In recent years interest was shown in geographical characteristics within public health, particularly in the areas of urban and rural communities. Past research has documented a difference between urban and rural health care, usually expressed in terms of healthcare access and utilization, cost, and geographic distribution of providers and services.(Milton, 2009) There are numerous unique health care issues facing rural people and rural places. By examining the determinants of health, we can identify environment-specific factors that lead to different health conditions for urban and rural communities. The focus on the environmental and social determinants of health has made a rapid change in rates of urban populations across the world. The rapid urbanization reflects changes in global political, economic, and social forces.( Mainous AG III, Kohrs FP, 1995) As more people worldwide live in cities, it is imperative to understand how urban living affects population health.
URBAN CONTEXT
Urban development professionals should be concerned about variations in health statistics within and between urban areas. Firstly, because the statistics represent vast numbers of early deaths and debilitating illnesses.( Freudenberg N , 2000) Secondly, because the distribution of health inequalities in urban areas reflects wider social inequalities: on average the urban rich live for longer and in better health than the urban poor. Urban areas provide great opportunities for individuals and families to prosper and can provide a healthy living environment through enhanced access to services, culture and recreation.(Campbell-Lendrum D and Corvalán C, 2007) However, city dwellers continue to face health hazards and new health challenges have emerged. While the characteristics of each city vary local context, common urban health and social challenges include: overcrowding; air pollution; rising levels of risk factors like tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol; inadequate infrastructure, transport facilities, and insufficient access to health facilities in slum areas.
THE ISSUES IN URBANIZATION
The social environment:
Urban environments will see large differences in socioeconomic status(Krieger J, Higgins DL, 2002), higher rates of crime and violence, the presence of marginalized populations with high risk behaviours, and a higher prevalence of psychological stressors that implies increased density and diversity of cities. The environment of a city can support or damage health(Judd FK et. al, 2002) but also provides higher levels of social support. Interpersonal violence is growing fast in large cities and becoming a major public health issue. In urban areas, young people aged 15 to 24 commit the largest number of violent acts and are also the prime victims of violence. The lives and health of city dwellers are at risk during wars and conflicts.
Urbanization impacts population health:
Many trends are followed in different parts of the world. Some cities and regions are experiencing rapid growth as urbanization and its health impacts are not just an issue for cities with over 10 million residents, whereas other cities and regions are in population decline.( Dora C, Phillips M, 2000) Urbanization involves migration, reclassification and natural growth, when they expand horizontally and absorb hamlets and towns.
The physical environment:
In densely populated urban areas we have lack of facilities and outdoor areas for exercise and recreation. In addition, air quality is often lower which cause chronic diseases.( WHO/UNEP, 2008) Lack of basic infrastructure can increase rates of infectious disease and further perpetuate the cycle of poverty. In many cases, especially in the developing world, the speed of urbanization has outpaced the ability of governments to build essential infrastructure. Issues related are: Housing, land tenure and securityWaterSanitationFoodUrban transportNoise exposureAir pollutionClimatic change
Access to health and social service:
Majority of the lower socioeconomic status and minority populations are likely to live in urban areas and are more likely to lack health insurance(Milton, Angela, 2009) Thus, these populations face barriers to care, receive poorer quality care, and disproportionately use emergency systems. (Department of Commerce, 2000)Without health insurance a great burden is created on the high prevalence of individuals on available systems. This often will lead to vast disparities in health care outcomes as well as the health care system where insured individuals will have access to preventive and routine health care while marginalized populations utilize emergency room care. Cities have better health and social services compared to rural areas even though for low- and middle-income countries in particular, the scenario is different. Access to services for the urban poor may be limited by ability to pay, even in the context free health services where medications and supplies are not free, location or hours of operation is inconvenient, and care is of poor quality. This results in low utilization of the most basic preventative and curative health services.
RURAL CONTEXT
The social environment:
” Health educators are increasingly aware of the need for culturally sensitive approaches to modifying unhealthy behaviour, but few rural health researchers say rural residence reinforce negative health behaviours”.( Morgan A, 2002) Majority of the public health problems are not responding to the available health services. Instead, this challenge calls for a social perspective with a focus on prevention and a healthy lifestyle.( Hartley DA, 2004)Despite negative health behaviours, many aspects of rural social life contribute to positive health outcomes. ” Rural areas frequently have strengths including dense social networks, social ties of long duration, shared life experiences, high quality of life, and norms of self-help, and reciprocity”. Addressing the needs of rural areas requires building upon the positive aspects of rural life while addressing the health, public health, infrastructure, and economic needs of rural areas.
The physical environment:
Rural women, especially less educated women, are more inactive than urban women. Rural individuals are less habituated to sidewalks, streetlights, high crime, access to facilities, and frequently seeing others exercise in their neighbourhood. While poor air quality and crime rates are likely to be less of an issue in rural areas, insufficiencies in the built environment make it difficult for rural residents to exercise and maintain healthy habits.
Access to health and social service:
Evidence indicates that rural residents have limited access to health care and that rural areas are underserved by primary care physicians. In the developing and developed world, rural people need to travel a substantial distance for the health care centres and need a long time to reach there than the urban counterparts.(Passchier-Vermeer W, Passchier WF, 2000) Furthermore, some rural areas have a higher proportion of uninsured and individually insured residents than urban areas.
PROBLEMS OF RAPID URBANIZATION
More than 50% of the world’s population now lives in urban areas.(Phillips DR, 1993) Urbanization implies ” considerable changes in the ways in which people live, how they earn their livelihoods, the food which they eat, and the wide range of environmental factors to which they are exposed.”(Satterthwaite D, 2000) There is an underlying assumption that urban populations will be healthier than their rural counterparts and research about the features of urban areas that influence health has been relatively sparse but often indicates increased health hazards. In the past most deaths were due to the infectious diseases and people did not often live long enough to be afflicted by chronic causes of death. Due to urbanisation people thought that the burden of disease would shift from infectious to chronic causes. But now a days both the infectious and chronic are dead full.(WHO, Geneve, 2009) This double burden is often present in areas that have experienced rapid urbanization. Throughout most of human history, populations were not large enough to sustain highly transmissible infectious diseases for long periods of time. (WHO, Geneva, 2008) Now, this is no longer the case. Because people are living closer to one another, the potential for infectious disease transmission is much higher due to the unsanitary environment. For example, poor urban individuals who live in moldy apartments are more likely to be afflicted with asthma. Furthermore, overworked factory employees are more likely to suffer from work-related injuries and environmental pollution. To understand urban health and the phenomenon of urbanization, we must shift our focus away from disease outcomes and toward urban exposures, namely, the characteristics of the urban context that influence health and well-being. This can include methods relevant to the study of urban health including epidemiology, health policy, and urban planning. In addition, practical issues for developing healthy cities should be addressed, such as preventive strategies, the provision of health services, and education. Campbell-Lendrum D and Corvalán C. Climate change and developing-country cities: implications for environmental health hazards and health equity. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 2007; Vol. 84, No. 1, pp. i86-i97. Department of Commerce, Bureau of the Census. Qualifying urban areas for census 2000. Federal Register Part 7. May 1, 2002. Dora C, Phillips M, eds. Transport, environment and health. WHO Regional Publications, European Series, No. 89. World Health Organization, Copenhagen, 2000. 4) Freudenberg N. Time for a national agenda to improve the health of urbanpopulations. Am J Public Health. 2000; 90: 837–840. Ghosh S, Shah D. Nutritional problems in urban slum children. Indian Pediatrics, July 2004; 41(7): 682-696. Global health risks: mortality and burden of disease attributable to selected major risks. World Health Organization, Geneva, 2009. Hartley DA. Rural health disparities, population health, and rural culture. Am J Public Health. 2004; 94: 1675–1678. Human Settlements Programme. The state of the world’s cities, 2010–2011. Nairobi [in production 2010]. Judd FK, Jackson HJ, Komiti A, Murray G, Hodgins G, Fraser C. High prevalence disorders in urban and rural communities. Aust N Z J Psychiatry. 2002; 36: 104–113. Krieger J, Higgins DL. Housing and health: time again for public health action. American Journal of Public Health, 2002; 92(5): 758-68. Mainous AG III, Kohrs FP. A comparison of health status between rural and urban adults. J Comm Health. 1995; 20: 423–431. McMichael AJ, Woodruff RE, Hales S. Climate change and human health. Lancet, 11 March 2006; 367(9513): 859–869. Milton, Angela. Rural Vs. Urban Access to Health Services. http://www. healthsystems2020. org/content/blog/detail/2257/ Accessed September 14, 2009. Montgomery MR. The Urban Transformation of the Developing World. Science, 2008; 319(5864): 761–764. Morgan A. A national call to action: CDC’s 2001 urban and rural health chartbook. J Rural Health. 2002; 18: 382–383. Passchier-Vermeer W, Passchier WF. Noise exposure and public health. Environmental Health Perspectives, 2000; 108 Suppl 1: 123-131. Peden M, Scurfield R, Sleet D, Mohan, Hyder AA, Jarawan E, Mathers A. World Health Report on road traffic injury prevention. World Health Organization, Geneva, 2004. Phillips DR, 1993. Urbanization and human health. Parasitology106(Suppl): 93–107. Population Division of the Department of Economic and Social Affairs of the UnitedNations Secretariat (UNDESA). World Population Prospects: The 2006 Revision andWorld Urbanization Prospects: The 2007 Revision. United Nations, New York, 26February 2008. [http://esa. un. org/unup]. Satterthwaite D. Will most people live in cities? BMJ, 2000; 321(7269): 1143-1145. WHO/UNEP. Healthy transport in developing cities. Health and Environment Linkages Policy Series. World Health Organization, Geneva, 2008.
