The Final Report (3 500 words) is due in Week 30 (Wednesday 20st May 2015) and carried a weight of 65% of the module’s total marks. You can prepare and write the Final Report on the same urban health issue you chose for the Urban Health Profile, Assessment Component 01.

The following is what you should consider for this assessment component:

  1. a) Report Title – should include the health issue, target population group and the area. London or New York based papers should look at the boroughs; elsewhere you can just look at the whole city as one study unit.
  2. b) Introduction – brief overview of the urban health issue and signposting to show the sections you will include in the work.
  3. c) Rationale of why this is an urban health issue – identify and explain the evidence including epidemiological data you will use to show why this is an urban health problem.
  4. d) Explain the urban context and determinants that you will look at to explain the impact on the health issue. If you are looking at the same topic and borough as before, you can draw on the Urban Health Profile. Remember to draw on the wider context, including London if you are looking at a London borough.
  5. e) Identify and explain the public health consequences and implications of this urban health problem that impact on the general populations, on the individual and on the health services.
  6. f) Explain what strategies and interventions for addressing this urban health problem you will critique in the paper.
  7. g) What recommendations and conclusions you expect to make?


Final Report Marking Criteria

The Final Report will be assessed against LOs 1, 2, 3, 4 and 5 and marks will be awarded as follows:

  1. a) Content Relevance: reflecting the module’s learning outcomes 30%
  2. b) Analysis and Critical Thinking: synthesis, analysis, interpretation, discussion and critique 50%
  3. c) Research: seeking relevant literature and referencing*, structure, writing and presentation 20%


***Students will fail the assessments if their work is not correctly referenced in the Harvard method, both in the main text and in References list. Please see the relevant section of your student handbook concerning referencing procedures and grading criteria. In addition, you are strongly advised to consult referencing resources provided on Blackboard (Web Learn).




Component 4 (Essay) Tips and Comments

1) Title: The essay is an analysis of an urban health issue; hence it might be more appropriate to have the title as: “An Analysis of ………….” Provide a complete title rather than ‘blank’ and incomplete statements like Diabetes in Islington. Make sure you include the urban health issue, the population group and the borough / city in the title of your work.

2) Introduction – explain to readers what the essay is studying / analysing and signpost the work, letting readers know what they expect to see in the rest of the work (explain the structure of your work, outlining what is covered in each section of the essay).

3) Rationale, Urban Context and Epidemiology of the Urban Health Issue – Begin by justifying your choice of the health issue, the chosen population group and the city / London borough chosen for the analysis.

Then move on to explain and justify why what you are studying / writing about is an urban health issue. Note that prevalence data, trends and high costs to the NHS are outcomes which do not explain why the health issue you are studying is an urban health issue. For most of the issues we are studying, looking at the urban characteristics, context and environment is a better way to help you explain why something is an urban health issue.

Growth of many cities is associated with distinctive and diverse population groups, high density of socio-economic activities, areas of high deprivation, concentration of low socio-economic families, increased obesogenic environments, high density of transport networks, ect. These characteristics are most common in inner cities and give rise to the ‘urban health penalty’.

Thus, the complex interaction and influence of the urban environment on health inequalities, deprivation, low socio-economic status, marginalisation and urban vulnerability lead to many negative health outcomes such as high levels of childhood obesity, high levels of type 2 diabetes, high levels of cardiovascular diseases in population groups usually living in poorer neighbourhoods.

Nevertheless, cities can also provide better opportunities for rewarding employment, accessing public services, health promotion and health service provision. This leads to the ‘urban health advantage’ in cities. Thus, in most cases, to explain why something is an urban health issue, you have to link the discussion to the key concepts studied at the beginning of the Module like the ‘urban health penalty’, ‘urban health advantage’, and the Sicky City Hypothesis. Remember to give an overview of the city or London context of the health issue as a way of justifying your choice of the city or London borough chosen.

This part should help you to provide a comprehensive analysis of the epidemiology of the health issue to show the depth of the problem in the city or London borough chosen, the trends (changes over years), patterns of distribution (sex, age, ethnicity, place), related problems (mortality, morbidity, cost to health services) and the related determinants of health (including the urban context). Use academic literature and evidence to support the discussion in your work

– 4) A critique of the interventions developed to tackle the urban health issue identify and explain the measures developed in the city / London borough to tackle this urban health issue. Go beyond a descriptive account and provide a critique supported by evidence from evaluation studies of the impact of such measures on this urban health issue. You should also look at the challenges related to the implementation of such measures. Do the interventions relate to the determinants you discuss in the earlier part of your essay? Do you see any gaps in interventions in terms of tackling the causes? Use academic literature and evidence to support the discussion in your work.

5) Recommendations and Conclusions – this Section discusses your suggestions on what has to be done in order to better tackle this urban health problem. Recommendations should be tailored to specific stakeholders (e.g. if you are looking at childhood obesity, your recommendations may be aimed at children, parents, schools, local authority, city council, businesses, and other organisations). Your conclusions should summarise and re-cap the key points of the sections of your essay, highlighting any implications for policy and practice in relation to this urban health issue.

6) References a) In-text referencing – all citations should be presented using the Harvard in-text referencing style of author-date, e.g. (Peterson, 2010; Peterson et al, 2009) with page number/s where direct quotes are used, e.g. “An urban health profile is a presentation of health data profiling an urban community or population sub-group” (Musoro, 2010: 8). No initial/s of authors should be included, for example, it is not correct to have (Musoro, L, 2010: 8). Full-stops should be placed right at the end of sentences – take note of this especially where a reference is given at the end of the sentence, e.g. it is wrong to have [“It is easy to produce a good urban health profile if one follows instructions, avoiding being descriptive and maintain a high level of innovative thinking”. (Musoro, 2013: 7).], but correct to present this as [“It is easy to produce a good urban health profile if one follows instructions, avoiding being descriptive and maintain a high level of innovative thinking” (Musoro, 2013: 7).] b) References list (end-text referencing) – this Section should include all citations used in the work, presented in the Harvard referencing style. Items should be presented in alphabetical order without numbering or using bullet points. All items should have names of authors, date published, name of document, place of publication and publisher.

7) Appendices – this Section should include items you judge as important for readers to look at if they want additional information about a point of data presented. However, items that should be put in the

Appendices should not be core material. In other words, any material you think you cannot complete the work without presenting constitutes core and should not be put in the Appendices but in the main body of the work. On the other hand, even though only non-core material should go into Appendices, nothing should go in here if no reference to it is made in the main body of the work.




Table of Contents


Table of Contents

Introduction. 3

Rationale. 3

Urban context and determinants. 4

Consequences of the public health problem: to the individual, the general population and the public health system   7

Strategies and interventions for addressing the urban health problem.. 8

Recommendations and conclusions. 10

References. 13


An analysis of coronary heart disease please among men in the London borough of Bromley: An urban health report


Cardiovascular disease is a term describing the disease of the heart and the blood circulatory system (NHS, 2015). Cardiovascular disease is caused by different factors including smoking and lifestyle factors like poor eating and lack of exercise (NHS, 2015).

The London borough of Bromley is the largest of the London boroughs occupying an area of approximately 153km2. Bromley is perhaps the most rural among all the London boroughs. As per the 2011 estimate, Bromley had a population of 306,361 people (Bromley Council, 2011). This population is expected to rise due to the increasing birth rate that is being experienced in the borough (Bromley Council, 2011). According to the South East Public Health Observatory (SEPHO), cardiovascular disease (CVD) is the second largest cause of death in England. CVD accounted for more than 29% of deaths in 2011. Among all the cardiovascular diseases, stroke causes the most deaths (SEPHO, 2013). In Bromley, the prevalence of coronary heart disease increases significantly after men attain the age of 40 years (SEPHO, 2013). This paper will analyse the issue of coronary heart disease among the populations in Bromley. The report will start by explaining the risk factors for coronary heart diseases in Bromley by considering the urban context and determinants of the issue. The report will analyse the impact of coronary heart diseases on individuals, the general society and the public health system. The report will also identify interventions that can help reduce the burden of coronary heart diseases in Bromley.




The NHS defines cardiovascular diseases as conditions that involve narrowing or blockage of the blood vessels. The blockage and narrowing of the blood vessels leads to other complications like heart attack, stroke and chest pain (NHS, 2015). The rationale of the topic was that the urban environment in Bromley exposed men to risk factors of cardiovascular diseases.

Over the years, London has grown to become one of the largest cities in the world. The growth of London has been characterised with increased diversity of the London population as people from diverse walks of life visit the city. The economic hardships that is experienced in many cities has resulted in concentration of low-income families and high deprivation areas. These factors have given rise to the concept of urban health penalty. Urban health penalty is a concept that postulates that the concentration of low-income earners in deprived regions in cities exposes such people to unhealthy social and physical environments (Freudenberg, Galea & Vlahov, 2005). On the other hand, the people of London are expected to have a health advantage due to the easy availability and access to health services. This is in contrast to the sick city hypothesis that considers urban areas to have more risk factors for many health conditions thereby making the people in the cities to be sicker than the people in rural areas.

Urban context and determinants

Today the place of residence of an individual is not considered as an important predictor of their health (Roux et al, 2001). This is because of the dominance of lifestyle and genetic factors as predictors of health. However, people’s neighbourhoods are important predictors of health (Robert, 1999). The socio-economic environment of residence has been shown to be a predictor of health (Robert, 1999).

The socio-economic status is also a predictor of health behaviour like smoking, alcohol consumption, physical activity and dietary habits (Lang et al, 2011). When considering cardiovascular risk in Bromley, there are different neighbourhood characteristics that may expose the citizens to risk. Some of these characteristics include availability of resources to maintain a healthy lifestyle within the population and social and physical environment of the neighbourhood (Lang et al, 2011). The deprivation in the urban neighbourhoods makes the population to have unhealthy eating lifestyles. In addition, these neighbourhoods do not have recreational facilities and the communities cannot participate in activities like cycling and jogging. This increases the body mass index of the populations thereby exposing the risk of cardiovascular diseases (Ompad et al, 2007).

The mechanisms involved in the development of coronary heart disease including the behavioural and biological factors involved have now been well understood. The relative reduction in prevalence of coronary heart disease especially in industrialised nations has also been well understood (Lang et al, 2011). However, there are other factors that need to be considered when analysing the issue of social determinants of health in Bromley. First, it is important to acknowledge that the social inequalities of health have not disappeared from the Asian men living in Bromley. The prevalence of coronary heart disease among the Asian men in Bromley is 14.2% (Bromley Council, 2011). The prevalence in London is 17.3% and 17.4% in the UK (SEPHO, 2013). This brings about the importance of the concept of urban context and social determinants when considering the issue of coronary heart disease in the London borough of Bromley.

Social determinants are the social environments in which people live and work and which may have an effect on their health (Ompad et al, 2007). These environments do not only affect the urban environments. However within the urban setting like London, the social determinants help in explaining important issues like density, size, complexity and diversity that exists among populations in urban environments (Lawrence, 2006). Due to immigration and globalisation, density and diversity are characteristics of many urban cities in the world. Diversity is mainly concerned with increasing the cultural interaction among different cultures within the city. Density on the other hand is about interaction of populations within a geographical area. All these may create a problem as the health care system will need to be designed to effectively meet the diverse needs of the populations (Lang et al, 2011). If not well designed, the health care system may increase health inequalities and thereby increase the burden of disease for some populations (Vlahov et al, 2007). The following section will analyse the different risk factors of coronary heart disease within the urban context and environment in Bromley.

The first risk factor that will be considered is urban atmospheric pollution. There are different sources of environmental pollution including motor vehicle emission and industrial activities (Maitre et al, 2006). These sources generate different pollutants including particulate matter, nitrogen oxides and ozone among other pollutants (Maitre et al, 2006). The pollutants have an effect of reducing the urban air quality. There are studies that have found a relationship between urban population and coronary heart disease (Pope et al, 2004). In these studies, it has been found out that exposure to fine particles among other pollutants may trigger the development of coronary heart disease (Ruidavets et al, 2005). This is because exposure to these pollutants may increase blood coagulability and therefore increase the risk for thrombosis (Scarborough et al, 2012). Due to their location, many people in Bromley are exposed to this risk factor. In addition, exposure to these pollutions may increase the risk for myocardial infarction (Hoffman et al, 2006).

The second urban determinant of coronary heart disease is temperatures. This can be confirmed from the study done by Tian et al, (2012) in China. The results of the study found out that extreme low temperatures like the ones experienced in Bromley in some instances may increase the risk of coronary heart disease.  The results of the Tian et al. study are similar to another study done by Scarborough et al, (2012) who determined the geographical variation of coronary heart disease in England. The Scarborough study determined the different biological reactions that result from cold weather. In particular, cold weather may increase blood pressure and blood cholesterol. This has an effect of increasing the viscosity of blood thereby exposing the individual to thrombosis (Toledano, Shaddick & Elliott, 2005). In addition, low exposure to sunlight may also increase the cholesterol levels in blood (Scarborough et al, 2012).

The third urban determinant is employment and work environment. The job environment for most people in Bromley may expose them to different stressors (Rosengren et al, 2004). This may increase their risk for coronary heart disease. Apart from the work environment, the other factor is the manner in which these people are empowered to accomplish their roles. If people are not well empowered using technology and other necessary materials, then the job may be a stressor (Lang et al, 2011). The stress levels may lead to other negative health behaviours like poor eating and not engaging in physical activity. In addition, job stress may make people start consuming alcohol. There are studies that have shown relationship between alcohol consumption and increased mortality of coronary diseases (Marmot, 2001). Work related stress may lead to problem drinking or heavy drinking and this may expose the individual to coronary heart disease (Corrao et al, 2000).

The fourth urban determinant is ethnicity. As has been mentioned, from the estimates 7.6% of Bromley’s population is deprived. Most of the deprived people are people from the black and minority ethnic groups who constitute 15.7% of the entire population (Bromley Council, 2011). The highest prevalence of coronary heart diseases in Bromley is in the minority population (SEPHO, 2013). Racism and discrimination that may result due to such diversity may also act as a stressor for the members of the minority community thereby increasing their risk for coronary heart disease (Vlahov et al, 2007).

Consequences of the public health problem: to the individual, the general population and the public health system

Coronary heart disease has negative effects on the health of men in Bromley and the overall health care system. To individuals, coronary heart disease may lead to weakness and fatigue (NHS, 2015). In more adverse cases, coronary heart disease leads to death of individuals. For example, from the data presented above, it has been shown that due to death from coronary heart disease the percentages will reduce to 23.3% for men and 26.8% for women by 2021 (Bromley Council, 2011). Coronary heart disease may also be a source of stress for individuals and this may lead to other negative health consequences (Lang et al. 2011).

To the population, the statistics have shown that coronary heart disease reduces the life expectancy of the population (Bromley Council, 2011). This will have some social effects as it will increase the number of orphaned children. Such children may not have good parental care and this may increase the prevalence of other social evils like substance abuse, crime and prostitution. The high crime levels may have an effect on the health of the other members of the Bromley community. For example, criminals may impact bodily harm on the residents. In addition, fear of crime may lead to other negative health effects like stress and social isolation. This may limit development of health promoting behaviour like exercise among the population (Robert, 1999). The other social impact is that patients and their families may have to move closer to medical facilities for easier access to care. If the patient was the breadwinner for the family, then this responsibility has to be transferred to another member of the family. This can increase the stress levels for the family (Everson-Rose & Lewis, 2005).

Coronary heart disease also has an effect on the public health system. The burden of the disease for individuals and communities will increase the burden to the public health system (Everson-Rose & Lewis, 2005). This may increase health care costs and reduce the amount of money available for provision of other services for the people in Bromley, London and England.

Strategies and interventions for addressing the urban health problem

There are different strategies that have been used to help in addressing the problem of coronary heart diseases in Bromley. The first strategy that has been used by the authorities is prevention. In addition, even though there is no clear national policy on screening for coronary heart diseases, there are different services available. For example, health care professionals perform opportunistic screening of coronary heart diseases when patients visit the care facilities. This helps in early identification of the conditions helping in better management. In addition, the Bromley Council together with the NHS have focused on eliminating the health inequalities that are associated with deprivation and burden for coronary heart diseases.

The other strategy is that the authorities have focused on health care education where the community members are taught on the different ways in which they can effectively manage coronary heart disease. This complements the efforts of the NHS Health Checks Programme. Through this, the authorities expect that the number of people availing themselves for screening will increase (Bromley Council, 2011).

The authorities have also worked hard to help reduce the crowding in environments where people live in (Bromley Council, 2011). This will help in reducing the adverse effects of pollution and also help in reducing other health burdens that may be a risk factor for coronary heart disease. This has been done through provision of better housing and more job opportunities for the people in Bromley (Bromley Council, 2011). The other burden that has been reduced in this case is educational attainment. The authorities have focused on improving the literacy levels within the population. The essence of this is to help the population understand the importance of the interventions and increase the uptake of the interventions within the community.

There are other lifestyle interventions that have been proposed as a means of reducing the prevalence of coronary heart diseases in Bromley. As has been mentioned, there have been educational interventions. These have been integrated with interventions to bring about lifestyle changes among the members of the Bromley community. For example, the authorities have supported smoking cessation and interventions geared towards reducing incidences of alcohol abuse in the community (Bromley Council, 2011). This is because smoking and substance abuse are some of the biological predisposing risk factors for coronary heart diseases.

In general, the health care system has been improved and designed in a manner that understands the diverse needs of the populations. The NHS has focused on patient-centred care to help improve the quality outcomes for the patients. In addition, health care professionals are increasingly being informed of the importance of focusing on patient centred care (NHS, 2015).This is done through training and informing the professionals on the importance of patient centred care.


Recommendations and conclusions

While looking at the recommendations for reducing the burden of coronary heart disease for the people in Bromley, it is important to consider the different social determinant models. This will help in understanding how best to focus interventions so that they have a sustainable effect on the populations. The different models include the latent model, the pathway model, the social mobility model and the cumulative model (Jeemon & Reddy, 2010).

The latency model of the social determinants asserts that different individuals have different socio-economic and psychological conditions early in their lives. These differences will have an effect later on in the lives of these individuals and communities (Jeemon & Reddy, 2010). This means that certain life events may have effects on adult health (Power & Hertzman, 1997).

The pathway model focuses on the cumulative effects of the life events and the reinforcing effect of the different socio-economic and psychological environments that individuals and communities could be facing throughout their life cycle (Jeemon & Reddy, 2010). The duration of exposure to the social risk conditions has an adverse effect on the health of individuals and communities. The implication of this is that early life may place an individual in a particular trajectory which may determine the future health of the individual (Hertzman et al, 2001).

The social mobility model hypothesises that levels of exposure to different risk factors changes as an individual moves from one socio-economic class to another (Jeemon & Reddy, 2010). However, some studies have confirmed that there is a risk of coronary heart disease for people who are initially deprived in their childhood and who live in affluence in their adulthood. This is due to the elevation of adult cholesterol levels (Jeemon & Reddy, 2010).

The cumulative model emphasises that social determinants of health experienced during childhood and adulthood accumulate to have an effect on adult health (Jeemon & Reddy, 2010). The implication is that if different factors operating for different people are combined, then there will be large differences in exposing factors for coronary heart disease (Smith, Ben-Shlomo & Lynch, 2002).

The first strategy for reducing the burden of coronary heart disease for the people in Bromley is for the policymakers and health and social care professionals to understand the risk factors and the different models of risk. This will help in changing the interventions from the biomedical model to a model that can meet the diverse needs of the communities (Jeemon & Reddy, 2010). This means that a multi-professional approach should be taken to eliminate the burdens. This is because some of the burdens or risk factors are social and economic causes.

The policymakers therefore need to identify and address the socio-economic issues that cause disparities in access to health care for the people in Bromley (Jeemon & Reddy, 2010). This means that population wide interventions should be developed instead of considering the individual based interventions like proposing for a lifestyle changes. Some of the individual based interventions may increase health inequalities because there could be a proportion of the population that may not have access to some of the interventions (White, Adams & Heywood, 2009). Inequalities may also be increased when individuals will be required to mobilise their cognitive and psychological resources to understand some of the interventions. Some of the members of the population may not have some of these resources (McLaren, McIntyre & Kirkpatrick, 2010).

In conclusion, coronary heart disease is one of the leading causes of death in London and other parts of the world. This report has discussed the issue of coronary heart disease in the London borough of Bromley. The London borough of Bromley is the largest of the London boroughs occupying an area of approximately 153km2. Bromley is perhaps the most rural among all the London boroughs. As per the 2011 estimate, Bromley had a population of 306,361 people (Bromley Council, 2011). This population is expected to rise due to the increasing birth rate that is being experienced in the borough (Bromley Council, 2011). According to the South East Public Health Observatory (SEPHO), cardiovascular disease (CVD) is the second largest cause of death in England. CVD accounted for more than 29% of deaths in 2011. Among all the cardiovascular diseases, stroke causes the most deaths (SEPHO, 2013).

There are different risk factors for coronary heart diseases in Bromley. Some of the risk factors include physical environment, pollution and temperatures, job conditions and work environment and ethnicity. Coronary heart diseases have different effects for individuals, populations and the entire public health system. There is therefore need that interventions are designed to ensure that prevalence of coronary heart disease in Bromley is reduced. Some of the interventions that have been used include screening to help in early detection of the disease for better management; educational interventions to help improve the uptake of other interventions and lifestyle interventions. From the models that have been discussed, it can be seen that models like improving the socio-economic conditions of the communities have better outcomes. This is because they do not result in increased inequalities for the population (Jeemon & Reddy, 2010). The research question has been comprehensively answered in the paper.


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