The document summarizes the Heart Healthy Hoods (HHH) project, which aims to study the association between social and physical features of the urban environment and cardiovascular health in Madrid, Spain. It provides details on the study design, which includes a whole-population study using electronic health records and a cohort study of over 2,500 participants from 31 primary health centers in Madrid. The HHH project uses mixed methods, including quantitative environmental assessments, qualitative interviews, and participatory research techniques. Results presented include descriptive data on cardiovascular risk factors from electronic health records in the study area, as well as early findings on features of the food, physical activity, tobacco, and alcohol environments.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
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
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
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
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
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
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
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,
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
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.
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
el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título
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
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
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
el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título
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
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
using a qualitative approach
aqui de pronto aparece nuestra "interdisciplinaridad" -->sugiero comentarlo en metodos y dejar la descripcion del team para el final de la presentación
Incluso en el comité asesor nacional e internacional INTERDISCIPLINARIDAD
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
HHH preguntas?
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.
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
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
tnemos que mejorar los apartados de cada parte del piloto que se ha hecho y unificar el formato....comenzar con objetivo, poblacion estudio...
Intro para empezar a hablar del food environment
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.
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.
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.
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
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
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.
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) .
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
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.
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
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
Incluso en el comité asesor nacional e internacional INTERDISCIPLINARIDAD
el logo arriba y abajo queda repetido. Propongo quitar la chapa y centrar el título