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In 2010, half of the world's population lived in cities, reaching three quarters in Europe.1 ,2 Health inequalities tend to be more marked in urban areas because they include neighbourhoods which concentrate deprived and poor populations. A number of scholars with a long tradition in studying ‘place effects and health’,3 ,4 ‘neighbourhoods and health’5 ,6 and ‘urban areas and health’2 ,7–13 have conceptualised the determinants of health inequalities in neighbourhoods and/or urban areas. All of them have stated the importance of aspects related to the physical environment, mainly the built environment,12 and also to the socioeconomic environment.
Based on these backgrounds, this editorial presents a conceptual framework of the factors and processes (determinants) influencing health inequalities in European urban areas (figure 1), which are also determinants of health behaviours, under the responsibility of municipal governments and citizens. National or international wider factors described by other authors have not been included,10 ,11 although the model may also be used for municipalities smaller than urban areas. We propose this framework as a helpful tool to analyse local policies to address inequalities in health as well as to place health equity in the political agenda of European cities. Compared with other frameworks based on urban areas, it focuses mainly on European cities, not highlighting aspects that may be more relevant for cities from other continents.2 Moreover, it includes aspects not taken into account in other approaches. The framework has been designed within the ‘Socioeconomic inequalities in mortality: evidence and policies in cities of Europe’ project (INEQ-CITIES, https://www.ucl.ac.uk/ineqcities/), funded by the European Union, which aims to analyse the different patterns of small-area health inequalities and to describe policies to reduce them in European cities. The paragraphs below detail the main sections of the framework as well as the relationships between them and references to other conceptual frameworks.
Governance is a concept which recognises that power exists inside as well as outside governmental institutions. It refers to political power of the government (local, regional, national) and to other actors who play important roles, such as the private sector and the civil society through community groups. Five principles of good governance are: (1) Legitimacy and voice: the implementation of policies of social determinants needs to be part of a process that has legitimacy and provides a voice for all parties, including the most vulnerable populations. (2) Direction and strategic vision: work on social determinants requires direction and strategic vision for sustained and long-term action needed to reduce health inequities. (3) Performance: it has to be ensured in both the process and its outcomes. (4) Accountability must be clear. (5) Fairness: the processes in decision-making and implementation of these decisions with the aim of reducing health inequalities need to be fair.14 It is worth mentioning that urban governance is included in WHO/UN-HABITAT's2 conceptual framework.
Good governance for action on social determinants to tackle the root causes of health inequities in cities implies building and implementing collaborative action between the sectors related with the physical and the socioeconomic environments (‘intersectoral action’).
It refers to the natural context (climate or geography) as well as other physical factors. The built environment is based on urban planning and housing policies which usually depend on local authority. Urban planning determines the public infrastructure (communications, sewerage system), the general regulations (concerning buildings and the use of public space) and the equipments in a neighbourhood or city (parks, gardens and green spaces, sport, health and education facilities, markets, libraries, etc). As an example, the built environment is a central aspect in the model described by Rydin et al.12 Housing policy (taxation, social housing for rent or for sale) can make high quality housing affordable for all income levels, and mainly for low income households. The absence of these policies can convert housing into a means of speculation. This policy can heavily influence income distributions by offering housing for a relatively cheap or moderate price. Furthermore, housing quality, informal settlements or overcrowding are also factors to be addressed. Another aspect of the physical environment is transport mobility, affecting the capacity to walk and use public or private transport. Natural context, built environment and transport can influence environmental characteristics, as for example, water and air quality and noise pollution, which are important determinants of health in urban areas. Food security and access to healthy food (availability and price) are also main issues. Finally, emergency management for terrorism, bioterrorism, climate change and natural disasters is included in this section.
This environment refers to different aspects such as economic factors (taxes), employment and working conditions, domestic and family environment, public services (education, healthcare, care services for families, etc) and social transfers (pensions, unemployment benefits, etc).15 Although most of these factors are the responsibility of the state government, cities have the capacity to modify them. For example, city governments can try to improve living conditions of the poor population by redistributing the income collected through city taxes or distributing income pensions to people under the poverty threshold. It is worth mentioning that domestic and family environments are not explicitly included in other frameworks, although these determinants are related with gender and social class inequalities in health.16 Other aspects included are safety and security, social networks, and community participation, aspects that have also been associated with health inequalities.2
A setting is where people actively use and shape the environment; thus, it is also where people create or solve problems relating to health. Settings included in the framework are neighbourhoods, schools and workplaces, although there are many others such as places of worship, clubs and community activities, and places for recreation and leisure. Settings are related with the physical and socioeconomic environments. Examples of these relationships are actions to provide access to public spaces in neighbourhoods to carry out physical activity (such as green areas17 or sport facilities, aspects of the built environment) or actions to promote safety, social networks and participation (aspects of the socioeconomic environment). Macintyre et al3 point out ‘Availability of healthy environments at home, work and play’ as one of the five features of local areas that might influence health.
Segregation may be important in settings and refers to the separation of humans into groups determined by axes of inequality, as for example, social class or race. Segregation may exist where people live (residential segregation) and also in other settings. Many cities worldwide have highly segregated neighbourhoods with multiple barriers which prevent social groups from mixing. The characteristics of the built and socioeconomic environments influence this residential segregation implying that people of disadvantaged social classes or migrants from low income countries tend to live in neighbourhoods with lower property values and with concentration of people from the same origin. The conceptual framework of Diez Roux and Mair6 describing neighbourhoods and health also includes the role of residential segregation. Furthermore, schools can be segregated by country of origin: those located in neighbourhoods with more immigration will have a higher proportion of immigrated children.
Axes of inequalities
The different determinants commented above may change according to the different social axes of inequality such as social class, gender, age or ethnicity/migration which are social constructs that determine the social structure. For example, working conditions are not the same for men and women or for people of different social classes and it can be expected that there will be differences in the degree of exposure experienced by different genders and social classes as well. Axes of inequality have the following characteristics in common:18 (1) They are contextual and dynamic as they change throughout history and in different contexts; for example, it is not the same being a woman in Europe today that it was a century ago when the majority of women's rights did not have any recognition. (2) These axes are social constructs; therefore, they depend on social variables rather than any inherent quality that people possess themselves (as biology). (3) They are systems that involve relations of power and domination: a group exercising power over another. For example: people belonging to privileged social classes, from rich countries and men have more power than people from working social classes, of low income countries or women. (4) Axes of inequality are present at the structural or macro (society) level and also at the micro level (referring to people in their daily lives) and they are expressed simultaneously at both the society and individual levels as every individual is located in each of the dimensions or axes. The conceptual framework of Northridge et al7 includes inequalities in material wealth, employment opportunities, educational opportunities and political influence.
To conclude, it is worth mentioning that this framework can be useful for analysing health inequalities and implementing policies to reduce them in urban settings as it helps to conceptualise and better understand how the factors and processes described influence health inequalities in cities. Moreover, it may be useful as an advocacy tool to promote health equity in cities.
Acknowledgements We would like to acknowledge all INEQ-CITIES researchers who have shared with us the ideas included in this commentary.
Contributors All authors have participated in conception and design, drafting the article or revising it critically for important intellectual content and final approval of the version to be published.
Funding This manuscript has been partially funded by the project INEQ-CITIES, ‘Socioeconomic inequalities in mortality: evidence and policies of cities of Europe’; project funded by the Executive Agency for Health and Consumers (Commission of the European Union), project n°2008 12 13.
Competing interest None.
Provenance and peer review Commissioned; externally peer reviewed.