Examining the significance of physical and social environments to healthy living.
Noncommunicable diseases (NCDs) place a significant burden on population health, resulting in high treatment costs, imposing a direct economic burden on health systems, households, and society as a whole. There is also an indirect economic burden through sizable productivity losses via premature mortality, early labor force exits, absenteeism, and work at lowered capacity.
Changing social and economic factors such as more people moving to cities and the spread of unhealthy lifestyles, have fueled the NCD crisis. To reduce the effects of NCDs in a cost-effective and sustainable manner, healthcare must focus on lifestyle factors which are the root cause of most chronic illnesses. Policies and interventions need to address the behavioral, social, environmental, socioeconomic, and political factors that impact health and well-being.
Based on projections by the UN Department of Economic and Social Affairs (UN DESA), over 55% of the world’s population lives in urban areas – a proportion that is expected to increase to 68% by 2050. However, most of the 4.2 billion people living in cities suffer inadequate housing and transport, poor sanitation and waste management, and air quality that fails WHO guidelines. Pollution, such as noise, water, and soil contamination as well as a lack of space for physical activities, further combine to make cities epicenters of chronic diseases.
According to Schwab et al. (2015), urban health is strongly linked to mental illness, being overweight, smoking behaviors, diabetes mellitus, hypertension, and coronary disease. Research has shown that encouraging people to make sustainable lifestyle changes through behavioral change management techniques can be very effective. To this end, policies that target the physical and social environment where people live, work, and play can have a substantial influence on health.
Policies such as reducing car dependency and traffic congestion, improving mobility and accessibility as well as deterring tobacco use can have a positive effect on healthy living (Schwab et a.l 2015). Conversely, policies on legalizing drugs such as cannabis can also lead to increased use of the drug which may have negative side effects.
As the impact of NCDs grows rapidly, affecting people of all ages and income levels in all regions of the world, the concept of Healthy Cities has gained new attention and significant prominence in the context of health promotion agendas. Healthy Cities and Cittaslow are urban initiatives that acknowledge the importance of physical and social environments to healthy living, whereas the more commonly considered factors such as access and use of health care services often have less impact.
The Healthy Cities initiative was conceived in 1986 by the World Health Organization (WHO) with the objective of placing health high on the political and social agenda of cities and building a strong movement for public health at the local level. Cittaslow, which was founded in Italy in 1999, was conceived to improve the quality of life in towns by slowing down its overall pace, especially in a city’s use of spaces and the flow of life and traffic through them. The ultimate goal is to create a serene and calm environment where one can live life to its fullest, far from stress, anxiety, and the rat race.
Based on the principles of Healthy Cities and Cittaslow, Schwab et al. (2015) aimed to establish comparisons and formulate plausible hypotheses for the relationship between healthy cities and chronic diseases/conditions. The research is a qualitative observational and comparative study from a socio-anthropological perspective carried out in five cities. In this study, data were collected by the same researcher in Greve in Chianti (Italy), Cowichan Bay (Canada), Antônio Prado (Brazil), Curitiba (Brazil), and Vancouver (Canada), from August 2012 to July 2013. The selection of cities was based on their connection to Healthy Cities and Cittaslow movements.
The research found that due to a concern for the community and social order, shifting from the individual level to the collective, Healthy Cities and Cittaslow improve the capacity of communities to identify and address problems. Individual choices regarding health and well-being are easier in a healthy environment, and the improved capacity to develop the full human potential helps to prevent or manage chronic conditions. This is why the development of healthy cities is useful for facing these conditions.
The findings also indicate that a “Healthy City” is not a final result, but rather an ongoing process, and must be thought of as a construction of urban health through an awareness of social conscience. Obstacles to obtaining a Healthy City are often not technical or even financial but are more closely related to governance and public participation. Particularly, it depends on political commitment and society.
Another policy initiative that has been examined is the advancement of a public health approach to substance use disorders and the overdose epidemic through legal and policy strategies that promote evidence-based treatment and support recovery (Richter, Vuolo & Oster, 2021). There is a dichotomy between a widespread belief that cannabis is an effective treatment for a wide assortment of ailments, and a lack of scientific knowledge on its effects which has been somewhat exacerbated in recent times by a trend toward legalization. Since 1990, there has been an increasing trend in favor of legalizing cannabis in the United States.
It is worth considering, as highlighted in Gali et al. (2021), that if perceptions of the health benefits of cannabis use increase over time and become more widespread (i.e., normative), cannabis use may increase further. Cannabis dependency may also increase, which has been linked to other substance use, depression, and low satisfaction with life.
In a 6-month prospective observational study carried out in 2018, Gali et al. (2021) examined the changes in adult cannabis use patterns and health perceptions following broadened legalization of cannabis use from medical to recreational purposes in California.
In the California study, findings indicated a younger age associated with cannabis use pre- and post-legalization. These findings are consistent with previous national studies on adults in the United States where cannabis use decreased with increasing age. Significant correlates of cannabis use at all time points included depression diagnosis while having another mental illness diagnosis was significantly associated with cannabis use only 6 months post-legalization.
It was noteworthy that the number of days of cannabis use increased on average from 11 days pre-legalization to 13 days post-legalization, which may reflect movement toward cannabis abuse and dependency. A study in California found a link between the density of cannabis dispensaries and neighborhood ecology on cannabis abuse and dependency before the legalization of recreational cannabis (Mair et al., 2015). Of interest is whether the density of dispensaries in California overall and particularly in economically disadvantaged neighborhoods, occurred post-legalization and if cannabis use and dependency have risen disproportionately in some areas.
Further research examining the long-term effects of legalized recreational cannabis on health outcomes, perceptions, and use, especially among young people and those with depression and other mental illnesses, is needed. Also warranted is further research on the long-term patterns of health perceptions, exposures, and behaviors following the legalization of adult recreational cannabis use to inform future public health policies, interventions, and educational initiatives.
With a growing trend of people moving to urban areas, understanding the health-promoting potential of cities is an important area of research that can have a big impact on health across population groups. Urban environments have the potential to become engines of good health and healthy lifestyles, but there needs to be political and social will by governments and communities to make the necessary changes in policies that promote physical activity, healthy eating, clean air, and green spaces.
In our next blog, we wrap up the series with highlights of some of the achievements of the ATHP Research Initiative since 2005. Stay tuned!
Sherry Joseph
Author
References
Armenise, A. Cittaslow movement: What is a slow city? Pretty Slow. Retrieved August 3, 2022, from https://prettyslow.life/cittaslow-movement-slow-city-sustainable-living/
Courtnee MeltonI, (2018) The Drivers of Health, The Sycamore Institute https://www.sycamoreinstitutetn.org/drivers-of-health/
DESA, U. (2018). The 2018 Revision of World Urbanization Prospects produced by the Population Division of the UN Department of Economic and Social Affairs (UN DESA) United Nations. New York.
Gali, K., Winter, S. J., Ahuja, N. J., Frank, E., & Prochaska, J. J. (2021). Changes in cannabis use, exposure, and health perceptions following legalization of adult recreational cannabis use in California: a prospective observational study. Substance abuse treatment, prevention, and policy, 16(1), 1-10.
Mair, C., Freisthler, B., Ponicki, W. R., & Gaidus, A. (2015). The impacts of marijuana dispensary density and neighborhood ecology on marijuana abuse and dependence. Drug and Alcohol Dependence, 154, 111–116.
Richter, L., Vuolo, L., Oster, R. (2021) “Recent Legislation Can Dramatically Improve Substance Use Prevention: Here’s How To Seize The Opportunity”, Health Affairs Blog.
Schwab, G. L., Moysés, S. T., França, B. H. S., Werneck, R. I., Frank, E., & Moysés, S. J. (2015). Healthy cities fighting against chronic conditions. Environmental Practice, 17(1), 16-24.
Urban health. (2020). World Health Organization. Retrieved August 3, 2022, from https://www.who.int/health-topics/urban-health#tab=tab_1
