Urbanisation and Non-Communicable Diseases (NCDs) are increasing in parallel. In the face of this trend, Health Outcomes from Raised Urban Settings (HORUS) addresses the imperative need to rethink the design of our cities and the way we interact with them. Building on evidence-based interventions, we seek to empower citizens, particularly the most vulnerable and socially disadvantaged, to adopt behaviours that decrease the risk of NCDs in urban settings. Our proposal aims to be a catalyst for promoting healthy urban environments and lifestyles in an increasingly urbanised world. HORUS provides a comprehensive solution through the integration of urban and behavioural dimensions in the same epistemic and methodological framework. By providing planners, policy makers and health providers with tools to address the challenge of NCDs, this project aims to set a benchmark in urban health promotion, contributing to shape our cities towards a healthy, resilient and sustainable future.

NCDs, especially diabetes and cardiovascular diseases, are the leading causes of morbidity and mortality worldwide. Cardiovascular diseases kill more people globally than any other disease, accounting for 17.9 million deaths per year. Diabetes, on the other hand, accounts for 2 million deaths annually. These diseases have a greater impact on vulnerable populations, such as low-income communities, migrants, ethnic minorities. NCDs are the result of several factors, including genetic, behavioural, and environmental factors. Strategies promoting healthier lifestyles to address these factors are needed to tackle the challenges of NCDs. On the one hand, behaviour change interventions are key to modify individual factors, such as dietary habits, physical activity and substance abuse. On the other hand, environmental factors may be addressed through the optimal use of healthy urban built environments. All these factors shape HORUS, which will try to respond to the following issues identified in the scientific literature.

As presented, cardiovascular diseases are the leading NCDs and the incidence and prevalence of diabetes have been steadily increasing over time. In fact, a close link exists between cardiovascular disease and diabetes (type 2 diabetes mellitus), being cardiovascular diseases the most prevalent cause of morbidity and mortality in diabetic patients. This is mainly due to cardiovascular risk factors, such as dyslipidaemia, hypertension, and obesity are frequent in diabetic persons and raise the likelihood of heart attacks and stroke. High blood glucose from diabetes can damage the blood vessels and the nerves that control the heart and blood vessels and over time, this damage can lead to heart disease. In a recent systematic review on the prevalence of cardiovascular disease in type 2 diabetes (T2DM) with a sample of 4,549,481 persons with T2DM4, the prevalence of cardiovascular diseases among persons with diabetes was 32.2%, and the cardiovascular mortality rate among patients with diabetes was 9.9%. Accordingly, effective strategies to prevent, control and treat diabetes and cardiovascular diseases are essential to curbing the growing prevalence and progression of these particular NCDs.

The burden of NCDs, especially cardiovascular disease and diabetes, poses specific challenges for vulnerable populations, such as those living in low-income communities or households. In fact, poverty is closely linked with NCDs and NCDs risk factors are more prevalent among poorer communities than in those with high socioeconomic status. In particular, migrants and ethnic minorities experience an increasing prevalence of NCDs, especially diabetes and cardiovascular disease. This increased prevalence is related to a range of social and environmental factors, lifestyles, and the impact of behavioural determinants such as use of tobacco and alcohol, unhealthy diet and lack of exercise, ageing, social exclusion, low levels of health literacy and limited access to health care. Migrants or ethnic minorities are still undertreated and unprotected by most of the healthcare systems with a lack of quality of care for NCDs and lack of preventive measures specifically adapted for them. Therefore, offering solutions to vulnerable populations, such as people in low-income households or communities, especially migrants and ethnic minorities, is essential to tackle the challenge of NCDs and to meet the needs of migrant and ethnic minority populations in future EU health policies and health care planning at both national and EU level.

In order to offer effective solutions to tackle the challenge of NCDs, we need to address their related risk factors. In this regard, the 4×4 framework for NCDs focuses on the four main NCDs cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes and four main modifiable behavioural risk factors  tobacco and alcohol use, unhealthy diet, and physical inactivity. According to this framework and massive evidence, most NCDs are preventable by addressing these four behavioural risk factors. In particular behaviour change techniques have shown to be the most effective interventions aiming to address excessive alcohol use, smoking, unhealthy dietary behaviours, and physical inactivity. How we conduct ourselves (behaviours) and the pattern of behaviours (lifestyles) is the product of a complex range of factors which, in combination, shape the societies in which we live, in ways that in turn facilitate or constrain intentions and actions. In fact, many people can be engaged in lifestyles and behaviours that damage their health because they do not have the capabilities or the opportunities to choose otherwise. And, as previously mentioned, this is particularly relevant when it comes to low income households or communities, especially migrants and ethnic minorities.

Moreover, creating environments that support good health and healthy lifestyles is key to address the rise in NCDs. Urbanization is a key socio-environmental factor linked to the rise in NCDs. It restricts access to nature and health promotive features, increasing residents’ exposure to climatic and environmental risks. Notably, a significant part of public health risks in urban settings stems from the interplay between functional aspects of the physical-social environment and human behaviour, specifically individual health behaviours encouraged by a given environment. It is well known that the urban physical-social environment influences the decisions that neighbours make on a day-to-day basis, making certain individuals more or less willing to adopt health-risk behaviours according to their personal traits, and it may also influence subjective well-being.