ZHENG Wen Jing,QI Xiao,#,YAO Hong Yan,LIU Jian Jun,YU Shi Cheng,and ZHANG Tao

1. Office of Epidemiology, Chinese Center for Disease Control and Prevention, Beijing 102206, China; 2. Chinese Center for Disease Control and Prevention, Beijing 102206, China; 3. Aerospace Center Hospital, Beijing 100049,China

Abstract Objective To assess the subjective perception of residents on the built environment in hygienic cities and its relation to the self-rated health (SRH) status of residents, providing a basis for a better promotion on construction of health-supportive environments.Methods The online survey was adopted with the respondents recruited from residents living in Chaoyang District of Beijing in January 2021. With SRH level as the dependent variable, two-category logistic regression analysis was conducted to analyze the impact of the built environment in hygienic cities on the SRH status of residents.Results A total of 1,357 respondents were enrolled in this study. After controlling confounding factors,four aspects in the built environment in hygienic cities were detected remarkable influences on the SRH level of residents, including enough green space in the living area [odds ratio (OR) = 1.395, 95%confidence interval (95% CI): 1.055-1.845], clean and hygienic living environment (OR = 1.472, 95% CI:1.107-1.956), residents' confidence in drinking water safety in the living area (OR = 1.856, 95% CI:1.354-2.544) and residents' confidence in food safety in the living area (OR = 1.405, 95% CI:1.027-1.921).Conclusion Regarding city construction, the government should focus more on the subjective perception of residents on built environments to build a supportive environment benefiting the health of residents.

Key words: Hygienic city; Built environment; Self-rated health

INTRODUCTION

Built environments refer to all kinds of buildings and places artificially constructed and renovated as well as environments able to be changed through policies and human behaviors[1]. Studies have demonstrated that built environments have a close association with human health[2]. Such factors as population density,walkability and facility layout in built environments would affect the behaviors and activities of individuals, thereby impacting personal health,including the lifespan, cardiovascular disease incidence rate, mental health and subjective health assessment of residents, such as Self-rated health status (SRH)[3]. Based on empirical studies in the United States, community environment is the second largest influencing factor for the physical health of residents, only second to individual characteristics.As a result, the improvement of urban built environments plays a positive role in promoting public health[4].

In China, the construction of hygienic cities,which began in 1989, is originally aimed at solving the problems during urban development, i.e. dirty,chaotic and poor sanitation situation. Following 30 years of development, it has become a public policy led by the Chinese government, with cooperation between departments and the join of the entire society. Its main purpose is to change the living environment and health behavior of people through urban infrastructure construction, policy advocacy and other measures, and construct an urban built environment centered on population health. Studies have manifested that the construction of hygienic cities has achieved remarkable outcomes in improving urban hygienic environment, intensively treating domestic sewage, improving air quality,preventing and controlling vector organisms (rats,mosquitoes and flies) and reducing the incidence rate of infectious diseases[5-7]. “China Model” of healty cities has been estabilshed through achieving the greatest health benefits with the least investment[8]. In 2013, the Chinese government was awarded the “WHO special recognition to China for Healthy city (hygienic city) initiative” for the notable outcomes in the process of hygienic cities initiatives in China.

SRH, also known as self-reported health status, is a subjective health measurement index comprehensively reflecting the physical and mental health of individuals. Compared with traditional health indicators, SRH indicator can more efficiently reflect the objective health status of the population with the advantage of easy applicability. This study aims to explore the relationship between the built environment in hygienic cities and the SRH status of residents from the perspective of subjective perception of residents on the built environment,with Chaoyang District of Beijing as the survey field,so as to offer a basis for better facilitating the construction of health-supportive environments in cities.

RESEARCH SUBJECTS AND METHODS

Survey Methods and Respondents

A cross-sectional survey was conducted using the network platform “Wen Juan Xing”, with the residents living in Chaoyang District of Beijing as the respondents. Chaoyang District of Beijing started the process of national hygienic city construction in 2017 and passed the acceptance of national hygienic city successfully In 2021. Residents can more clearly perceive the impact of policy implementation during this period. The inclusion criteria for respondents were set as follows: 1) people living in Chaoyang District of Beijing for 1 year and above, and 2) aged over 18 years old. Questionnaires were sent to the respondents through WeChat official account, web page, email and other forms. Residents who were willing to participate in the survey need finish the following two questions firstly: "Do you live in Chaoyang District of Beijing for 1 year and above",and "Are you aged over 18 years old". Only residents who answer "yes" to both of the above two questions can proceed to the formal questionnaire survey. In this study, a total of 1,603 residents were surveyed, and 1,357 of them submitted valid questionnaires.

Survey Content

Assessment of SRH Status of RespondentsIn this study, the health status of respondents was assessed according to their answer to the item "What do you think of your current health"[9], with a 5-Likert scale(from 1 to 5 = very unhealthy, unhealthy, general,healthy and very healthy).

Evaluation of Subjective Perception on the Built Environment in Hygienic CitiesA Subjective evaluation scale was used to assess the subjective perception of the residents[10]. The scale composed of five dimensions with 22 items, including urban lifestyle, governance, basic functions, environmental sanitation, and amenities. The Cronbach’s α coefficient of the scale was 0.876, and the split-half reliability coefficient was 0.796. The CFA(confirmatory factor analysis) results indicate that each inspection level was within the standard limit.

Demographic Characteristics of RespondentsThe demographic information of respondents included gender, age, education level, annual household income, marital status, occupation, type of community, length of residence and regular physical activity.

Statistical Analysis

The SRH status of residents was divided into high-score and low-score groups. The respondents rating "very unhealthy" "unhealthy" and "general"were categorized into low-score group, while those rating "healthy" and "very healthy" were categorized into high-score group.

The demographic characteristics of respondents and their subjective perception on the built environment in hygienic cities were statistically described. Univariate analysis was implemented,with SRH status as the dependent variable and the demographic characteristics of respondents and the items determining the built environment in hygienic cities as the independent variables. The independent variables with statistical significances in the univariate analysis were selected for further multivariate logistic regression analysis, by using likelihood ratio (LR) method withPvalue for entry at 0.05 elimination at 0.10.

RESULTS

Demographic Information of Respondents

A total of 1,357 respondents (564 males and 793 females, 33.56 ± 9.21 years) were involved. The respondents with college level or above accounted for 94.6%. As to marital status, the proportion of respondents being married was 64%; 72.8% of respondents had the annual household income which was over RMB 100,000 yuan; 53.8% of respondents had lived in the aera for more than 5 years; most of respondents lived in new integrated communities (46.7%) and traditional neighborhood communities (30%); 52.3% of respondents participated in regular physical activities (Table 1).

SRH of Respondents

The analysis results showed that there were no residents reported "very unhealthy", 33 (2.4%)residents reported "unhealthy" and 361 (26.6%)reported "general". The residents reported "healthy"and "very healthy" accounted for 46.4% and 24.5,respectively. After grouping the answers into two groups ("high-score group" and "low-score group"),71% of respondents were in high-score group, while,29% of them were in low-score group.

According toχ2test results, age, gender,occupation, type of community and regular physical exercise showed significant differences between high-score group and low-score group of SRH status of residents (Table 1).

Correlation between Subjective Perception on the Built Environment and SRH Status of Respondents

χ2test results showed that the 22 items, such as adequate public fitness facilities, enough green space and night lighting, displayed significant differences between high-score group and low-score group on the SRH status of residents (Table 2).

Multivariate Logistic Regression Analysis on Influencing Factors of SRH Status

Multivariate logistic regression analysis was used to identify the influencing factors of SRH status, with the factors statistically related to the dependent variable in the univariate analysis as the independent variables.

The results showed that the residents aged 25 years old and below had a higher SRH compared with the residents aged 36-45 years old (OR= 0.546,95%CI: 0.351-0.851 ) and 46 years old above (OR=0.295, 95%CI: 0.175-0.497).

Women had a lower SRH than men (OR= 0.680,95%CI: 0.514-0.900). In addition, the SRH status of the residents living in commercial comprehensive community was higher than that living in urban fringe community (OR= 2.019, 95%CI: 1.177-3.464).Moreover, the residents who regularly participated in physical exercise had a higher SRH status than those who without regular physical exercise (OR=6.589, 95%CI: 4.903-8.854). Additionally, the respondents with enough green space (OR= 1.395,95%CI: 1.055-1.845), clean and hygienic community environment (OR= 1.472, 95%CI: 1.107-1.956),confidence in drinking water safety (OR= 1.856, 95%CI: 1.354-2.544) and food safety (OR= 1.405, 95%CI:1.027-1.921) were detected a higher SRH status(Table 3).

DISCUSSION

SRH has been included in periodically collected items of public health surveys by the WHO and other institutions[11-13]. A study demonstrated that SRH is affected by many factors, such as sociodemographic factors, economic and social factors and healthrelated lifestyles[14]. This study focused on the relationship between the urban built environment and SRH status of residents.

The measurement indicators of urban built environments include objective indicators and subjective perception indicators. According to the findings of a study, subjective perception and objective measurement on the urban environments do not match in about one-third of the population[15]. For instance, a walking-friendly community based on objective indicators may offer poor spatial experience in the micro environment due to shortcomings in quality maintenance, hygiene

and management systems[16]. Therefore, subjective perception indicators can better reflect the problems in the details of city management. However, existing studies have paid scant attention to the role of subjective perception on built environments. In this study, the built environment in hygienic cities was subjectively measured from 22 aspects including public fitness facilities, green coverage,environmental hygiene and air quality, and the relation between the built environment in hygienic cities and the SRH status of residents was investigated from the perspective of subjective perception of residents on the built environment.

Table 1. Demographic characteristics of respondents

Table 2. Correlation between built environment and SRH status

Continued

It was found in this study that after controlling confounding factors, the enough green space in the living area can significantly affect the SRH level of residents, consistent with existing research conclusions[17]. The accessibility to such public spaces as green spaces and parks can directly or indirectly affect the level of physical and mental health by lowering exposure to environmental pollution,providing opportunities for outdoor physical activities and increasing social interaction and community participation[18-19]. In addition, there are studies demonstrating that increasing public facilities such as green parks and sports venues can effectually reduce the rate of obesity and the development of chronic diseases[20-22].

Based on the reports of the WHO, hygienic environment is the main influencing factor for the health of residents[23]. The report of Preventing Disease Through Healthy Environments showed at least a quarter of the global burden of disease is caused by environmental factors, which account for 36% of deaths among children aged 0-14. Globally,24% of DALYs and 23% of deaths can be attributed to environmental factors[24]. The results of this study also revealed that the residents living in clean and hygiene environments had a higher SRH level.

Furthermore, the confidence in drinking water safety was found to be an important factor affecting the SRH of residents. Access to safe drinking water means that people can persistently, stably and permanently obtain drinking water that does not notably impair health. It is a key factor in determining the personal health status of residents[25]. Where the access to safe drinking water is difficult, health risks are often high[26]. Improving water quality has been proven to make a significant contribution to the reduction of diarrhea and mortality in different countries[27]. The residents drinking tap water have significantly better SRH than those drinking non-tap water[28].

Regarding the correlation between food safety and health status of residents, existing studies have denoted that a higher food safety awareness score suggests stronger subjective well-being of residents[29], and the subjective well-being is positively related to the SRH status of residents[30].Moreover, the access to healthy and safe food has a significant impact on the health status of the population[31-33]. In this study, the relationship between the access to healthy and safe food and the health level of residents was also confirmed from the standpoint of residents' confidence in food safety.

This study has several limitations. This study wasperformed in the form of web survey that is suitable for the rapid evaluation of a certain problem. This form of survey maynot include the population who are not web/phone users. The proportion of the elderly in respondents was very small, which may have affect the generalization of results. And the survey is only conducted in Chaoyang District. It could not represent the status in other regions of China.

Table 3. Multivariate logistic regression analysis on influencing factors of SRH status

In conclusion, this study found that, the enough green space, clean and hygienic living environments,confidence in drinking water safety and food safety in the living area signally affect the SRH level of residents. It is suggested that the government should pay more attention to the subjective perception of residents on the built environment during urban construction, and build a supportive environment that is conducive to the health of residents.

Received: January 22, 2022;

Accepted: May 5, 2022