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Centro Nacional de Epidemiología
19 Enero 2017
Ciudades y Salud Cardiovascular:
Proyecto ERC Heart Healthy Hoods
@HHHproject
Manuel Franco MD, PhD
Profesor Titular
Universidad de Alcalá
Adjunct Associate Professor
Department of Epidemiology
Johns Hopkins Bloomberg School of Public Health
http://hhhproject.eu
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.”
http://hhhproject.eu
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.
http://hhhproject.eu
Opportunities for NCDs prevention within
Urban Health Research
1. By 2050: 66% of the world population will live in cities
2. Challenge of aging and chronic diseases already in our cities
3. Social determinants as working conditions, unemployment
and poverty are clearly patent in our cities
4. 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
Date
Physical
Environment
Social
Environment
SOCIAL
EPIDEMIOLOGY
Studies 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
Cardiovascular
Health
Presenter’s Name
Date
Physical
Environment
Social
Environment
Cardiovascular
Health
HEART
HEALTHY
HOODS
Obesity
Physical
Activity
Diet
Alcohol
Physical Activity
Environment
Food
Environment
CVD
Smoking
Tobacco
Environment
Social and Physical
Environment
Individual
Cardiovascular Health
Alcohol
Environment
NeighborhoodSocioeconomicStatus
Unemployment–Education–Poverty
ImmigrationComposition
IndividualSocioeconomicStatus
Occupation–Income–Education
Gender–Immigration
Heart Healthy Hoods Study
Main Goal
http://hhhproject.eu
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 objective
Policy and research implications
http://hhhproject.eu
Photography
Knowledge
Dissemination
Citizen Science
Epidemiology
Health Sociology
University of Salamanca
Johns Hopkins School of Public Health
Geography
University of Alcalá
CRESH Edinburgh
LSHTM
Interdisciplinary team
PI: Social Epidemiology
University of Alcalá
Johns Hopkins School of Public Health
http://hhhproject.eu
INTERDISCIPLINARY TEAM
https://hhhproject.eu/people/
Madrid Team
International Collaborations
http://hhhproject.eu
HHH Kick off meeting
September 2014
http://hhhproject.eu
21 Districts
128 Neighborhoods
2.412 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
http://hhhproject.eu
HHH Study Design
Baseline Visit
Cohort
Study
1st Database
Mining
Population-
based EHR
study
4 yr follow up
2,576 participants Final Visit
Final Database
Mining
1,4 million people
Environment
Tobacco
Alcohol
Food
Physical Activity
1st Assessment 2nd AssessmentNeighborhoods
Multilevel Association
Analysis
http://hhhproject.eu
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
http://hhhproject.eu
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
http://hhhproject.eu
Primary Healthcare Centers of Madrid
Cohort HHH centers
1 C.S. ADELFAS
2 C.S. ALPES
3 C.S. ANGELA URIARTE
4 C.S. ARTILLEROS
5 C.S. BARAJAS
6 C.S. CARAMUEL
7 C.S. CERRO ALMODOVAR
8 C.S. CIUDAD JARDIN
9 C.S. DAROCA
10 C.S. DR. CASTROVIEJO
11 C.S. ELOY GONZALO
12 C.S. ENTREVIAS
13 C.S. ESPRONCEDA
14 C.S. FEDERICA MONTSENY
15 C.S. FUENCARRAL
16 C.S. GARCIA NOBLEJAS
17 C.S. GENERAL RICARDOS
18 C.S. GUAYABA
19 C.S. IBIZA
20 C.S. LAGASCA
21 C.S. LAS CORTES
22 C.S. LAVAPIES
23 C.S. LOS YEBENES
24 C.S. MAR BALTICO
25 C.S. MONOVAR
26 C.S. PAVONES
27 C.S. SAN ANDRES
28 C.S. SAN FERMIN
29 C.S. TORITO
30 C.S. VALDEBERNARDO
31 C.S. VILLAAMIL
http://hhhproject.eu
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
http://hhhproject.eu
21 Madrid districts
31 Primary Healthcare centers
Sample size
N=2576
370 Physicians and
nurses trained
The CoHHHort Study
http://hhhproject.eu
Clinical visit
Telephone
survey
Biological
cardiovascular risk
factors
Behavioral
cardiovascular risk
factors
The CoHHHort Study
 Variables:
http://hhhproject.eu
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
http://hhhproject.eu
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Median
Area of Madrid (Usama Billal)
b) Results by domains
a) Food
b) Physical Activity
c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
HHH Analyses and Results
http://hhhproject.eu
Mixed Methods Approach
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.
http://hhhproject.eu
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.
http://hhhproject.eu
http://hhhproject.eu
Exploratory Study Sociodemographic Profile
Primary 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%
http://hhhproject.eu
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
http://hhhproject.eu
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) Qualitative Research
HHH Analyses and Results
http://hhhproject.eu
http://hhhproject.eu
Cross-city differences
http://hhhproject.eu
Walking access to healthy food
MADRID BALTIMORE
Preventive Medicine 2016, Diez J et al.
http://hhhproject.eu
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
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) Food
b) Physical Activity (Pedro Gullón)
c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
HHH Analyses and Results
http://hhhproject.eu
Urban Environment and active
transportation in Madrid
http://hhhproject.eu
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,
http://hhhproject.eu
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
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
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) Food
b) Physical Activity
c) Tobacco (Xisca Sureda)
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research
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
http://hhhproject.eu
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
http://hhhproject.eu
Outdoor tobacco consumption signs
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) 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 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
http://hhhproject.eu
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)
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) Food
b) Physical Activity
c) Tobacco
d) Alcohol (Xisca Sureda)
c) Results by working groups
a) Urban Geography (Alba Cebrecos)
b) Qualitative Research
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
f x =
1
𝑛ℎ
i=1
n
K
x − Xi
h
Kernel Density Estimation
(KDE)
WALKABILITY
HFAI
HFAI & WALKABILITY
STUDY AREA
METHODOLOGY
http://hhhproject.eu
RESULTS
http://hhhproject.eu
a) Mixed Methods Exploratory Study in a Madrid Median Area
b) Results by domains
a) Food
b) Physical Activity
c) Tobacco
d) Alcohol
c) Results by working groups
a) Urban Geography
b) Qualitative Research (Paloma Conde)
HHH Analyses and Results
http://hhhproject.eu
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
Individualism
Rapid rhythms of
life
(-) Lack of time
Change in
gender/age role
Generation
and cultural
fracture
NEIGHBORHOOD
CHANGES
Economic crisis
Impoverishment
and lack of
resources
High working hours
SOCIAL CHANGES
New
Demographic
composition
New socio-
cultural
values
Economic
aspects
Qualitative results RESIDENTS’ HEALTH PERCEPTIONS
Loss 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
http://hhhproject.eu
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
http://hhhproject.eu
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)
http://hhhproject.eu
• 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
http://hhhproject.eu
HHH Team
Thank you very much !
Centro Nacional de Epidemiología
19 Enero 2017
¡ Gracias !
Todos los investigadores HHH
y Manuel Franco
@HHHproject

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Ciudades y Salud Cardiovascular: Proyecto ERC Heart Healthy Hoods

  • 1. Centro Nacional de Epidemiología 19 Enero 2017 Ciudades y Salud Cardiovascular: Proyecto ERC Heart Healthy Hoods @HHHproject Manuel Franco MD, PhD Profesor Titular Universidad de Alcalá Adjunct Associate Professor Department of Epidemiology Johns Hopkins Bloomberg School of Public Health
  • 3. 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.”
  • 4. http://hhhproject.eu 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.
  • 5. http://hhhproject.eu Opportunities for NCDs prevention within Urban Health Research 1. By 2050: 66% of the world population will live in cities 2. Challenge of aging and chronic diseases already in our cities 3. Social determinants as working conditions, unemployment and poverty are clearly patent in our cities 4. 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
  • 6. 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
  • 7. Presenter’s Name Date Physical Environment Social Environment SOCIAL EPIDEMIOLOGY Studies 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 Cardiovascular Health
  • 8. Presenter’s Name Date Physical Environment Social Environment Cardiovascular Health HEART HEALTHY HOODS Obesity Physical Activity Diet Alcohol Physical Activity Environment Food Environment CVD Smoking Tobacco Environment Social and Physical Environment Individual Cardiovascular Health Alcohol Environment NeighborhoodSocioeconomicStatus Unemployment–Education–Poverty ImmigrationComposition IndividualSocioeconomicStatus Occupation–Income–Education Gender–Immigration Heart Healthy Hoods Study Main Goal
  • 9. http://hhhproject.eu 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
  • 10. 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 objective Policy and research implications
  • 11. http://hhhproject.eu Photography Knowledge Dissemination Citizen Science Epidemiology Health Sociology University of Salamanca Johns Hopkins School of Public Health Geography University of Alcalá CRESH Edinburgh LSHTM Interdisciplinary team PI: Social Epidemiology University of Alcalá Johns Hopkins School of Public Health
  • 13. http://hhhproject.eu HHH Kick off meeting September 2014
  • 14. http://hhhproject.eu 21 Districts 128 Neighborhoods 2.412 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
  • 15. http://hhhproject.eu HHH Study Design Baseline Visit Cohort Study 1st Database Mining Population- based EHR study 4 yr follow up 2,576 participants Final Visit Final Database Mining 1,4 million people Environment Tobacco Alcohol Food Physical Activity 1st Assessment 2nd AssessmentNeighborhoods Multilevel Association Analysis
  • 16. http://hhhproject.eu 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
  • 17. http://hhhproject.eu 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
  • 18. http://hhhproject.eu Primary Healthcare Centers of Madrid Cohort HHH centers 1 C.S. ADELFAS 2 C.S. ALPES 3 C.S. ANGELA URIARTE 4 C.S. ARTILLEROS 5 C.S. BARAJAS 6 C.S. CARAMUEL 7 C.S. CERRO ALMODOVAR 8 C.S. CIUDAD JARDIN 9 C.S. DAROCA 10 C.S. DR. CASTROVIEJO 11 C.S. ELOY GONZALO 12 C.S. ENTREVIAS 13 C.S. ESPRONCEDA 14 C.S. FEDERICA MONTSENY 15 C.S. FUENCARRAL 16 C.S. GARCIA NOBLEJAS 17 C.S. GENERAL RICARDOS 18 C.S. GUAYABA 19 C.S. IBIZA 20 C.S. LAGASCA 21 C.S. LAS CORTES 22 C.S. LAVAPIES 23 C.S. LOS YEBENES 24 C.S. MAR BALTICO 25 C.S. MONOVAR 26 C.S. PAVONES 27 C.S. SAN ANDRES 28 C.S. SAN FERMIN 29 C.S. TORITO 30 C.S. VALDEBERNARDO 31 C.S. VILLAAMIL
  • 19. http://hhhproject.eu 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
  • 20. http://hhhproject.eu 21 Madrid districts 31 Primary Healthcare centers Sample size N=2576 370 Physicians and nurses trained The CoHHHort Study
  • 24. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Median Area of Madrid (Usama Billal) b) Results by domains a) Food b) Physical Activity c) Tobacco d) Alcohol c) Results by working groups a) Urban Geography b) Qualitative Research HHH Analyses and Results
  • 27. 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.
  • 28. http://hhhproject.eu 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.
  • 30. http://hhhproject.eu Exploratory Study Sociodemographic Profile Primary 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%
  • 31. http://hhhproject.eu 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
  • 32. http://hhhproject.eu 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) Qualitative Research HHH Analyses and Results
  • 35. http://hhhproject.eu Walking access to healthy food MADRID BALTIMORE Preventive Medicine 2016, Diez J et al.
  • 36. http://hhhproject.eu 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
  • 37. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Madrid Median Area b) Results by domains a) Food b) Physical Activity (Pedro Gullón) c) Tobacco d) Alcohol c) Results by working groups a) Urban Geography b) Qualitative Research HHH Analyses and Results
  • 38. http://hhhproject.eu Urban Environment and active transportation in Madrid
  • 39. http://hhhproject.eu 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,
  • 40. http://hhhproject.eu Physical Activity Results Pedro Gullón et al. September 2015 Journal of Urban Health,
  • 41. 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
  • 42. 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
  • 43. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Madrid Median Area b) Results by domains a) Food b) Physical Activity c) Tobacco (Xisca Sureda) d) Alcohol c) Results by working groups a) Urban Geography b) Qualitative Research HHH Analyses and Results
  • 44. 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)
  • 45. Tobacco in HHH http://hhhproject.eu 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
  • 46. DENSITY OF TOBACCO POINT OF SALES LOW EDUCATIONAL LEVEL
  • 48. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Madrid Median Area b) Results by domains a) 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
  • 49. 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)
  • 50. 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
  • 51. 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)
  • 52. OHCITIES Validation Results http://hhhproject.eu 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)
  • 53. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Madrid Median Area b) Results by domains a) Food b) Physical Activity c) Tobacco d) Alcohol (Xisca Sureda) c) Results by working groups a) Urban Geography (Alba Cebrecos) b) Qualitative Research HHH Analyses and Results
  • 54. 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.
  • 55. http://hhhproject.eu f x = 1 𝑛ℎ i=1 n K x − Xi h Kernel Density Estimation (KDE) WALKABILITY HFAI HFAI & WALKABILITY STUDY AREA METHODOLOGY
  • 57. http://hhhproject.eu a) Mixed Methods Exploratory Study in a Madrid Median Area b) Results by domains a) Food b) Physical Activity c) Tobacco d) Alcohol c) Results by working groups a) Urban Geography b) Qualitative Research (Paloma Conde) HHH Analyses and Results
  • 58. http://hhhproject.eu 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)
  • 59. Breakdown of traditional forms vs Individualism Rapid rhythms of life (-) Lack of time Change in gender/age role Generation and cultural fracture NEIGHBORHOOD CHANGES Economic crisis Impoverishment and lack of resources High working hours SOCIAL CHANGES New Demographic composition New socio- cultural values Economic aspects Qualitative results RESIDENTS’ HEALTH PERCEPTIONS Loss 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
  • 60. http://hhhproject.eu 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
  • 61. http://hhhproject.eu 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)
  • 62. http://hhhproject.eu • 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
  • 64. Centro Nacional de Epidemiología 19 Enero 2017 ¡ Gracias ! Todos los investigadores HHH y Manuel Franco @HHHproject

Editor's Notes

  1. el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título
  2. Mapa de 1937 delimitando zonas por nivel de seguridad, que tenían un efecto directo en la compra de casas y las hipotecas que se daban. Empresas seleccionaban exclusivamente residentes blancos para las áreas de nueva construcción. Estas politicas de segregacion activa se mantuvieron desde 1890 hasta 1950
  3. Mapa de 1937 delimitando zonas por nivel de seguridad, que tenían un efecto directo en la compra de casas y las hipotecas que se daban. Empresas seleccionaban exclusivamente residentes blancos para las áreas de nueva construcción. Estas politicas de segregacion activa se mantuvieron desde 1890 hasta 1950
  4. Mapa de 1937 delimitando zonas por nivel de seguridad, que tenían un efecto directo en la compra de casas y las hipotecas que se daban. Empresas seleccionaban exclusivamente residentes blancos para las áreas de nueva construcción. Estas politicas de segregacion activa se mantuvieron desde 1890 hasta 1950
  5. el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título
  6. Te propongo cambiar le orden de las diapos 6 y 7 --> introducir primero CV health y social epidemiology para despues presentar la 7 para ver como se relacionan una con la otra. La 7 sirve para introducir el marco conceptual...la 6 más bien como justificaicón del estudio
  7. Hacer un poco más pequeña la imagen para dejar márgenes Repasar animacion! Porque al final sale el titulo de la diapo...valorar si el tñitulo sale desde el principio
  8. using a qualitative approach
  9. aqui de pronto aparece nuestra "interdisciplinaridad" -->sugiero comentarlo en metodos y dejar la descripcion del team para el final de la presentación
  10. Incluso en el comité asesor nacional e internacional INTERDISCIPLINARIDAD
  11. Tipo de estudio--> aqui parece que solo se hace cohort y population --> debría presentarse la metodología cualitativa, systemactic observation... A lo mejor podrías añadir una diapo de como se hace el environmental assessment
  12. HHH preguntas?
  13. 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. To explore different quantitative and qualitative measurements characterizing the social and physical urban environment in relation to food, alcohol, tobacco and physical activity.
  14. hay mas apartados....publications, HHH and media...no salen en el seminar outline... quitar Intro European Research Council por un punto que sea HHH introducción --> dentro de introducción ya explicarás la financiación de este proyecto
  15. hay mas apartados....publications, HHH and media...no salen en el seminar outline... quitar Intro European Research Council por un punto que sea HHH introducción --> dentro de introducción ya explicarás la financiación de este proyecto
  16. tnemos que mejorar los apartados de cada parte del piloto que se ha hecho y unificar el formato....comenzar con objetivo, poblacion estudio...
  17. Intro para empezar a hablar del food environment
  18. We aimed to understand cross-national differences in the local food environment between Madrid and Baltimore by comparing an average neighborhood in each city in terms of food store types, healthy food availability, and residents' pedestrian access. 
  19. Method: Throughout a street network analysis (200m, 400m and 800m) of food stores with high healthy food availability, we estimated residents' pedestrian accessibility. Results: In Madrid, 77% of the residents lived within less than 200m from a food store with high healthy food availability. In contrast, 95% of Baltimore's residents lived further than 400m from these stores. 
  20. On the NEMS-S: is widely recognized as a robust and valid tool for assessing the community and consumer nutrition environment, with high reliability and validity. It measures the availability, quality and cost of healthy foods options (compared to unhealthy food options) within 11 main food categories, based on a mainstream American diet It is considered a “pseudo-gold standard” to assess directly on field the community or consumer food environment.
  21. hay mas apartados....publications, HHH and media...no salen en el seminar outline... quitar Intro European Research Council por un punto que sea HHH introducción --> dentro de introducción ya explicarás la financiación de este proyecto
  22. Thank you JR for invite me today to present this Project that we are goin to conduct in Madrid city in the next few month
  23. En los últimos años ha habido especial interés en cómo el entorno social, urbano y cultural contribuye a la conformación de los resultados en salud y factores de riesgo comportamentales.
  24. la accesibilidad al tabaco (en términos de densidad de puntos de venta de tabaco, proximidad a los puntos de venta, tipo de localización dónde adquirir tabaco y horarios de venta al público) ha estado mucho más desregulada. Aunque existe todavía poco literatura del tema se ha vistos que la densidad de puntos de venta de tabaco y la ubicación de éstos también podría influir en las características de consumo de tabaco. Ademas diversos estudios han demostrado también la posible relación entre el gradiente socioeconómico del barrio o lugar de residencia con una distribución desigual de la accesibilidad al tabaco. En el mapa vemos la densidad de estancos por cada 10,000 habitantes para cada uno de los 128 barrios del municipio de Madrid utilizando los datos del comisionado para el mercado de tabacos (2013) y la proporción de población con bajo nivel educativo por barrio (obtenido de los datos del padrón municipal de Madrid (2014). Los resultados mostraron un aumento de la densidad de estancos a mayor población con menos nivel educativo (Ver mapas anexo) .
  25. Thank you JR for invite me today to present this Project that we are goin to conduct in Madrid city in the next few month
  26. En los últimos años ha habido especial interés en cómo el entorno social, urbano y cultural contribuye a la conformación de los resultados en salud y factores de riesgo comportamentales.
  27. SPACES es una herramienta de medición diseñada por Pikora para estudiar la disposición de una calle a facilitar la caminabilidad a los transeúntes. En este estudio se utilizó la herramienta adaptada por P.Gullón para la ciudad de Madrid (M_SPACES). Todas las tiendas de alimentación fueron medidas utilizando la herramienta NEMS diseñada por Glanz en su versión abreviada. A partir de estas medidas se calculó un índice de disponibilidad de alimentos saludables que varía de 0 – 27.5 (puntuaciones mas altas, tiendas más saludables) Toda la info obtenida de la observación social se geolocalizó y se integró dentro de un GIS que nos permitió calcular superficies de densidad de Kernel. h: bandwith (determina el grado de suavidad) n: number of cases (sample size) x-Xi= distancia geográfica entre el caso Xi y otro caso K= Kernel function ( en este caso se utiliza la quadratica K(t)=3/4(1-t^2) (conceptualmente) sobre cada punto ajusta una superficie curva suave . El valor de la superficie es más alta en la localización del punto y disminuye al aumentar la distancia desde el punto, llegando a cero en el limite del bandwith desde el punto. El espacio debajo de la superficie es igual al valor HFAI para cada punto. La densidad en cada celda de la imagen de salida se calcula sumando los valores de todas las superficies del Kernel en el que se superponen
  28. Caracterización a nivel de sección censal por ser la unidad administrativa más pequeña en la que se encuentran las estadísticas sociodemográficas. Characterization created by using natural Jenks grouped the census sections into 4 categories about themselves according to the average score: low (17.7 to 21.6), medium-low (21.7 to 30.8), medium-high (30.9 to 35.1) and high (35.2 to 43.8). 4.2% de la población vive en una sección caracterizada como saludable. Un 41% vive en unas sección caracterizada como poco saludable
  29. Incluso en el comité asesor nacional e internacional INTERDISCIPLINARIDAD
  30. el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título