Urbanization and the Determinants of Health: The Cities Changing Diabetes Programme

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1 Urbanization and the Determinants of Health: The Cities Changing Diabetes Programme Rome December 11, 2017 A. David Napier Professor Medical Anthropology, University College London Director Science, Medicine, and Society Network, University College London Global Academic Lead, Cities Changing Diabetes Programme

2 The Rule-of-Halves: Understanding the Diabetes Challenge Only about half of those with diabetes have been diagnosed. Only half of those diagnosed receive professional care. Of the people receiving care, only half achieve their treatment targets. and of those only half live life free from diabetesrelated complications. Hart, JT (1992) Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. Br J Gen Pract. 42(356):

3 Diabetes Research on Clinical Adherence A matter of behaviour change? Capability Opportunity Motivation

4 Share conventional values (misalignment of practices)

5 The Rule-of-Halves: Understanding the Diabetes Challenge Socio-culturally Social and Cultural Domain Bio-social Domain Biomedical Domain

6 The Need for a New Evidence Base: Diabetes Research and Social and Cultural Factors Diabetes Publications past 10 years ISI Web of Science SCOPUS PubMed Science and Technology/ Life Sciences 767, , ,816 Social Sciences/ Humanities 62,667 (or: 8.16%) 9, 209 (or: 2.8%) - We spend much of our effort on only a small part of a very big problem.

7 The Need for a New Evidence Base One that focuses less on Randomized Control Trials (RCTs which work by reducing variables to measure specific causes and effects). And more on compounding effects of diverse variables that is, on life as it is lived.

8 The Rule-of-Halves: Taking into Account Obesity and Overweight ,0 Billion Overweight 650 Million Obese Obese and Overweight Estimated Diabetes Population Diagnosed Diabetes Population In Treatment Achieve Treatment Target Achieve Desired Outcome

9 The Need for a New Evidence Base: The Problem Social and cultural factors are Complex Locally diverse Difficult to identify and study Evidence Gap

10 Mapping complexity Case Definitions Biological Factors Social Factors Geographical Factors Cultural Factors Age Education level Character of neighbourhood Food culture Familial history Access to care Environmental givens Attitude to physical activity Ethnicity Access to resources Distance work-home Trust in government/ health care BMI Employment status Local Infrastructure Body image and stigma Blood glucose levels Health insurance Access to water, transportation, etc. Access to food/ economic status General health (co-morbidities, chronic vs. acute, etc.) Socio-economic status Attitude towards large body size Living situation Peer appearance Level of social support

11 WHO Health-in-all-Policies Framework 1) Housing 6) Occupational Factors 7) Physical Activity 2) Water and Sanitation 5) Health Communication 8) Food Production and Distribution 3) Transportation 4) Exposure to chemicals and their mixtures 9) Physical, Natural, and Social Environments

12 The Health-in-all-Policies Framework The Framework and Diabetes 1) Housing limited movement; dangerous 1) Housing 6) Occupational Factors 7) Physical Activity 2) Water and Sanitation drinking water; food safety 2) Water and Sanitation 5) Health Communication 8) Food Production and Distribution 3) Transportation 4) Exposure to chemicals and their mixtures 9) Physical, Natural, and Social Environments 3) Transportation long commuting for work; no exercise

13 The Health-in-all-Policies Framework The Framework and Diabetes 4) Exposure to chemicals and their mixtures absence of laws regarding food labelling; air quality; environmental racism 1) Housing 2) Water and Sanitation 6) Occupational Factors 5) Health Communication 7) Physical Activity 8) Food Production and Distribution 5) Health Communication information about prevention and consequences; reversal of prediabetes; management of insulin dependence 3) Transportation 4) Exposure to chemicals and their mixtures 9) Physical, Natural, and Social Environments 6) Occupational Factors Long hours; workplace hazards

14 The Health-in-all-Policies Framework The Framework and Diabetes 7) Physical Activity its absence [at work, in transportation, in ability to exercise] 1) Housing 6) Occupational Factors 7) Physical Activity 8) Food Production and Distribution availability of cheap high-energy, low-nutrition food; poor or inaccurate labelling 2) Water and Sanitation 3) Transportation 5) Health Communication 4) Exposure to chemicals and their mixtures 8) Food Production and Distribution 9) Physical, Natural, and Social Environments 9) Physical, Natural and Social Environment no place to plant a garden, no time to do so, pressure to conform to 'modern' ideas about the good life; breakdown of extended families

15 Conclusion We have an opportunity to build a new evidence base that will not only improve diabetes care but also that will improve all healthcare.

16 Cities Changing Diabetes Research: New Kinds of Evidence

17 Why these tools? They allow us to understand vulnerability and barriers to behaviour change in real time. They allow complex case definitions of vulnerability to be scaled up to big data.

18 Diabetes Vulnerability Assessments Understanding the Diabetes Challenge in Each Partner City Assessments in 5 cities average 2 hrs interviews 75 fieldworkers trained largest database on lived experience of diabetes

19 Local Rule-of-Halves and Vulnerability Assessments: Understanding the Diabetes Challenge in Each Partner City

20 Cities Changing Diabetes: A New Approach to Research and Action.

21 Cities Changing Diabetes: Cross-Sector Partnerships. Approach: engage different cross-sector partners to address the diabetes and obesity challenge Media Companies and other stakeholders Community representative s City governments Academia City planners/ urban designers Health communities (incl. patient voice)

22 12 Cities to Change Urban Diabetes: Representing More Than 100 Million People. VANCOUVER LEICESTER Launch Feb COPENHAGEN BEIJING Launch Dec TIANJIN SHANGHAI HOUSTON HANGZHOU Launch Dec MEXICO CITY ROME JOHANNESBURG XIAMEN Reference

23 Overall Goals 1) To discover actionable insights into health vulnerabilities among at-risk populations. 2) To create opportunities for dissemination of findings through new knowledge networks. 3) To work with local and global advocates to reverse the diabetes and obesity epidemics.

24 Thank you.

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