ABSTRACT

Objective

Qualitative methods may help to understand features related to health urban inequalities as a way to include citizens’ perceptions of their neighbourhoods in relation to their health-related behaviours. The aim of this article is to describe the methods and design of a qualitative urban health study.

Methods

The Heart Healthy Hoods (HHH) analyses cardiovascular health in an urban environment using mixed methods: electronic health records, quantitative individual questionnaires, physical examination, semi-structured Interviews (SSIs), focus groups (FGs) and participatory technics such as photovoice. This article focuses on the HHH qualitative methods and design. A case study was used to select three neighbourhoods in Madrid with different socioeconomic levels: low, medium, and high. The selection process for these three neighbourhoods was as follows: classification of all Madrid's neighbourhoods (128) according to their socioeconomic level; after ranking this classification, nine neighbourhoods, three by socioeconomic level, were short-listed; different urban sociology criteria and non-participant observation were used for the final selection of three neighbourhoods. After selecting the three neighbourhoods, thirty SSIs were held with residents and six SSIs were held with key informants. Finally, twenty-nine FGs will be conducted over the course of 8 months, between May and December of 2018.

Conclusions

Systematization in the selection of neighbourhoods and the use of adequate techniques are essential for the qualitative study of urban health inequalities.

Keywords:
Qualitative method; Urban health; Health inequalities; Neighbourhoods

RESUMEN

Objetivo

La metodología cualitativa puede ayudar a entender aspectos relacionados con las desigualdades en salud urbana, incluyendo la percepción de los ciudadanos de su barrio en relación con los comportamientos relacionados con su salud. El objetivo de este artículo es describir los métodos y el diseño de un estudio cualitativo sobre salud urbana.

Método

Heart Healthy Hoods (HHH) es un estudio que analiza la salud cardiovascular en un ámbito urbano, utilizando métodos mixtos: registros electrónicos de salud, cuestionarios individuales cuantitativos, exploraciones físicas, entrevistas semiestructuradas (ESE), grupos de discusión (GD) y técnicas participativas como el fotovoz. Este artículo se centra en los métodos y el diseño de la fase cualitativa del HHH. Se aplicó un estudio de caso, seleccionando tres barrios de Madrid con diferente nivel socioeconómico: bajo, medio y alto. El proceso de selección para estos tres barrios fue el siguiente: clasificación de todos los barrios de Madrid (128) según su nivel socioeconómico; tras graduar la clasificación se seleccionaron nueve barrios de Madrid, tres por nivel socioeconómico; se utilizaron diferentes criterios de sociología urbana y observación no participante para la selección final de tres barrios. Tras la elección de los tres barrios, se realizaron 30 ESE a vecinos y 6 ESE a informantes clave. Finalmente, se están organizando 29 GD con vecinos durante 8 meses, entre mayo y diciembre de 2018.

Conclusiones

La sistematización en la selección de barrios y la utilización de las técnicas adecuadas son fundamentales para el estudio cualitativo de las desigualdades en el entorno urbano.

Palabras clave:
Metodología cualitativa; Salud urbana; Desigualdades en salud; Barrios

Introduction

The study of the urban environment and cardiovascular health is a recurrent topic in recent years in public health and urban sociology.¹1. Diez-Roux AV, Nieto FJ, Muntaner C, et al. Neighborhood environments and coronary heart disease: a multilevel analysis. Am J Epidemiol. 1997;146: 48-63.^-22. Diez-Roux AV. Residential environments and cardiovascular risk. J Urban Health. 2003;80:569-89. The new dynamics of city life have been shaped by external factors such as globalization, the impact of technologies, deregulation, and new communications.³3. Castells M. The informational city: economic restructuring and urban development. Oxford: Basil Blackwell; 1989. p. 402.^-44. Sassen S. The global city: New York, London Tokyo. Princeton: University Press; 1991. p. 480. These dynamics have led to changes such as “urban outsourcing”, a phenomenon whereby city centers have become the setting for offices, businesses, services and shops.⁵5. Borrell C, Pasarín MI. Inequalities in health and urban areas. Gac Sanit. 2004;18:1-4. Another phenomenon caused by the new dynamics is “gentrification”.⁶6. Smith N. Gentrification and the rent gap. Annals of the Association of American Geographers. 1987;77:462-5.^-77. Jacobs J. The death and life of great American cities. New York: Random House; 1992. p. 457. We assume the concept of “gentrification” of Neil Smith⁶6. Smith N. Gentrification and the rent gap. Annals of the Association of American Geographers. 1987;77:462-5. which is briefly defined as the transformation of inner-city working-class neighborhoods into middle-and upper-middle class neighborhoods.

The analysis of urban setting and its relationships with cardiovascular health leads to the study of inequality in health in the cities, which is based mainly on an analysis of the distinctive features of city neighborhoods. Several studies have confirmed the existence of health inequalities in urban settings.⁸8. Marí-Dell'Olmo M, Gotsens M, Palencia L, et al. Socieconomic inequalities in cause-specific mortality in 15 European cities. J Epidemiol Community Health. 2015;69:432-41.

9. Marín FJ, March JC. Social inequalities in health in the city of Malaga (Spain). Gac Sanit. 1992;6:198-206.^-1010. Perini W, Aqyemang C, Snijder MB, et al. Ethnic disparities in educational and occupational gradients of estimated cardiovascular disease risk: the Healthy Life in an Urban Setting study. Scand J Public Health. 2018;46: 204-11.

The main risk factors of cardiovascular diseases involve physical inactivity, diet, harmful alcohol consumption, and smoking.⁹9. Marín FJ, March JC. Social inequalities in health in the city of Malaga (Spain). Gac Sanit. 1992;6:198-206. The relationship between city neighborhoods and these risk factors of cardiovascular health has been previously studied.¹¹11. Bilal U, Díez J, Alfayate S, et al. Population cardiovascular health and urban environments: the Heart Healthy Hoods exploratory study in Madrid Spain. BMC Med Res Methodol. 2016;16:104.^-1212. Rudolph KE, Glass TA, Crum RM, et al. Neighborhood psychosocial hazards and binge drinking among late middle-aged adults. J Urban Health. 2013;90: 970-82.

We emphasize the main research studies which have been conducted using a qualitative method applied to the analysis of health inequalities regarding cardiovascular risk factors in an urban environment.¹³13. Burgoyne L, Coleman R, Perry IJ. Walking in a city neighbourhood, paving the way. J Public Health. 2007;29:222-9.

14. Yen IH, Scherzer T, Cubbin C, et al. Women's perceptions of neighborhood resources and hazards related to diet, physical activity, and smoking: focus group results from economically distinct neighborhoods in a mid-sized U.S. city. Am J Health Promot. 2007;22:98-106.

15. Israel BA, Schulz AJ, Estrada-Martínez L, et al. Engaging urban residents in assessing neighborhood environments and their implications for health. J Urban Health. 2006;83:523-39.^-1616. Roy B, De Koninck M. The qualitative research on social inequalities in health: the life courses. Can J Public Health. 2014;104:154-8. Qualitative research in this area has been based either on one single cardiovascular risk factor or on a specific group, i.e., physical inactivity or Latin women.¹³13. Burgoyne L, Coleman R, Perry IJ. Walking in a city neighbourhood, paving the way. J Public Health. 2007;29:222-9.^-1414. Yen IH, Scherzer T, Cubbin C, et al. Women's perceptions of neighborhood resources and hazards related to diet, physical activity, and smoking: focus group results from economically distinct neighborhoods in a mid-sized U.S. city. Am J Health Promot. 2007;22:98-106. It is important to emphasize that previous qualitative studies are designed for the later use of quantitative questionnaires¹⁵15. Israel BA, Schulz AJ, Estrada-Martínez L, et al. Engaging urban residents in assessing neighborhood environments and their implications for health. J Urban Health. 2006;83:523-39. or have focused only on poverty and social exclusion.¹⁶16. Roy B, De Koninck M. The qualitative research on social inequalities in health: the life courses. Can J Public Health. 2014;104:154-8.

In short, qualitative studies are necessary to analyze the four main dimensions in the risk of cardiovascular and chronic diseases from the perspective of health inequalities in urban settings. This approach will facilitate the understanding of structural factors explaining health inequalities as well as the understanding of multiple behaviors in context. In addition, the use of qualitative methods must be accompanied by a suitable design allowing a relevant selection of different socioeconomic areas. This design is fundamental for making suitable comparisons between neighborhoods.

Within this framework, the study objective is to describe the design, methods and qualitative technics used to understand urban cardiovascular health inequalities in the Heart Healthy Hoods (HHH) Project.

Method

The methodological design of the qualitative study is an ancillary study of the HHH Project. The HHH Project was funded by the European Research Council as a starting grant in 2013 and will be conducted until 2019. The main goal of the HHH study is to understand the physical and social elements impacting upon city residents’ cardiovascular health. The HHH Project uses different techniques such as analysis of electronic health records, questionnaires, physical examination, semi-structured Interviews (SSIs), focus groups (FGs) and participatory technics as photovoice.¹¹11. Bilal U, Díez J, Alfayate S, et al. Population cardiovascular health and urban environments: the Heart Healthy Hoods exploratory study in Madrid Spain. BMC Med Res Methodol. 2016;16:104. ¹⁷17. Gullón P, Bilal U, Cebrecos A, et al. Intersection of neighborhood dynamics and socioeconomic status in small-area walkability: the Heart Healthy Hoods project. Int J Health Geogr. 2017;16:21.

18. Díez J, Conde P, Sandin M, et al. Understanding the local food environment: a participatory photovoice project in a low-income area in Madrid Spain. Health Place. 2017;43:95-103.

19. Franco M, Bilal U, Díez-Roux AV. Preventing non-communicable diseases through structural changes in urban environments. J Epidemiol Community Health. 2015;69:509-11.^-2020. Carreño V, Franco M, Gullón P, et al. Studying city life, improving population health. Int J Epidemiol. 2017;46:14-21.

Photovoice is a participatory action research method used to reflect reality and empower the residents through photography. Within the HHH project this technic has been used for understanding key determinants of the urban environment influencing residents’ health from a residents’ perspective.¹⁸18. Díez J, Conde P, Sandin M, et al. Understanding the local food environment: a participatory photovoice project in a low-income area in Madrid Spain. Health Place. 2017;43:95-103.

Design of the HHH qualitative study

The city of Madrid (Spain) is administratively organized into 21 districts and 128 neighborhoods. We decided to include as the study setting three neighborhoods exemplifying (every one of them) the different socioeconomic levels in the city: high, medium and low. We could consider this design as a case study approach similar to the single case-design, type 2, embedded (multiple units of analysis).²¹21. Sequera J, Janoschka M. Gentrification dispositives in the historic centre of Madrid: a reconsideration of urban governmentality and state-led urban reconfiguration. In: Loreta L, Shin HB, López-Morales E, editors. Uneven development and displacement. Bristol: Policy Press; 2015. p. 375-94. The following steps were taken to finally select these three neighborhoods:

Techniques to be used in the HHH qualitative Project

Once the three neighborhoods have been selected, SSIs were held with residents and key informants, i.e., school principals and health professionals in each one of the three neighborhoods selected. The key informants would help explain the dynamics related to all four health dimensions in every neighborhood: alcohol, tobacco, physical activity and diet. The FGs will be conducted during the course of 8 months, between May and December of 2018.

The authors have decided to use methodological triangulation²⁸28. Knafi KA, Breitmayer BJ. Triangulation in qualitative research: issues of conceptual clarity and purpose. In: Morse JM, editor. Qualitative nursing research. A contemporary dialogue. London: Sage Publications; 1991. p. 226-39. choosing SSIs and FGs as the main techniques because both techniques shed light on the relationship between local residents and their neighborhoods. The SSIs reveal an individual life plan related to the four dimensions studied (tobacco and alcohol consumption, physical activity and diet) and their relationship with the neighborhood.²⁹29. Barriball KL, While A. Collecting data using a semi-structured interview: a discussion paper. J Adv Nurs. 1994;19:328-35. The FGs (in this case and to avoid problems in the understanding, the authors consider to FGs similar to “discussion groups” according to the Latin-American tradition³⁰30. Gutiérrez J. Discussion group: follow up, variation or break with the focus group? Cinta Moebio. 2011;41:105-22.) help to understand how the neighborhood is perceived collectively, and the behaviors related to the four dimensions according to the different collectives, i.e., migrants, pensioners, etc.³¹31. Quine S, Focus groups. In: Kerr CB, Taylor JR, Heard GS, editors. Handbook of public health methods. 3rd ed. London: Sage Publications; 1999. p. 527-32.

Both SSIs and FGs involving residents have been designed according to specific profiles determined by the following criteria: sex, age, education level, number of children, labor situation, income, family responsibility related to children or grandchildren, years of living in the neighborhood, immigration, tobacco consumption (smoker, ex-smoker, smoker who has participated in health programs to quit smoking), alcohol consumption (occasional drinker or regular drinker), and participation in fitness programs. In the high socioeconomic level neighborhood immigrants were not included. This decision is due to the fact that the highest percentage of immigrants in Madrid live in low and medium socioeconomic level neighborhoods and their impact on these kinds of neighborhoods can be very relevant. A pilot study, conducted between January 2014 and January 2015 in a middle-low socioeconomic neighborhood in Madrid³²32. Conde P, Gutiérrez M, Sandín M, et al. Changing neighborhoods and residents' health perceptions: the Heart Healthy Hoods Qualitative Study. Int J Environ Res Public Health. 2018;15:1617., helped defining the residents’ profiles to be interviewed and the profile of FGs participants. These profiles are shown in the online Appendix (tables 2 and 3).

Selected neighborhoods

Out of the nine neighborhoods short-listed, three were finally selected for an in-depth study or case study: low socio-economic level: San Diego (Puente de Vallecas district); medium socio-economic level: El Pilar (Fuencarral-El Pardo district); high socio-economic level: Nueva España (Chamartín district)

The three finally selected neighborhoods are shown in Figure 1.

Distribution of semi-structured interviews and focus groups in the selected neighborhoods

A total of thirty SSIs were held, twenty-nine FGs will be conducted with residents, and six SSIs were held with key informants.Table 1 shows the distribution of SSIs and FGs organized in the three neighborhoods in regard to the health dimensions under study.

Discussion

Several qualitative studies have been conducted to analyze the relationship between neighborhoods and health;¹³13. Burgoyne L, Coleman R, Perry IJ. Walking in a city neighbourhood, paving the way. J Public Health. 2007;29:222-9.

14. Yen IH, Scherzer T, Cubbin C, et al. Women's perceptions of neighborhood resources and hazards related to diet, physical activity, and smoking: focus group results from economically distinct neighborhoods in a mid-sized U.S. city. Am J Health Promot. 2007;22:98-106.

15. Israel BA, Schulz AJ, Estrada-Martínez L, et al. Engaging urban residents in assessing neighborhood environments and their implications for health. J Urban Health. 2006;83:523-39.^-1616. Roy B, De Koninck M. The qualitative research on social inequalities in health: the life courses. Can J Public Health. 2014;104:154-8. nevertheless, none of them have provided a systematic design for selecting neighborhoods through the case study or for implementing SSIs and FGs according to different profiles. This is a fundamental issue when studying urban health inequalities.

We used the case study, type 2, embedded (multiple units of analysis), according to Yin²⁴24. Yin R, Case study research. Design methods applied social research methods series, 5, 3rd ed. London: Thousand Oaks, Sage Publications; 2003. p. 180. because it can be useful to describe and to explain different behaviors related to health and it allows the use of several research techniques.

The authors decided to use SSIs and FGs as qualitative techniques. We emphasize the complementarity of SSIs and FGS, i.e. triangulation. The SSI allows us to focus on analyzing the topic without restricting the discourse of the interviewed person.²⁹29. Barriball KL, While A. Collecting data using a semi-structured interview: a discussion paper. J Adv Nurs. 1994;19:328-35. The FGs collect collective discourses in the neighborhood on social practices related to health.³¹31. Quine S, Focus groups. In: Kerr CB, Taylor JR, Heard GS, editors. Handbook of public health methods. 3rd ed. London: Sage Publications; 1999. p. 527-32. In addition, non-participant observation was used as a criterion of selection of the studied neighborhoods due to this technique enabling us to include a larger space than participant observation without the obligation of participating.²⁵25. Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47:2025-47.

The authors ruled out the use of other qualitative research techniques such as participant observation or life story interviews. The participant observation technique takes a long time, and would have made it difficult to find results within the deadline of our project.³³33. Spradley JP. Participant observation. Illinois: Waveland Press; 1980. p. 183. The life story interviews would have favored a deeper understanding of the life plan of the people interviewed, but the versatility of profiles would have been lost with this technique.³⁴34. Atkinson R. The life story interview. Qualitative research methods, 44. London: Sage Publications; 1988. p. 104.

Right after, neighborhood exclusion/inclusion criteria by socio-economic level will be explained.

In the low socioeconomic level San Cristobal (Villaverde district) was excluded because it was being studied by the HHH team through the photovoice technique.¹⁸18. Díez J, Conde P, Sandin M, et al. Understanding the local food environment: a participatory photovoice project in a low-income area in Madrid Spain. Health Place. 2017;43:95-103. Many people in San Cristobal may be familiar with the HHH project. An information booklet published by the local government³⁵35. Grupo de Epidemiología Social y Cardiovascular, Universidad de Alcalá. Photovoice Villaverde. A participatory study on food through photography. Madrid: Heart Healthy Hoods, Ayuntamiento de Madrid; 2016. p. 99. and results in the media need to be taken into account. This information could come to social desirability.²⁵25. Krumpal I. Determinants of social desirability bias in sensitive surveys: a literature review. Qual Quant. 2013;47:2025-47. Pradolongo (Usera district) has also been excluded because of its administrative definition. Its identity does not exist as such because its residents think their neighborhood is Usera, but Usera is not a neighborhood but a district (a district is formed by many neighborhoods, in this case by seven neighborhoods). In addition, Pradolongo has a very small and dispersed population compared with the other neighborhoods. There are 16,881 people registered in the census, which could make difficult to find an adequate selection of individuals for a FG who, for instance, do not know each other.

San Diego has been chosen in this socioeconomic level for the following reasons:

In the medium socioeconomic level Palacio was excluded for the following reasons:

The authors consider this neighborhood could be influenced by the gentrification phenomenon, and so it has not been considered suitable for this kind of study.

Apóstol Santiago was excluded as unsuitable for several reasons:

In the high socio-economic level, Fuentelarreina was excluded for the following reasons:

Nueva España and El Viso neighborhoods (both in Chamartin district) have very similar economic indicators. Finally, Nueva España was selected for three main reasons: there are more people (23,409) than in El Viso (16,847); the socioeconomic indicator is also slightly higher than in El Viso, which probably has a stronger local neighborhood identity, but El Viso is similar to what has happened to Apóstol Santiago, i.e., there was an historic El Viso neighborhood that is now only part of nowadays El Viso, so there is a risk of misunderstanding.

Regarding the limitations of the present study, we acknowledge this is a case study conducted in three neighborhoods with different socioeconomic levels. Therefore, it may not have all the desired representativeness of a large city such as Madrid and there will probably be aspects which we will not be able to consider. Moreover, in spite of our sampling efforts it is very difficult to control the social homogeneity the neighborhoods, especially at a medium socioeconomic level, which could be a handicap for identifying “useful” discourses.

The methods and design of this urban health qualitative study may be useful as a reference and guide for researchers considering a qualitative approach to urban health inequalities. In any research project, as in qualitative research, it is important to follow a rigorous process in the selection of the final settings to be studied and the people whose discourse will be finally analyzed. An accurate and systematic design may allow population studies to incorporate qualitative techniques and case studies into their design for analyzing urban health inequalities.

We consider that this study may help understanding how population health is determined by three dimensions: the place where one lives, the social structure and the collective cultural dimension. Qualitative methodologies allow us to delve into these dimensions, and in turn the dimensions will give us the keys to understanding, for example, why and how in some neighborhoods more physical activity is done and more tobacco and alcohol is consumed than in others. Furthermore, we will be able to understand why and how in some neighborhoods people eat in a different way with respect to others. Therefore, this study might provide useful evidence for the development of urban health policies.

Acknowledgements

The authors would like to thank Caolán O’Crualaoich for his linguistic assistance on this manuscript, and Daniel Arribas Molero for his collaboration in non-participant observation in the selected neighborhoods in the study.

Appendix A   Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.gaceta.2018.07.010.

References

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