Mary E. Northridge

Sorting out the connections between the built environment and health: a conceptual framework for navigating pathways and planning healthy cities.

The overarching goal of this article is to make explicit the multiple pathways through which the built environment may potentially affect health and well-being. The loss of close collaboration between urban planning and pulic health professionals that characterized the post-World War II era has limited the design and implementation of effective intervention and policies that might translate into improved health for urban populatons. First, we present a conceptual model that developed out of previous research called Social Determinants of Health and Environmental Health Promotion. Second, we review empirical research from both the urban planning and public health literature regarding the health effects of housing and housing interventions. And third, we wrestle with key challenges in conducting sound scientific research on connections between the built environment and health, namely: (1) the necessity of dealing with the possible health consequences of myriad public and private sector activities; (2) the lack of valid and reliable indicators of the built environment to monitor the health effects of urban planning and policy decisions, especially with regard to land use mix; and (3) the growth of the “megalopolis” or “super urban region” that requires analysis of health effects across state lines and in circumscribed areas within multiple states. We contend that to plan for healthy cities, we need to reinvigorate the historic link between urban planning and public health, and thereby conduct informed science to better guide effective public policy.

Social Determinants of Health: Implications for Environmental Health Promotion

In this article, the authors draw on the disciplines of sociology and environmental and social epidemiology to further understanding of mechanisms through which social factors contribute to disparate environmental exposures and health inequalities. They propose a conceptual framework for environmental health promotion that considers dynamic social processes through which social and environmental inequalities—and associated health disparities—are produced, reproduced, and potentially transformed. Using empirical evidence from the published literature, as well as their own practical experiences in conducting community-based participatory research in Detroit and Harlem, the authors examine health promotion interventions at various levels (community-wide, regional, and national) that aim to improve population health by addressing various aspects of social processes and/or physical environments. Finally, they recommend moving beyond environmental remediation strategies toward environmental health promotion efforts that are sustainable and explicitly designed to reduce social, environmental, and health inequalities.

A multilevel analysis of income inequality and cardiovascular disease risk factors

Recent research has suggested that inequality in the distribution of income is associated with increased mortality, even after accounting for average income levels. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we investigated whether inequality in the distribution of income within US states is related to the prevalence of four cardiovascular disease risk factors (body mass index (BMI), history of hypertension, sedentarism, and smoking). Multilevel models (including both state-level and individual-level variables) were used to examine associations of state inequality with risk factor levels before and after adjustment for individual-level income. For three of the four risk factors investigated (BMI, hypertension, and sedentarism), state inequality was associated with increased risk factor levels, particularly at low income levels (annual household incomes <

Social Epidemiology and the Fundamental Cause Concept: On the Structuring of Effective Cancer Screens by Socioeconomic Status

25,000), with associations persisting after adjustment for individual-level income. Inequality was also positively associated with smoking, but associations were either stronger or only present at higher income levels. Associations of inequality with the outcomes were statistically significant in women but not in men. Although not conclusive, findings for three of the four risk factors are suggestive of a contextual effect of income inequality, particularly among persons with lower incomes.

Home hazards and falls in the elderly: The role of health and functional status

Since the early 1800s, studies have consistently demonstrated that people higher in the socioeconomic hierarchy live longer than people of lower rank. One hypothesis for the persistence of this association is that people who are relatively better off are more able to avoid risks by adopting currently available protective strategies. In a partial test of this idea, the social distributions of two cancer screening tests--Pap smears and mammography--were examined. A review of the literature and an analysis of Behavioral Risk Factor Surveillance System (BRFSS) data showed a consistent association between indicators of socioeconomic status and recent screening. These findings support the theory that societies create and shape patterns of disease. Innovations beneficial to health are carried out within the context of inequalities that shape the distribution of the health benefit, thereby affecting patterns of morality.

Addressing the Childhood Asthma Crisis in Harlem: The Harlem Children’s Zone Asthma Initiative

OBJECTIVES This study was undertaken to determine whether vigorous and frail older people who identify environmental hazards in their homes have an increased risk for falls. METHODS A 1-year prospective study was conducted among 266 female and 59 male community-dwelling volunteers aged 60 to 93 years who had fallen at least once during the previous year. Composite measures of home safety and of frailty were derived using principal components analysis. Participants were divided into vigorous and frail groups, and associations between baseline home safety measures and falls at home over the follow-up year were compared between the two groups. RESULTS Frail individuals were more than twice as likely as vigorous individuals to fall during follow-up (rate ratio [RR] = 2.24; 95% confidence interval [CI] = 1.54, 3.27). In the study group as a whole, falls were not strongly associated with the presence of home hazards. However, when compared with vigorous older persons living with fewer home hazards, vigorous older persons living with more home hazards were more likely to fall. The increased risk for falls among vigorous elderly was limited to falls where home hazards were present. By contrast, living with more home hazards was not associated with increased likelihood of falls among frail older persons. CONCLUSIONS While frail older persons experience higher overall fall rates, vigorous older persons should not be overlooked in fall prevention projects.

Environmental Equity and Health: Understanding Complexity and Moving Forward

OBJECTIVES We determined the prevalence of asthma and estimated baseline asthma symptoms and asthma management strategies among children aged 0-12 years in Central Harlem. METHODS The Harlem Childrens Zone Asthma Initiative is a longitudinal, community-based intervention designed for poor children with asthma. Children aged 0-12 years who live or go to school in the Harlem Childrens Zone Project or who participate in any Harlem Childrens Zone, Inc, program were screened for asthma. Children with asthma or asthma-like symptoms were invited to participate in an intensive intervention. RESULTS Of the 1982 children currently screened, 28.5% have been told by a doctor or nurse that they have asthma, and 30.3% have asthma or asthma-like symptoms. To date, 229 children are enrolled in the Harlem Childrens Zone Asthma Initiative; at baseline, 24.0% had missed school in the last 14 days because of asthma. CONCLUSION The high prevalence of asthma among children in the Harlem Childrens Zone Project is consistent with reports from other poor urban communities. Intensive efforts are under way to reduce childrens asthma symptoms and improve their asthma management strategies.

Dietary patterns in six European populations: results from EURALIM, a collaborative European data harmonization and information campaign

The authors invoke a population health perspective to assess the distribution of environmental hazards according to race/ethnicity, social class, age, gender, and sexuality and the implications of these hazards for health. The unequal burden of environmental hazards borne by African American, Native American, Latino, and Asian American/Pacific Islander communities and their relationship to well-documented racial/ethnic disparities in health have not been critically examined across all population groups, regions of the United States, and ages. The determinants of existing environmental inequities also require critical research attention. To ensure inclusiveness and fill important gaps, scientific evidence is needed on the health effects of the built environment as well as the natural environment, cities and suburbs as well as rural areas, and indoor as well as outdoor pollutants.

Prevalence and social correlates of cardiovascular disease risk factors in Harlem.

Objective: To determine and describe the extent to which European dietary data collected in disparate surveys can be meaningfully compared.Design: Seven independent population-based surveys from six European countries were initially included. Differences in study designs and methodological approaches were examined. Risk factor data for 31, 289 adults aged 40–59 y were harmonized and pooled in a common, centralized database.Results: Direct comparisons of dietary measures across studies were not deemed appropriate due to methodological heterogeneity. Nonetheless, comparisons of intra-population contrasts by gender across sites were considered valid. Women consumed fruit and vegetables more often than men. Age-standardized gender differences in the prevalence of low fruit and vegetable consumption ranged from 7 to 18% and 5 to 15%, respectively. Data on energy intake showed good agreement across study populations. The proportion of total energy from macronutrients was similar for women and men. Gender differences for relative intakes of saturated fatty acids (percentage energy) were small and only in France were they significant. Dietary fibre density was significantly higher in women than in men. Overall, the participating Southern European populations from Italy and Spain exhibited more healthful food composition patterns.Conclusions: Contrasts in dietary patterns by gender across populations may provide the basis for health promotion campaigns. The most favourable patterns observed may serve as attainable goals for other populations. An international risk factor surveillance programme based upon locally run, good quality studies has the potential to provide the needed data.Sponsorship: European Community (DG V), project 96CVVF3-446-0; Swiss Federal Office for Education and Science, OFES 96.0089.European Journal of Clinical Nutrition (2000) 54, 253–262

Obesity and other health determinants across Europe: the EURALIM project.

OBJECTIVES This study examined the prevalence, social correlates, and clustering of cardiovascular disease risk factors in a predominantly Black, poor, urban community. METHODS Associations of risk factor prevalences with sociodemographic variables were examined in a population-based sample of 695 men and women aged 18 to 65 years living in Central Harlem. RESULTS One third of the men and women were hypertensive, 48% of the men and 41% of the women were smokers, 25% of the men and 49% of the women were overweight, and 23% of the men and 35% of the women reported no leisure-time physical activity over the past month. More than 80% of the men and women had at least 1 of these risk factors, and 9% of the men and 19% of the women had 3 or more risk factors. Income and education were inversely related to hypertension, smoking, and physical inactivity. Having 3 or more risk factors was associated with low income and low education (extreme odds ratio [OR] = 10.2, 95% confidence interval [CI] = 3.0, 34.5 for education; OR = 3.7, CI = 1.6, 8.9 for income) and with a history of unstable work or of homelessness. CONCLUSIONS Disadvantaged, urban communities are at high risk for cardiovascular disease. These results highlight the importance of socioenvironmental factors in shaping cardiovascular risk.