Assessing Urban Health Inequities through a Multidimensional and Participatory Framework: Evidence from the EURO-HEALTHY Project

Abstract

Urban health inequities often reflect and follow the geographic patterns of inequality in the social, economic and environmental conditions within a city-the so-called determinants of health. Evidence of patterns within these conditions can support decision-making by identifying where action is urgent and which policies and interventions are needed to mitigate negative impacts and enhance positive impacts. Within the scope of the EU-funded project EURO-HEALTHY (Shaping EUROpean policies to promote HEALTH equitY), the City of Lisbon was selected as a case study to apply a multidimensional and participatory assessment approach of urban health whose purpose was to inform the evaluation of policies and interventions with potential to address local health gaps. In this paper, we present the set of indicators identified as drivers of urban health inequities within the City of Lisbon, exploring the added value of using a spatial indicator framework together with a participation process to orient a place-based assessment and to inform policies aimed at reducing health inequities. Two workshops with a panel of local stakeholders from health and social care services, municipal departments (e.g. urban planning, environment, social rights and education) and non-governmental and community-based organizations were organized. The aim was to engage local stakeholders to identify locally critical situations and select indicators of health determinants from a spatial equity perspective. To support the analysis, a matrix of 46 indicators of health determinants, with data disaggregated at the city neighbourhood scale, was constructed and was complemented with maps. The panel identified critical situations for urban health equity in 28 indicators across eight intervention axes: economic conditions, social protection and security; education; demographic change; lifestyles and behaviours; physical environment; built environment; road safety and healthcare resources and performance. The geographical distribution of identified critical situations showed that all 24 city neighbourhoods presented one or more problems. A group of neighbourhoods systematically perform worse in most indicators from different intervention axes, requiring not only priority action but mainly a multi- and intersectoral policy response. The indicator matrices and maps have provided a snapshot of urban inequities across different intervention axes, making a compelling argument for boosting intersectoral work across municipal departments and local stakeholders in the City of Lisbon. This study, by integrating local evidence in combination with social elements, pinpoints the importance of a place-based approach for assessing urban health equity.

Keywords: Determinants of health; Indicators; Lisbon; Local level; Multidimensional assessment; Participatory approach; Stakeholder engagement; Urban health equity.

Fig. 1

Indicator identity card. Illustrative example for the indicator “Fatality rate due to road traffic accidents (Number per 1000 victims)”

Fig. 2

Matrix of indicators provided to workgroup A (13 indicators)

Fig. 3

Matrix of indicators provided to workgroup B (20 indicators)

Fig. 4

Matrix of indicators provided to workgroup C (13 indicators)

Fig. 5

Photos illustrating the consultation process (a) and the workgroup discussions at the workshops 1 and 2 (b and c). a Consultation material. b Workshop 1. c Workshop 2

Fig. 6

Final matrix of critical situations for health equity in the municipality of Lisbon

Fig. 7

Geographical distribution of identified critical situations by intervention axis, in the municipality of Lisbon. Note: Civil parishes are coloured using a monochromatic colour scheme with a gradient ranging from light red to dark red according to the number of indicators identified by the majority as a critical situation. Civil parishes in light red were marked as critical in less than 25% of the indicators selected in the intervention axis. Civil parishes in dark red were marked as critical in more than 75% of the selected indicators. Civil parishes in white were not marked red for any indicator of the intervention axis.