As of 2017, the urban access rate to safe water sources in 2017 stood at 84% while rural access was still around 45%. The rates for sanitation were 44% and 22%, respectively. Since the 1980s many high-profile reforms supported by international organizations have been implemented in the region in an attempt to close the access gaps in the water and sanitation sector (WSS). Two recommendations with high international exposure were an increased role for large-scale private sector participation in the management and financing of national or regional utilities and the creation of separate sector regulatory agencies to increase the independence of regulation. Both reforms seemed to contribute to improved water access rates, at least for the urban population, but not enough to catch up with the demands of a fast-growing population; and both failed to deliver on sanitation. The progress these initiatives allowed was correlated with improvements in the average health outcomes for some indicators (i.e., under-five mortality associated to diarrhea) but once again, it was not enough and was not fairly distributed. Indeed, improvements seem to have mostly benefited upper- and middle-income groups. Unfortunately, an evaluation of the health effects of these two reforms have not yet been fully established empirically, which is why it seems prudent to talk about correlations rather than causal effects. Most of the statistically robust evidence on the impact of utilities and regulatory reforms on health is incomplete because details of several dimensions of these reforms and their context are not measured consistently across countries or within countries. In addition, the small amount of econometric evidence available is based on pre-2010 data for SSA. The imperfect data is however solid enough to suggest that without further governance changes in the region, the health risks are likely to increase. This is because due to the high population growth rate of the region, closing the access gaps is likely to get tougher considering current investment levels and technological choices. The necessary changes require improving the match between policy and technological choices, including service delivery technologies that are consistent with the ability to pay and the tariff and subsidy levels adopted to ensure cost recovery without excluding any category of users.
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Article
The Health Impact of Water and Sanitation Utilities Privatization and Regulation in Sub-Saharan Africa
Lisa Bagnoli, Salvador Bertomeu-Sanchez, and Antonio Estache
Article
The Investment Case for Strengthening Primary Healthcare and Community Health Worker Programs in Low- and Lower-Middle-Income Countries
Henry B. Perry and Jeffrey D. Sachs
Universal health coverage is within reach of even the poorest countries if these countries are helped to expand their systems of primary healthcare (PHC). The overriding theme is that PHC (with a strong community outreach component) is the best bargain on the planet—alongside spending on primary and secondary education. Investing in PHC, both from domestic revenues and international grants and loans as necessary, can save millions of lives per year at a remarkably low cost. Many low- and middle-income countries (LMICs) direct too many resources to tertiary care rather than PHC. Community outreach programs, notably those that include community health workers, are chronically underfunded, even disproportionately relative to overall funding government for healthcare. In many or most LMICs, the political pressure on national policymakers is, strangely enough, to expand investments in higher level health facilities and specialized care—especially for hospitals. As a result, the underfunding of PHC leads to a vicious cycle. Because PHC services are underfunded, the quality of these services is weak, and patients bypass these facilities to obtain urgent PHC services they need at hospitals. Underutilization of PHC services at PHC facilities and provision of PHC services at hospitals leads to increased funding for hospitals, at leading to progressively lower levels of funding for PHC facilities and for strong community outreach. There is an immediate need to recognize community-level health programs as a permanent feature of effective health systems (even in high-income countries). Additional funding is needed to enable the concerted strengthening and expansion of PHC services in low- and lower-middle-income countries. This would enable, among other things, community health workers to reach their full potential and provide a broad range of life-saving and life-improving services by allocating the skills, supplies, supervision, salaries, and career opportunities that are needed.
Article
Theory of Change in Sports-Based Urban Youth Programs: Lessons from Creating Chances
Rachel Baffsky, Lynn Kemp, and Anne Bunde-Birouste
Sports-based positive youth development (SB-PYD) programs are health promotion programs that intentionally use sports to build life skills and leadership capacity among young people at risk of social exclusion. The defining characteristics of SB-PYD programs are that they are strengths-based, holistic, and use sports as a vehicle to maximize young people’s health, social, and educational outcomes. SB-PYD programs aim to enhance modifiable social determinants of health (such as social inclusion) by explicitly addressing three Ottawa charter action areas; strengthening community action, developing personal skills, and creating supportive environments. These programs have been increasingly implemented since the early 2000s to address the United Nations’ sustainable development goals.
Despite their growth, research indicates that SB-PYD programs are often designed, implemented, and evaluated without evidence-based theories of change. An evidence-based theory of change is a visual depiction of a program’s assumptions, activities, contextual factors, and outcomes supported by scientific findings. A lack of evidence-based theory of change becomes problematic at the implementation phase when practitioners are trying to determine if their programs should be adapted or fixed. Without an evidence-based theory of change, practitioners are making changes based on their intuition, which limits program outcomes.
However, the process of developing a theory of change is time-consuming and resource intensive. Multiple calls to action have been made for SB-PYD practitioners who have successfully developed evidence-based theories of change to share their process with others in the field. This will provide a blueprint for other SB-PYD practitioners to develop and articulate their own theories of change to optimize program development and adaptation.
Traditional translational research models assume the development of an evidence-based theory of change is the first step in a linear process of developing a sustainable health promotion program. However, in the 2010s, researchers started to observe that the development and adaptation of health promotion programs was rarely a linear process in reality, and that case studies are needed to provide empirical support for this claim. It is valuable for SB-PYD practitioners to consider the benefits of using translational research to develop and revise evidence-based theories of change for programs at any stage of implementation to maximize their public health impact.
Article
The People’s Health Movement
Ravi Narayan, Claudio Schuftan, Brendan Donegan, Thelma Narayan, and Rajeev B. R.
The People’s Health Movement (PHM) is a vibrant global network bringing together grass-roots health activists, public interest civil society organizations, issue-based networks, academic institutions, and individuals from around the world, particularly the Global South. Since its inception in 2000, the PHM has played a significant role in revitalizing Health for All (HFA) initiatives, as well as addressing the underlying social and political determinants of health with a social justice perspective, at global, national, and local levels.
The PHM is part of a global social movement—the movement for health. For more than a century, people across the world have been expressing doubts about a narrowly medical vision of health care, and calling for focus on the links between poor health and social injustice, oppression, exploitation, and domination. The PHM grew out of engagement with the World Health Organization by a number of existing civil society networks and associations. Having recognized the need for a larger coalition, representatives of eight networks and institutions formed an international organizing committee to facilitate the first global People’s Health Assembly in Savar, Bangladesh, in the year 2000. The eight groups were the International People’s Health Council, Consumer International, Health Action International, the Third World Network, the Asian Community Health Action Network, the Women’s Global Network for Reproductive Rights, the Dag Hammarskjold Foundation and Gonoshasthaya Kendra. All these groups consistently raised and opposed the selectivization and verticalization of Primary Health Care (PHC) that followed Alma Ata leading to what was called Selective PHC (i.e., not the original comprehensive PHC). These groups came together to organize the committee for the first People’s Health Assembly and then to form the Charter Committee that led to the People’s Health Charter, which finally led to the actual PHM.
Within PHM, members engage critically and constructively in health initiatives, health policy critique, and formulation, thus advancing people’s demands. The PHM builds capacities of community activists to participate in monitoring health-related policies, the governance of health systems, and keeping comprehensive PHC as a central strategy in world debate. The PHM ensures that people’s voices become part of decision-making processes. The PHM has an evolving presence in over 80 countries worldwide, consisting of groups of individuals and/or well-established PHM circles with their own governance and information-sharing mechanisms. It additionally operates through issue-based circles across countries.
Article
The Politics of Primary Health Care
David Sanders and Louis Reynolds
The global project to achieve Health for All through Primary Health Care (PHC) is a profoundly political one. In seeking to address both universal access to health care and the social determinants of health (SDH) it challenges power blocs which have material vested interests in technical approaches to health and development.
The forces that have shaped PHC include Community Oriented Primary Care and the Health Centre Movement, the “basic health services approach,” and nongovernmental and national initiatives that exemplified comprehensive and participatory approaches to health development. The 1978 Alma-Ata Declaration codified these experiences and advocated Health for All by the year 2000 through PHC. It emphasized equitable and appropriate community and primary-level health care as well as intersectoral actions and community participation to address the social and environmental determinants of health. This would need the support of a new international economic order.
The concept of “Selective Primary Health Care” emerged soon after Alma-Ata, privileging a limited set of technical interventions directed at selected groups, notably young children. This was soon operationalized as UNICEF’s Child Survival Revolution. The visionary and comprehensive policy of PHC was further eroded by the 1970s debt crisis and subsequent economic policies including structural adjustment and accelerated neoliberal globalization that deregulated markets and financial flows and reduced state expenditure on public services. This translated, in many countries, as “health sector reform” with a dominant focus on cost efficiency to the detriment of broad developmental approaches to health. More recently this selective approach has been aggravated by the financing of global health through public-private partnerships that fund specific interventions for selected diseases. They have also spawned many “service delivery” NGOs whose activities have often reinforced a biomedical emphasis, supported by large philanthropic funding such as that of the Gates Foundation.
Educational institutions have largely failed to transform their curricula to incorporate the philosophy and application of PHC to inform the practice of students and graduates, perpetuating weakness in its implementation.
Revitalizing PHC requires at least three key steps: improved equity in access to services, a strong focus on intersectoral action (ISA) to address SDH and prioritization of community-based approaches. The third sustainable development goal (SDGs) focuses on health, with universal health coverage (UHC) at its center. While UHC has the potential to enhance equitable access to comprehensive health care with financial protection, realizing this will require public financing based on social solidarity. Groups with vested interests such as private insurance schemes and corporate service providers have already organized against this approach in some countries. The SDGs also provide an opportunity to enhance ISA, since they include social and environmental goals that could also support the scaling up of Community Health Worker programs and enhanced community participation.
However, SDG-8, which proposes high economic growth based substantially on an extractivist model, contradicts the goals for environmental sustainability. Human-induced environmental degradation, climate change, and global warming have emerged as a major threat to health. As presciently observed at Alma-Ata, the success of PHC, and Health for All requires the establishment of a new, ecologically sustainable, economic order.
Article
The Role of Service User Preferences and User-Centered Approaches in Adult Social Care
Helen Dickinson and Robin Miller
In recent years we have seen growing interest in a range of countries around how service user preferences can be accommodated in adult social care and how these services might be oriented to be more user-centered. There is a diverse array of different initiatives that might be classified as creating more user-centered approaches. Those at the strategic (macro) and organizational (meso) levels typically have greater amounts of evidence available than those at the individual (micro) level. However, many of these struggle to significantly disrupt power relations and clearly demonstrate an impact on service users. Those at the micro level more readily demonstrate impact, although the very local nature of these interventions means that they are not always well evaluated, and lessons may not be easy to transfer from one context to another. Overall, there is no system that has managed to reorient its adult social care system in a wholesale way; this is an issue that requires both technical and cultural change. Such changes take time to achieve, but there is much that can be learned from the existing evidence base.
Article
The Use of Appropriate Sanitation Technology in Low-Income and Informally Occupied Areas: A Case Study of EMBASA’s Experience With the Condominial Sewerage System in Salvador da Bahia, Brazil
Júlio Mota and Ivan Paiva
This article describes how the State of Bahia Water and Sanitation Company (Empresa Baiana de Águas e Saneamento [EMBASA]) expanded sewerage coverage in the city of Salvador, in the state of Bahia, Brazil. In 2021, the city had a sewerage network that served over 80% of its population, despite the fact that at least 70% of the city was composed of informal settlements. To overcome the enormous challenges of installing sewerage systems in areas with informal settlements, EMBASA decided to use the condominial sewerage model, a methodology that combines technical changes in the design of the collection systems coupled with a strong community participation component. The principal technical changes in the collection system were adapting the solution to local circumstances in each neighborhood, universalization of service, the use of the concept of microsystems (subbasins), and the use of the urban block as the basic collection unit. The methodology was first used during a program to expand the sanitary sewerage system of Salvador between 1995 and 2004, when household connections to the sanitary sewage system increased from 26% to 60% in the municipality. The condominial sewerage methodology was adopted because it was the only system capable of solving the enormous problems of informal occupation, community participation, and social inequality, among other things. With the success of the program, investments in sanitary sewerage were continued, and in 2021, the connection rate was 81%. Many challenges to increasing coverage remained, especially those related to the occupation of urban land, which continued in a disorderly manner; social inequalities; and changes in the sanitation regulatory framework.
Article
Time in Health Promotion and Public Health
Lyndall Strazdins
Being physically active and eating fresh foods could reduce the growing burdens of cardiovascular disease, cognitive decline, obesity, some cancers, diabetes type II, depression, and anxiety. Increasing these health behaviors has been a public health focus for decades, yet over one half of adults around the world remain insufficiently physically active and four in ten are overweight or obese. When people are asked why they don’t exercise more or eat healthy food, the most common reason they give is lack of time. Everyone has 24 hours in a day, so why do so many people say they lack time to be healthy?
Time is a challenging (and intriguing) concept. Usually, time is thought about in terms of hours and minutes which evenly divide a day, and its lack a consequence of misguided priorities. This assumes that all hours are equal and available for use and that every person has agency over their time. Although having sufficient time is fundamental to health (exercising, preparing healthy food, resting, accessing services, and maintaining social bonds all take time), other dimensions such as control, flexibility, intensity, and timing are essential for understanding how time and health are connected. Like income, time is exchanged and given within households, so it can be fruitful to view time as a household resource rather than an individual’s resource. In the labor market, time is exchanged for payment, and this underscores time’s potency as a social and economic resource.
Historically, research on the social determinants of health and health equity have focused on the harms linked to work hours, including the length and timing of the work day and flexible hours. Yet this research missed the importance of time outside the labor market, which alters the health consequence of work hours, delivering only a partial analysis of how time shapes health. Research since the early 2000s is supplying new evidence of the interplay between work, care, and other non-market time, allowing a more accurate insight into how time shapes health and how this relationship connects to social and gender equity. Debates remain, however, and these include the extent to which time pressure and time scarcity are problems of motivation and perception and whether time scarcity is a problem of only the affluent.
There are precedents to address time costs and inequities. A first step for health prevention and health promotion practitioners is to value time in ways comparable to how the field values money. This would mean limiting the time costs of health interventions and services, including the requirement to “find time” outside of work or care roles to be healthy. The field also needs to challenge the idea that the income-poor are time-rich since this is rarely the case if they are caregivers. As well as minimizing time burdens, policies to address the social determinants of time from urban planning, transport systems, and work-hour regulations will be critical to achieving a fairer and healthier world.
Article
Traditional Chinese Medicine and Public Health
Paul Unschuld
In many countries, Traditional Chinese Medicine has acquired a status similar to other historical healthcare systems that are not at all or only partially legitimated by modern science, such as Ayurveda and homeopathy. They all contribute in one way or another to the health of the public. And yet, Chinese medicine eludes inclusion in modern, global public health concepts. Its focus on the individual patient-healer relationship, its diverse non-Chinese terminologies, often developed by individuals regardless of the historical meaning of the original Chinese terms, and an increasingly uncoordinated development of TCM in China and the rest of the world, with heterogenous educational standards resulting in very different skill levels of practitioners, make it impossible to draw far-reaching conclusions and contribute generalizable suggestions for the continued improvement of global public health.
Article
Traditional Medicine and Indigenous Health in Indigenous Hands
Gerard Bodeker and Kishan Kariippanon
An estimated 370 million Indigenous people reside in 90 countries and make up 5% of the global population. Three hundred million Indigenous people live in extremely disadvantaged rural locations. Indigenous people have suffered from historic injustices due to colonization and the dispossession of their lands, territories, and resources, thus preventing them from exercising their right to development according to their own needs and interests. Across the board, Indigenous people have poorer health outcomes when compared to their non-Indigenous fellow citizens.
Cancer, respiratory disease, endocrine, nutritional, and metabolic disorders, primarily diabetes, affect Indigenous people disproportionately. Newborns of Indigenous women are more than twice as likely to be of low birth weight as those born to non-Indigenous women. Indigenous rates of suicide are the highest in the world.
For public health to be effective, a social determinants approach, along with health interventions, is insufficient to create lasting health impact. Partnerships with Indigenous organizations, Indigenous researchers, and the professionalization of health workers is essential. Integration of traditional medicine and traditional health practitioners can enable the Western biomedical model to work in partnership with Indigenous knowledge systems and become more locally relevant and accountable.
The Indigenous health workforce is increasingly using evidence-based, innovative approaches to address the shortage of health professionals as they move toward universal health coverage. Internet, mobile, and communication technologies are enhancing the mobilization of Indigenous health efforts and the support for health workers in rural locations. Presented are country examples of integrated medicine and Indigenous partnerships that effectively implement health interventions.
Article
Urban Guerrilla Gardening and Health
Alec Thornton
The benefits of gardening for mental and physical health are well known. Gardening is also recognized as a local-level or grassroots response to the negative effects of climate change and global warming. In urban areas, dense neighborhoods, limited green spaces, contaminated brownfield sites, and, at times, restrictive council regulations on the public use of parks and verges can act as barriers to gardening. In the 1970s, guerrilla gardening emerged as a clandestine, environmentally conscious, grassroots activity to reclaim and transform neglected or derelict urban spaces into healthy green spaces. Although not as subversive since its inception, guerrilla gardening in cities is as much a recreational activity as it is an ecological statement of urban activism, which effectively provides urban dwellers an entry point to engage with the outdoors for the planting of edible and nonedible plants in artificial places and spaces where natural life struggles to exist. Guerilla gardening has been impactful to city life through its contributions and controversies in improving urban ecosystems, educating neighbors on nutrition and food production where gardens crop up, and broadly to the health of humans (and other creatures) who live there.
Article
Urban Health and Disaster Resilience
David Sanderson, Ronak Patel, and Kelsey Gleason
As cities and towns across the world continue to grow to accommodate most of the world’s population increase, so too are they increasingly and often disproportionately exposed to the threat of natural hazards—including those worsened by climate change—such as floods, earthquakes, windstorms, and fires. Efforts that aim to enhance and safeguard urban health are those that seek to build the resilience of people and systems before, during, and after disasters. Yet where these efforts fail or fail to exist, components of vulnerability and urban diversity inform disaster risk. Taking a systems approach is especially essential to recognize the interconnected, complex, and dynamic issues that include and impact on the spectrum of urban health.
Article
Urban Health and Healthy Cities Today
Evelyne de Leeuw, Jean Simos, and Julien Forbat
The authors of this article purport that for current understanding of Healthy Cities it is useful to appreciate other global networks of local governments and communities. In a context where the local level is increasingly acknowledged as decisive in designing and implementing policies capable of tackling global threats such as climate change and their health-related aspects, understanding how thousands of cities across the world have decided to respond to those challenges appears essential. Starting with the concept of “healthy cities” in the 1980s, the trend toward promoting better living conditions in urban settings has rapidly grown to encompass today countless “theme cities” networks. Each network tends to focus on more or less specific issues related to well-being and quality of life. These various networks are thus not limited to more or less competing labels (Healthy Cities, Smart Cities, or Inclusive Cities, for instance), but entail significant differences in their approaches to the promotion of health in the urban context. The aim of this article is to systematically typify these “theme cities.” A typology of “theme cities” networks has several objectives. First, it describes the health aspects that are considered by the networks. Are they adopting a systemic perspective on all health determinants, such as Healthy Cities, or are they focusing on “hardware” determinants like Smart Cities? Second, it highlights the key characteristics of the networks. For instance, are they pushing for technological solutions to health problems, like Smart Cities, or are they aiming at strengthening communities in order to mitigate their detrimental effects, like Creative Cities? Third, the typology has the potential to be used as an analytical tool, for example, in the comparison of the results obtained by different types of networks in urban health issues. Finally, the typology offers a tool to enhance both transparency and participation in the policymaking process taking place when selecting and engaging in a network. Indeed, by clarifying the terms of the debate, decisions can be made more explicit and achieve a greater level of congruence with the overall objectives of the city. Indeed, Healthy Cities today need to make alliances with other theme networks, and this typology gives the keys to find which networks are the “natural best allies,” avoiding mutually harmful antagonisms. In that sense, the typology developed should be of interest to any actor involved in health promotion at the city level, whether in an existing “theme cities” policy process or as willing to participate in such a program, and to scholars interested in better understanding the main drivers of “theme cities” networks, a rapidly growing field of study.
Article
Urban Health in Latin America and the Caribbean
Luiz Galvão, Waleska Teixeira Caiaffa, Solimar Carnavalli Rocha, and Bernhard Liese
Urbanization can enhance the quality of life in cities and promote healthy living conditions. Unfortunately, according to the World Health Organization, 24% of urban populations live in unhealthy slums, making early intervention and public policies imperative. While urban areas have the advantage of access to essential services like transportation and healthcare, inadequate planning can lead to health issues.
Rural populations also face challenges accessing safe drinking water and sanitation, leading to unequal distribution of drinking-water quality. Climate change exacerbates these issues, resulting in conflicts, social and economic instability, and adverse environmental and public health effects. Additionally, population growth and improved water access have intensified wastewater treatment problems, and waste generation remains a significant issue in Latin America. Homeless communities in urban areas are particularly vulnerable to crises like COVID-19 and climate change. Access to healthcare is crucial for urban health, but half of the population lacks this access, leading to poverty due to healthcare expenses. Promoting social equity through healthcare access is vital.
The United Nations recognizes the devastating impact of COVID-19 and calls for a transformative approach to rebuild economies that prioritize social equity and environmental sustainability. Sustainable development policies can combat poverty, hunger, climate change, and environmental degradation. The Barcelona Institute for Global Health has developed a framework that connects healthy urban development to the sustainable development goals, emphasizing intersectoral work, health equity, and data quality. However, COVID-19 has severely affected the implementation of the 2030 Agenda.
Research in Brazil and Latin America reveals that economic segregation and inequality contribute to higher homicide rates and lower life expectancy. Effective urban policies can improve population health, and understanding the factors that impact elderly health can lead to better planning for active aging and reducing health disparities.
Successful approaches to research and addressing urban health issues involve interdisciplinary collaboration among academia, public and private sectors, and communities. Policies that impact health, with particular attention to the social, economic, and urban determinants of health in urban areas, are essential. The aim of the authors of this article, as public health researchers, is to identify targets for large-scale policy interventions in these areas.
The Belo Horizonte Observatory for Urban Health was founded in 2002 through a process led by the local university and health services to bring together academics and public sector services as part of a broader agenda to strengthen local and national health systems. This model could be a modern approach to Urban Health and play a central role in the current global health challenges.
Article
Urban Homelessness Policy in OECD Nations
Charley E. Willison and Amanda I. Mauri
Homelessness is a public health challenge for modern governments. Homelessness emerged as a formal policy problem for rich nations in the mid- to late 20th century as nations developed stable economies and democracies, including housing and job markets, and social welfare mechanisms to protect citizens from disenfranchisement. In early 21st-century Organisation for Economic Co-operation and Development (OECD) nations, homelessness arises most often among at-risk or vulnerable populations, such as historically marginalized groups and/or persons with constrained access to welfare state mechanisms, such as immigrants or refugees. Thus, homelessness in OECD nations is very different from informal housing or mass poverty in poor nations and/or non-democratic regimes.
Homelessness affects individual and population health, requiring complex policy solutions across multiple domains of health, as well as intergovernmental coordination. Policy responses to homelessness vary across OECD nations in their approach and efficacy. There are four key factors influencing how OECD nations respond to homelessness: (a) the strength and inclusivity of the welfare state; (b) degrees of decentralization in homeless policy governance; (c) the strength, capacity, and inclusivity of the health and behavioral healthcare systems; and (d) the role of federated structures in health and welfare state policy. Overall, nations with weaker welfare states and health/behavioral healthcare systems face greater risks of homelessness. The inclusivity of these systems also shapes who may be eligible for protection or experience homelessness. Local governments, especially those in large metropolitan areas, are the frontline providers of homelessness services. Yet local governments are constrained at both ends: Policies designed, delivered, and funded at larger units of government—such as welfare state provisions—influence many of the determinants of homelessness, such as housing, and the resources available to subnational actors to combat homelessness. Local actors are also constrained by the degree of decentralization. Devolution of homelessness policy to smaller units of government or even solely to nongovernmental actors, through federated mechanisms or decentralization, may create barriers to locally tailored solutions by perpetuating disparities across jurisdictions and/or constraining authority and resources necessary to design or deliver homeless policy.
Article
Urbanization in the Global South
Warren Smit
The term “global South” (or just “South” or “south”) refers to the diverse range of countries in Asia, Africa, and Latin America that have a colonial past and are usually characterized by high levels of poverty and informality. The term global South has widely replaced other, similar, terms such as the Third World, developing countries, and low- and middle-income countries. Urbanization, in its narrow sense, refers to an increase in the proportion of the population living in urban areas; in its wider sense it refers to all the social, economic, biophysical, and institutional changes that result from and accompany urban growth, many of which have a profound impact on human health and well-being. The global South is the most rapidly urbanizing part of the world. Since about 2015, more than 75% of the world’s urban population lives in the global South. It is projected that by 2025, the urban population of the global South will be 3.75 billion (54.3% of the total population of the global South). Most of this urbanization is as a result of urban areas having higher natural population growth rates than rural areas, but migration to urban areas also plays a significant role. Although urbanization processes vary considerably across different countries in the global South (e.g., between different regions and between middle-income and low-income countries), there are a number of broad common trends: a rapid increase in the number of megacities (urban agglomerations with a population of more than 10 million), ongoing strong urban–rural linkages and increased blurring of “urban” and “rural,” increased urban sprawl and fragmentation, and growing intra-urban inequalities. There has been much debate about the nature of cities and urban life in the global South, giving rise to a body of literature on “southern urbanism,” characterized by case studies of everyday life. Urbanization processes in the global South have contributed to the growth and complexity of the burden of disease. Infectious diseases have continued at high levels due to poor environmental conditions in many parts of cities, particularly in informal settlements and other types of slums. Noncommunicable diseases are also growing rapidly in the global South, linked to changes in living conditions and lifestyle associated with urbanization. It is anticipated that the burden of disease in cities of the global South will continue to increase as urbanization continues, as a result of increased traffic injuries and respiratory disease resulting from increased numbers of motor vehicles; growing levels of violence due to growing levels of poverty and inequality in many cities; growing obesity as a result of changed lifestyles associated with urbanization; growing numbers of unsafe settlements in hazardous areas; and a high risk of infectious diseases. Climate change is likely to exacerbate these risks.
Article
Urban Water Regulation and Health: The Case of Chile
Michael Hantke-Domas and Ronaldo Bruna
In 50 years, Chile achieved nearly full urban water and sanitation coverage—even higher than some developed countries. Furthermore, in just a decade, the country obtained full urban wastewater treatment, making it probably the only developing country that will successfully meet the Sustainable Development Goals (SDGs) in this matter. These achievements can be attributed to policies oriented towards the incremental or gradual improvement of the water and sanitation sector sustained for more than 50 years. This policy was mainly focused on (a) increasing public investment in expanding coverage levels, both for potable water and sewerage; (b) reducing enteric diseases and infant mortality; (c) improving child nutrition; (d) streamlining public utilities; (e) establishing a legal framework for economic regulation applied by an independent body applicable to all utilities; (f) building efficient institutions; (g) a full cost recovery tariff policy; (h) bringing private capital into the industry; (i) subsidizing those who need it most; and (j) de-politicizing the sector. The Chilean experience is not well documented or, at least, there are few references regarding its success story, which reinforces the motivation to understand its history.
Article
Using Large Data Sets to Measure Health Status and Service Use of Older Adults
Kimberly E. Lind and Magdalena Z. Raban
Commonly used data sources for measuring health status and service use of older adults include national surveys and secondary data analysis of electronic data sources including healthcare claims data and electronic health records (EHRs). Depending on how the data are generated in EHRs and medical claims, and depending on how long people are observed for, the ability to measure prevalence or incidence of chronic conditions and the ability to measure incidence or a history of acute conditions will vary. Various data types spanning standardized data (diagnostic codes, procedure codes), medication administered or prescribed, unstructured free text such as clinical notes, and clinical assessment data can all be used to measure health status and service use. Different data sources and types of variables have different benefits and limitations depending on how data are generated and the incentives for those recording data (i.e., healthcare providers and billing staff) to be complete. Testing assumptions and exploring the validity of measures can be accomplished by approaches such as comparing agreement of measures (e.g., disease prevalence) across data tables within a data source, comparing agreement with linked data sources, and comparing rates of disease or service use to rates in data sources that have similar populations. Future directions for administrative data such as data linkage and natural language processing will improve the utility of administrative data. The information and concepts are broadly applicable, but for illustrative purposes, examples of how these approaches have been applied to electronic data from administrative records including EHRs and claims data to fill important knowledge gaps and measure health status and quality of care from Australia and the United States are presented.
Article
Using Lifestyle Interventions to Reduce Alzheimer’s Risk in African Americans
Robert L. Newton, Jr., George W. Rebok, Andrew McLeod, and Owen Carmichael
Currently, there are no pharmacological interventions that have been shown to reduce the risk of developing dementias such as Alzheimer’s disease. However, it is recognized that modifiable behaviors are associated with increased risk of developing dementias. Lifestyle interventions are designed to assist participants in changing these modifiable behaviors. Typical behaviors targeted include dietary intake, sleep patterns, and social, cognitive, and physical activities. It is hypothesized that these effects occur through physiological and biological pathways. African Americans have a high risk of developing dementias, and altering lifestyle behaviors may be effective for reducing risk in this population. Identifying these interventions is important, as effective interventions for a majority non-Hispanic White population do not necessarily translate into effective interventions for African Americans.
Article
Vaccine Hesitancy
Eve Dubé and Noni E. MacDonald
Vaccination is one of the greatest public health successes. With sanitation and clean water, vaccines are estimated to have saved more lives over the past 100 years than any other health intervention. Vaccination not only protects the individual, but also, in many instances, provides community protection against vaccine-preventable diseases through herd immunity. To reduce the risk of vaccine-preventable diseases, vaccination programs rely upon reaching and sustaining high coverage rates, but paradoxically, because of the success of vaccination, new generations are often unaware of the risks of these serious diseases and their concerns now concentrate on the perceived risk of individual vaccines. Over the past decades, several vaccine controversies have occurred worldwide, generating concerns about vaccine adverse effects and eroding trust in health authorities, experts, and science. Gaps in vaccination coverage can, in part, be attributed to vaccine hesitancy and not just to “supply side issues” such as access to vaccination services and affordability.
The concept of vaccine hesitancy is now commonly used in the discourse around vaccine acceptance. The World Health Organization defines vaccine hesitancy as “lack of acceptance of vaccines despite availability of vaccination services. Vaccine hesitancy is complex and context specific, varying across time, place and vaccines.” A vaccine-hesitant person can delay, be reluctant but still accept, or refuse one, some, or all vaccines. Technical, psychological, sociocultural, political, and economic factors can contribute to vaccine hesitancy. At the individual level, recent reviews have focused on factors associated with vaccination acceptance or refusal, identifying determinants such as fear of side effects, perceptions around health and prevention of disease and a preference for “natural” health, low perception of the efficacy and usefulness of vaccines, negative past experiences with vaccination services, and lack of awareness or knowledge about vaccination.
Very few interventions have been shown to be effective in reducing vaccine hesitancy. Most of the studies have only focused on metrics of vaccine uptake and refusal to evaluate interventions aimed at enhancing vaccine acceptance, which makes it difficult to assess their potential effectiveness to address vaccine hesitancy. In addition, despite the complex nature of vaccination decision-making, the majority of public health interventions to promote vaccination are designed with the assumption that vaccine hesitancy is due to lack or inadequate knowledge about vaccines (the “knowledge-deficit” or “knowledge gap” approach). A key predictor of acceptance of a vaccine by a vaccine-hesitant person remains the recommendation for vaccination by a trusted healthcare provider. When providers communicate effectively about the value and need for vaccinations and vaccine safety, people are more confident in their decisions. However, to do this well, healthcare providers must be confident themselves about the safety, effectiveness, and importance of vaccination, and recent research has shown that a proportion of healthcare providers are vaccine-hesitant in their professional and personal lives. Effective strategies to address vaccine hesitancy among these hesitant providers have yet to be identified. A better understanding of the dynamics of the underlying determinants of vaccine hesitancy is critical for effective tailored interventions to be designed for both the public and healthcare providers.
