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15. Interventions to Improve Urban Health
- Vanderbilt University Press
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294 15 Interventions to Improve Urban Health Nicholas Freudenberg Introduction The goal of public health is to “assure the conditions of health” for populations. Thus, the highest priority for urban health professionals is to plan and implement interventions to improve the health of people living in cities.1 As discussed in previous chapters, such interventions occur within a particular social, economic, and political context and operate at multiple levels of social organization. In this chapter, I identify the unique characteristics of urban settings that influence public health interventions; describe various approaches to improving the health of urban populations, with an emphasis on strategies used in United States in the past two decades; use the model for the study of urban health presented in Chapter 1 to classify current urban intervention strategies; and examine the roles of health professionals in these efforts. I conclude by suggesting promising directions for interventions to promote urban health. Public health interventions are here defined as organized activities designed to improve the health or well-being of a defined population. Participants can include health professionals, public officials , advocates, community residents, and others. Unique Characteristics of Urban Environment A key theme of this volume is that cities are different from nonurban areas. Effective interventions must address these defining urban characteristics. How are cities different in ways that influence public health interventions? First, urban areas are characterized by population density and diversity. Density enables public health programs to reach large sectors of the population efficiently, while diversity necessitates tailoring interventions to meet the needs of different subpopulations. Interventions to Improve Urban Health 295 Finding the right balance between these competing pressures is a constant challenge for planners of urban health interventions.2, 3 Second, compared with other areas, cities have a rich array of social and human resources, from dense social networks and myriad community-based organizations to multiple formal and informal service providers. These human resources and the social capital inherent within them constitute key assets for urban health promotion. Effective public health programs use them both to root interventions in a specific urban context and to reduce the need for external resources.4–6 Finding the right assets, mobilizing them, and ensuring their sustainability are important tasks for urban health interventionists. Third, cities are complex. Multiple systems interact; pluralistic political structures create competing stakeholders; cities are inextricably linked to other sociopolitical levels, such as neighborhoods, metropolitan regions, and nation-states, each of which makes demands and offers resources to the other levels; and local political and social forces create wide variations in the contexts in which programs are delivered. As a result, simple interventions are rarely sufficient to solve problems, many programs have unintended as well as intended outcomes, and generalization from one setting to another can be problematic. This contextual complexity requires a similar level of intervention complexity. Fourth, because most cities are characterized by high levels of inequality, interventions —even beneficial ones— run the risk of reinforcing or even widening disparities in health. Helping everyone get more of the necessities of life often further advantages the better off.7 To avoid this unintended effect, urban public health planners need to define disparity reduction as an explicit goal. Finally, because city governments and urban populations have limited resources to face multiple problems (e.g., in education, employment, crime prevention , environmental protection, and sanitation), it is difficult for health interventions to attract and retain the attention and support of policy makers and residents. Politics rather than need often drives resource allocation and few public health problems can be solved within the time span of the election or budget cycles in which policy makers operate. Thus, health interventions always compete for support with other interventions and only when public health planners operate effectively in scientific, economic, and political arenas will they win the means to implement the policies and programs they advocate. In summary, urban health interventions differ from interventions in other settings both because urban populations present a different health profile and because the urban environment is markedly different from suburban or rural ones. To be successful, public health interventionists must address both types of differences. Effective public health programs must use available scientific evidence to meet the unique needs of urban populations and a thorough understanding of the relevant social and political contexts in order to manage the process of program implementation and institutionalization. It is hardly surprising that many interventions founder in one or the other of these shoals. [3.81.222.152] Project...