Applying an ecosystem approach to the determinants of health in Centro Habana

The difficult economic times that Cuba has had to fare have taken a conside rable toll on its urban ecosystems, with data suggesting that indicators of health, the environment, and social services have been deteriorating. This has been particularly evident in Centro Habana, a municipality with the hi ghest population density in the country. More than half the population was without daily access to potable water, waste disposal was insufficient, ove rcrowding was serious, disease vectors were prevalent, and rates of various infectious as well as noncommunicable diseases and injuries were highest i n the country. To improve the situation, the municipality requested help fr om the National Institute for Hygiene Epidemiology and Microbiology (INHEM) to determine the best use of scarce resources to improve health. INHEM per formed an ecological descriptive study and conducted focus groups in five c ommunities to assess perceptions of health, social, and environmental facto rs, followed by a household survey. INHEM then engaged collaborators at the University of Manitoba to assist in developing a framework, analyzing the data, and planning and undertaking the evaluation requested. Maximum likeli hood factor analysis was used to reduce the dimensionality of the data. The perception data were then merged with the ecological level health and envi ronmental data to ascertain the relationship between these two data sources and determine which indicators might be useful for an intervention analysi s. The perception results indicated that the greatest community concern was quality of housing, but that the risk perception results were independent of ecological data on morbidity, mortality, and basic sanitation indicators . Based on this conclusion, it was decided to use a combined qualitative an d quantitative approach to evaluate actual and potential interventions, usi ng the driving force-pressure-state-exposure-effects-action (DPSEEA) framew ork. It was also decided to adopt an ecosystem approach that fully involves the community in developing a set of ecosystem human health indicators. Da ta from repeat focus groups and household surveys are planned, with these d ata to again be integrated with ecological data including environmental, so cioeconomic, and health outcome information, using a pre- versus postinterv ention with concurrent control design. Our findings in this first phase ind icated that an ecosystem framework is invaluable in ascertaining determinan ts of health and prioritizing and evaluating interventions to improve the h ealth of communities.