The European Journal of Public Health, Vol. 31, No. 6, 1190–1196 ß The Author(s) 2021. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. doi:10.1093/eurpub/ckab132 Advance Access published on 26 September 2021 ............................................................................................................... Associations between density and quality of health promotion programmes and built environment features across Jerusalem Omri Besor 1 , Ora Paltiel 1 , Orly Manor 1 , Milka Donchin 1 , Orly Rauch 1 , Vered Kaufman-Shriqui 2,3 1 Department of Nutrition Sciences, Braun School of Public Health & Community Medicine, The Hebrew University- Hadassah, Jerusalem, Israel 2 Department of Nutrition Sciences, School of Health Sciences, Ariel University, Ariel, Israel 3 Centre for Urban Health Solutions (C-UHS), St. Michael’s Hospital, Toronto, Canada Correspondence: Vered Kaufman-Shriqui, Department of Nutrition Sciences, School of Health Sciences, Ariel University, Ariel 407000, Israel, Tel: þ972 3 9066 241, Fax: þ972-3-5423553, e-mail: veredks@ariel.ac.il Background: Health promotion programmes (HPPs) have the potential to influence individual health, depending on their quality and characteristics. Little is known about how they interact with built environment features and neighbourhood demographics in cities with substantial health disparities. Methods: Using the European Quality Instrument for Health Promotion (EQUIHP), we assessed the quality of HPPs, operating between 2016 and 2017, among adults aged 18–75 in Jerusalem. Areas were characterized by ethnicity and area socioeconomic level. Health information (body mass index, physical activity level) was obtained from the city profile survey. Geospatial information on the location and length of walking paths and bicycle lanes was obtained. Spearman correlations were used to assess associations among variables. Results: Ninety-three HPPs operating in 349 loca- tions in Jerusalem were identified. Programmes were unevenly distributed across urban planning areas (UPAs), with the highest density observed in the southwest, areas populated mainly by non-orthodox Jewish residents. However, the best performing HPPs based on EQUIHP score were in the north and east UPAs, inhabited primarily by Arab residents. At a neighbourhood level, characteristics of the built environment positively correlated with higher total EQUIHP scores: the ratio between walking lane length to the neighbourhood’s population size (r ¼ 0.413, P < 0.001) and length of bicycle lane per population (r ¼ 0.309, P ¼ 0.5). Median EQUIHP score negatively correlated with the number of programmes per neighbourhood size (m 2 )(r ¼À0.327, P ¼ 0.006) and neighbour- hood average socioeconomic status (SES; r ¼À0.266, P ¼ 0.027). Conclusions: Our findings suggest that higher quality HPPs were preferentially located in areas of lower SES and served minority populations in Jerusalem. ............................................................................................................... Introduction J erusalem is a unique metropolis, combining ancient and new archi- tecture and hosting a mixture of different populations, features that pose a challenge for urban and social planning. Jerusalem’s population comprised more than 925 000 people in 2018. The city is home to residents of the three monotheistic religions: Jews (with varying levels of religious observance ranging from secular, progressive, orthodox and ultra-orthodox), Muslims, Christians and other religious groups. 1,2 Hebrew-speaking Jews make up 63% of the population, while the Arabic-speaking minority comprises 37% of the population, of which 98% are Muslim. The city also encompasses a wide variation in socio- economic levels, though as a whole, Jerusalem is ranked in the second lowest socioeconomic rank of municipalities and districts in Israel. 3,4 In Jerusalem, the ultra-orthodox and Arab communities are gen- erally characterized by a lower socioeconomic status (SES), higher body mass index (BMI) and are more likely to suffer from non- communicable diseases than the general population. 5–8 There are known differences in resource allocation between eastern to western Jerusalem 2 and general disparities between the health of Jewish and Arab populations in Israel. 9,10 In the context of Israel’s social welfare policy, disadvantaged populations usually receive more aid, and in Jerusalem, especially these communities, receive special attention. 5,11 A previous study 2 showed that fewer of Jerusalem’s residents en- gage in any type of physical activity (PA) in comparison to the national average (33.8% vs. 56%), and a smaller proportion of them reached the recommended amount of 150 min/week (12.2% vs. 32.4%). Also, only 17.6% of its citizens consume five portions of fruit and vegetables per day, as recommended. 2 Furthermore, high rates of overweight and obesity were reported across lower SES areas of the city. 1,2 Arab women and ultra-orthodox Jews report lower levels of PA, and some ethnic groups have higher levels of obesity. 2,12,13 Area of residence is one of the main upstream contributors to human health beyond the contribution of individual SES, genetics and physiology. Residential factors may influence health by shaping health-related behaviours that contribute to active, healthy liv- ing. 14,15 Higher BMI tends to cluster in socioeconomically disadvan- taged, rural, minority neighbourhoods. 16,17 Decreased street connectivity and lower walkability have been associated with higher rates of adult obesity and diabetes 18 and higher childhood obesity. 19 Moreover, premature mortality has been associated with neighbour- hood decreased walkability and low SES. 20 A higher walkability index correlated with moderate PA in adults according to the WHO recommendations. 21,22 Frank et al. 21 referred to walkability as a combination of land-use, residential density and intersection density that allows residents to commute by walking. Large-scale PA data analysis of 111 countries shows that in more walkable cities, activity is greater throughout the day and throughout the week, across age, gender and BMI groups, with the greatest increases in 1190 European Journal of Public Health Downloaded from https://academic.oup.com/eurpub/article/31/6/1190/6375572 by guest on 17 December 2022