title: Urbanisation, urbanicity, and health: a systematic review of the reliability and validity of urbanicity scales.
abstract: BACKGROUND
  Despite a plethora of studies examining the effect of increased urbanisation on health, no single study has systematically examined the measurement properties of scales used to measure urbanicity. It is critical to distinguish findings from studies that use surrogate measures of urbanicity (e.g. population density) from those that use measures rigorously tested for reliability and validity. The purpose of this study was to assess the measurement reliability and validity of the available urbanicity scales and identify areas where more research is needed to facilitate the development of a standardised measure of urbanicity.
  
  
  METHODS
  Databases searched were MEDLINE with Full Text, CINAHL with Full Text, and PsycINFO (EBSCOhost) as well as Embase (Ovid) covering the period from January 1970 to April 2012. Studies included in this systematic review were those that focused on the development of an urbanicity scale with clearly defined items or the adoption of an existing scale, included at least one outcome measure related to health, published in peer-reviewed journals, the full text was available in English and tested for validity and reliability.
  
  
  RESULTS
  Eleven studies met our inclusion criteria which were conducted in Sri Lanka, Austria, China, Nigeria, India and Philippines. They ranged in size from 3327 to 33,404 participants. The number of scale items ranged from 7 to 12 items in 5 studies. One study measured urban area socioeconomic disadvantage instead of urbanicity. The emerging evidence is that increased urbanisation is associated with deleterious health outcomes. It is possible that increased urbanisation is also associated with access and utilisation of health services. However, urbanicity measures differed across studies, and the reliability and validity properties of the used scales were not well established.
  
  
  CONCLUSIONS
  There is an urgent need for studies to standardise measures of urbanicity. Longitudinal cohort studies to confirm the relationship between increased urbanisation and health outcomes are urgently needed.
authors.affiliation: Global Health and Society Unit, School of Public Health and Preventive Medicine, Monash University, 99 Commercial Road, Melbourne VIC 3004, Australia.
authors.forename: Sheila
authors.initials: S
authors.lastname: Cyril
authors.forename: John C
authors.initials: JC
authors.lastname: Oldroyd
authors.forename: Andre
authors.initials: A
authors.lastname: Renzaho
mesh_terms: D002947:Cities; D006304:Health Status; D006801:Humans; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000592:standards*; D011156:Population Density; D015203:Reproducibility of Results; D014505:Urban Population