A Presentation By Ebele Mogo, DrPH. By 2050, two-thirds of the global population will live in cities. Already, over half of the world’s population lives in urban centers. In line with Goal 11 of the Sustainable Development Goals (S.D.G.s), these urban centers need to be made sustainable. Healthy and resilient urban development prioritizes the physical and social environment of urban residents and safeguards their health in the face of future stresses. This mixed methods study sought to understand the extent to which health and resilience were integrated into the development of the Lagos metropolis. This study serves as a case study for other metropolises on how to integrate and considerations for integrating urban health and resilience into city planning processes.

1. A Mixed Methods Study On Urban Health And
Community Resilience In The Lagos Metropolis.
Ebele Mogo
DrPH Candidate,
Community and Behavioural Health
Colorado School of Public Health

2. What are healthy and resilient
cities?
● Resilient cities are able to bounce back from stresses (Rockefeller
Foundation, 2014)
● Examples of stresses: ebola, shootings, hurricane, cholera outbreak
● e.g ebola outbreak: rapid response, fast containment/quarantine
people, spread health information, well-resourced healthcare centers,
trained health workers, integrated communities, social capital

3. What are healthy and resilient
cities?
●Healthy cities work to improve the physical, social environment
and community resources for urban residents (World Health
Organization, 2015)
●e.g. infrastructure for walking and cycling, streetlights, noise
pollution, air pollution, safety, green spaces
●connected to physical activity, hypertension, cancer,
psychological well being etc

4. Study overview/aims
● This study used the Lagos metropolis as a case study for integrating
health and resilience into urban development
●Aim 1: Conduct an archival analysis to understand the government’s
strategy for urban development
●Aim 2. Administer built environment audits to quantitatively characterize
the urban built environment and assess urban health priorities in Lagos
●Aim 3. Administer interviews to government and civil society groups to
understand urban governance priorities

5. Model

6. Why The Lagos Metropolis?
● Fastest urbanizing region of the world (Coker et al, 2015)
● Most populous region of Nigeria and 7th fastest growing city in the world
(Nigerian Population Commision, 2014)
● Population growth rate of 6-8% (Okunlola, 2015)

7. Putting it in perspective
●Population of 21 million (Ilesanmi, 2015, Nigeria Population
Commission, 2014)
●Population density of 20000 people per km squared (Helsinki
University of Technology, 2015)
●Compare to Denver: 2.8million people, 1,561 people /square
kilometer), population growth rate of about 2.8%
●Lagos is relevant globally, and given paucity of urban research
on African cities (African Center for Cities, 2016)

8. A qualitative study on urban health
and resilience governance in
metropolitan Lagos

9. Methodology
● Key informant interviews were administered to 16 civil society and
government workers
● These practitioners were chosen due to expertise working on urban
health issues such as health, environment, housing and safety
● Questions concerned urban development priorities, the priority
accorded to health issues and the key actors for implementing said
priorities
● e.g. Are there any documents or frameworks that guide your decision-
making processes? If so, please describe.

10. Themes: Environmental management
● motor-vehicle and generator emissions
● waste management
● enforcement of regulations concerning waste management
● climate change mitigation and adaptation especially flooding
● education of communities

11. ●“The long term goal is to make sure that the environmental
situation in Lagos is very convenient to the people living in Lagos,
very attractive, and also to make sure that it’s neat, it’s proper and it
could be a tourist center for people visiting from all over the world.”

12. Themes: Housing and Human
Settlement
● managing the housing deficit
● residents living in buildings prone to collapse
● enforcing housing regulations
● civil society concerns about the exclusion of low income groups

13. ●“Housing for us is almost like a forerunner of other things.
Everything I am telling you about housing is applicable with respect
to healthcare…When people’s livelihoods are not settled, when their
lived environment is in a state of flux then you cannot even
determine how they have access to potable water, other services,
schools, healthcare systems and all of that”

14. ●“They are confined to the fringe of the city. They are invisible to the
city. They are invisible to planners. They are invisible to budget
officials. Whereas in an election year, the same officials who denied
their existence who for example will tell you that Makoko is not a
fixed address because Makoko is on water but during the election
year that Makoko…is like a beehive of political activities”

15. Themes: population engagement
and stewardship of the environment
● poor information/language barrier
● spatial exclusion
● poor maintenance culture
● poverty
● mistrust of government and civil society

16. ●“People are not ready to learn. They are just obstinate”

17. Theme 4: challenges of overpopulation
● resource constraints
● security challenges
● mental health and infectious diseases
● noise and air pollution (generators, traffic, wastes)
● environmental vulnerability

18. ●“The only way government can face this issue of population
is to generate enough revenue and that is what government
is doing…It usually means more taxes”

19. Themes: Partnerships
● inter-sectoral partnerships: happened as needed but were not well-
defined
● intra-sectoral partnerships: decision making mostly took place at the
higher levels of power
● public-private partnerships were growing as a financing innovation
● partnerships with iNGOs to meet technical and financing needs
● partnerships with local civil society to access communities

20. Priority areas identified for public
health● Need for greater inclusion e.g. with regard to housing solutions
● Need to involve communities in planning and implementation
● Need to ensure goal alignment and incentivize long term, systemic and
preventive health efforts in PPPs
● Need to incentivize inter-sectoral, intra-sectoral and systemic thinking
● Need to build political will for health as a shared priority between sectors

21. An audit of urban neighbourhoods
in metropolitan Lagos, Nigeria

22. What is the urban built environment?
● Physical features such as design, land use diversity, urban sprawl,
walkability, greenery, active transportation, safety
● They are related to physical activity, obesity, injury, violence, mental
health, cardiovascular diseases
●The population growth rate of Lagos is roughly equivalent to rate of slum
growth (Clemans, 2015)
●Low and middle income contexts are not well represented in urban
public health governance and data collection (Cleman, 2015)

23. Research goals
● To pilot a neighbourhood audit by Brownson et al, 2004 in metropolitan
Lagos
● To determine the utility of the audit and adapt it to a new context
● To characterize built environment features in this setting
● To yield recommendations for improving the urban built environment
for improved urban health

24. Methodology
● Piloted the audit with two assistants until at least 85% agreement was
reached between raters
● Informal features were added to the audit
● okadas (motorcycles)
● informal on-street parking
● mai-guards (informal security guards) and formal security guards
● molues (informal transport buses)
● keke napeps (tricycles)

25. Methodology
●Administered audits in 3 closed segments + 3 open segments
per ward
●Audited 4 wards per local government
●Audited 1 low income, 1 middle income, 1 high income local
government
●(3+3) x 4 x 3 = 72 street segments audited

26. Methodology
●Descriptively analysed the audit data
● means, medians and standard deviations for continuous data
● modes and percentages for categorical data
● assessed variability by aggregate income of the local government
● assessed variability by whether the segment was enclosed or open

27. Methodology
●Calculated Cronbach’s Alpha to measure reliability of the audit
●Used an exploratory factor analysis to investigate the factor
structure

28. Results
● Built environment features fell into three categories:
● residential destinations e.g single family homes, multiple family homes
● commercial destinations e.g shops, restaurants
● few public destinations (mosques, churches, health centres and schools)
● Primarily informal provision of goods and services, waste management,
security, transport and parking
● There was a high level of disorder, poor waste management, inadequate
road infrastructure and an absence of active transportation infrastructure
in neighbourhoods

29. Results
● Individual attempts to safeguard security through barbed wires, electric
fences, broken glasses and hiring security personnel
● Significant noise pollution with generators contributing to noise

30. Results
●The Cronbach’s alpha of the audit was 0.4584 (moderate
significance)
●The exploratory factor analysis showed a two factor structure
capturing
● residential locations and community services
● commercial services

31. Key takeaways
● The built environment could be characterized into residential, community
and commercial features
● The following intervention areas were identified for public health:
● physical disorder
● power supply
● security
● waste management
● neighbourhood governance
● road infrastructure
● provisions for active transportation

32. Key takeaways
●Auditing efforts in similar settings need to account for informality
●The neighborhood level built environment is underserved by
government services
●Subsequently, it is worthwhile to explore leveraging informal service
provision for public health
●To improve the built environment, efforts to build community
ownership and participatory governance of neighbourhoods are needed

33. Is Lagos State planning for urban
health and community resilience?

34. Methodology
●Use the Lagos metropolis as a case study on how the health sector can
provide a public health perspective for policy
● Integrated three frameworks: the social determinant of health, the resilience
framework and the socio-ecological model
● Reviewed government archives to identify key documents

35. Methodology
●Identified documents:
● the Lagos State Development Plan
● the 2016 Budget
● the 2013 Digest of Statistics
● the Manifesto of Governor Akinwunmi Ambode

36. Methodology
●Carried out a content analysis of the documents
●This involved:
● reading through the documents
● noting the categories of information
● organizing similar concepts into categories
● organizing similar categories into major categories
● comparing and the collating categories from each archival document

37. Themes
● Environment: environmental management, housing, slum reduction,
mortgage provision and enforcement of regulations
● Transport: road infrastructure and diversification of transportation
● Poverty and unemployment: simplify business creation, skills
development, power supply, job creation
● Food security: providing farming and fishing estates, incentives to
support agro-processing and production, funding for farmers

38. Theme
● Safety: improving the capacity, resources and data of the police
force, and building partnerships with communities, protecting the
vulnerable
● Health: improving the quality and affordability of health services,
private sector engagement, sector standards, capacity and citizen
involvement
● Civic participation : improving inclusion and participation in politics,
supporting marginalized groups, closing the wealth gap and ensuring
community cohesion

39. Key takeaways
● Priorities showed a focus on issues without a focus on processes
● There was a top-down transactional relationship between
government and citizens
● Strategic plans need to be supported by locally relevant
measures, data and engaged communities
● Surveillance systems needed to be strengthened through
strengthened capacity and data disaggregation

40. Key takeaways
● The urban context needs to be a priority intervention area for public health
● Health priorities need to move beyond from a sole focus on medical
institutions to the urban living context as a determinant of health
● In line with this, there is need to strengthen capacity to govern, collect
data on and intervene on the urban living environment as a determinant
of health

41. Overview and implications of the
project
● This project aimed to contribute a public health lens to urban
development of the metropolis and to create preliminary evidence for
larger scale studies by:
● using quantitative methods to characterize the built environment
features and priority areas for intervention
● using qualitative methods to critically evaluate governance priorities
for the metropolis

42. Recommendations for action
● There is need for action on the urban neighbourhood as a
determinant of urban health
● This will involve:
● a strengthened focus on urban environmental management
● a higher priority on housing as an urban health determinant
● investing in infrastructure maintenance and active transportation
● stronger surveillance systems to inform strategic action

43. Recommendations for action
●Participatory urban governance needs to be operationalized
●This will include:
● leveraging informal service provision arrangements
● moving from transactional governance to community engagement
● developing intra and inter-sectoral cooperation

44. Limitations of this project
1. The auditing protocol was subjective although inter-rater
reliability was used to minimize this challenge
2. There was no qualitative survey to understand what the built
environment characteristics observed meant to residents.
3. Archival analyses are limited by survival bias of data

45. Room for further research
● how to strengthen governance mechanisms for urban health - public
private partnerships, informal sector, civil society
● incentives for sharing power between higher and lower levels of power
and strengthening intersectoral cooperation
●rigorous and objective ways of assessing the urban environment in
African settings where features are complex, informal and formal overlap

46. Room for further research
●to assess built environment features in African cities to produce
a standard set of features, and variations by city.
●test findings on a larger scale and examine the place of health
and resilience in other city planning processes in Nigeria and
across Africa.
Therefore yielding a regional understanding of challenges and
opportunities to improve urban health and resilience.

47. Room for further research
● how to ensure improve governance at the grassroots levels -
neighbourhood domains were poorly maintained and underserved by
government resources
● how individuals conceptualize their sphere of responsibility in urban
settings and how to expand it
● how to leverage positive social interactions in neighbourhoods for urban
health governance
● how to leverage the informal sector for urban health

48. Thank you
● Committee
● Professors and administrative staff
● Peers
● Friends
● Questions?

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59. + For more pictures: www.instagram.com/ebyral