Why is the relationship between women and cities important to nurses who care for women and infants? Today, more than one half of the world's population lives in urban environments (World Health Organization [WHO], 2011a). Rapid industrialization and the need for employment in developing and developed countries have resulted in migration from rural to urban settings and within and between countries. As a result, slow, consistent changes have occurred in urban environments, especially within the “microcities” that develop in neighborhoods. Some affluent urban neighborhoods exist; however, urban neighborhoods are most often occupied by persons of low socioeconomic status. These neighborhoods are associated with high rates of unemployment, crime, hostility, and physical decay. Residents experience lack of safety, poor social support networks, and disintegrating family ties. These conditions disproportionately affect women, and the gap between the number of poor men and poor women continues to widen in urban neighborhoods. Poor urban women tend to have lower-paying jobs or work the same jobs as their male counterparts for less pay. Women also have higher levels of illiteracy (WHO & United Nations Human Settlement Programme [UN-HABITAT], 2010).
Focusing on the health of women residing in urban settings is of utmost importance because women's health affects families, neighborhoods, cities, nations, and the world. Women generally assume the role of liaison between their families and neighborhoods and often decide if their family members should access health care outside of the home. In addition, these women also decide where family members should receive care. Therefore, women are frequently viewed as the guardians of the community's health (Eastlick Kusher & Harrison, 2011). To optimize their families’ health and subsequently their communities’ health, women must first take care of their own health needs.
Two important risk factors, stress and violence, are repeatedly associated with the health of women residing in urban environments. Stress, caused by chronic difficulties encountered while residing in urban neighborhoods, increases women's vulnerability to certain health disorders. Evidence indicates that chronic stress results in a physiologic response in the hypothalamic-pituitary-adrenal axis and sympathetic nervous system that ultimately negatively constitutes the body's immune system and results in an increased susceptibility to disease (Rich-Edwards & Grizzard, 2005). This results in a cascading effect, where one disease has important implications for women's health in general. For example, stress is associated with the development and progression of periodontal disease, which results in a systemic inflammatory response that has been associated with women's health problems including cardiac disease and preterm labor (Clothier, Stringer, & Jeffcoat, 2007; Fisher, Borgnakke, & Taylor, 2010).
Not only is chronic stress a risk factor associated with urban women, but also violence has been identified as one of 10 health and social risk factors associated with women's health worldwide (WHO, 2011b). The WHO suggested that dense urban environments are associated with increased violence towards women (WHO, 2011b), and women living in crowded, low socioeconomic urban neighborhoods are challenged by day-to-day threats. Fear of violence hinders women's ability to participate fully in urban activities, such as attending neighborhood outdoor events, walking to a store, visiting neighbors, or going for a bike ride. This inability to partake in activities ultimately affects quality of life and results in feelings of insecurity, discomfort, anxiety, and helplessness. These feelings contribute to social isolation, reduced mobility, and reduced involvement in urban life. In 2010, the WHO and UN-HABITAT (2011) jointly published Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings. This document addresses challenges for poor urban dwellers, and the authors state:
Crime and violence are typically most severe in urban areas and are compounded by their rapid growth. Sixty percent of urban dwellers in developing and transitional countries have been victims of crime, over a five-year period, with victimization rates reaching 70% in parts of Latin America. (p. 22)
Additionally, the WHO (2011b) has indicated that women are at increased risk for experiencing violence compared to men.
To respond to these alarming statistics, women's health nurses need to continue to explore ways to promote the health of women residing in urban environments. Realizing that the downstream effect on women living in unhealthy urban environments is disease, three possible areas for exploration are partnerships with women in the community, nursing's role in community health promotion, and community participatory research.
Nurses are ideally positioned to develop partnerships for care with women who are residents in the community as nurses have a long history of providing public health care and continue to be one of the highest ranked “trusted” professional by the community. Many times residents know what health promotion solutions may be effective to support the health of their communities, but women are often not empowered and lack resources to affect change. Nurses positioned within health delivery systems have resources to facilitate change that can promote the health of women and the community. Some nurses have the skills and knowledge to conduct meaningful community participatory research. This type of research embodies close community partnerships and empowerment of residents and can be used to develop effective programs and subsequent outcome evaluation.
Our challenge as nurses is to facilitate health-promoting environments for poor, urban women and their families. Can nurses collaborate with women in the community to facilitate healthy lifestyles within the microcity of neighborhoods that may affect a particular health concern such as women and cardiac disease, preterm birth, obesity, and asthma? Can the lessons from past community or public health initiatives create different interprofessional models of sustainable health promotion at the neighborhood level?
Several organizations may have some answers to these questions. The United Nations Women, the WHO, the National Institutes of Health Office of Research on Women's Health, and the International Council of Women's Health are just a few of the major interprofessional organizations that have specific strategic goals related to women. These organizations appreciate the interrelatedness of the health of women to the health of their families, neighborhoods, cities, nations, and the world (International Council of Women's Health, 2011; UNWomen, 2011; WHO, 2011a). Perhaps as women's health nurses, we may have greater influence on the health of the women if we more actively engage with these types of organizations.