Two Articles: Engaging communities in the design and use of their streets and Sexual health promotion for youth through telemedicine
Engaging communities in the design and use of their streets
II Turning transportation infrastructure into social infrastructure
III Small-scale changes, big health impact
IV Challenges and solutions
V Concluding thoughts
--Submitted by Nadha Hassen
The next time you walk down the street where you live, take an honest look at what is in the space around you. Perhaps there is a multitude of tall trees or instead, no tree canopy at all. You could think about where your closest park is and the material underneath your feet. Are there spaces for people to come together? Are there children playing on the streets or grandparents sitting on porches? What is the state of the infrastructure? Are there benches or street lights? Is it child-friendly, youth-friendly, senior-friendly? In Ontario, there is a growing movement of individuals and organizations who want communities to be involved in designing their streets and neighbourhoods. Well-designed spaces can enable communities to re-engage with their neighbourhoods and each other. The evidence base linking the built environment to both population and individual health is strong and continues to grow. Specific features of street design and frontage can have positive effects on physical and mental health and increase outcomes such as social capital and community engagement. [1, 2]
II Turning transportation infrastructure into social infrastructure
In the City of Toronto, 12.7% of the city’s land base is dedicated to parklands while 25% is dedicated to rights of way, e.g., streets. [3, 4] The population of Toronto continues to grow, however the space for infrastructure growth and expansion is limited. It is necessary to look at our existing space allocation and the ways we use our spaces to find smarter ways of achieving multiple goals at once. Streets present an opportunity for turning transportation infrastructure into social infrastructure. Retrofitting streets has precedents in urban planning and is a cost-effective, sustainable way to promote health through improving the built environment. Streets are here to stay, but if we can maximize their use, everybody wins.
III Small-scale changes, big health impact
Together with Joël León, I co-founded a project called Asphalt Park which is an intervention toolkit that enables communities to temporarily transform their street space through health-promoting activities. The intervention toolkit (http://nadhahassen.com/wp-content/uploads/2015/03/Hassen_Leon_Asphalt_Pa...) maps each intervention according to activity and built form focus area (walkability, cyclability, accessibility, social, recreational, sports and safety), temporality (from short-term to permanent), scale of cost and demographic (including infants and those with physical disabilities).
We used urban acupuncture as a primary lens which focuses on the ability of a small scale intervention to create a larger impact on its surrounding.  This intervention toolkit serves as a catalyst for promoting healthy activities in neighbourhoods. In conceptualizing the project, we acknowledged and prioritized the end-user i.e., the community. It is essential that the community be actively involved in identifying its needs for its neighbourhood and this also encourages a vested interest in the project. Aesthetics and upkeep of a neighbourhood are associated with more positive social behaviours, community engagement and less social isolation. [6, 7] Often, it is the higher-income neighbourhoods that are visually attractive, with a tree canopy, street furniture, well-maintained streets, no litter and access to green space. This toolkit is designed with the range of neighbourhood types in mind. The disparity in built environment infrastructure contributes to growing health inequities and should not be overlooked. 
The project is in the final stages of data gathering and building community partnerships and much of the groundwork has been laid to ensure feasibility, long-term impact and sustainability. Pilot interventions in a specific neighbourhood with selected streets are targeted for Spring 2016. Asphalt Park was conceived by two graduate students at the time and there have been a number of lessons learned. We initially introduced Asphalt Park in 2013 October at the Healthier Cities and Community Symposium and since then have been collecting ideas from community members on what they would like to see in their neighbourhood streets. The garage-door cinema is a popular option and we have been provided with new and increasingly ambitious suggestions from pickleball to an outdoor ice rink. Imagine being able to gather to watch a movie projected in your neighbourhood on a warm, Saturday evening, or an evening of skating and hot chocolate on a front lawn ice rink built by the community. Jane Jacobs’ “Eyes on the Street” philosophy comes into effect  and it is possible to safely push a stroller for an evening walk or for the neighbourhood kids to have a game of street hockey.
IV Challenges and solutions
One of the key challenges of retrofitting streets is the policies behind temporary street closure; however there are ways to ensure disruption to transportation is minimal by scheduling community events during off-peak times (e.g., Sunday morning), strategically selecting streets, and working on and supporting by-laws for temporary street closure. There are precedents through cultural and food festivals in public spaces across the Greater Toronto Area (GTA). For instance, the organization 8–80 Cities brought Open Streets to Toronto in the summer of 2014, highlighting the importance of streets for active transportation (walking, cycling etc.). The organization has also supported other pilot projects across Ontario. It is possible to engage communities in designing their streets and having a voice in the multiple functions their streets can take on.
V Concluding thoughts
Well-designed neighbourhoods will have long-term positive health impacts across Ontario. With the growing evidence on the importance of walkable neighbourhoods that promote social connectedness and community engagement, it only makes sense to think about how we can get the most out of our existing infrastructure. In denser areas like Toronto, retrofitting is a viable and cost-effective solution.
Health promoters and those in public health have a key role to play in this movement. We need support for these built environment initiatives from health promoters, community members, urban planners and designers, as well as policymakers. We need investment in projects that address the root causes of population health issues. We need vibrant communities and neighbourhoods where it is easy for people of all demographics to keep active and engaged. We need to start thinking innovatively about our infrastructure and not be afraid to reimagine our neighbourhoods.
Nadha Hassen is a master of public health candidate with an undergraduate degree in architectural design. Her interests are health equity, determinants of health and addressing population health through the design of the built environment. Follow her on Twitter @nadhassen
Joël León recently completed a master of architecture at the University of Toronto, John H. Daniels Faculty of Architecture, Landscape and Design. He is one of the lead researchers at the Designing Ecological Tourism Lab. Follow him on Twitter @Joel_LeonD
Asphalt Park Phase 1 by Nadha Hassen and Joel Leon: http://nadhahassen.com/wp-content/uploads/2015/03/Hassen_Leon_Asphalt_Pa...
Open Streets Toronto: http://www.openstreetsto.org/
Healthier Cities and Communities Hub: http://healthiercitiescommunities.com/about/
 Semenza, J.C. & March, T.L. (2009) An urban community-based intervention to advance social interactions. Environment and Behavior, 41 (1), p. 22-42.
 Leyden, K.M. (2003) Social Capital and the Built Environment: The Importance of Walkable Neighborhoods. American Journal of Public Health, 93 (9), p. 1546-1551.
 The City of Toronto. Parks, Forestry and Recreation [Internet].Toronto: City of Toronto; 2013 [cited 2015 March 12]. Parks Plan 2013 - 2017. Available from http://www.toronto.ca/legdocs/mmis/2013/pe/bgrd/backgroundfile-57282.pdf
 Hess, P.M. & Milroy, B.M. (2006). Making Toronto’s Streets. Report funded by the Centre for Urban Health Initiatives, University of Toronto [Internet]. 103p. Available from http://faculty.geog.utoronto.ca/Hess/Downloads/Hess%20Milroy%20Making%20...
 Lerner, J. (2014). Urban Acupuncture. Washington, D.C.: Island Press.
 de Vries, S., van Dillen, Sonja M. E, Groenewegen, P. P, Spreeuwenberg, P. (2013) Streetscape greenery and health: Stress, social cohesion and physical activity as mediators. Social Science & Medicine, 94, p. 26-33.
 Ziersch, A. M., Baum, F. E. MacDougall, C. & Putland, C. (2005) Neighbourhood life and social capital: The implications for health. Social Science & Medicine, 60(1), p. 71-86.
 Dannenberg, A., Frumkin, H., & Jackson, R., (eds). (2011) Making Healthy Places: Designing and Building for Health, Well‐being, and Sustainability. Washington, D.C.: Island Press.
 Jacobs, J. (1961). The Death and Life of Great American Cities. New York: Random House.
Sexual health promotion for youth through telemedicine
II What is known in the literature
-- Submitted by Katherine Robrigado
Telemedicine refers to health-related diagnosis, treatment, promotion, or dissemination of information and resources through the use of remote communications and across distances (Sood et al, 2007; World Health Organization [WHO], 1998; WHO, 2010). Telemedicine can be used to repackage existing health information into more user-friendly and engaging messages that are cost-effective and targeted to a particular audience (WHO, 2010). Information can range from prevention strategies, resource acquisition tips, or direct counseling, and examples include social networking through social media sites, text messaging, and email. The potential for telemedicine to be used interactively despite geographical distance is what garners appeal, where distance can pose barriers to equitable access of health care services (Strehle and Shabde, 2006; WHO, 1998; WHO, 2010). Today, the uses for telemedicine range from quickly diagnosing and treating strokes to providing pediatric mental health care. Brian Eastwood’s (2012) article in CIO on 10 Ways Telemedicine is Changing Healthcare IT (http://www.cio.com/article/2390576/healthcare/10-ways-telemedicine-is-ch...) provides more uses of telemedicine.
Telemedicine also presents tremendous opportunity for providing health care and education to youth, especially in sexual health. Seeing as youth are considered at high risk of unintended pregnancies and sexually transmitted infections (STIs) related to low sexual health knowledge, sexual health promotion is of particular importance for this group (Gold et al., 2011b; Perry et al., 2012). Technology-based interventions are thought to be well-received by youth because they represent the majority of new technology users (Gold et al., 2011b; Perry et al., 2012). As well, youth tend to be an inaccessible and underserved population, and telemedicine can be used to provide more accessible, convenient, and discreet sexual health information and services (Perry et al., 2012; WHO, 2010).
In order to optimize telemedical sexual health promotion tailored to youth, it is important to first ask, “How is telemedicine currently being used for sexual health promotion among youth?”
II What is known in the literature
Many studies have found that telemedicine used for sexual health promotion was well-received and viewed as relevant by youth. When surveyed, 13–19 year olds were accepting of telemedicine for sexual health promotion because of their frequent use of cell phones and social networking sites (Buhi, Klinkenberger, Hughes, and Blunt, 2013). Other studies have gathered information from youth on level of interest for text messages about sexual health (Perry et al., 2012) and using avatars in gaming-like environments to create an interactive virtual clinic where players could interact and access resources without risking stigmatization through physical presence (Gabarron, Serrano, Wynn, and Armayones, 2012).
Much of the appeal of online sexual health promotion was due to youth being able to access sexual health information and services without privacy concerns (Gabarron et al., 2012). These studies are highlighted to showcase how researchers are engaging populations to self-identify the best methods for their own sexual health promotion, a core tenet in health promotion.
Studies have measured baseline and post-telemedicine sexual health knowledge and behaviours (Gold et al., 2011a; Gold et al. 2011b). Post-telemedicine, a significant increase in sexual health knowledge, STI testing, and condom use with new partners was reported (Gold et al., 2011a; Gold et al. 2011b). There was also a significant decrease in new partners and acceptance of telemedicine by youth (Gold et al., 2011a; Gold et al., 2011b). Telemedicine interventions were often created in accordance with the Theory of Planned Behaviour, which explains behaviour change according to an individual’s beliefs about likely consequences, normative expectations of others, and the presence of challenges or facilitators to the intended behaviour (McKenzie, Neiger, and Thackeray, 2013). Telemedicine interventions were also aimed at promoting youth's feelings of self-efficacy, and providing information about the importance, but more compellingly around the ease of behaviours, like STI testing. Although text messaging was successful in increasing sexual health knowledge telemedicine revealed limitations in inciting behaviour change and providing tangible resources (Gold et al., 2011a; Gold et al., 2011b). Another limitation is that there may still be some populations that are inaccessible with telemedicine, such as street-near youth. Therefore, health promoters and other supporters of telemedicine must keep in mind structural barriers that limit youth’s access to resources, like poverty, racism, sexism, or ableism, when creating interventions.
Being mindful of messaging content intended for youth was also emphasized as important. Messages focused on preventing communicable diseases and pregnancy, provided statistics, education, or myth-busting, sometimes paired with a call for action (e.g., to get tested or use a condom). Creativity in messaging was evident through the use of poems and pairing the theme of the message with events like popular music festivals, or holidays like Easter long weekend, Mother’s Day, or Valentine’s Day, for example the following text message: “Roses are red, daisies are white, use a condom if you get lucky tonight. Happy Valentine’s Day!” (Gold et al., 2011b).
Strategies to provide accessible resources could include interactive messages with clickable links, like a text message reading, “Scared to talk to ur parents about sex. It might not be so bad. Some ideas on how to start @ www.teensource.org” (Perry et al., 2012). Other resources could include GPS, (e.g., to locate clinics or free contraceptives), or two-way communications through text or online chat with a health care professional – all feasible, with telemedicine (Gabarron et al., 2012; Perry et al., 2012).
Because of youth’s frequent engagement with technology, it is believed that sexual health promotion through telemedicine would be well accepted. As discussed, telemedicine could have significant implications for the improvement of sexual health knowledge in youth, but face limitations in facilitating individual behaviour change. To overcome this, telemedicine must be used in a way that promotes not just knowledge, but also development of skills and acquisition of resources. When creating messaging content, health promoters should be challenged to think beyond STI testing and condom use. In the future, telemedicine can be used to advocate for awareness and social change on issues around sexting, sexual assault, sexual health rights, and skills-based teachings, such as how to effectively say "No." Moving forward, health promoters and researchers should continue strategizing innovative ways to engage youth and promote sexual health, including through the promising use of telemedicine.
Theory at a Glance - A Guide for Health Promotion Practice (Second Edition) published in 2005 by the U.S. Department of Health and Human Services gives an overview of many behaviour change theories in health promotion. Theory of Planned Behaviour is displayed in a chart on page 16, broken down by concepts (behavioural intention, attitude, subjective norm, and perceived behaviour control), definition, and measurement approach.
HP 101 Health Promotion On-line Course offered by Ontario Health Promotion Resource System discusses behaviour change theories in health promotion in Module 4. Module 4 includes a figure illustrating the major elements of the Theory of Planned Behaviour. The module emphasizes that the Theory of Planned Behaviour can be useful in the information-gathering stage of program development, and highlights the importance of self-efficacy or feelings of individual confidence and control.
Buhi, E. R., Klinkenberger, N., Hughes, S., Blunt, H. D., and Rietmeijer, C. (2013). Teens’ Use of Digital Technologies and Preferences for Receiving STD Prevention and Sexual Health Promotion Messages: Implications for the Next Generation of Intervention Initiatives. Sexually Transmitted Diseases, 40(1): 52-54.
Eastwood, B. (2012, Nov. 7). 10 Ways Telemedicine is Changing Healthcare IT. CIO. Retrieved from http://www.cio.com/article/2390576/healthcare/10-ways-telemedicine-is-ch...
Gabarron, E., Serrano, J. A., Wynn, R., & Armayones, M. (2012). Avatars using computer/smartphone mediated communication and social networking in prevention of sexually transmitted diseases among North-Norwegian youngsters. BMC Medical Informatics and Decision Making, 12(120):1-5.
Gold, J. et al. (2011a). A randomized controlled trial using mobile advertising to promote safer sex and sun safety to young people. Health Education Research, 26(5): 782-794.
Gold, J. et al. (2011b). Determining the Impact of Text Messaging for Sexual Health Promotion to Young People. Sexually Transmitted Diseases, 38(4): 247-252.
McKenzie, J.F., Neiger, B.L., and Thackeray, R. (2013). Theories and models commonly used for health promotion interventions. In (6th edition) Planning, implementing and evaluating health promotion programs: a primer (Chapter 7, pages 162-2014). Boston, Massachusetts: Pearson Education Inc.
Perry, R. C. W. et al. (2012). Adolescents’ Perspectives on the Use of a Text Messaging Service for Preventative Sexual Health Promotion. Journal of Adolescent Health, 51:220-225.
Sood S. P. et al. (2007). Differences in public and private sector adoption of telemedicine: Indian case study for sectoral adoption. Studies in Health Technology and Informatics, 130:257–268.
Strehle E. M., and Shabde, N. (2006). One hundred years of telemedicine: does this new technology have a place in paediatrics? Archives of Disease in Childhood, 91(12):956-959.
World Health Organization [WHO]. (1998). A health telematics policy in support of WHO’s Health-For-All strategy for global health development: report of the WHO group consultation on health telematics, 11–16 December, Geneva, 1997. Geneva, Switzerland.
World Health Organization [WHO]. (2010). Telemedicine: Opportunities and Developments in Member States: report on the second global survery on eHealth. Geneva, Switzerland.