Agency, access, and Anopheles: neighborhood health perceptions and the implications for community health interventions in Accra, Ghana.

BACKGROUND: Social and environmental factors are increasingly recognized for their ability to influence health outcomes at both individual and neighborhood scales in the developing urban world. Yet issues of spatial heterogeneity in these complex environments may obscure unique elements of neighborhood life that may be protective or harmful to human health. Resident perceptions of neighborhood effects on health may help to fill gaps in our interpretation of household survey results and better inform how to plan and execute neighborhood-level health interventions. OBJECTIVE: We evaluate differences in housing and socioeconomic indicators and health, environment, and neighborhood perceptions derived from the analysis of a household survey and a series of focus groups in Accra, Ghana. We then explore how neighborhood perceptions can inform survey results and ultimately neighborhood-level health interventions. DESIGN: Eleven focus groups were conducted across a socioeconomically stratified sample of neighborhoods in Accra, Ghana. General inductive themes from the focus groups were analyzed in tandem with data collected in a 2009 household survey of 2,814 women. In-depth vignettes expand upon the three most salient emergent themes. RESULTS: Household and socioeconomic characteristics derived from the focus groups corroborated findings from the survey data. Focus group and survey results diverged for three complex health issues: malaria, health-care access, and sense of personal agency in promoting good health. CONCLUSION: Three vignettes reflecting community views about malaria, health-care access, and sense of personal agency in promoting good health highlight the challenges facing community health interventions in Accra and exemplify how qualitatively derived neighborhood-level health effects can help shape health interventions.

Defining Neighborhood Boundaries for Urban Health Research in Developing Countries: A Case Study of Accra, Ghana.

The neighborhood has been used as a sampling unit for exploring variations in health outcomes. In a variety of studies census tracts or ZIP codes have been used as proxies for neighborhoods because the boundaries are pre-defined units for which other data are readily available. However these spatial units can be arbitrary and do not account for social-cultural behaviors and identities that are significant to residents. In this study for the city of Accra, Ghana, our goal was to create a neighborhood map that represented the boundaries generally agreed upon by the residents of the city using the smallest available census unit, the enumeration area (EA), as the base unit. This neighborhood map was then used as the basis for mapping spatial variations in health within the city. The first step in demarcating the boundaries was to identify features that limit a person's movement including the major roads, drainage features, and railroad tracks that people use to partially define their neighborhood boundaries. Once an initial set of boundaries were established, they were iteratively modified by walking the neighborhoods, talking to residents, public officials, and others. The resulting neighborhood map consolidated 1,723 EAs into 108 neighborhoods covering the entire Accra metropolitan area. Results indicated that the team achieved 71 percent accuracy in mapping neighborhoods when the neighborhood keyed to the survey EA was compared with the response given by the interviewees in the 2008-2009 Women's Health Survey of Accra when asked which neighborhood they lived in.

Connecting the Dots Between Health, Poverty and Place in Accra, Ghana.

West Africa has a rapidly growing population, an increasing fraction of which lives in urban informal settlements characterized by inadequate infrastructure and relatively high health risks. Little is known, however, about the spatial or health characteristics of cities in this region or about the spatial inequalities in health within them. In this article we show how we have been creating a data-rich field laboratory in Accra, Ghana, to connect the dots between health, poverty, and place in a large city in West Africa. Our overarching goal is to test the hypothesis that satellite imagery, in combination with census and limited survey data, such as that found in demographic and health surveys (DHSs), can provide clues to the spatial distribution of health inequalities in cities where fewer data exist than those we have collected for Accra. To this end, we have created the first digital boundary file of the city, obtained high spatial resolution satellite imagery for two dates, collected data from a longitudinal panel of 3,200 women spatially distributed throughout Accra, and obtained microlevel data from the census. We have also acquired water, sewerage, and elevation layers and then coupled all of these data with extensive field research on the neighborhood structure of Accra. We show that the proportional abundance of vegetation in a neighborhood serves as a key indicator of local levels of health and well-being and that local perceptions of health risk are not always consistent with objective measures.

Neighborhoods and Fertility in Accra, Ghana: An AMOEBA-based Approach.

Fertility levels remain high in most of sub-Saharan Africa, despite recent declines, and even in a large capital city such as Accra, Ghana, women are having children at a pace that is well above replacement level and this will contribute to significant levels of future population growth in the city. Our purpose in this paper is to evaluate the way in which neighborhood context may shape reproductive behavior in Accra. In the process, we introduce several important innovations to the understanding of intra-urban fertility levels in a sub-Saharan African city: (1) despite the near explosion of work on neighborhoods as a spatial unit of analysis, very little of this research has been conducted outside of the richer countries; (2) we characterize neighborhoods on the basis of local knowledge of what we call "vernacular neighborhoods"; (3) we then define what we call "organic neighborhoods" using a new clustering tool-the AMOEBA algorithm-to create these neighborhoods; and then (4) we evaluate and explain which of the neighborhood concepts has the largest measurable contextual effect on an individual woman's reproductive behavior. Multi-level regression analysis suggests that vernacular neighborhoods are more influential on a woman's decision to delay marriage, whereas the organic neighborhoods based on socioeconomic status better capture the factors that shape fertility decisions after marriage.