Understanding Urban Health Inequalities: Methods and Design of the Heart Health Hoods Qualitative Project

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GacSanit.2019; :517–522

Original

Understanding

Urban

Health

Inequalities:

Methods

and

Design

of

the

Heart

Health

Hoods

Qualitative

Project

Jesús

Rivera

Navarro

a,∗

_,

_Manuel

_Franco

_Tejero

b,c,d

_,

_Paloma

_Conde

_Espejo

b

_,

_María

_Sandín

_Vázquez

e

_,

Marta

Gutiérrez

Sastre

a

_,

_Alba

_Cebrecos

b

_,

_Adelino

_Sainz

_{Mu ˜noz}

a

_,

_Joel

_Gittelsohn

c

a_Sociology_and_{Communication}_Department,_Social_Sciences_Faculty,_Salamanca,_Spain

b_Social_and_{Cardiovascular}_Epidemiology_Research_Group,_School_of_Medicine,_University_of_Alcalá,_Alcalá_de_Henares_(Madrid),_Spain

c_Global_Obesity_Prevention_Center,_Department_of_{International}_Health,_Johns_Hopkins_Bloomberg_School_of_Public_Health,_Baltimore_(Maryland),_United_States_of_America d_Department_of_{Epidemiology,}_Johns_Hopkins_Bloomberg_School_of_Public_Health,_Baltimore,_(Maryland),_United_States_of_America

e_Surgery_and_Medical_and_Social_Sciences_Department,_School_of_Medicine,_University_of_Alcalá_de_Henares,_Alcalá_de_Henares_(Madrid),_Spain

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received17January2018 Accepted16July2018

Availableonline25October2018

Keywords:

Qualitativemethod Urbanhealth Healthinequalities Neighbourhoods

a

b

s

t

r

a

c

t

Objective: Qualitativemethodsmayhelptounderstandfeaturesrelatedtohealthurbaninequalities asawaytoincludecitizens’perceptionsoftheirneighbourhoodsinrelationtotheirhealth-related behaviours.Theaimofthisarticleistodescribethemethodsanddesignofaqualitativeurbanhealth study.

Methods:TheHeartHealthyHoods(HHH)analysescardiovascularhealthinanurbanenvironmentusing mixedmethods:electronichealthrecords,quantitativeindividualquestionnaires,physicalexamination, semi-structuredInterviews(SSIs),focusgroups(FGs)andparticipatorytechnicssuchasphotovoice. ThisarticlefocusesontheHHHqualitativemethodsanddesign.Acasestudywasusedtoselectthree neighbourhoodsinMadridwithdifferentsocioeconomiclevels:low,medium,andhigh.Theselection pro-cessforthesethreeneighbourhoodswasasfollows:classificationofallMadrid’sneighbourhoods(128) accordingtotheirsocioeconomiclevel;afterrankingthisclassification,nineneighbourhoods,threeby socioeconomiclevel,wereshort-listed;differenturbansociologycriteriaandnon-participant observa-tionwereusedforthefinalselectionofthreeneighbourhoods.Afterselectingthethreeneighbourhoods, thirtySSIswereheldwithresidentsandsixSSIswereheldwithkeyinformants.Finally,twenty-nineFGs willbeconductedoverthecourseof8months,betweenMayandDecemberof2018.

Conclusions:Systematizationintheselectionofneighbourhoodsandtheuseofadequatetechniquesare essentialforthequalitativestudyofurbanhealthinequalities.

Comprensión

de

las

desigualdades

en

salud

urbana:

métodos

y

dise ˜

nos

del

proyecto

cualitativo

Heart

Health

Hoods

Palabrasclave:

Metodologíacualitativa Saludurbana Desigualdadesensalud Barrios

r

e

s

u

m

e

n

Objetivo:Lametodologíacualitativapuedeayudaraentenderaspectosrelacionadosconlasdesigualdades ensaludurbana,incluyendolapercepcióndelosciudadanosdesubarrioenrelaciónconlos compor-tamientosrelacionadosconsusalud.Elobjetivodeesteartículoesdescribirlosmétodosyeldise ˜node unestudiocualitativosobresaludurbana.

Método: HeartHealthyHoods(HHH)esunestudioqueanalizalasaludcardiovascularenunámbito urbano,utilizandométodosmixtos:registroselectrónicosdesalud,cuestionariosindividuales cuanti-tativos,exploracionesfísicas,entrevistassemiestructuradas(ESE),gruposdediscusión(GD)ytécnicas participativascomoelfotovoz.Esteartículosecentraenlosmétodosyeldise ˜nodelafase cualita-tivadelHHH.Seaplicóunestudiodecaso,seleccionandotresbarriosdeMadridcondiferentenivel socioeconómico:bajo,medioyalto.Elprocesodeselecciónparaestostresbarriosfueelsiguiente: clasi-ficacióndetodoslosbarriosdeMadrid(128)segúnsunivelsocioeconómico;trasgraduarlaclasificación seseleccionaronnuevebarriosdeMadrid,trespornivelsocioeconómico;seutilizarondiferentes cri-teriosdesociologíaurbanayobservaciónnoparticipanteparalaselecciónfinaldetresbarrios.Trasla eleccióndelostresbarrios,serealizaron30ESEavecinosy6ESEainformantesclave.Finalmente,se estánorganizando29GDconvecinosdurante8meses,entremayoydiciembrede2018.

Conclusiones:Lasistematizaciónenlaseleccióndebarriosylautilizacióndelastécnicasadecuadasson fundamentalesparaelestudiocualitativodelasdesigualdadesenelentornourbano.

∗ Correspondingauthor.

E-mailaddress:[email protected](J.RiveraNavarro).

https://doi.org/10.1016/j.gaceta.2018.07.010

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Introduction

Thestudyoftheurbanenvironmentandcardiovascularhealth is a recurrenttopic in recent years in publichealth and urban sociology.1,2 _The_new_dynamics_of_city_life_have_been_shaped_by external factors suchas globalization, the impact of technolo-gies,deregulation,andnewcommunications.3,4 _These_dynamics haveledtochangessuchas“urbanoutsourcing”,aphenomenon wherebycity centershave becomethesetting for offices, busi-nesses,servicesandshops.5 _Another_phenomenon_caused_by_the newdynamics is “gentrification”.6,7 _We _assume_the _concept _of “gentrification” of Neil Smith6 _which _is _briefly _defined _as _the transformation of inner-city working-class neighborhoods into middle-andupper-middleclassneighborhoods.

Theanalysisofurbansettinganditsrelationshipswith cardio-vascularhealthleadstothestudyofinequalityinhealthinthecities, whichisbasedmainlyonananalysisofthedistinctivefeaturesof cityneighborhoods.Severalstudieshaveconfirmedtheexistence ofhealthinequalitiesinurbansettings.8–10

The main risk factors of cardiovascular diseases involve physical inactivity, diet, harmful alcohol consumption, and smoking.9 _The _relationship _between _city _{neighborhoods} _and theserisk factors of cardiovascular health has been previously studied.11,12

We emphasize the main research studies which have been conductedusinga qualitativemethodappliedtotheanalysisof healthinequalitiesregardingcardiovascularriskfactorsinanurban environment.13–16_Qualitative_research_in_this_area_has_been_based either onone single cardiovascular risk factor or on a specific group,i.e.,physicalinactivityorLatinwomen.13,14_It_is_important toemphasizethatpreviousqualitativestudiesaredesignedforthe lateruseofquantitativequestionnaires15_or_have_focused_only_on povertyandsocialexclusion.16

Inshort,qualitativestudiesarenecessarytoanalyzethefour maindimensions in therisk of cardiovascular and chronic dis-easesfromtheperspectiveofhealthinequalitiesinurbansettings. Thisapproachwillfacilitatetheunderstandingofstructural fac-torsexplaininghealth inequalitiesaswellastheunderstanding ofmultiplebehaviorsincontext.Inaddition,theuseof qualita-tivemethodsmustbeaccompaniedbyasuitabledesignallowinga relevantselectionofdifferentsocioeconomicareas.Thisdesignis fundamentalformakingsuitablecomparisonsbetween neighbor-hoods.

Withinthisframework,thestudyobjectiveistodescribethe design,methodsandqualitativetechnicsusedtounderstandurban cardiovascular health inequalities in the Heart Healthy Hoods (HHH)Project.

Method

Themethodologicaldesignofthequalitativestudyisan ancil-lary 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 studyistounderstandthephysicalandsocialelements impact-ingupon cityresidents’ cardiovascularhealth. TheHHHProject uses different techniques such as analysis of electronic health records, questionnaires, physical examination, semi-structured Interviews(SSIs),focusgroups(FGs)andparticipatorytechnicsas photovoice.11,17–20

Photovoiceisaparticipatoryactionresearchmethodusedto reflectrealityandempowertheresidentsthroughphotography. Withinthe HHHproject this technichas beenused for under-standingkeydeterminantsoftheurbanenvironmentinfluencing residents’healthfromaresidents’perspective.18

DesignoftheHHHqualitativestudy

ThecityofMadrid(Spain)isadministrativelyorganizedinto 21 districts and 128 neighborhoods. We decided to include as thestudysettingthreeneighborhoodsexemplifying(everyoneof them)thedifferentsocioeconomiclevelsinthecity:high,medium andlow.Wecouldconsiderthisdesignasacasestudyapproach similartothesinglecase-design,type2,embedded(multipleunits ofanalysis).21_The_following_steps_were_taken_to_finally_select_these threeneighborhoods:

•Classificationof allMadrid neighborhoods(128) accordingto socioeconomiclevel.Anadhocindexwascreatedforthis classi-fication.Alowvalueinthisindexrepresentsneighborhoodswith lowsocioeconomiclevel,whileahighervaluerepresents neigh-borhoodswithhighsocioeconomiclevel.Weconsideredseven indicators to represent the demographic and socioeconomic structureofMadridneighborhoods.Wecalculatedpercentages foralltheindicators asfollows:1)percentage of the popula-tionregisteredasunemployedoverthewholepopulationaged between16and64;2)percentageofpeopleregisteredwiththe Social Security(SS)systemwithtemporarycontracts; 3) per-centageofpeopleregisteredwiththeSSsystemwithpart-time contracts;4)percentageofpeopleregisteredwiththeSSsystem withoutauniversitydegree,suchasofficeworkersandlaborers; 5)percentageofthepopulationovertheageof25who“donot knowhowtoreadorwrite,withoutformalstudiesorprimary education”;6)percentage of thepopulationbornin aforeign country;and7)percentageofhouseholdswithasingleparent andoneormorechildren.Allthesedatahavebeengatheredfrom theLocalGovernmentofMadrid’swebsite.22

•Tobuildtheindex,westandardizedeachindicatorusingZ-scores andperformedanunweightedlinearadditionobtaininganindex foreachneighborhood.TheZ-scoresstandardizationiscalculated bysubtractingtoeachdataits averageand dividingitbythe standarddeviation.Witheachstandardizationanewindicator isobtainedwithanaverageequalto0andavarianceequalto1. Next,westratifiedMadridneighborhoodsintotertiles;thefirst tertileincludedneighborhoodswithahighsocioeconomiclevel. Thethirdtertileincludedtheneighborhoodwithalow socioeco-nomiclevel.

•Afterbuildingtheclassificationaccordingtotheabovecriteria, nineneighborhoodswereshort-listedaccordingtotheir socioe-conomiclevel(threeneighborhoodsbytertile):

•Highsocioeconomiclevel(tertile1):Fuentelarreina (Fuencarral-ElPardo district); Nueva Espa ˜na (Chamartín district);El Viso (Chamartíndistrict).

•Mediumsocioeconomiclevel(tertile2):Palacio(Centrodistrict); ApóstolSantiago(Hortalezadistrict);ElPilar(Fuencarral-ElPardo district).

•Lowsocio-economiclevel(tertile 3):SanCristóbal(Villaverde district); SanDiego (Puente de Vallecas district); Pradolongo (Useradistrict).

•Madriddistricts,aswellasthelocationofthenineselected neigh-borhoods,areshowninFigure1.Thefollowingurbansociology criteriawereusedforthefinalselectionofthethree neighbor-hoods:

•Social heterogeneity in the neighborhood. Social homogene-ity will allow us to detect differences in lifestyles between neighborhoods.Evenacceptingthatwithineachneighborhood therearedifferencesinsocialstructure,studyingneighborhoods withhighsocialpolarizationcouldleadtothemixtureofvery

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Madrid region

Madrid municipality

Study areas

Neighborhoods

Socioeconomic status

Selected Pre-selected Not selected

High Medium Low

0 1 2km

Calle alcalá Paseo castellan

a

M-30

Figure1.Mapofselectedneighborhoods.

differentdiscourses,andlimitedrepresentationwithrespectto each neighborhood.The selection ofthethree neighborhoods shouldthereforereduceheterogeneityasfaraspossible.

•Gentrificationprocessesinthecity.Thegentrificationprocessis takingplaceincitieslikeMadrid,modifyingthesocialstructureof someneighborhoods.21,23_{Gentrification}_is_not_one_of_the indica-torsusedintheclassificationofneighborhoods,buttheauthors contendthatthisprocessshouldbeconsideredwhenselecting thethreeneighborhoods.

•Previousresearchinsomeofthenineneighborhoodsselected. ThereisoneneighborhoodcalledSanCristóbalthatisbeing ana-lyzedbytheHHHprojectteamthroughthephotovoicetechnique indimensionssuchasdiet24 _or_physical_activities._The_reason fornotstudyingSanCristóbalfromaqualitativepointofviewis thatresidentscoulddiscovertheobjectivesandcontentofthe HHHproject,possiblytriggeringthephenomenoncalled“Social Desirability”.25

•Identification with the neighborhood. In the chosen neigh-borhoods, their residents must feel identified with their neighborhoodandtheiradministrativedefinitions.Ifthe identi-ficationwiththeneighborhoodisnotfittingtoitsadministrative definition,itwouldbedifficulttofindadiscourseonthat neigh-borhood.

•Inaddition,non-participantobservationtechnique26_was_applied in the nine neighborhoods short-listed. This technique was useful27_for _a_better_{understanding}_of_the_{neighborhoods,}_i.e., adding information to that provided by the indicators, for instance,toknowthetypeofpersonswhouseparksandthetype

ofactivities.Aguidefornon-participantobservationwasused andcanbeseenintheonlineAppendixofthearticle.

TechniquestobeusedintheHHHqualitativeProject

Oncethethree neighborhoodshavebeenselected,SSIs were held with residents and key informants, i.e., school principals andhealthprofessionalsineachoneofthethreeneighborhoods selected. The key informants would help explain the dynam-icsrelatedtoallfourhealthdimensionsineveryneighborhood: alcohol,tobacco,physicalactivityanddiet.TheFGswillbe con-ductedduringthecourseof8months,betweenMayandDecember of2018.

Theauthorshavedecidedtousemethodologicaltriangulation28 choosingSSIsandFGsasthemaintechniquesbecauseboth tech-niquesshedlightontherelationshipbetweenlocalresidentsand theirneighborhoods.TheSSIsrevealanindividuallifeplanrelated tothe fourdimensions studied(tobacco and alcohol consump-tion, physicalactivity anddiet) and theirrelationship withthe neighborhood.29 _The_FGs_(in_this _case_and_to_avoid_problems_in theunderstanding,theauthorsconsidertoFGssimilarto “discus-siongroups”accordingtotheLatin-Americantradition30₎_help_to understandhowtheneighborhoodisperceivedcollectively,and thebehaviorsrelatedtothefourdimensionsaccordingtothe dif-ferentcollectives,i.e.,migrants,pensioners,etc.31

Both SSIs and FGs involving residents have been designed accordingtospecificprofilesdeterminedbythefollowing crite-ria:sex,age,educationlevel,numberofchildren,laborsituation, income, family responsibility related to children or grandchil-dren, yearsof livingin theneighborhood,immigration,tobacco

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consumption(smoker,ex-smoker,smokerwhohasparticipatedin healthprogramstoquitsmoking),alcoholconsumption(occasional drinkerorregulardrinker),andparticipationinfitnessprograms.In thehighsocioeconomiclevelneighborhoodimmigrantswerenot included.Thisdecisionisduetothefactthatthehighestpercentage ofimmigrantsinMadridliveinlowandmediumsocioeconomic level neighborhoodsand theirimpact onthesekinds of neigh-borhoodscanbeveryrelevant.Apilotstudy,conductedbetween January2014andJanuary2015in amiddle-lowsocioeconomic neighborhoodinMadrid32_,_helped_defining_the_residents’_profiles tobeinterviewedandtheprofileofFGsparticipants.Theseprofiles areshownintheonlineAppendix(tables2and3).

Selectedneighborhoods

Outofthenineneighborhoodsshort-listed,threewerefinally selectedforanin-depthstudyorcasestudy:lowsocio-economic level: San Diego (Puente de Vallecas district); medium socio-economic level: El Pilar (Fuencarral-El Pardo district); high socio-economiclevel:NuevaEspa ˜na(Chamartíndistrict)

ThethreefinallyselectedneighborhoodsareshowninFigure1.

Distributionofsemi-structuredinterviewsandfocusgroups

intheselectedneighborhoods

AtotalofthirtySSIswereheld,twenty-nineFGswillbe con-ductedwithresidents,andsixSSIswereheldwithkeyinformants. Table1showsthedistributionofSSIsandFGsorganizedinthethree neighborhoodsinregardtothehealthdimensionsunderstudy.

Discussion

Severalqualitativestudieshavebeenconductedtoanalyzethe relationshipbetweenneighborhoodsand health;13–16 neverthe-less,noneofthemhaveprovidedasystematicdesignforselecting neighborhoodsthroughthecasestudyorfor implementingSSIs andFGsaccordingtodifferentprofiles.Thisisafundamentalissue whenstudyingurbanhealthinequalities.

Weusedthecasestudy,type2,embedded(multipleunitsof analysis),accordingtoYin24_because_it_can_be_useful_to_describe andtoexplaindifferentbehaviorsrelatedtohealthanditallows theuseofseveralresearchtechniques.

TheauthorsdecidedtouseSSIs andFGsasqualitative tech-niques.Weemphasize thecomplementarityofSSIsandFGS,i.e. triangulation.TheSSIallowsustofocusonanalyzingthetopic with-outrestrictingthediscourseoftheinterviewedperson.29_The_FGs collectcollectivediscoursesintheneighborhoodonsocial prac-ticesrelatedtohealth.31_In_addition,_{non-participant}_observation wasusedasacriterionofselectionofthestudiedneighborhoods

Table1

Distributionofsemi-structuredinterviewsandfocusgroupstobeconductedin thethreedifferentsocioeconomiclevelneighborhoodsoftheHeartHealthyHoods QualitativeStudybyhealthdomains.

Lowsocioeconomic levelneighborhood

Mediumsocioeconomic levelneighborhood

Highsocioeconomic levelneighborhood 2SSIswithkey

informants

2SSIswithkey informants

Alcoholandtobaccoconsumption

7FGs 5SSIs

5FGs 6SSIs

2FGs 5SSIs

Physicalactivityanddiet

7FGs 5SSIs

6FGs 3SSIs

2FGs 6SSIs FGs:focusgroups;SSIs:semi-structuredinterviews.

duetothistechniqueenablingustoincludealargerspacethan participantobservationwithouttheobligationofparticipating.25

Theauthorsruledouttheuseofotherqualitativeresearch tech-niquessuchasparticipantobservationorlifestoryinterviews.The participantobservationtechniquetakesa longtime,and would havemadeit difficulttofindresultswithinthedeadlineof our project.33_The_life_story_interviews_would_have_favored_a_deeper understandingofthelifeplanofthepeopleinterviewed,butthe versatilityofprofileswouldhavebeenlostwiththistechnique.34

Rightafter,neighborhoodexclusion/inclusioncriteriaby socio-economiclevelwillbeexplained.

InthelowsocioeconomiclevelSanCristobal(Villaverde dis-trict)wasexcludedbecauseitwasbeingstudiedbytheHHHteam throughthephotovoicetechnique.18_Many_people_in_San Cristo-balmaybefamiliarwiththeHHHproject.Aninformationbooklet publishedbythelocalgovernment35_and_results_in_the_media_need tobetakenintoaccount.Thisinformationcouldcometosocial desirability.25_Pradolongo_(Usera_district)_has_also_been_excluded becauseofitsadministrativedefinition.Itsidentitydoesnotexist assuchbecauseitsresidentsthinktheirneighborhood isUsera, butUseraisnotaneighborhoodbutadistrict(adistrictisformed bymanyneighborhoods,inthiscasebysevenneighborhoods).In addition,Pradolongohasa verysmallanddispersed population comparedwiththeotherneighborhoods.Thereare16,881people registeredinthecensus,whichcouldmakedifficulttofindan ade-quateselectionofindividualsforaFGwho,forinstance,donot knoweachother.

SanDiegohasbeenchoseninthissocioeconomiclevelforthe followingreasons:

•Ithasatraditionalidentitythatdatesbackalongtime.Although itbelongstoPuentedeVallecasdistrict(apopularareawiththe leftandwithmanysocialmovements)36_this_neighborhood_is_not tobeconfusedwithothersinthisdistrict.Itissmall,butwitha highpopulationdensity(39,323residents).Thislargepopulation anditsidentitywouldallowstudyingtheneighborhoodbyitself.

•San Diego’s characteristics make a paradigmatic low socioe-conomic setting: a high percentage of immigrants, a well-establishedRomanycommunity,highunemploymentrate,high percentageofpart-timelabor,etc.Itisthesecondpoorest neigh-borhoodafterSanCristóbal.

InthemediumsocioeconomiclevelPalaciowasexcludedforthe followingreasons:

•Highpercentageofrentedaccommodation.

•Highmobility(oneoftheconditionstobeinginterviewedasa residentistohavebeenlivingintheneighborhoodforatleast fiveyears).

•Highnumberofhotelsortourists’accommodation.

Theauthorsconsiderthisneighborhoodcouldbeinfluencedby thegentrificationphenomenon,andsoithasnotbeenconsidered suitableforthiskindofstudy.

ApóstolSantiagowasexcludedasunsuitableforseveralreasons:

•Thefirstdisadvantagerelatestoidentity.Peoplelivingin this neighborhooddidnotidentifythemselveswithitsadministrative boundaries.Inthepast,aplaceincludedinthecurrentApostol Santiagoneighborhood(Manoteras)wasthefocusofthe iden-tityoftheresidents,thisidentificationcontinueshappening.This phenomenoncouldcausechaoticdiscourses(inSSIs andFGs) relatedtotheneighborhoodboundaries.

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•IthasasocialdiversitythatcouldmakeformingtheFGs compli-cated.

•Only16,212peopleareregistered inthecensus, which could makeitdifficulttoformFGswithouttheirmembersknowing eachother.

ElPilarwasfinallyselectedasthemediumneighborhoodforthe followingreasons:

•Itistheparadigmofamiddle-classneighborhoodinMadrid.El Pilarreflectsthe“classic”dynamicsofamiddle-class neighbor-hoodinMadrid:themovingofthesecondgenerationtoother partsofthecityandasmallinfluxofimmigrantshasledtoan agingpopulation.32

•ElPilarhasacleardefinedidentityasaneighborhood.

•ElPilarhas45,947inhabitants,whichmeansitcanbestudied withoutanyproblems.

Inthehighsocio-economiclevel,Fuentelarreinawasexcluded forthefollowingreasons:

•Ithasthehighestscoreinthesocioeconomicindicators,butithas twoverydifferentparts,whichweretheoldPuertadeHierroarea withveryluxurioushousingandaveryhighstandardofliving, andanenclosedresidentialareawithblocksof5-11floorsbuiltin the1970s,someofwhichhaveaverydilapidatedappearance.To mixpeoplefromtheoldPuertadeHierroareaandtheenclosed residentialareainaFGisnotrecommendedduetotheeconomic differenceswhichwouldhinderafree-flowingdiscourse.

•Ithasa problemof numbers,asonly3,203peoplelivethere. ThissmallnumberofresidentswouldmakeformationoftheFGs difficult.

NuevaEspa ˜naandElVisoneighborhoods(bothinChamartin district) have very similar economic indicators. Finally, Nueva Espa ˜nawasselectedforthreemainreasons:therearemorepeople (23,409)thaninElViso(16,847);thesocioeconomicindicatoris alsoslightlyhigherthaninElViso,whichprobablyhasastronger local neighborhood identity,but ElVisois similarto what has happenedtoApóstolSantiago,i.e.,there wasanhistoricElViso neighborhoodthatisnowonlypartofnowadaysElViso,sothere isariskofmisunderstanding.

Regardingthelimitationsofthepresentstudy,weacknowledge thisisacasestudyconductedinthreeneighborhoodswith differ-entsocioeconomiclevels.Therefore,itmaynothaveallthedesired representativenessofalargecitysuchasMadridandtherewill probablybeaspectswhichwewillnotbeabletoconsider. More-over,inspiteofoursamplingeffortsitisverydifficulttocontrol thesocialhomogeneitytheneighborhoods,especiallyatamedium socioeconomiclevel, which couldbea handicap for identifying “useful”discourses.

Themethodsanddesignofthisurbanhealthqualitativestudy maybeusefulas a referenceand guidefor researchers consid-eringaqualitative approachtourbanhealthinequalities.Inany research project, as in qualitative research, it is important to followarigorousprocessintheselectionofthefinalsettingstobe studiedandthepeoplewhosediscoursewillbefinallyanalyzed. Anaccurateandsystematicdesignmayallowpopulationstudies toincorporatequalitativetechniquesandcasestudiesintotheir designforanalyzingurbanhealthinequalities.

Weconsiderthatthisstudymayhelpunderstandinghow pop-ulationhealthisdeterminedbythreedimensions:theplacewhere onelives,thesocialstructureandthecollectiveculturaldimension.

Qualitativemethodologiesallowustodelveintothesedimensions, andinturnthedimensionswillgiveusthekeystounderstanding, forexample,whyandhowinsomeneighborhoodsmorephysical activityisdoneandmoretobaccoandalcoholisconsumedthanin others.Furthermore,wewillbeabletounderstandwhyandhow insomeneighborhoodspeopleeatinadifferentwaywithrespect toothers.Therefore,thisstudymightprovideusefulevidencefor thedevelopmentofurbanhealthpolicies.

Whatisknownaboutthetopic?

Qualitativemethodshavebeenonlypartiallyusedinurban healthresearch,i.e.poorneighborhoodshavebeenstudied applyingsemi-structuredinterviewsorfocusgroups. Analyz-ing, inaqualitative andsystematic fashion, neighborhoods ofdifferentsocioeconomicleveltounderstandurbanhealth inequalitiesisanovelandnecessaryapproach.

Whatdoesthisstudyaddtotheliterature?

The presentstudy describesafeasible methodologyfor investigatinghealthinequalitiesinlargeurbansettingsusing aqualitativeapproach.Qualitativeapproachesinthisresearch areamayshedlightcomplementarytootherquantitativeand geospatialanalysesconductedinthesameurbansettingsasit isthecaseoftheHeartHealthyHoodsprojectinMadrid(Spain).

Editorincharge

EricaBriones-Vozmediano.

Transparencydeclaration

Thecorrespondingauthoronbehalfoftheotherauthors guar-antee the accuracy, transparency and honesty of the data and informationcontainedinthestudy,thatnorelevantinformation hasbeenomittedandthatalldiscrepanciesbetweenauthorshave beenadequatelyresolvedanddescribed.

Authorshipcontributions

Alltheauthorsmadeasubstantialcontributiontothedesign andexecutionofthiswork,aswellastotheinterpretationofits results.J.RiveraandP.Condedraftedthemanuscript,whichwas criticallyrevisedbyalltheauthors,whoalsoapprovedthefinal version.

Acknowledgements

TheauthorswouldliketothankCaolánO’Crualaoichforhis lin-guisticassistanceonthismanuscript,andDanielArribasMolero forhiscollaborationinnon-participantobservationintheselected neighborhoodsinthestudy.

Funding

This work is part of two funded projects: “Urban environ-mentandhealth:qualitativeapproachinthestudyHeartHealthy Hoods”(referenceCSO2016-77257-P)fundedbytheSpanish Min-istryoftheEconomyandCompetitiveness[MinisteriodeEconomía y Competitividad], and “Heart Healthy Hoods” funded by the EuropeanResearchCouncilundertheEuropeanUnion’sSeventh

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FrameworkProgramme(FP7/2007-2013/ERCStartingGrantHeart HealthyHoodsAgreementn.336893).

Conflictsofinterest

None.

AppendixA. Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.gaceta.2018.07.010.

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