Centre for Global NCDs Seminar Series November 14 2016
Urban Environment and Cardiovascular Health: ERC Project
Heart Healthy Hoods Manuel Franco MD, PhD
Associate ProfessorSchool of Medicine, University of Alcala, Spain
Adjunct Associate ProfessorDepartment of Epidemiology
Johns Hopkins Bloomberg School of Public Health
http://hhhproject.eu
First, some questions
• Let´s think first about the place where you live/work
• Let´s think now about the opportunities for being physically active and mantain a healthy diet where you live
• Let´s think now about the social norms regarding physical activity and diet where you live
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Second, some reflections about Madrid
• Opportunities / resources for being physically active and mantain a healthy diet in Madrid
• Social norms regarding physical activity and diet in Madrid
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http://hhhproject.eu
Physical activity environment in Madrid, HHH study
International Journal of Epidemiology 2015, Franco M
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.”
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Food environment in Madrid, HHH study
International Journal of Epidemiology 2015, Franco M In press
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.
http://hhhproject.eu
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
ERC Starting GrantsFUNDING 1.5 million € for 5 years
OBJECTIVE To encourage independent careers of excellent investigators providing enough support in the critical moment (starting to develop their own team).
ELEGIBILITY PI must have a PhD degree in the last 2 to 7 years. Available to non-EU researchers.
REQUISITES At least one relevant publication without his/her thesis advisor
At least 50% effort
PROFILE High potential, project with potential social Impact in Europe.
Presenter’s Name
Date
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
Date
PhysicalEnvironment
Social Environment
CardiovascularHealth
HEARTHEALTHYHOODS
Obesity
Physical Activity
DietAlcohol
Physical ActivityEnvironment
Food Environment
CVD
Smoking
Tobacco Environment
Social and PhysicalEnvironment
Individual Cardiovascular Health
AlcoholEnvironmentN
eigh
borh
ood
Soci
oeco
nom
ic S
tatu
sU
nem
ploy
men
t – E
duca
tion
– P
over
tyIm
mig
ratio
n C
ompo
sitio
n
Indi
vidu
al S
ocio
econ
omic
Sta
tus
Occ
upat
ion
–Inc
ome
– E
duca
tion
Gen
der –
Imm
igra
tion
Heart Healthy Hoods Study Main Goal
http://hhhproject.eu
To study the impact of the
social and physical environment in terms of
tobacco, alcohol, food and physical activity
on residents cardiovascular health
Heart Healthy Hoods Overall Objectives
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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
http://hhhproject.eu
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
http://hhhproject.eu
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
http://hhhproject.eu
INTERDISCIPLINARY TEAM
https://hhhproject.eu/people/madrid-team/
Madrid Team
International Collaborations
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HHH Team Kickoff September 2014
http://hhhproject.eu
Madrid City
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 million residents 40-75 ys. old
http://hhhproject.eu
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
http://hhhproject.eu
21 distritos
32 Centros de Salud
Participantes de la cohorteN=2576
Profesionales
Métodos CoHHHorte
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CentrosC.S. ADELFASC.S. ALPESC.S. ANGELA URIARTEC.S. ARTILLEROSC.S. BARAJASC.S. CANAL de PANAMAC.S. CARAMUELC.S. CERRO ALMODOVARC.S. CIUDAD JARDINC.S. DAROCAC.S. DR. CASTROVIEJOC.S. ENTREVIASC.S. ESPRONCEDAC.S. FEDERICA MONTSENYC.S. GARCIA NOBLEJASC.S. GENERAL RICARDOSC.S. GUAYABAC.S. JAZMINC.S. LAGASCAC.S. LAS CORTESC.S. LAVAPIESC.S. LOS YEBENESC.S. MAR BALTICOC.S. MONOVARC.S. PAVONESC.S. SAN ANDRESC.S. SAN FERMINC.S. SILVANOC.S. TORITOC.S. VALDEBERNARDOC.S. FUENCARRALC.S. VILLAAMIL
CS HHH
http://hhhproject.eu
Criterios de selección
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Resumen calendario global del estudio
Corte 2016 Seguimiento 2017 Corte 2018 Seguimiento
2019
Visita clínica + Encuesta telefónica
Recoger algunos datos de Historia
clínica
Visita clínica + Encuesta telefónica
Recoger algunos datos de
Historia clínica
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Visita 1
Visita Telefónica• Dieta• Tabaco• Alcohol• Actividad Física
¿Precisa Analítica?
NO
SI
Analítica + Visita 2 (Entrega
de resultados)
Flujo de visitas
Abrir en HCE episodio A97
http://hhhproject.eu
http://hhhproject.eu
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) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
http://hhhproject.eu
Selecting average neighborhoods for cross-city comparisons in Urban Health studies: the Median Neighborhood Index Bilal U, Diez J, Cebrecos A, Franco M (Submitted)
Median Neighborhood Index (MNI)
Average rank distance to the median neighborhood in each city in four sociodemographic and urban form variables: aging (% > 65 years old), education (% with college education), segregation (% foreign-born for Spain, or % non-White for the US), and urban form (population density)
http://hhhproject.eu
Mixed Methods Approach
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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 characterizing the social and physical urban environment in relation to food, alcohol, tobacco and physical activity.
http://hhhproject.eu
http://hhhproject.eu
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.
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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.
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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 – Provides insights on quantitative findings
• Quantitative -> qualitative
– Guides future quantitative data collection (formative)• Qualitative -> quantitative.
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http://hhhproject.eu
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
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• Population 45-106 ys. old: 7,252• Sex: 59% Women• Diabetes Prevalence: 12%• Diabetes Control (HbA1c<7): 63%• Hypertension Prevalence: 34%• Obesity (BMI >30): 20%• Dyslipidemia, all types: 32%
Exploratory Study Cardiovascular ProfilePrimary Health Care Records
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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
b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
http://hhhproject.eu
http://hhhproject.eu
Conceptual frameworkUrban Food Environment
• Diet is a cardiovascular risk factor influenced by the local food environment
• Local food environments are a critical influence, that may restrict or increase people’s abilities to make healthy eating decisions.
• Conceptual framework from:
Franco M., Bilal U., Díez J. (2016). Food Environment.
In The Encyclopedia of Food and Health. B. Caballero, Finglas, P., and Toldrá, F. (Eds) Academic Press, Oxford: 3: 22-26
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Exploratory study Type of food stores Healthy Food Availability Index
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Food environment measures
• Objective. To develop a system to characterize, and track changes of the
local food environment, using in-store audits and secondary databases
• Methods.
1) Ground-truthing (in-store audits)
• Observers assessed all food stores present in all 42 census sections
June-July 2016, using an adapted version of the NEMS-S tool to
better reflect a Mediterranean food environment
• We integrated the NEMS-S tool in a web-based app
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2) Secondary database
• Public database “Censo de Locales”, updated monthly and freely
accessible from the city council.
• We selected all food stores located within the 42 census sections,
derived through their code provided in the database.
• We matched the food stores assessed on field and those listed in the
database based on GPS coordinates and business name and address.
• We assessed the level of agreement between the secondary database
and on field observations (sensitivity analysis, and PPV analysis) by
store type and by census section-SES
Food environment measures
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Cross-city differences
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Walking access to healthy food
Madrid (left) and Baltimore (right)
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a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity (Pedro Gullón) c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
http://hhhproject.eu
Urban Environment and active transportation in Madrid
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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,
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M-SPACES AUDIT TOOL
Pedro Gullón et al. 2015 Journal of Urban Health,
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M-SPACES AUDIT TOOL
Pedro Gullón et al. September 2015 Journal of Urban Health,
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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
Socioeconomic Determinants of Small-Area Walkability in a European city like
Madrid: The Heart Healthy Hoods Project
http://hhhproject.eu
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
http://hhhproject.eu
0
5
10
Per
cent
-7.5
-5-2
.50
2.5
57.
5P
redi
cted
Wal
kabi
lity
Inde
x (9
5% C
I)
-2.35 -1.16 -0.85-0.61-0.39-0.14 0.24 0.67 0.95 1.26 2.00Socioeconomic Status Index
95% CI
Figure 2. Restricted cubic splines with 5 knots representing the relationship between SES and walkability in the census sections of Madrid (N=2415)
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a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco (Xisca Sureda) d) Alcohol
c) Results by working groups
a) Urban Geography
b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
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
Urban determinants of smoking behaviour
http://hhhproject.eu
Availability & Accessibility
Second-hand smokeexposure in terracesof hospitality venues
Smoking behaviour
Self-reportedsecond-hand smoke
exposure
Urban environments Individual behaviours
Signs of tobaccoconsumption in outdoor places
Nei
ghbo
rhoo
dso
cioe
cono
mic
char
acte
ristic
s
Indi
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cioe
cono
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acte
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Tobacco availability
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Density of tobacco point of sales Educational level in Madrid
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Measurements and variables: Systematic Social Observation in 42 neighborhoods in Madrid
lugar fecha hora área (m2)
altura (m) ventilación señales olor a
tabaco cenicero cenizas personal fumando
usuarios fumando observaciones
Indicators of the presence of tobacco smoking: number of smokers, presence ofashtrays, presence of cigarette butts and tobacco smell, presence of tobacco vending machines, hours of sales in places where you can get tobacco.
Information for every measurementsampling: location, area, outdoor or quasi-outdoor space, smoke-free zone signage
Tobacco consumption signs outdoors
SHS exposure outdoor hospitality venues
http://hhhproject.eu
PM 2.5 measurements
Measurements and variables: Tobacco Airborne Markers
Airborne nicotine
We measured a total of 79 outdoor terraces in 42 neighborhoods
People smoking in a covered terraces
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a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
• Alcohol (Madrid, Barcelona, Edinburgh, Baltimore)a) Results by working groups
a) Urban Geography
b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
Alcohol in HHHUrban determinants of alcohol behaviour
Sureda X, Villalbí JR, Espelt A, Franco M. Living under the influence: Normalization of alcohol consumption in our cities. Gac Sanit (in press)
OHCITIES instrument
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OHCITIES Validation Results
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92 on-premise alcohol outlets (50% bars and 20% restaurants)
53,7% with promotion associated to the outlet
We measured 180 items in 92 On-Premise and 24 off-premise alcohol outlets in 7 census sections in Madrid
24 off-premise alcohol outlets (54% grocery stores)
88,2% with promotion associated to the outlet
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7 alcohol promotion in public spaces (57% sponsorship)
58 signs of alcohol consumption
Time to complete one census section: between 225 and 87 minutes depending on the total number of alcohol-related elements in the urban environment.
Time to complete each item: on and off-premises aprox. 5-10 min; promotion and signs of alcohol consumption in public spaces aprox. 3 min
OHCITIES Validation Results
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domainsa) Food
b) Physical Activity
c) Tobacco
d) Alcohol (Xisca Sureda)
c) Results by working groups
a) Urban Geography (Alba Cebrecos)b) Participatory Action Research PHOTOVOICE
HHH Analyses and Results
http://hhhproject.eu
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.
http://hhhproject.eu
METHODOLOGY
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f̂ ( x )= 1h𝑛 ∑i=1
n
K ( x− X ih )
Kernel Density Estimation (KDE)
WALKABILITY
HFAI
HFAI & WALKABILITY
STUDY AREA
METHODOLOGY
http://hhhproject.eu
RESULTS
Manuel Franco, Principal Investigator
Understanding community food environment through Photovoice:
a participatory action research project in Villaverde, Madrid
Co-funded by
http://hhhproject.eu
Citizen Science
http://hhhproject.eu
Citizen Science
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http://hhhproject.eu
CENTROCENTRO Cibeles Madrid, April 13th – October 30th 2016
https://hhhproject.eu/photovoice/photovoice-publications/
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https://www.youtube.com/v/VIiFggKzVas&yt:cc=on&hd=1
Photovoice whole project video
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Photovoice Publications
1. “Understanding the local food environment: a participatory Photovoice project in a low-income area in Madrid, Spain” Under review
2. “Barriers and facilitators for accessing healthy foods: a mixed methods study using GIS, on field measures and photovoice” In progress
3. “Translating participatory research into food policy recommendations: The Photovoice Villaverde Food Project in Madrid.” In progress
4. “Photovoice as a tool to gain empowerment? : Evaluating the transformative potential of a Participatory Action Research project in Villaverde (Madrid) for their female participants.” In progress
5. “Improving the retail food environment in cities. A stakeholder public discussion in Madrid: The Heart Healthy Hoods Project.” In progress
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HHH Current Scientific Achievements
• 7 international papers and 3 book chapters
• Bilingual photobook and public exhibition
• 4 funded ancillary studies
• 3 Predoctoral and one Erasmus master fellowships
• Intramural: 2 communications awards
• 4 travel grants for US (Joel Gittelsohn and Luisa Borrell) and UK researchers (Daniel Lewis and Jamie Pearce)
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HHH future scientific steps
Waiting on grants: • Photovoice on urban environment and physical activity
• Alcohol Urban Environment in Madrid and Barcelona (Collaboration: Madrid, Barcelona, Edinburgh, Baltimore)
Working on training grant: • Cardiovascular Prevention and Policy Research Initiative for
Europe and Latin America (CAPRIELA)
• Liverpool, Utrecht, Lima and Buenos Aires
Open for collaborations with LSHTM researchers
http://hhhproject.eu
• Participants
• Whole HHH Madrid team and collaborations
• Different funding agencies: • European Research Council• Fundación Mapfre• Ayuntamiento de Madrid • Fondo de Investigación Sanitaria• Plan Nacional de Investigación• Center for a Livable Future, Johns Hopkins
• LSHTM Centre for Global NCDs
Acknowledgements
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HHH TeamThank you very much !
Centre for Global NCDs Seminar Series November 14 2016
¡ Gracias !
Manuel Franco MD, PhD
for the HHH investigators
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