuracy and geographic resolution (i.e., county vs. zip code vs. census tract, etc.) Most are publically available, i.e.: Local government: Planning departments, Boards of health, Assessor data, School data State government: Surveys, Tax information, Some states have more information others Federal government: Health surveys, Labor Department information, Census data, May not be available for local areas

environmental impact assessment

Established by the National Environmental Policy Act of 1969 Also called an Environmental Impact Statement Used to evaluate everything from single development proposals to the impacts of general plans Best for certain types of impacts such as air pollution, storm water runoff, and the output of hazardous chemicals Based on this, projects can be approved, modified or cancelled Limitations Assessment must be tied to specific laws or regulations Highly formal process Limited public involvement Doesn't directly address impacts such as obesity and social capital

fast food

Fried food typically contains more calories (as well as salt and fat) than meals prepared with fresh ingredients, prepared in a lighter style (i.e., salads and sandwiches) Healthier options may still contain, however, more salt than in fresh food prepared at home Knowing the nutritional content of food helps individuals make healthier choices

1991 - First National People of Color Environmental Leadership Summit, Washington, D.C.

Gathering of wide range of activists concerned with environmental justice issues Adoption of principles written by a coalition of local groups- helped establish and frame movement Key concept: all people have the right to a clean and healthy place to live, work, play and go to school Connects existing inequities with respect to peoples of color with historical issues, and contemporary global issues

why obesity is on the rise

Globally, one of the biggest changes to occur during the last four decades has been to the food system. There is now: An increased supply of cheap, palatable, highly processed, energy-dense foods (containing added sugar, fats, salt, and flavor enhancers) Food has become more accessible and convenient, much is pre-prepared More persuasive and pervasive food marketing, particularly to children Increasing body-mass index is strongly associated with urbanization This might result from dietary changes, reduced physical activity in addition to increased psychological stress, and interruption of traditional family links Most countries are also shifting to a more sedentary lifestyle In most high-income countries, the calories needed for daily life has decreased since the beginning of the 20th century, with changes in technology and urbanization

food environments and food deserts

How does the food environment impact health? Determines the availability of specific food types in a community Food types may be more or less nutritious Availability is associated with consumption Key aspects of the food environment: Structure - privately owned, franchise, chain store, etc. Type - including restaurants (fast food and other types, spanning from dinners to gourmet); convenience stores; supermarkets; farmers markets Density - how often? Proximity - how far? Research has found these associations: Fast food restaurants and street food Strongly associated with high intake of salt, animal fat, excessive calories Corner convenience stores Associated with canned goods (higher in salt than fresh), sugar drinks and snacks, lack of healthy choices Supermarkets Associated with greater availability of health choices and greater consumption of fresh foods, including fruits and vegetables Raises issues/concerns over larger food distribution system Farmers Markets Associated with greater consumption of fresh foods, especially those that are locally grown Street food is also very popular in most urban areas It accounts for a large proportion of the food intake, both of adults and children, in many developing countries The total calories, fat and salt of street food is largely unknown, as it depends heavily on ingredients and method of preparation. In general, it is likely to be like fast food. The kinds of food available for purchase differs depending on area: Affluent suburbs: wide variety of food-buying choices, including large supermarkets and specialty stores Low-income, urban areas: often lack a grocery story; corner convenience stores, fast food restaurants/street food more likely; alcohol, tobacco products often readily available Low-density rural locations: small grocery with limited fresh food, gas station/mini marts selling fast food predominate; little within walking distance for most residents; area farms, summer gardens possible, to supply some products Areas with few or limited nutritious options = food deserts

diseases and the homeless

Infectious diseases are common in the homeless, especially tuberculosis, viral hepatitis, HIV infection and other sexually transmitted diseases Often requires more hospital-based care than non-homeless Adolescents have higher rates of sexually transmitted disease, such as Chlamydia and Gonorrhea Female street youth, especially those involved in prostitution, have a higher risk of HIV Injection drug users have a higher risk of viral hepatitis (HVC) Directly observed therapy for lengthy drug regimen; contact tracing of homeless especially difficult No signs or symptoms, can't infect others, but without treatment, greater chance of developing active TB due to weakened immune system; those with HIV at considerably higher risk Chronic diseases in the homeless are often under diagnosed and inadequately treated Include hypertension, diabetes, chronic obstructive pulmonary disease (COPD) Much higher prevalence of hypertension among homeless than non-homeless Care of diabetes is particularly difficult for homeless - diet and coordinating meds with meal times problematic Homeless children are much more likely to have asthma than housed, low-income children (6x national average) Smoking rates are very high (70%) among homeless High risk of cancer, especially among homeless males of the oral cavity and pharynx, larynx, esophagus and lung The homeless are not as likely to receive recommended cancer screening, such as Pap smears (cervical cancer in women) Interventions for smoking cessation and routine screenings would be very useful

health impact assessment

Objective is to give communities and policymakers the information they need to understand what is happening or may happen to the health of a population or community Aims to inform decision-making A voluntary process, with heavy emphasis on public involvement Lends itself to evaluations of housing affordability, mental health services, social capital investments, access to schools, noise, pedestrian injuries, physical activity and obesity Comprised of six main steps (module 12 slide 8) Limitations May be expensive Not mandatory, no legal leverage Can be difficult to include in the development process

ideas and theories on the impact of urban living on mental health have changed over time

Often based on perceptions of foreign-born immigrant populations living in urban areas Heavily influenced by sociology; more recently by psychology as well as the environmental movement Immigrants and their experiences have also changed over time, impacting theories about urban life In the past, many immigrants were from rural areas Today, many immigrants have already experienced the complexities of modern city life and are familiar with other societies due to the media and globalization

food and the built environment

The availability of food in a specific place is shaped by both the food environment and by foodways: Food environment: includes the structure, type, density, and proximity of food outlets We'll look at this in detail now Foodways: processes involved in the production, safety, distribution, purchase, preparation, consumption, sharing—or absence—of food within communities Impacts the types of food available to consumers Both are influenced by the built environment, as well as by the social environment

age-the elderly

The elderly are another especially vulnerable population, due to biological as well as social factors: Our cognitive and organ systems decline due to natural aging process Results in decreased peripheral vision, slowed reaction times and other sensory, physical or cognitive impairments Heavy traffic is a danger to all pedestrians, particularly older people with slower reaction times The elderly have a greater likelihood of death than other age groups in pedestrian accidents Medications often increase their vulnerability Some increase sensitivity to the environment, especially temperature and sunlight Side effects may affect steadiness and decrease mobility The elderly often have special dietary needs, requiring access to a supermarket Balance and walking are common problems, regardless of medication Falling is a major health risk Stairs and uneven surfaces present enormous problems Seniors are often limited by low income In the U.S., many depend on social security and have little other financial resources saved for retirement Many remain in environments they were living in at a younger age that may not be elderly-friendly Many elderly use canes, walkers; some need wheelchairs Many elderly can no longer drive Neighborhoods may not support walking or have adequate public transportation available Many elderly suffer from social isolation Spouse may be deceased, children or other relatives no longer nearby Friends may also be elderly, not able to provide support Social isolation may be decreased in urban areas, where there are greater opportunities for social interaction Older adults with inadequate or no health insurance are less likely to receive consistent primary care (needed for both chronic disease management and immunizations) Typically, Medicare eligibility begins at 65 Need to pay for supplementary coverage About ¾ of older men and women live in metropolitan areas in U.S., which includes both cities and suburbs Typically, adults living in the center city fare less well than those living in the suburbs As with U.S. population overall, the urban population is also aging: More older women than older men in cities Males are more likely to die of chronic illness at a younger age, women more likely to live longer but with disability In cities, older adults are a highly heterogeneous group Wide range of incomes Some remain active and vigorous into extremely advanced age, some do not Some age in place, other seek assisted living situations This leads to different preventative care and access needs at different stages of health There are also many positive aspects to living in an urban area for elderly adults: Pubic transportation, buildings with elevators are huge benefits Greater opportunities for social interaction Greater community services are also important Greater number of community transport vans, greater number of community services and health care facilities Close to academic medical centers and other sources of high-quality care There are also negative aspects for the elderly to city living: Air pollution, especially particulate matter and ground level ozone, acerbates asthma, other lung conditions Particulate matter is also associated with increased hospitalization and outpatient care, and increased cardiovascular conditions Overcrowding increases stress, noise, and may disrupt sleep (an important problem for older adults) Fear of street crime may limit physical activity and promote social isolation Inadequate housing, especially among the poorer urban residents can have a particularly detrimental affect: Probably lack effective heating and air conditioning Poor electrical and heating systems Urban elderly have a higher risk of injury/death in home fires Poorly maintained residences can lead to injuries or falls Particularly bad for mobility issues or disabilities Ways to reduce vulnerabilities for the elderly include: Designing the built environment to take into account the needs of seniors and the disabled Widened sidewalks, benches, elevators, specially designed housing Support programs that let elderly age in place, keeps them in social networks and familiar surroundings Rent, transportation, shopping, and other forms of assistance will most likely be needed Older adults contribute substantially to urban neighborhoods Many are homeowners, with a greater interest and stake in preserving the community Contribute to neighborhood social cohesion, which is associated with lower rates of violence They are stabilizing forces Less likely to migrate than younger adults Affluent retired adults are beneficial to tax base 1990 Americans with Disabilities Act (U.S.) Pertains to all disabled Americans, not just the elderly Established guidelines for built environment Intended to maximize participation of people, but doesn't pertain to private residences Universal design movement Incorporates principles that promote healthy walking and other activities Principles include equitable use, flexibility in use, low physical effort, perceptible information

urban inequality

The movement drew attention to the role of the urban environment and motivated research in this area Poor health and inadequate access to healthy living environments were key features of urban inequality Re-established the emphasis on environmental health, built environment, public health and urban planning

policy and programs

Two state-administered, Federal nutritional subsidy programs: Supplemental Nutritional Assistance Program (SNAP) Commonly referred to as "food stamps" Based on household assets, income and size New system resembles a credit card, less stigma attached Women Infants and Children program (WIC) Open to women during pregnancy and for one or more years if breast-feeding, and to children under age of 5 years Also income-based, may be other eligibility requirements Common issues with SNAP and WIC: Guidelines on what may be purchased, may not fit with individual preferences Not everybody who needs and qualifies for these programs applies for it Many states have burdensome application processes States need to reach out to target populations Food pantries (also called "food banks") and Emergency Food Assistance form a critical part of U.S. food infrastructure Supplied by private non-profits, including churches and other faith-based institutions Often target special populations, i.e., elderly, non-native English speakers, etc. Federal subsidized free school lunch program A major source of nutrition for school children Continues in the summer in some places Provides meals to over 30 million children in over a hundred thousand schools Still, ongoing concerns about the quality of food provided

defensible space

Unsafe areas tend to be where no one is watching or where no one seems to be in control Areas with fewer crime issues are private or semi-private tend to be better maintained Private entries, private yards, windows on streets are best Do not inhibit sightlines or lighting near entrances Defensible space can be implemented in most housing styles, including public-housing Number of units per entrance way kept to a minimum and yards outside entrance should be deeded space Parking should be near units and within sight of them Many features now mandatory in building codes or strongly advised

urban environments

Urban areas are typically polarized environments, combing both risks as well as protective behaviors These environments can present a variety of challenges that diminish health for some groups These environments also present a variety of ways to protect and promote health This polarization is usually related to how goods and resources are distributed within the urban area Cities typically contain extremes of wealth and poverty Wealthier neighborhoods often have easier access to services and goods (such as high quality food) that foster better health The benefits of urban living include a high level of dissemination of health related information and higher levels of community resources, e.g.: Opportunities for physical activity, anti-smoking campaigns, health education among adolescents Preventive paradox: everyone may benefit from being exposed to multiple sources of information and services in an urban area, even lower socioeconomic (SES) groups Example: cigarette smoking rates are typically lower in urban settings than they are in rural areas, regardless of SES status However, not all resources are a part of this paradox Urban health penalty - describes conditions that exist when healthier, more affluent persons leave the city and the remaining residents experience health problems that interact with the city's physical and economic deterioration Poverty zones created by deterioration, that become epicenters for economic decline, job loss and major health problems, including increased violence and drug use Urban areas - even those located within the same country or state - can differ considerably in the extent of this, depending on the local economy and other related factors

evidence based design

Uses outcomes to assess the built environment based upon the work of Ulrich and others Medical outcomes are also used to assess the built environment. Key trends in hospitals/clinics: Individual rooms instead of semi-private to reduce hospital acquired infections Better ventilation and circulation systems Increasing soundproofing to reduce noise levels Construction of healing gardens for patients (above) Used in education and in manufacturing, too: Depending on the facility, outcomes may include absences, injuries, productivity and/or test scores

legal framework

Using laws and regulations is valid and effective, but overregulation can result in a severe, political backlash Must demonstrate what is to be prevented, solved or promoted Use data, use measurable outcomes whenever possible

age-children

Vulnerabilities are not static across the lifespan, but at greater at both the beginning and end of life Children have special physiological vulnerabilities that leave them more vulnerable to environmental insults Children's needs vary over different age levels Bodies are still developing Encountering toxins during certain stages can result in development problems Childhood exposures can result in a lifetime of health problems In the U.S., nearly one third of all children under age 18 live in cities Urban children are more likely to lack insurance, live in family with income below the poverty line, live with a parent who does not possess a high school degree, and live in a single parent home All have health implications In the future, more children will live in cities and urban children in the U.S. will be more racially/ethnically diverse Not all children are equally exposed to positive aspects of growing up in a city: Cities can provide rich institutional environments, such as museums, theaters, libraries, schools, parks, zoos, stadiums, shops, many houses of worship, music halls, etc. Large and diverse peer group and multicultural environments - languages, festivals, foods Lots of variation can be stimulating - traffic, crowds, noises, architecture, different neighborhoods Cities also contain many negative aspects, such as vacant lots and unsafe areas (crime, sex workers, drugs), brownfields, etc. In the U.S., the health status of urban children tends to lag behind children living in non-urban areas, especially for these outcomes: Higher infant morality rate Higher rates of childhood asthma Greater number of injuries due to pedestrian accidents and youth violence Inner city children living in poverty are of particular concern: Housing quality, air quality, and food quality often poor Neighborhoods have heavier burdens of crime, drugs and violence Childhood asthma is a particular problem in cities Factors include: cockroach, rat and mouse allergens; dust mites; deteriorating housing stock; outdoor air pollution, especially due to particulate matter and ground level ozone Among the impoverished, poorer access to care The prevalence of asthma is increasing globally, with disproportional increases among the impoverished Asthma has a high economic burden - it is the largest single cause of hospital admissions in U.S. and major cause of missed school days Children need built environments that foster physical activity and safety Great need for parks and playgrounds Safety from traffic and in play areas The school system is an important factor influencing both health and intellectual development of children

environmental determinism

environment contributes to the propensity for people to behave in certain ways Drove tenement reform, urban renewal, etc.

biological determinism

genes and biological mechanisms contribute or influence health A more contemporary idea, largely used to identify who might be at increased risk for chronic diseases, substance abuse issues, etc.

environmental justice

refers to the organized effort to address these inequities People of color have had longstanding concerns about the safety of their neighborhoods Many environmental justice problems relate to the built environment- i.e., location of waste facilities, highways EJ Movement in the US Began in the1980s and had its roots in community concerns including: Farm workers in California protesting pesticides Unregulated dumping of toxic and hazardous waste in African American communities in the rural south Uranium mining, mineral extraction and hazardous wastes on Native American lands Highway and prison siting in East Los Angeles Location of bus depots in West Harlem and rising asthma rates Common theme: Low-income, communities of color found ways to bring attention to their concerns Normally these groups are under-represented in the mainstream political process Strategies included community organization, demonstrations, letter-writing campaigns, & involvement of civil rights activists Successful communities found ways to take charge of the research process and own study results Drew attention to short comings of the larger environmental movement Mainstream environmental movement was more suburban in nature; perceived to have anti-urban bias Few members of leadership were members of race/ethnicity minority groups Failed to protect low-income neighborhoods from burden of environmental problems Slowly, an off-shoot movement developed to address these issues: Environmental Justice movement

obesity

there has been a global surge in obesity over the last 4 decades that began in most high income countries in 1970s and 80s; afterwards in middle and low income countries Obesity is usually measured by Body-mass index (BMI). As of 2010: Over 1.46 billion adults globally were overweight (BMI >25 kg/m2) Over 502 million adults obese (BMI >30 kg/m2) Over 170 million children (including teenagers) classified as overweigh or obese The global rise of obesity follows a predictable pattern: In low and middle income countries, obesity tends to affect middle-aged adults (particularly women) from wealthier, urban environments In high income countries, obesity affects both sexes and all ages but is disproportionately greater in disadvantaged groups, especially: Individuals of low socioeconomic status living in urban areas Individuals living in low-density rural areas Obesity is caused by a chronic energy imbalance involving both dietary intake and physical activity patterns. Consuming more calories than expended results in weight gain Unchecked weight gain can result in obesity Obesity has serious health effects Raised BMI increases risk for type 2 diabetes, hypertension cardiovascular disease and many cancers Obesity results in premature death and disability In the U.S. and some other regions, obesity is overtaking tobacco as the largest preventable cause of disease burden. While obesity has increased in all countries, there is still wide variation in the prevalence of obesity internationally This is projected to rise, affecting future populations, many of which live in urban areas

types and levels of interventions

. Community interventions - targeting neighborhoods and community where people live Example: improving diet and exercise to target obesity and other chronic diseases Promote active environments that foster walking or physical activity by focusing on parks, playgrounds, physical design of community, safe sidewalks Promote alternatives to cars, such as special lanes for bike riding, shared bike programs, special and desirable parking areas for bikes Address food environments, so that fresh, nutritious foods are within reach Communities may have organizations or other institutions that public health workers can partner with Often run on a volunteer basis and are self-funded Lots of variation in terms of size, purpose, and organization Examples of local organizations include: Health clinics Community development corporations Job training organizations After-school programs Sports clubs Youth groups Church groups . School-based interventions - Children are vulnerable populations and spend much time in school. Policies and programs aimed at this environment have particular value. Example: target rising childhood obesity Promote programs that increase physical activity Reestablish requirements for daily recess and physical education, improve degraded school play spaces Reduce exposures to non-nutritious foods by removing or restricting vending machines offering candy or other high sugar/salt/fat snacks Consider changing the siting of schools Schools sited on periphery of communities prevents children from being able to walk Requires transportation, with associated increase in air pollution, etc. May not be feasible, but worth considering . Individual interventions - targets an individual's health knowledge or behaviors Individual interventions may extend well beyond efforts to modify the built environment Often aimed at teaching individuals how to cope with limits of environment they live in Example: target rising obesity Programs that teach them how to adopt and maintain healthy eating and physical activity behaviors Ways to cope in food deserts, such as making healthier vs. unhealthier choices in fast food restaurants How to cope in environments that do not foster physical activity

ways to improve social capital

. Fostering neighborhood empowerment Assisting neighborhoods and their residents to implement their own solutions increases social capital and collective efficacy Approach hasn't always been used in public health Often community has little say in priorities Even when priorities match, public health programs may not improve neighborhood social capital unless funds flow directly to local community groups Requires groups be structured in such a way that they learn and apply new tools to other health challenges Improving the neighborhood environment Assumes physical conditions of a community communicate social norms and influence behavior (also called "Broken window theory" ) Neighborhood disorder (i.e., litter, graffiti, abandoned buildings) invites more disorder by communicating that unlawful behavior is accepted Maintaining/restoring neighborhood is beneficial Don't blame a neighborhood for its disorder Outsiders may be littering or defacing buildings Disorder may also be indicative of other social, economic, environmental justice or political issues . Restrict/Reduce the advertising of alcohol and tobacco products Low income and minority neighborhoods have increased alcohol and tobacco advertising This may influence behavior through the suggestion of goods or social norms, ultimately contributing to increased smoking and alcohol abuse rates Reducing advertising in these areas and prohibiting them near schools may have a positive health effect . Addressing the "culture of poverty" 19th century view as to why people are poor Poor societies were somehow less civilized Seen as a "poverty of culture" Now rejected for its racist and classist views 20th century view: Poor people have behavioral norms that reinforce poverty They have a culture of poverty U.S. social policy focuses on breaking up this, sometimes with devastating consequences - i.e., urban renewal Criticism: ignores structural and social factors that cause poverty Better ways to address the culture of poverty than by destroying communities: HOPE VI program in 1990s sought to do something similar by changing the concentration of poverty - introduce non-poor families into public housing Move To Opportunity (MTO) - part of HUD settlement Female head of households that moved from low-income community to one that was not had improved physical and mental health status and their children had better school performance Did not improve employment status or incomes, though Other approaches taken in other countries that may be less disruptive with better outcomes Move entire communities en masse - preserve social ties Micro-lending movement - very small loans to individuals in groups allowing them to stay in place and help themselves, rather than sever existing ties

critical issues and stumbling blocks

1. Defining Disproportionate burden Unifying concept of movement is that some communities are more burdened with environmental problems than others, hence the idea of disproportionate burden But, no set definition of what is this is Why? It's difficult to quantify and measure Lack of scientifically validated way to add up individual risks from different environmental media (i.e., water pollution, soil pollution, air pollution) Different measures, different scales, different health effects 2. Quantifying exposure Many communities face multiple hazardous or toxic exposures More than one way to get exposed Complex combinations of exposures Even single exposures can be difficult to quantify Most not adequately studied for safety When they are studied, they are usually studied in isolation Multiple exposures add to the difficulty Health effects of combinations largely unknown Limited ability to infer cause Current scientific practices are not well-equipped to evaluate it In addition, researchers often use the distance (proximity) to the environmental hazard as basis for exposure Is this an accurate measure or an assumption? How far away is safe? Data on the direct health impact of hazard is usually not documented -slide 17 for third reason 4. Establishing temporality Sometimes unclear which came first, the location of the environmental hazard or the community around them Various schools of thought, based on answers to these: Did individuals exert choice and move to that community after the hazard was established? Did they know about burden and consider risk worthwhile? Yes: usually less support for government intervention, thought unfair to industry No: usually more support for mediation and compensatory action, low-income people have few options for housing 5. Problems with U.S. regulatory process and enforcement Most environmental laws do not ban chemicals outright Federal permit systems allows for pollution Regulatory process is set up to allow a certain amount of release that is deemed "safe" Each facility is addressed independently in permitting process Process does not necessarily consider other pollution or underlying population vulnerabilities Frustrating for local governments trying to reduce exposures Ability to protect largely limited to zoning and permit approval process Environmental inequities are often the result of social inequities - not easily addressed through regulations Also, pollution may not be a local matter Polluter may have local impact, but be 1000s of miles away Example: native communities in Alaska depend upon subsistence for fish, but fish is poisoned by dioxin and mercury emitted in distinct parts of globe Limits of regulatory/scientific processes such as risk assessment: Inadequate to assure health of communities

legal basis

1994 - President William Clinton signs executive order to set up appeal process and legal basis for environmental injustice Called for consideration environmental justice in federal decision-making Recognized problem was national in scope and there was a need for federal involvement Since 1994, the Environmental Protection Agency now routinely incorporates EJ concerns into regulatory and decision-making process (that's good...) BUT, little action taken to substantially reduce existing injustices Difficult to make legal case - unclear if racism was the intent

adolescent issues

Adolescents in some immigrant populations have higher rates of substance use than their counterparts in country of origin Adolescents immigrants typically acculturate more rapidly than other family members Substance use may be related to difficulties with assimilation and effects of immigration on family cohesiveness Risk of substance use appears to increase with time spent in U.S. Gang issues and increased exposure to firearms also problems among adolescent immigrants

stressors and health

Allostatic load represents the amount of stressors that have been affecting an individual over time greater the stress=greater allostatic load Common stressors include: Job pressures Family responsibilities Financial issues and pressures Coping with health issues Lack of secure and/or affordable housing Food insecurity Racism and discrimination Crime - fear of it, or experienced Domestic violence or abuse Harassment Everyone has stress, but the poor face more stressors than the affluent Stressors affecting the homeless are especially great Top stressors: Lack of a job/ lack of control over one's job Lack of housing/lack of control over one's housing These populations constantly lack or struggle with basic resources - makes it hard to reduce stressors The association between constant stress and declining health has been well-documented

neighborhood change

Also impacts mental health History of urban neighborhoods often shows that one racial/ethnic group displaced by another Voluntary displacement: can be positive for health Individuals leaving often see it as advancement, leading to a better life Usually takes place gradually, over time Gives people time to adjust, set up new social networks Involuntary displacement: can be negative for health Individuals leaving have little/no control Loss of community, loss of social capital/social networks Collective sense of grief, loss, disconnect = rootshock = psychological impact of displacement Urban renewal is a prime example of involuntary displacement Large-scale neighborhood change, rapid, forced Psychological impact on the displaced persists for decades Gentrification may have similar impacts on existing low-income neighborhoods Not as abrupt as urban renewal, but pushes people out as rents in that neighborhood rise Cities often promote gentrification to increase tax base Rent control can help protect older residents stay in community - prevents rent being set to the new standard as the neighborhood changes

ethnic enclaves

Are a common settlement patterns in urban areas This often provides employment opportunities, sense of security/familiarity, especially for non-English Language speakers Settlement tends to follow certain patterns: Suburban areas - occupied predominately by skilled workers, middle range professionals, upper level civil service workers Tenements - lower paid blue and white collar workers leaving in cheaper single family homes Relatively abandoned areas - large numbers of homeless and unemployed persons

assessment tools

Assessment tools are usually commissioned directly in response to an individual development plan or policy under consideration Environmental Impact Assessment Health Impact Assessment Usually draws data from existing sources Large, diverse array of information Synthesized together using the assessment tool New studies can be undertaken, but not always necessary

building design

Can contribute to issues with urban living: Modernist style favored high rises - allow in sunlight and ventilation, distant views of nature/parks Evidence suggests that high-rise living is bad for low-income families with children; may not have negative health impact for others High-rises may have indirect impact on health by increasing the urban heat island effect Multiple surfaces for the reflection and absorption of sunlight, increases the efficiency that urban areas are heated Blocks wind, and in so doing inhibits cooling by convection Also reduces pollution from dissipating Jane Jacobs and New Urbanism - growing dissatisfaction of with skyscrapers: Disconnect from street life has a negative impact; living in walk-ups up to 5 stories high best Connection to street life and neighborhood helps prevent crime, fosters greater socialization/networks, and perhaps greater mental health Oscar Newman - studies on NY city public housing: Certain types of architectural designs were better than others in terms of public and personal safety

ideas and theories: 19th century

Changing views of the city accompanied large-scale urbanization Concerns that cities and city living were bad for health, especially mental health Reality of 19th century city in U.S. and U.K.: death rates were higher than those in rural areas Observations of that time period: Social pathologies seemed to cluster in urban slums Drunkenness, prostitution, abandonment, crime Cities appeared to promote self-destructive behaviors Addressing these issues lead to the rise of modern professions of sociology and social work

urban greening

Cities are landscapes that offer both hard and soft surfaces Promote sustainability with urban greening efforts Key Problem: tree loss during 2000s in many U.S. cities Causes include disease (Dutch elm disease and wooly algid on hemlocks), also declining municipal budgets Results in: Reduced pedestrian activity, warmer temperatures, increased air pollution, reduced capacity to absorb CO2, Loss of trees can also increased runoff during storms and increase risk of flooding Possible Solution: Many cities have programs to replant trees Diversity of type to prevent mass-loss if new disease or pest strike Programs require substantial amount of time and money Long-term efforts - will not see benefits immediately Requires cooperation of residents and businesses Ideal if able to increase neighborhood social capital with tree-planting efforts

OWN- Organization of Waterfront Neighborhoods 1996

Concerned with health effects of concentrated, privately owned, waste transfer stations in neighborhoods With Consumers Union, put forth a plan that attempted to provide comprehensive city wide solution to waste problem OWN Plan based on three principles: 1. Retrofit existing marine waste transfer stations - which were underused and more evenly spread throughout city and substitute barges for tractor trailers 2. Fully support recycling 3. Enact measures to prevent and reduce waste Plan would distribute waste more equitably throughout the city - but this was met with resistance

south bronx today

Condos and farmer's markets on the Grand Concourse The Gateway Center at Bronx Terminal Market New development underway and more is planned Encroaching gentrification: Increasing amenities, increasing median incomes But, increasing rents and increasing rates of homelessness: between 2005 and 2010, rents in the Bronx increased by 10 percent between and homelessness grew 33 percent Work is slated to begin at the Hub in the South Bronx, a set of projects that hopes to revitalize the area's busy commercial district with a supermarket, college center and redesigned plaza. The first project, set to kick off as early as this month, is the $40 million, two-building development known as the Triangle Plaza Hub. Triangle Plaza - being developed by Triangle Equities — will bring a branch of the city's Metropolitan College of New York, a Fine Fare supermarket, and other shops and restaurants to two sites by East 149th Street. And later in the fall, the city will move to install a $12.7 million seating area complete with trees and a fountain at Roberto Clemente Plaza near the Hub's intersection, DNAinfo reported. The project will be followed by one to build affordable housing units as well as commercial spaces.

urban living in the US

Cons: Social problems appear to cluster in cities Concentrated poverty and associated problems of homelessness and crime Clustering of unwanted land uses - lack of open space, higher air pollution levels than rural areas Pros: Greater proximity to healthy food and medical services Walkability, social contact both very beneficial For the poor, easier to live in a city on a low income than in a rural area - greater access to low-income housing, social services, mobility

stress response

Continued exposure to stressors can lead to increased risk of sickness (morbidity) and death (mortality) Stress stimulates the stress-response and results in higher levels of a hormone known as cortisol Normal to have acute episodes, after which the body returns to normal Negative health effects occur when the stress-response is constant Constant levels of cortisol are strongly associated with high blood pressure (hypertension), cardiovascular disease, kidney disease and very likely Type II diabetes Note that the prevalence (frequency) of these diseases (hypertension, cardiovascular disease, diabetes) are often highest in populations with multiple vulnerabilities This suggests that in addition to diet and other lifestyle factors, the stress response also plays a role in the patterns of disease we observe in these populations Contributes to their cumulative risk Reducing one's response to stressors is often beyond an individual's control Not enough to be aware Policies and programs that help address these are beneficial to vulnerable populations

CVD

Currently, cardiovascular disease (CVD) is the leading cause of mortality worldwide, with more than 80% of CVD deaths occurring in low- and middle-income countries. CVD is multifactorial in nature (i.e., due to multiple factors), include those that are: Biological (hypertension, dyslipidemia, and diabetes) Behavioral (diet, physical activity, and tobacco use related) Sociocultural (income, education, belief and other related factors) CVD is strongly associated with obesity and hypertension (high blood pressure) Globally, almost ¾ of people with hypertension live in developing countries - many are undiagnosed/untreated # of cases is on the rise as life span increases As with obesity, urbanization is strongly correlated with an increase in the prevalence of hypertension In most developing countries, hypertension is more prevalent in urban and semi-urban areas, than in rural areas

place and social capital

Do certain types of places (urban vs. suburban vs. rural) promote social capital more than others? Difficult to answer, hard to separate out effects of poverty and other factors on individual vs. Community For example, social capital tends to be lower in inner-city, impoverished areas (concentrated poverty) Complex set of factors contribute, including decline of inner-city economies, institutions and social relations While on the other hand, mixed-use, pedestrian-active streets in urban areas help promote social capital Fosters social bonds and also protects against crime and violence

1987 - United Church of Christ report entitled "Toxic Wastes and Race in the United States"

Documented that Latino, African American and Native American communities were more likely to be sites of toxic/hazardous waste than White communities Disproportionate burden of environmental problems fell on these groups Appears to be systematic, national and scope of the problem needed to be redressed Coined the phrase "environmental racism"

environmental design

Efforts to improve sustainability can take place on building-by-building basis: Key problem: Traditional roofs made of asphalt or black rubber Absorb energy from sunlight and contribute to the urban heat island effect Impervious roofs also add to storm runoff problems

violence and the homeless

Experienced by both homeless men and women Many shelter residents (50-60% in Sydney, Australia) report having had a serious physical assault or being raped in their lifetime Homeless women have greater risk (3x in San Francisco) of sexual assault than women who are marginally housed Street youths often experience physical or sexual assault (85% in Seattle), with serious mental-health consequences (20% met criteria for post-traumatic stress disorder)

noise and stress

Exposures to high noise environments can lead to health problems: Stimulates the nervous system and creates a distress-like response, that can lead to chronic stress In urban areas, noise levels can be loud, often constant Noise issues in suburbs, too, especially lawn and garden equipment Noise can be reduced by zoning and time restrictions: Sound walls around highways to reduce traffic noise Banning takeoffs at airports during certain hours and changing runway layout Restrict hours lawn mowers and leaf blowers can be used

city repair in Portland Oregon

Focused on intersections - nexus points where individuals can come together Essential aspect: collaboration between city officials and neighborhoods City officials find out what neighborhoods are interested Flyers, forums get the word out Interested neighborhoods receive a "request for proposal" where they propose their idea Core groups are formed City provides professionals to assist with design Permitting process Cities have rules on what can be done to streets and how it must happen Issues of concern that need to be addressed in application Traffic safety and safety of individuals Vandalism and crime Disability accommodation Maintenance 4. Construction Workshop and Implementation Once approved, organizing committee is formed to implement the project Volunteers may be students, neighbors, professionals, builders, designers, activists, artists, etc. As documented on the previous slides, the goals of the intervention to the built environment may be modest in scale In order for the intervention to be successful, it is critical for city workers to involve neighborhoods in all phases of the intervention The process itself is one of the goals Fosters social networks and collective efficacy Should help a community enhance their social capital Offers direct and indirect benefits for improve community health

other common problems to the homeless

Foot problems - due to exposure to cold and damp (climate), poor footwear and inadequate hygiene, includes: Blisters, fungal infections, ulcers, frostbite, diabetic infections Sunburn - also due to constant exposure (climate) Bites due to infestations - lice, scabies, bedbugs Dental problems - advanced cavities, periodontal disease, ill-fitting/missing dentures Pregnancy - major barriers to contraception Particularly common among homeless adolescences Lack of prenatal care likely, puts baby at higher risk

GIS

Geographical Information Systems Computer based system for mapping and analyzing spatial data Used to identify, communicate and analyze issues Combines technology with data on communities Provides a way to combine different types of information and visual it Relies on computer group programs with a variety of degrees of difficulty of use Only as strong as the data that underlies the analysis Able to map how things change over time GIS creates an "Intelligent" map Appears to your eye as 'a map' , but Integrates many types of spatial data Spatial data stored as layers Each layer associated with tabular data Large range of Applications Map cases of disease, abandoned housing, location of liquor stores, extent of tree cover Can demonstrate many things including how multiple environmental risks affects a neighborhood Example: Lead paint poisoning GIS can be used to set priorities for interventions: Childhood Lead Poisoning Risk Variables put into GIS to create risk map, including: Density of vacant land, Distance to vacant land, Number of children under 6, Median age of housing, Number of houses before 1979 ban, Distance to properties with housing code violations, Distance to major streets, Density of public housing, Number of reported cases of childhood lead cases

food insecurity and affordability

Globally, the risk of famine has been substantially reduced in recent decades, but food insecurity and affordability remain ongoing problems Food insecurity means having to go without enough food for an active, healthy life Impoverished parents may reduce meal size or skip meals in order to have adequate food for their children Cheaper food is often less nutritious, higher in fat, salt, sugar and other carbohydrates, and calories Associated with obesity and other negative health outcomes, such as cardiovascular disease and hypertension Food insecurity and affordability affects people of lower socioeconomic status everywhere- not just in developing countries In U.S., some people do not have enough money to purchase adequate food About 10% of all U.S. households may experience food insecurity at some point during a given year Individuals living in inner cities as well as rural areas at higher risk Food insecurity can be exacerbated by high housing costs, leaving less money to spend on food

green building design

Goal is to make building contribute to sustainability while still ensuring that occupants are satisfied with design Technical and financial issues may make some developers reluctant to embrace green building design Environmental impacts must be reduced at each stage in development, construction, maintenance and demolition Stages include: Development: siting (location) is an issue will it increase commuting or have other environmental impacts Construction: architects and planners try to reduce energy impacts and water use and reuse materials; also, consider more efficient heating and cooling systems - reduce energy needs Maintenance: reduction of operating costs, maintain energy efficiency, design to reduce need for solvents during maintenance and cleaning Demolition: although most building can be used for decades, need to consider if hazardous materials have been used Leadership in Energy and Environmental Design (LEED) Voluntary program of certification for buildings that achieve certain standards Offers best practices regarding design, construction and energy efficiency A cafeteria approach to design options (pick and choose) Points given for each desirable aspect/item Certain number of points results in certification Specific LEED guidelines for different types of buildings and communities Core concepts include: Sustainable sites Water efficiency Energy & Atmosphere Materials & resources Indoor environmental quality Innovation in design Concerns: No requirement for upkeep to maintain certification - so what is the long-term impact? Some LEED certified buildings have been in inappropriate locations LEED-neighborhood certification also possible to address siting concerns Bottom line: LEED is an evolving process

neighborhood walkability tools

Goal is to provide impartial assessment of community conditions Survey is meant to be conducted while out in a community; not a tool that can be used inside a research office Has sections on types of residences, stores, facilities and other land uses in a neighborhood; also includes access to services, streets, places for walking and cycling, safety and crime, neighborhood surroundings and satisfaction Several standardized assessment tools Strong need for training of people conducting assessments Has been successfully used in a variety of environments and for a variety of demographic groups

global climate change and greenhouse gases

Health effects of climate change have been noted Increased heat events results in increased deaths among the elderly Increased number of extreme weather events increases risk to many, especially vulnerable populations Changing the environment can also impact infectious diseases (increasing vector-borne disease habitats) as well as the food supply (rainfall, crop-failure, pests) The built environment affects energy use Automobile focused communities produce more greenhouse gases and urban sprawl has been linked to greater amounts of driving Building design and location also contributes

building healthier cities

Healthy cities are planned; they don't just happen Requires constant work and reevaluation Ceaseless stream of interventions to improve environmental, occupational and economic conditions required The following slides provide an example of an intervention to foster a healthier city based on "Building Healthy cities: A focus on Intervention", by Jan C. Semenza. For details, see the Selected Sources list at the end of this lecture Purpose: retrofitting the Grid with public gathering spaces Many American cities were developed with a grid pattern Streets and side streets cross at right angles No public gathering spaces unless blocks in the grid are set aside for this use and preserved Have many social and physical benefits If created by the community, helps foster collective sense of responsibility, trust, tolerance while enhancing the neighborhood (collective efficacy)

targeting children

Historically in the U.S., advertisements targeting children usually focus on high sugar foods, such as candy, sugared cereals and sodas, as well as fast food Healthier items such as fruit juice and dairy, get far less promotion Policy makers are often reluctant to regulate reductions in marketing of obesogenic foods and beverages But, usually there is greater support and interest in restricting the marketing of fast foods and sugar-sweetened drinks, to children Seen as protection of the rights of children and early preventive action In the U.S., there has been increasing support for: Farm to school programs, connecting schools with local farmers Regulation of vending machine offerings, by including more nutritious items such as granola, fruit juice instead of candy and soda Establishment school gardens, which offer many tangible advantages in terms of using the food in school breakfasts and lunches; also possible to incorporate garden activities into math/writing lessons

health issues

Immigrant health issues may differ from native-born populations: Communicable diseases acquired in home country may be undiagnosed problems Tuberculosis (TB), hepatitis B, HIV Multi-drug resistant TB is of particular concern Diseases that spread person-to-person have implications for disease control Parasitic infections such as Malaria, Trichuriasis (whipworm), Amebiasis, Schistosomiasis and Ascariasis (roundworm) often remain undiagnosed after entry to U.S. Physicians may not recognize the symptoms of infections that are otherwise rare in U.S. Can have huge, detrimental impact on the health status of an individual over time

Immigrant health

Immigrant populations tend to settle in or near metropolitan areas By the turn of the 20th century, 87% of Chicago, 80% of New York, 84% of Detroit's population consisted of immigrants U.S. cities with greatest number of immigrants today are: New York Los Angeles San Francisco Miami, FL Chicago Washington, DC

urban density and health

In U.S. and U.K., infectious diseases were top killers in early 19th and 20th centuries Overcrowding contributed to their spread, i.e. tuberculosis People who were undernourished, working long hours in poorly ventilated spaces, without access to clean water, &/or children were most at risk Many of these diseases were brought under control during second half of the 20th century in U.S. and U.K. Tenement reform made huge progress - focused on greater ventilation, sunlight and less crowding Only later were antibiotics and vaccines used Research since 1950: 1960s rat studies appeared to demonstrate that high population densities lead to a breakdown of social order and "behavioral sinks" Reevaluation of these studies found that it was not overcrowding but withholding of food that led to behavioral problems Little evidence that high-density communities in other countries foster social and mental problems Also, some of the most problematic cities in the U.S. experienced greater problems as density decreased over time Bottom line: anti-density evidence largely discredited Density-to-health pathway is socially mediated, not a biological imperative

vulnerable populations and urban demographics

In any environment, some populations are more vulnerable than others In public health, vulnerability = facing a cluster of risks Sometimes we use the word "factor" instead of or in addition to "risk", as in "risk factor" Some populations are exposed to multiple risk factors, which typically affects their health status and health outcomes Health outcome: A change (or lack of change) in health status caused by a therapy or factor when compared with a previously documented health status using disease-specific measures, general quality of life measures, or utility measures Cumulative risk = series of factors that together are responsible for some populations having worse health status or health outcomes than others Product of multiple factors or risks Risk factors can affect people across their lifespans Risks can be transmitted across generations Risks can accumulate over time, and may result in a process called weathering Weathering is due to a variety of acute and chronic stresses, and results in prematurely aging and/or a lifelong decrease in health status The built environment contributes to cumulative risk and vulnerabilities Risks are not randomly distributed across the landscape Often related to race/ethnicity, income/SES, age Some areas have higher levels of risks that others The environment itself may foster the vulnerability Social processes also underlie many health-related vulnerabilities People vary in their ability to move away from risk Lack of access to resources is key; often related to income Also related to other factors including dependence on family, community, lack of mobility due to job, home, etc. In today's lecture we will focus on three key vulnerabilities and how they affect urban populations: Race/ethnicity Income, especially poverty Age, at the extremes of life (children and the elderly) In several of our previous lectures, we identified factors that affect some vulnerable populations, such as air quality, water quality, food environment, etc.

foodways: alternatives

In recent years, there has been increasing interest in alternatives to industrial agriculture and large-scale livestock operations. These include: Organic foods Food grown with lower-impact farming practices Can results in safer food, reduced pollution, better tasting, higher quality goods Establishing standards and labeling important May be locally grown (Locavore movement) Considers "food miles" (how far it traveled to get to the consumer) Typically sold at farmer's markets and some supermarkets Farmer's markets Locally produced food, sold directly to consumer from farmers Reduces cost of transportation Typically higher quality foodstuffs than what is available in groceries, but cost may also be a little higher May not be available year-round, however, due to local climate Numerous cities in U.S. have made efforts to bring in farmer's markets, include inner-city areas, facilitate the acceptance of food stamps Community supported agriculture (CSA) Programs supporting local farmers Allow consumers to contract for a season or a year's worth of foodstuff from an individual farm In some areas, meat, milk, and/or eggs may also be available Often a very nutritious option for families Commitment to cooking and eating seasonally is needed; canning and freezing are often done with this Urban Gardens Provide an important source of locally grown food Within inner cities, they can be used to manage and improve vacant or abandoned land Land ownership is an issue Many positive effects - increase socialization in community, community pride/enjoyment, provide opportunity for physical activity, increase permeable surfaces, etc.

sustainability movement

In the 1990s, communities set out to develop programs and policies that would lead to greater sustainability at the local or regional level Landmark event: United Nations Summit on the Environment, Rio de Janeiro, 1992 Encouraged local communities to work on sustainability, including transportation, land use, housing and open space Some cities and states have adopted sustainability policies Policies usually modify built environment and focus on issues such as global climate change: Decreased greenhouse gas emissions Improving energy efficiency of buildings Using alternative fuel vehicles Historically, many cities in U.S. expanded without any consideration of their environmental impact Wetland drained or filled Forests cleared Hillsides graded Ecosystems destroyed Coastal cities filled in near-shore areas Indifference to local environments began to change in 1950s Landmark work: Ian McHarg - Design with Nature (1969) People are a part of ecosystems A goal of planning should be to support a healthy environment Brought concept of environmental design into mainstream of landscape architecture and urban planning Today many communities try to use their planning and zoning powers to promote sustainability and environmentally friendly design Some federal/state laws also incorporate this Examples: greenbelts, land preservation, programs to slow or reverse the amount of sprawl These programs can be hard to implement, however, as they require extensive financing and political support

infant mortality rate

In the U.S., the infant mortality rate declined steadily between 1900 and 2000: 162 vs. 6.9 deaths per 1,000 per year, respectively Even though rate for the U.S. is much lower today than it was in 1900, there is still a gradient by race/ethnicity What accounts for the racial/ethnic differences in infant mortality in the U.S.? Infants with the highest risk of dying are often born with low birth weight to mothers who may be single, have low socioeconomic status, low maternal education, and/or poor access to prenatal care; these factors are often strongly associated with race/ethnicity These mothers often have higher levels of stress and comorbidities (other illnesses), and lack social support Many of these high-risk populations are found in cities Affected by urban health issues, including redlining, gentrification, and segregation Differential practices, past and present, were often discriminatory in nature: Redlining refers to the practice of not providing loans for the purchase of housing or home improvements, or insurance Gentrification involves the buying and selling of older, often dilapidated properties and turning them into middle-income condos, townhouses, single-family dwellings, lofts and apartments Segregation refers to composition and spatial distribution of a segment of a population across a neighborhood We looked at some of these in previous lectures, but will look in more detail at the health effects of segregation next Addressing the effects of race/ethnicity on health must target both the individual as well as the societal level: The individual level - targeted interventions/coping strategies, often done through health providers Examples include: smoking cessation programs, infant nutrition and other healthy baby initiatives, alcohol and drug counseling The societal level - addressing underlying inequality through policies and programs Examples include: Curbing tobacco and alcohol advertising that predominates in low-income neighborhoods; Establishing and maintaining parks and playgrounds; Economic incentives to establish supermarkets or sources of other fresh food in low-income communities

1990s, the EJ movement spread across the U.S.:

Individuals struggled with industries, utilities, and waste facilities that contaminated their communities and were suspected of causing major health problems such as cancer, asthma and respiratory disease Tried to documented that environmental health risks are not uniform across social groups Challenged public policies that contributed to the disproportionate burden of pollution

public health interventions

Interventions are widely used in public health May improve social capital or other objectives Levels of intervention may differ given the purpose and objective, Some target individuals and others target groups Often multi-pronged approach, targeting both Interventions that try to reconnect public health and urban planning are of particular interest Public health has a long history of working on the built environment Examples: zoning laws, sanitation, building codes However, focus shifted away from this during 20th century Public health departments and advocates reluctant to become involved in day-to-day decision making processes that shape today's built environment Recent attempts to reconnect it, particularly with urban planning Requires working with public, developers and decision makers Requires data, research and education Changing/developing programs, policies and organizations

targeting smoking-example

Interventions that targeted individuals Warnings on cigarettes packages, anti-tobacco TV and radio advertisements, the nicotine patch or other individual tobacco cessation aids Result: Effective, but didn't go far enough Interventions that targeted groups Raising cigarette taxes, laws banning smoking in workplace, educational campaigns Result: After these higher level interventions were undertaken, greatest reduction in smoking seen -

social capital

Key concept: "The amount of money or assets an individual, family, or society has that can be used to pay for goods and services, invest in new business enterprises or capital-intensive infrastructure or save to meet future needs." Not identical to financial capital or human capital Social capital reflects the strength and capacity of social ties and networks Depending on the context, social capital can assist network members protect health or increase risk taking behaviors capital is a group construct It only applies to how a collection of individuals behave and describes interactions on the group level Multiple individuals form a network Limited meaning when an individual is considered in isolation out of social context Social capital has several sub-constructs that are used to describe and evaluate it Many of these overlap, including: The degree to which individuals can predict the behavior of others in the group The degree to which individuals can rely on these behaviors for support The richness and depth of their network Collective efficacy: the belief that a group can achieve goals and counteract internal as well as external threats All of these may influence behavior and health

urban vs rural living

Key phrase: Rural health advantage - access to clean air, sunlight, natural environments, reduced exposure to pollution, noise and other stressful aspects of city life is beneficial to health The answer as to which is healthier appears to depend on the relative differences between rural and urban areas Changes over time and place Factors include level of infrastructure, social services, poverty levels, environmental controls, community organization, etc. However, the belief that rural areas are inherently healthier persists

foodways: scrutiny and criticism

Large-scale livestock operations = "factory farming" Typically places livestock (chicken, hogs) in extremely cramped, inhumane conditions Feed combinations of highly processed grains, supplements and pharmaceuticals Well documented that animals exhibit signs of mental stress and physical illness Decline in quality of food also noted, especially when compared to taste of free-ranging animals Concerns over humanness for animals as well as for health of nearby residents (smells, contaminated groundwater) and farm workers

income and poverty

Low income is strongly associated with greater at-risk behaviors and poor health outcomes At-risk behaviors include: smoking, poor diets, physical inactivity Poor health outcomes: obesity, infant mortality, HIV infections, cardiovascular disease, cancer A low family income in childhood can have lifelong health implications Maternal poverty, in particular, is associated with adverse health outcomes for their children In general, low income is associated with: Decreased access to services and amenities for healthy living, such as health clinics, parks, supermarkets Higher burden of pollution exposures and poor quality housing Greater food insecurity Increased exposure to fast food, alcohol and tobacco Less access to or less well-supported municipal services including fire, police and schools Increased exposure to abandoned buildings, vacant lots, and other negative elements of the built environment Relative income is very important Absolute income is what you earn, but relative income is what you earn in relation to others in your society Relative income is related to income inequality Income inequality appears to be a risk factor for poor health As income inequality increases (on any level, i.e., state, local, federal), so does the risk of fair or poor health status U.S. has one of the highest median incomes in world, but also high level of income inequality During the 1980s and 1990s in the U.S., the gap between the rich and the poor widened: U.S. transitioned from a manufacturing to a service economy Many jobs migrated out of the urban centers to the periphery Individuals with lower skills and education levels were most affected, particularly those in urban areas Manufacturing jobs were more secure, had better benefits and wages Big impact on single parent households (often women) Difficult to balance travel time to work, childrearing, other household responsibilities Two very important concepts: Concentrated poverty - occurs when communities have high rates of poverty and overall low income, that ends up concentrating and exacerbating the problem Spatial mismatch - refers to the geographical disconnect between supply of jobs and supply of labor. Areas of high growth - particularly in the U.S. - are often located at the urban periphery, while those in greatest need of jobs often live in the urban center There is a high proportion of people living below the poverty level in inner cities Concentration of poverty can be extreme Strongly associated with race/ethnicity in urban areas, particularly Blacks and Hispanic/Latinos Often these areas lack adequate public transportation to jobs Lack of car ownership is strongly associated with poverty Impacts access to supermarket, jobs, parks BOTTOM LINE: Resolving transportation issues for the poor to address spatial mismatch may also help reduce concentrated poverty

Characteristics of Environmental Impact Assessment (EIA) and Health Impact Assessment (HIA)

Mandatory in some jurisdictions: Usually voluntary: Tied to exiting environmental law: Flexible enough to include built environment research: Goal is to inform decision-making: High level of familiarity among policy makers: Strong emphasis on public involvement and information:

race vs income

Most EJ studies find that both race and income have predictive power Income is better predictor when looking at risk at smaller scale, i.e., census tract or block group Race is better predictor when looking at larger geographic area, such as zip code or group of census tracts Both race and income are highly correlated While law protects one and not the other, they are intertwined Morally and ethically, though, does the distinction actually matter?

mental illness and substance abuse issues

Most common problems of homeless, based on a large, U.S. survey: 39% mental health problem 50% alcohol/drug problem 23% both mental health AND alcohol/drug problem U.S. patterns offer differ by age, sex, location, etc. Adolescents - higher rates of suicide attempts, sexually transmitted disease, pregnancy, drug abuse Single men - greater drug and alcohol abuse Single women - greater serious mental illness Common mental health disorders include major depression, bipolar disorder, schizophrenia, personality disorders Street youth use a wide range of drugs including hallucinogens, amphetamines, sedative/tranquillers, inhalants, cocaine and opiates Increases risk for other diseases and adverse health outcomes, directly (e.g., injection drug use) or indirectly (reduced ability to fight-off infections)

ideas and theories: 21st century

Nature deficit disorder Syndrome proposed by Richard Louv (2008) Intended to explain why people living in cities exhibit antisocial behavior thought to cluster there Posited as cause for attention deficit hyperactivity disorder, depression and mental health and behavior problems Does not explain the high rate of unhealthy behaviors including drug/alcohol use in rural areas Some evidence that children with Attention Deficit Hyperactivity Disorder (ADHD) are more attentive after nature walks

assessing physical activity

Need for instruments that measure physical activity in the general environment, groups and individuals Takes three main forms: 1. Self-report - may ask about specific activities such as walking, gardening, dancing, etc. and calculate measure based o subject's response Example: International Physical Activity questionnaire (IPAQ) - contains questions on duration, frequency and intensity of physical activity Self reported physical activity is often over-reported (and their for inaccurate) Observer report: Often used for studies or playgrounds, parks or bikeways or trails Observers usually observe facility for set of dates and times Small scale studies can utilize observers measuring physical activity of study subjects Sampling used for large studies 3. Pedometers, Accelerometer and other special assessment equipment Pedometer - measures number of steps a subject takes in a period of time Can capture intensity and amount of walking, but can be difficult to collect data from study subjects Does not measure non-walking physical activity Accelerometers - specialized instruments worn at the waist, wrist, etc. that measure almost all physical activity May be more expensive than pedometer or require additional software to read results Most accurate way to fully capture subjects' physical activity

effects of social capital

Not all aspects of social capital are positive Risk behaviors also influenced by group actions Gangs can promote aggression, while intolerance toward other groups can leading to violence, crime or other destructive behaviors Bonding vs. Bridging Bonding: refers to linkages within a group (also known as "localized") - Important for local level, but may also be more likely to enhance negative impacts of social capital Bridging: refers to linkages between peoples of different groups - May be better at establishing or reinforcing positive aspects of social capital In general, individuals in communities with lower social capital tend to have: Lower overall health status - increased morbidity Fewer health protective behaviors Greater harmful health behaviors Higher rates of communicable diseases, including sexually-transmitted diseases Increased mortality (i.e., death at a younger age) Increased deaths from firearms Increased mental health issues among adolescents The converse also appears to be true: individuals in communities with higher social capital tend to have lower rates of risky behaviors and more favorable health outcomes Social support and friendships reduce morbidity and mortality For example, increased trust between neighbors decreases the risk of cardiovascular incidents

reducing outdoor water use

Outdoor water use can represent a significant portion of residential water consumption Of increasing importance as aquifers are depleted or other sources of drinking water overstressed Communities may limit time and amount of water that can be used for this purpose Xeriscaping is also an option: plant with native plants or other vegetation that require less water be use for landscaping Benefits: Reduces water impacts, promotes long-term sustainability, helps control invasive species Costs: reduces greening in area

roof design

Possible solution: Green roofs Can be planted with native vegetation or be more manicured like a park Purpose: Prevent sunlight from being absorbed, reduces heat absorption and water runoff Issues: Must be designed to avoid structural or maintenance issues Unfortunately, not suitable for all climates (i.e., not in arid areas where they would require watering) Some cities give bonuses for green roofs (image above) Alternatives: using light colors for roofs to increase reflection of light and prevent absorption of sunlight

mental health issues

Post-traumatic stress disorder/depression has been higher in some immigrant populations Depression may be higher among those who were least acculturated - settling in ethnic enclaves appears to lower risk Mental health services appear to be underutilized by immigrant groups - could be due to language issues, cultural beliefs, difficulties accessing services, protecting of family members, etc. Elderly women reported high rates of loneliness Elderly immigrants may speak little English Depend upon family, children and neighbors for support Loneliness also depends on type and location of housing

cost benefit analysis

Quantifies the costs and the value of the benefits of the project, example: assess utility of a program to promote walking Not always easy to do Necessary to account for the different value of a cost or benefit that takes place in the future May be difficult to assign dollar values - for example, what is clean air worth? What is value of neighborhood institutions? Social costs especially hard to quantify, but doesn't mean they should be ignored Distribution of costs and benefits also an issue May not account for who pays the cost and who benefits Does not often take into account equity concerns May discriminate against poor

measures of sustainability

Quantifying impacts can be very difficult Need to measure How do you know if you are moving toward sustainability without adequate measurement? Trade off between simplicity of measure and need for incorporating all the necessary factors Key concept: Ecological footprint Area of land that it takes to support an area's population Can be for area's total population or for an individual's calculated support Ecological footprint, cont'd: Original concept focused on food; expanded concept includes totality of humanity's footprint on the environment Now includes transportation, consumer products, defense spending, and other similar impacts. Measures include: Acres per person Barrels of oil per person Tons of carbon dioxide per capita

vulnerabilities: race/ethnicity

Race Not a biological concept No gene that codes for race No genetic way to define race Race is socially defined and may change over time A person's race can vary if they move from one society to another Socially defined race can still have important health implications When gathering and discussing data on race in the U.S., a classification based on self-reported "race/ethnicity" is used Federal government requires its use in the U.S. census, national health surveys, etc.; also widely used by health researchers : Pick one of two ethnic origins: "Hispanic/Latino" OR "Not Hispanic/Latino" Choose one or more race group: White Black/African American American Indian and Alaskan Native Asian/Native Hawaiian/Other Pacific Islander Other More detail can be collected, such as ancestry, but data must fall under these groupings There are widespread disparities in the health status and health outcomes between different race/ethnicity groups in the U.S. Some common patterns: Cardiovascular disease, premature death, overall morbidity, and infant mortality all vary greatly by race/ethnicity African-Americans tend to have poorer outcomes than most other groups, especially whites Hispanic/Latinos of any race tend to have mixed outcomes - not always may fare better or worse, sometimes related to race Asians often fare better in many outcomes than all other groups

foodways

Recall that a foodway refers to the processes involved in the production, safety, distribution, purchase, preparation, consumption, sharing—or absence—of food within communities Foodways are related to health in various ways, including: The scale and type of farming is related to the quality and quantity of food produced (quantity does not always = quality) Impacts the environment and health of local residents Contributes to today's obesogenic environment Industrial agriculture has come under scrutiny and criticism in recent years: Large scale farming practice that is heavily reliant on chemicals, genetically modified foods Requires long range transport of foods Fruits and veggies often harvested before ripe Usually associated with less-satisfying taste/quality Nutritional content may also decline with transport/process Concern about energy (transportation) and environmental impacts (pesticides)

food and health

Research indicates that there is close association between the food we consume and health: The risk of hypertension and stroke are increased by a high intake of salt (increases blood pressure) The risk of heart attacks, stroke and certain cancers are increased by a diet high in animal fat (increases cholesterol and other body fat) The risk of diabetes is increased by high intake of carbohydrates, especially sugar (increases blood glucose levels) Consuming excess fat and carbohydrates is associated with an increase in body weight, which can result in obesity Consuming fresh fruit and vegetables lowers your risk of many chronic diseases as well as obesity, and may boost your immune system Obesity and hypertension have many common factors, including: Increasing age and family history Excessive in take of salt, calories, fat, and alcohol A sedentary occupation/lack of physical exercise Tobacco smoking Vitamin D deficiency Under-nutrition in childhood Sleep deprivation Low folic acid intake Dyslipidemia (abnormal amount of lipids, e.g. cholesterol and/or fat, in the blood), and increased triglycerides Prevention programs should try to increase public awareness, educate physicians, and encourage reduced salt intake Public health interventions aimed at reducing obesity by fostering the availability of healthy food and healthy choices is equally important Targeting urban areas for both obesity and hypertension is of key importance

active living research-example

Robert Wood Johnson foundation Seeks to reconnect public health and urban planning Trying to prevent childhood obesity and create active communities, http://activelivingresearch.org/ Funds research, brings together researchers and community advocates, publicizes best practices Took its inspiration from tobacco control measures Individual interventions only reduce smoking by so much Community interventions reduce smoking even more

segregation

Segregation affects people's health directly and indirectly, at both the individual and neighborhood level: For an individual, this can impact the quality of education, employment opportunities, health related behaviors, access to care and exposure to stress-related conditions For a neighborhood, this can impact the quality of physical environment, food resources, targeted tobacco and alcohol advertisements, housing opportunities, mobility as well as exposure to crime and violence High levels of urban segregation are associated with: Increased stress-related chronic health conditions, including hypertension, cardiovascular disease, asthma, diabetes High unemployment, concentrated poverty, high levels of crime including homicide, diminished basic resources and substandard housing Segregation works together with other factors to produce poor health status and health outcomes Disproportionately affects some groups, like African Americans

controversial topics

Should poorer communities willingly accept hazardous wastes? In U.S., issue has come up with Native Americans in particular Also a global issue Wealthier communities/ developed countries have hazardous waste they want to get rid of, willing to pay poor communities/countries to take it -slide 23 module 11

how is social capital measured

Social capital is a group construct, but only measured by asking individuals about their beliefs, actions and values Many different survey instruments have been developed Questionnaires that speak to trust, interactions with others, agreement with statements Measuring the number of organizations an individual belongs, including neighborhood, city, state, or other similar connections Voter participation rates may also be examined - may or may not be a good indicator of social capital

improving social capital

Social capital may be enhanced by promoting community organizing Strengthen social ties, build community efficacy and trust Helps change and build group expectations Changing the built environment to promote social interaction and increase pedestrian activity Parks, plazas, sidewalks, farmers markets, etc. Changing social norms to promote healthier behaviors Appeal to power of groups to reinforce positive behavioral norms Strategy used in public health campaigns encouraging use of designated drivers and ban smoking in workplaces

food deserts

Social factors also impact how much a food desert determines an individual's access to foodstuffs These factors include: Awareness and importance placed on the relationship of food to health Resources, such as access to a car, money Availability of time to shop or cook Neighborhood walkability and safety Taste preferences - may be associated with race/ethnicity Relationships between shopkeepers and shoppers, as well as perceived safety influence where people shop Sale of alcohol and cigarettes in same store may influence selection of food Low income residents face the greatest challenges - limited to local food environment, getting most for money Research Findings: Residents with a supermarket in their zipcode were10% less likely to be obese than those without a supermarket In general, supermarket access is usually associated with decreased obesity, while greater access to fast food restaurants and convenience stores was associated with a greater likelihood of being obese Particularly true for adolescents Abundance of low-cost fast food in conjunction with a scarcity of supermarkets/fresh food in inner cities appears to be associated with higher rates of disease (i.e., hypertension, diabetes) observed in those populations In general, it is difficult to obtain a healthy diet year-round in low-income urban areas and low-density rural locations A problem for low-income households, especially households without cars and the elderly, living alone Particular problem for some race/ethnicity groups: In U.S., 81% of African Americans live in urbanized areas and 60% live in urban centers See Chicago example, on next slide Efforts to address food deserts in U.S. include: Educational programs in schools targeting youths as to the risks and benefits associated with different diets Programs to promote supermarkets and farmers markets in urban areas Zoning/banning of fast food restaurants in high risk areas More controversial, impacts local economy in other ways Encourage community gardens, also called "urban gardens" More on this topic as well as on farmer's markets in the following section, entitled "Foodways"

healthy immigrant effect

Sometimes called "health migrant effect" At least initially, people who immigrate tend to be healthier than native-born residents in new country This protective effect appears to get weaker over time, with greater time spent in U.S. - See next slide Children of immigrants born in new country are less likely to have the same health advantage as their parents Reasons are not always clear, but quicker shift to new diet in new country, new ways of living likely to play a role

foodborne illness

Still a major source of illness in U.S. Each year, 1 in 6 Americans (or 48 million people) gets sick from and 3,000 die of foodborne diseases Reducing foodborne illness by just 10% would keep 5 million Americans from getting sick each year Preventing a single fatal case of E. coli O157 infection would save an estimated $7 million Foodborne illnesses are largely underreported Severe cases seeks medical attention, but others may not For less severe cases with mild, general symptoms (upset stomach, low grade fever), the cause may be not be determined or properly attributed to a food source In the U.S., these organisms are chiefly to blame for foodborne outbreaks: Campylobacter (poultry) E. coli O157 (ground beef, leafy greens, raw milk) Listeria (deli meats, unpasteurized soft cheeses, produce) Salmonella (eggs, poultry, meat, produce) Vibrio (raw oysters) Norovirus in many foods (e.g., sandwiches, salads) Toxoplasma (meats) In a foodborne outbreak, affected populations often widespread Due to nature and scale of food distribution system Contamination may occur at numerous points in the foodway, i.e., processing centers, packing plants, shipping containers Hard to prevent foodborne outbreaks given our current system of food production and inspection Food and Drug Authority (FDA) regulations stipulate standards, but monitoring for violations and/or testing samples limited Tightening regulations is politically difficult and expensive Important for consumer to maintain uncooked food at proper temperature (limits growth of organisms), heat to property temperature when cooking it (kills most organisms) Solutions include better sanitation, cleaner plants, and facilitating local foodways

sustainability

Sustainability = long-term ability to support the human population without seriously degrading the environment or other communities Influenced by built environment including land-use patterns, building codes, transportation infrastructure, etc. Note the key elements of sustainability: Long-term Population Harm or degradation Environment or area How these key elements are defined is not written in stone Not always consistent or easily defined More on issues with key elements of sustainability: No standard definition of time frame Difficult, maybe impossible, to predict very long-term consequences including future costs "Population" and "environment" may be narrowly or broadly defined - this has implications for many things, including the transportation and exchange of goods or services Bottom line: Definitions or assumptions about key elements must be made explicit during policy development and analysis Sustainable is not necessarily equitable Possible to have long-term stable societies without acceptable levels of equality However, it can be difficult to operationalize equity in sustainability Alternative concept: "Just sustainability" Proposed by researchers in environmental justice and sustainability Incorporates equity concerns into concept May help ensure that any effort to develop a sustainable future address current social, gender, racial and other inequities

ideas and theories: late 19th/early 20th century

The Chicago School of Sociology Researchers began studying urban communities Systematic observation and study of immigrant neighborhoods Influenced by European sociology (Emile Durkheim) Goal: study problems; assist communities in need Documented underlying strengths of even the poorest neighborhoods in tenements Social connections between neighbors, community institutions, shared experiences and histories Environmental context helps shape behaviors, for better or worse Helped define impact of urban immigration on mental health Anomie = a form of alienation, thought to be inherent in urban living Long persisting idea from late 19th century sociology popularized by Emile Durkheim in 1890s Key concept: The dislocation of people from traditional environments (i.e., villages) to new environments where they are forced to continually interact with strangers in new situations (i.e., cities) leads to psychological distress Thought to contribute to urban social problems by the disestablishment of social norms, resulting in certain pathologies: prostitution, drunkenness and abandonment Immigration and urbanization were believed to be a contributing factor to the breakdown in mental health and social order

the homeless

The homeless are perhaps our most vulnerable population, bearing the greatest level of stressors Lack a fixed, regular and adequate night-time residence, including individuals who may live in: Emergency or transitional shelters Motels or hotels (due to lack of alternative housing) Private or public spaces not intended for habitation Dwelling in non-residential spaces is most visible aspect: Cars, parks, abandoned buildings, bus or train stations common Tendency to concentrate in inner cities, closer to social services They are a "service-dependent population" U.S: About 70% of homeless live in urban areas Broad range of people - heterogeneous Single men: ~ 60%, Single women: ~16% Families with young children: ~ 15%, Adolescents: ~ 9% Composition varies in other countries- more homeless families in Germany and U.K. than in the Netherlands or Sweden Problem changes over time Number increased dramatically in U.S. during 1970s and 80s due to economic changes, cuts to social programs A complex interaction of factors contributes to homelessness Poverty alone does not necessarily lead to homelessness Individuals with severe mental illness can become homeless without social support and adequate outpatient care Combined vulnerabilities increases the risk Homelessness is associated with poor health outcomes The homeless have a higher rate of mortality than individuals of same age in general population (i.e., die at an earlier age) Men (in shelters): 2 to 8 times higher Women under age 45: 5 to 31 times higher Common causes of death include unintentional injuries, drug overdose, AIDS, suicide, homicide People living on the street are more likely to be disengaged from health system/social services than the homeless living in shelters Quality of homeless shelters matters a great Impact on diet, safety, disease transmission Homeless veterans depend heavily on Veterans health Administration for services Not always located where homeless are Involuntary displacement of homeless often increases high-risk behaviors such as survival sex and unsafe injection drug use

amenities

The rise of the movement drew attention to a key issue, that the absence of amenities also impacts health In general, low income neighborhoods and communities of color have unequal access to amenities Less access to parks or playgrounds Fewer grocery stores Less maintained pedestrian amenities Less access to mass transit facilities This effort represents a broadening of concerns beyond hazardous waste and pollution

health beliefs model

Widely used model first developed in the 1950s by social psychologists at the U.S. Public Health Service Suggests that individuals or community beliefs about health problems in conjunction with self or community efficacy, impact health promoting behavior(s) Interventions attempts to provide a stimulus or "cue to action", to trigger the uptake of health-promoting behavior(s) Changing perceived benefits to action and reducing the barriers to action are critical Downside: this model has limited value when individuals are not able to make rational choices Due to their age and/or limits of environment, etc. Example: A child's ability to make a nutritious choice in school depends on the availability and cost of more nutritious food, as much as their beliefs Usually, multiple programs are used to reduce the impact of complex health behaviors Example: Use of child safety seats in cars Influencing individual belief (health belief model): you are sure that using a special child seat in the car will increase you child's safety Changing social norms: parents not using a child safety seat for their children often face social disapproval, especially from family and friends Developing government regulation and policy: many states now have laws mandating the use of child safety seats and drivers not using them risk fines/penalties

social environmental determinism

an individual learns and adopts behavioral norms based on the actions and values of others around him or her