The difficult economic times that Cuba has had to face have taken a considerable toll on its urban ecosystems, with data suggesting that indicators of health, the environment, and social services have been deteriorating. This has been particularly evident in Centro Habana, a municipality with the highest population density in the country. More than half the population was without daily access to potable water, waste disposal was insufficient, overcrowding was serious, disease vectors were prevalent, and rates of various infectious as well as noncommunicable diseases and injuries were highest in the country. To improve the situation, the municipality requested help from the National Institute for Hygiene Epidemiology and Microbiology (INHEM) to determine the best use of scarce resources to improve health. INHEM performed an ecological descriptive study and conducted focus groups in five communities to assess perceptions of health, social, and environmental factors, followed by a household survey. INHEM then engaged collaborators at the University of Manitoba to assist in developing a framework, analyzing the data, and planning and undertaking the evaluation requested. Maximum likelihood factor analysis was used to reduce the dimensionality of the data. The perception data were then merged with the ecological level health and environmental data to ascertain the relationship between these two data sources and determine which indicators might be useful for an intervention analysis. The perception results indicated that the greatest community concern was quality of housing, but that the risk perception results were independent of ecological data on morbidity, mortality, and basic sanitation indicators. Based on this conclusion, it was decided to use a combined qualitative and quantitative approach to evaluate actual and potential interventions, using the driving force‐pressure‐state‐exposure‐effects‐action (DPSEEA) framework. It was also decided to adopt an ecosystem approach that fully involves the community in developing a set of ecosystem human health indicators. Data from repeat focus groups and household surveys are planned, with these data to again be integrated with ecological data including environmental, socioeconomic, and health outcome information, using a pre‐ versus postintervention with concurrent control design. Our findings in this first phase indicated that an ecosystem framework is invaluable in ascertaining determinants of health and prioritizing and evaluating interventions to improve the health of communities.

It is increasingly recognized that individual values, beliefs and behavior operate within a social context. There is growing consensus that local perceptions and indigenous knowledge should be important elements in the evaluation of programs aimed at improving health. Thus, an assessment of changes in health risk perception was included in the evaluation of a multi-component intervention project undertaken between 1996 and 1999 aimed at improving the health and well-being of residents in the inner city community of Cayo Hueso, in Centro Habana, Cuba. The community intervention involved a tremendous mobilization of government and non-governmental organizations, to promote social and cultural activities and address deficiencies in housing, water supply, waste disposal and street illumination. Prior to the interventions, 365 adults were surveyed regarding their perceived health risks regarding 41 health determinants, scored on four-point Likert scales ranging from 'without risk' to 'very risky'. A factor analysis of these data classified perception of risk into five areas: social environment, threats to personal health, lifestyle choices, environmental sanitation and housing conditions. The objective of the current analysis was to determine if there were changes in the level of perceived risk to health over the 5 years pre- versus post-intervention in Cayo Hueso, and if so, whether these changes were significantly different from changes seen during the same 5-year period in Colón, another community in Centro Habana not receiving focused interventions. During the first quarter of 2001, 1703 individuals living in 654 households in Cayo Hueso and Colón were interviewed in their homes using an enhanced version of the 1996 risk perception instrument. Ordinal logistic regression models, adjusted for age, gender and years of education, were fit to assess change in health risk perception between 1996 and 2001. Significant declines in perceived health risk were found in both Cayo Hueso and Colón within all five domains, with significantly greater declines in many areas in Cayo Hueso compared with Colón, particularly with respect to housing-related health risks, indeed the main target of the intervention. Risk perception surveys are useful characterizations of widely held views in a target population. Our findings of decreased perceived health risk following public health, physical and social interventions to improve health suggests that this line of inquiry merits consideration in planning evaluations of multi-sectoral community-based health promotion interventions.

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Perceptions of health risks were surveyed in the inner city of Centro Habana, Cuba. A questionnaire developed by community leaders and experts was administered to 348 residents to determine the level of perceived risk for each of 41 risk items. Ecologic-level data on morbidity, mortality, and environmental indicators were also gathered. Using factor analysis to reduce the dimensionality of the data, five factor groupings accounted for 60% of the variance, as follows: social environment (40.8%); infectious agents and other health-risk factors of immediate concern (6.1%); lifestyle risks (4. 9%); environmental sanitation (4.1%); and living conditions (3.3%). A relationship between the perception of risk and the ecologic data was found, with inconsistencies largely attributable to factors known to influence risk perception. The greatest concern identified throughout the municipality was housing conditions, highest in the neighborhood that had already begun to address this problem. The analysis was useful in planning targeted health promotion campaigns and prioritizing further interventions. Repeat evaluation of risk perception will be conducted following the completion of interventions.

It is increasingly acknowledged that the process of community involvement is critical to the successful implementation of community-based health interventions. Between 1995 and