Population Cardiovascular Health and Urban Environments: The Heart Healthy Hoods exploratory study in Madrid, Spain

Population Cardiovascular Health

and Urban Environments: The Heart

Healthy Hoods exploratory study in

Madrid, Spain

ICUH, April 2016, SF

Usama Bilal1,2([email protected]), Julia Díez1, Silvia

Alfayate1, Pedro Gullón1,3, Isabel del Cura4,5,

Francisco Escobar6, María Sandín1, Manuel Franco1,2

1. Social and Cardiovascular Epidemiology Res. Group, Universidad de Alcala, Madrid, Spain

2. Johns Hopkins Bloomberg School of Public Health, Baltimore, MD

3. Unidad Docente Medicina Preventiva y Salud Pública, National School of Public Health, Madrid, Spain.

4. Primary Care Research Unit. Gerencia de Atención Primaria. Madrid. Spain.

5. Department Preventive Medicine and Public Health, University Rey Juan Carlos, Madrid, Spain

6. Department of Geology, Geography and Environment, Faculty of Biology, Chemistry and Environmental

Sciences, University of Alcalá, Alcalá de Henares, Madrid, Spain.

Currently Under Review at BMC Medical Research and Methodology

http://hhhproject.eu

Background

• Cardiovascular diseases (CVD) 1st cause of death (1)

• Population preventive approaches needed (2)

• Neighborhoods offer opportunities for policy (place-based) interventions to address CVD (3)

• Mixed methods and GIS can help provide a better characterization of residential environments

References: (1) Beaglehole and Bonita, Lancet 2008; (2) Rose, Int J Epidemiol, 1985; (3) Franco, Bilal

and Diez-Roux, J Epidemiol Comm Health 2015


Objectives

1. To Describe the cardiovascular health profile of a population over 15,000 residents living in an area, analyzing the Madrid Primary Health Care System electronic health records

2. To Explore different quantitative and qualitative measurements to characterize the social and physical urban environment in relation to food, alcohol, tobacco and physical activity


Setting

• Average area in 4 variables (Median Neighborhood Index)

– Aging: % > 65 years of age or above

– Immigration (marker for segregation): % foreign-born

– Education (marker for SES): % with primary education or below

– Density: population/km2

• Looked for clusters of areas of ~15,000 people with a low value in the index (-> non-extreme areas)



Methods (quantitative)

• Cardiovascular Disease:

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

– Validated (1) data on physician-diagnosed: diabetes, hypertension, dyslipidemia, smoking and obesity.

• Urban environment

– Food: location and type of food stores and food services, directly measured healthy food availability (brief NEMS-S)

– Physical activity: SPACES audit tool for walkability and bikeability, SOPARC audit tool for open spaces.

– Alcohol and tobacco: location and type of retailers

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


Methods (qualitative)

• 11 semi-structured interviews with key informants: 4 long-term residents, 2 immigrants, 1 teacher, 1 community activist, 1 health care provider, 1 public health officer, 1 local food store owner

• Questions on health and the environment, focusing on sociodemographics, food, alcohol, tobacco and physical activity.

• Analysis by triangulation incorporating an interpretative phenomenological analysis.


Methods (integration)

• Geographic Information Systems

– Directly collected data + Secondary administrative data

– Joined to street sections by relational union or overlaid as administrative boundaries/blocks.

• Mixed Methods Approach: merging approach to combine

– Provides insights on quantitative findings • Quantitative -> qualitative

– Guides future quantitative data collection (formative)• Qualitative -> quantitative.


Results


Results

Photos by Victor Carreño and Franco M, Gullon P, Carreño V. Studying city life, improving population health. Int J Epidemiol 2015


Results

Alcohol(Restaurants and Liquor Stores)

Food Services (Bars, Restaurants and Fast Food)

Tobacco(Vending Machines & Stores)


Results


Results

• Use of parks was diverse, with levels of activity varying from sedentary (sitting), walking and vigorous (sports)



HHH Pilot Study

Qualitative Study

Food Environment: “I have my children and many years, so I

know what is good and what is bad…what one can afford is

different” (woman, >65 years)


HHH Pilot Study

Qualitative Study

Physical Activity Environment: “ When we are older,

because I’m on a wheelchair in the street … If I had benches

there, I would not need the wheelchair, because walking 20

meters is fine, but maybe 25 meters isn’t.” (Woman, > 65

years)



HHH Pilot Study

Qualitative Study

Alcohol Environment: “Social drinking customs are

disappearing, we used to go on Sundays to have a vermouth

with your neighbors and your friends. Nowadays, people are

doing it less, because of the economic crisis” (Food store

owner).



Pilot Qualitative Study

Emergent categories

The role of immigration in shaping behavior patterns related

to the use of open spaces "... In the past other people would go

there [park], but now the Romanians are there..." (men, < 65 years )




Emergent categories

The current economic crisis shaping the neighbor’s

behaviors "... Nowadays there are a lot of grandparents taking care

of the family…. Many unemployed descendants. So there is little

time for healthy habits like exercise... " (health care provider,

woman)




Emergent categories

The role of social networks shaping health behavior patterns

in residents "I'm happy with people in my neighborhood. Since my

husband died, ... adults and kids alike, boys like my sons, 50 years-

old, [have told me] ‘hey, I work on this, if I can help you... I will help

you with stuff if you ask me’ " (woman, > 65 years)



Conclusions

• Challenges in measuring a food environment that is much more dense compared to US/UK/etc.:– How to measure food markets and dense food environments?

– How to incorporate perceptions?

• Limited information on tobacco in qualitative interviews:– Use of focus groups?

• Integration of all the information in GIS– Composite indices?

Comparing local availability and accessibility to healthy foods across countries: A

case study in Madrid (Spain) and Baltimore (USA)

J. Diez (Sun/16:00)

Healthy urban environment characterization focused on physical activity and food: A

GIS-based method

A. Cebrecos (Fri/8:00)

Studying the Perceived local food environment through individual spatial cognition

analysis: a case study in Madrid

R. Valiente (Fri/8:20)

http://hhhproject.euPhotos by Victor Carreño and Franco M, Gullon P, Carreño V. Studying city life, improving population health. Int J Epidemiol 2015

Health & Medicine

Population Cardiovascular Health and Urban Environments: The Heart Healthy Hoods exploratory study in Madrid, Spain