ciudades y salud cardiovascular: proyecto erc heart healthy hoods

Centro Nacional de Epidemiología19 Enero 2017

Ciudades y Salud Cardiovascular: Proyecto ERC Heart Healthy Hoods

@HHHproject Manuel Franco MD, PhD

Profesor Titular Universidad de Alcalá

Adjunct Associate ProfessorDepartment of Epidemiology

Johns Hopkins Bloomberg School of Public Health

http://hhhproject.eu

Physical activity environment in Madrid, HHH study

International Journal of Epidemiology 2015, Franco M et al

Miguel, 45 years old, lives in Villaverde, Madrid. Low-income area.

Miguel goes out for a walk every afternoon to the park. “I used to run all the distance of the bike lane but I started having knee problems and now I prefer walking. When I am in a good mood I can walk all the way to the next large neighbourhood.”

Food environment in Madrid, HHH study

International Journal of Epidemiology 2015, Franco M et al.

María, 45 ys, resident of Villaverde. Low-income area. María and her friends meet twice per week to have a dinner snack at the Dehesa Boyal park, a pinewood and main park in San Cristobal. María lives in Spain for the last 4 years, unemployed for the last 8 months, and she often thinks about coming back to the Dominican Republic where her family lives.

Opportunities for NCDs prevention within

Urban Health Research1. By 2050: 66% of the world population will live in cities2. Challenge of aging and chronic diseases already in our cities 3. Social determinants as working conditions, unemployment

and poverty are clearly patent in our cities4. Segregation patterns and health inequalities are social

phenomena measurable in our cities

5. Cities, municipalities, districts, offer great (structural)1 opportunities to improve population health

6. New sources and types of health and urban data, allong with novel methodologies and interdisciplinary teams

7. Urban health research is directly linked to action(1) Franco, Bilal and Diez-Roux, J Epidemiol Comm Health 2015

Social and Physical Urban Environment and CV Health:

The Much Needed Population Approach

Manuel Franco MD, PhD

Starting Grant 2013 Start Date April 1st 2014

Presenter’s Name

PhysicalEnvironment

Social Environment

SOCIALEPIDEMIOLOG

YStudies social determinants of disease

Methodologies from Social Sciences and Public Health

Focus on population preventive approach

Addresses growing social inequalities in health

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

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

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

Traditional medical preventive approaches are individual

CardiovascularHealth

Presenter’s Name

PhysicalEnvironment

Social Environment

CardiovascularHealth

HEARTHEALTHYHOODS

Obesity

Physical Activity

DietAlcohol

Physical ActivityEnvironment

Food Environment

Smoking

Tobacco Environment

Social and PhysicalEnvironment

Individual Cardiovascular Health

AlcoholEnvironmentN

t – E

–Inc

der –

Heart Healthy Hoods Study Main Goal

1. To include a qualitative approach to understand the context and meanings of the urban environment in relation to cardiovascular health

2. To develop measurements to characterize the social and physical urban environments in a systematic and accurate fashion

3. To understand the already known relation between the urban environment and cardiovascular health in the United States with this relation in Europe

Heart Healthy Hoods Secondary Objectives

To provide scientific evidence to researchers, the

general population and policy makers to intervene at

the population level to prevent the first cause of

death in Europe.

HHH overarching objectivePolicy and research implications

Photography Knowledge

DisseminationCitizen Science

Epidemiology

Health SociologyUniversity of Salamanca

Johns Hopkins School of Public Health

GeographyUniversity of AlcaláCRESH EdinburghLSHTM

Primary Care System Primary Care Research Unit, Madrid

Interdisciplinary team PI: Social Epidemiology

University of AlcaláJohns Hopkins School of Public Health

INTERDISCIPLINARY TEAM

https://hhhproject.eu/people/

Madrid Team

International Collaborations

HHH Kick off meetingSeptember 2014

21 Districts128 Neighborhoods2.412 Census Sections (≅1.500 ps) 3,2 Mill. Residents

HHH will analyze the Integrated Primary Care Health System Electronic Health Records Database of 1,4 mill. residents 40-75 ys.

MADRID

HHH Study Design

Baseline VisitCohort Study

1st Database Mining

Population-based EHR

study4 yr follow up

2,576 participants Final Visit

Final Database Mining

1,4 million people

EnvironmentTobacco Alcohol

FoodPhysical Activity

1st Assessment 2nd AssessmentNeighborhoods

Multilevel AssociationAnalysis

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

from the city of Madrid. Likewise, to investigate the

association between social and physical features of

the urban environment with citizens’ CV health.

WHHHole-Population Study

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

million people). • Several secondary databases for urban environment.

Overall Objective

Whole-Population Study Secondary Objectives

1. To describe CVD annual incidence

2. To describe behavioral and biological risk factors

prevalence and incidence

3. To study the association between sociodemographic

profile and urban environment with CVD incidence

4. To study the Whole-Population results as compared

to HHH Cohort results

Primary Healthcare Centers of MadridCohort HHH centers

1 C.S. ADELFAS2 C.S. ALPES3 C.S. ANGELA URIARTE4 C.S. ARTILLEROS5 C.S. BARAJAS6 C.S. CARAMUEL7 C.S. CERRO ALMODOVAR8 C.S. CIUDAD JARDIN9 C.S. DAROCA

10 C.S. DR. CASTROVIEJO11 C.S. ELOY GONZALO12 C.S. ENTREVIAS13 C.S. ESPRONCEDA14 C.S. FEDERICA MONTSENY15 C.S. FUENCARRAL

16 C.S. GARCIA NOBLEJAS17 C.S. GENERAL RICARDOS18 C.S. GUAYABA19 C.S. IBIZA20 C.S. LAGASCA21 C.S. LAS CORTES22 C.S. LAVAPIES23 C.S. LOS YEBENES24 C.S. MAR BALTICO25 C.S. MONOVAR26 C.S. PAVONES27 C.S. SAN ANDRES28 C.S. SAN FERMIN29 C.S. TORITO30 C.S. VALDEBERNARDO31 C.S. VILLAAMIL

The CoHHHort Study

Main Objective:To study the association between environment characteristics and diet, smoking, physical activity, alcohol consumption, and cardiovascular risk

Target Population:- Men and women between 40 and 75 years old- Free of cardiovascular disease- Residents of Madrid city- Origin: Ecuador, Colombia, Perú y Bolivia

21 Madrid districts

31 Primary Healthcare centers

Sample sizeN=2576

370 Physicians and nurses trained

The CoHHHort Study

Clinical visit

Telephone survey

Biological cardiovascular risk factors

Behavioral cardiovascular risk factors

The CoHHHort Study

Variables:

2017 Follow-up 2018

Follow-up 2019

Follow-up 2020

Clinical visit+

Telephone survey

Electronic health

records variables

Clinical visit+

Telephone survey

Electronic health

records variables

Cohort Study calendar:

The CoHHHort Study

a) Mixed Methods Exploratory Study in a Median Area of Madrid (Usama Billal)

b) Results by domainsa) Food

b) Physical Activity

c) Tobacco

d) Alcohol

c) Results by working groupsa) Urban Geography

b) Qualitative Research

HHH Analyses and Results

Mixed Methods Approach

Methods (quantitative)

• Cardiovascular Disease:– Whole population (>99%) EHR through universal health system.– Validated (1) data on physician-diagnosed: diabetes, hypertension,

dyslipidemia, smoking and obesity.

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

measured healthy food availability (brief NEMS-S)– Physical activity: SPACES audit tool for walkability and bikeability,

SOPARC audit tool for open spaces.– Alcohol and tobacco: location and type of retailers

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

Methods (qualitative)

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

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

• Analysis by triangulation incorporating an interpretative phenomenological analysis.

Exploratory Study Sociodemographic ProfilePrimary Health Care Records

• Total Pilot Area Population: 15,751

• Population in the Primary Care Health System Geocoded to

census section level: 14,857 (95%)–Possibility of analyzing data for 1.4 million people

• Population 45-106 ys. old: 7,252

• Diabetes Prevalence: 12%

• Diabetes Control (HbA1c<7): 63%

• Hypertension Prevalence: 34%

• Dyslipidemia, all types: 32%

Métodos Medidas de Exposición Barrios

42 neighborhoods in Madrid (2 neighborhoods per district selected

according different SE charactersitics)

In each neighborhood we select the “median” census track in terms of

educational level, immigration, density of business and age.

Representative area of the municipality of Madrid in terms of SE characteristics

a) Mixed Methods Exploratory Study in a Madrid Median Area

b) Results by domains

a) Food (Julia Diez) b) Physical Activity

c) Tobacco

d) Alcohol

c) Results by working groups

a) Urban Geography

Cross-city differences

Walking access to healthy foodMADRID BALTIMORE

Preventive Medicine 2016, Diez J et al.

Food environment measures• Methods

1) Ground-truthing (in-store audits)

• Observers assessed all food stores present in all 42

census sections (June-July 2016), using a web-based

app, to measure healthy food availability and price.

2) Secondary database

• Public database “Censo de Locales”, updated monthly

and freely accessible from the city council.

• We assessed level of agreement by store type and by

census section-SES

b) Physical Activity (Pedro Gullón) c) Tobacco

d) Alcohol

a) Urban Geography

Urban Environment and active transportation in Madrid

Madrid Systematic Pedestrian and Cycling Environment Scan (M-SPACES)

- Function- Safety- Aesthetics- Destinations

M-SPACES AUDIT TOOL

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

Physical Activity Results

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

Pedro Gullón, Usama Bilal, Alba Cebrecos, Hannah M. Badland, Francisco Escobar, Iñaki Galán, Manuel Franco

Under Review: International Journal of Health Geographics

Socioeconomic Determinants of Small-Area Walkability in a European city like

Madrid: The Heart Healthy Hoods Project

Figure 1. Spatial distribution of Walkability Index (a) and Socio-Economic Status Index (b) by deciles in the census section (N=2415) of the city of Madrid

c) Tobacco (Xisca Sureda) d) Alcohol

a) Urban Geography

Tobacco retail environment, outdoor smoke-free policies

and smoking

HHH Ancillary Study PI: Xisca Sureda

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

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

Funding: European Research Council Starting Grant 2013 HeartHealthyHoods Agreement n. 336893 and Instituto de Salud Carlos III (PI15/02146)

Tobacco in HHH

1. To describe tobacco environment in neighborhoods in Madrid city in terms of:

1.1 Tobacco availability (point of sales of tobacco, volume of sales)

1.2 Signs of tobacco consumption outdoors (hospitality venues and other public spaces)

1.3 Second-hand smoke exposure interraces of bars and restaurants

2. To determine possible differences between tobacco urban environment and smoking behaviour and self-reported SHS exposure

DENSITY OF TOBACCO POINT OF SALES LOW EDUCATIONAL LEVEL

Outdoor tobacco consumption signs

c) Tobacco

• Alcohol (Madrid, Barcelona, Edinburgh, Baltimore)a) Results by working groups

a) Urban Geography

b) Participatory Action Research PHOTOVOICE

Alcohol urban environment, and the implementation of

regulatory policies

HHH Ancillary Study PI: Xisca Sureda

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

Alcalá University, Johns Hopkins Bloomberg School of Public Health, University of Edinburgh

Funding: European Research Council Starting Grant 2013 HeartHealthyHoods Agreement n. 336893 and Plan Nacional sobre Drogas (2016I047)

Alcohol in HHH

Sureda X, Villalbí JR, Espelt A, Franco M. Living under the influence: Normalization of alcohol consumption in our cities. Gac Sanit. 2017; vol 31(1): 66-68

1. To describe alcohol environment in in terms of availability, promotion and signs of consumption.

1.1 To determine possible differences between alcohol urban environment and alcohol drinking behaviour.

2. To conduct a participatory-action research strategy (Photovoice) to better understand the attitudes and practices in relation to alcohol consumption from a cultural and social perspective.

3. To compare the regulation of the alcohol urban environment and its implementation in Madrid and Barcelona and how these policies determine possible differences

OHCITIES instrument

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

OHCITIES Validation Results

53,7% with promotion associated to the outlet

88,2% with promotion associated to the outlet

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

c) Tobacco

d) Alcohol (Xisca Sureda)

a) Urban Geography (Alba Cebrecos)b) Qualitative Research

The aim was to design and implement a multicomponent method based on Geographic Information Systems to characterize and evaluate environmental correlates of obesity: the food and the physical activity urban environments.

f̂ ( x )= 1h𝑛 ∑i=1

K ( x− X ih )

Kernel Density Estimation (KDE)

WALKABILITY

HFAI & WALKABILITY

STUDY AREA

METHODOLOGY

RESULTS

c) Tobacco

d) Alcohol

c) Results by working groupsa) Urban Geography

b) Qualitative Research (Paloma Conde)

Neighborhoods under change and residents´ health perceptions: The Heart Healthy Hoods qualitative study.

Objectives:•To describe the social and neighborhood changes occurring in a middle low socioeconomic area of Madrid according to their residents.

•To explore how these neighborhood changes are connected to residents’ health perceptions.

Methods: Exploratory qualitative study within 12 months (from January 2014 to January 2015) using 16 semi-structured interviews. Residents + professionals.

Interview Topic guide:- Neighborhood description- Uses of the neighborhood- Health related to neighborhood

Conde P, Gutiérrez M, Sandín M, Díez J, Rivera J, Franco M. Neighborhoods under change and residents´ health perceptions: The Heart Healthy Hoods qualitative study (submitted)

Breakdown of traditional forms vs IndividualismRapid rhythms of life (-) Lack of timeChange in gender/age role

Generation and cultural

fracture

NEIGHBORHOOD CHANGES

Economic crisisImpoverishment and lack of resourcesHigh working hours

SOCIAL CHANGES

New Demographic composition

New socio-cultural values

Economic aspects

Qualitative results RESIDENTS’ HEALTH PERCEPTIONSLoss of trust relationships

(-) Loneliness and lack of social support

New diet practices(-) Not very healthy diets

New uses of public spaces(-) Loss of public space use

Associative networks support(+) Strengthen self-esteem(+) Decreases anxiety(+) Increases social cohesion

Participation of elderly in health promotion and education programs

(+) Promotes Active ageing

Unemployment and job insecurity(-) Unhealthy diets(-) Stress, Anxiety

(+) Intergenerational solidarity

HHH Ancillary Studies

1. Photovoice Villaverde, 2015

2. Usama´s Retrospective HHH, 2015-2016

3. Smoking in the City, 2016-2019

4. Qualitative HHH substudy, 2017-2020

5. Alcohol in the City, 2017-2020

HHH Current Scientific Achievements

• 8 international papers and 4 book chapters

• Bilingual photobook and public exhibition

• 5 funded ancillary studies

• 3 Predoctoral and one Erasmus master fellowships

• Intramural: 3 research awards Universidad de Alcalá

• 4 travel grants for US (Joel Gittelsohn and Luisa Borrell) and UK researchers (Daniel Lewis and Jamie Pearce)

• Participants

• Whole HHH Madrid team and collaborations

• Different funding agencies: • European Research Council• Ayuntamiento y Comunidad de Madrid • Fondo de Investigación Sanitaria• Plan Nacional de Investigación• Plan Nacional Sobre Drogas• Fundación Mapfre• Center for a Livable Future, Johns Hopkins

Acknowledgements

HHH TeamThank you very much !

Centro Nacional de Epidemiología19 Enero 2017

¡ Gracias ! Todos los investigadores HHH

y Manuel Franco

@HHHproject

ciudades y salud cardiovascular: proyecto erc heart healthy hoods

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