Urban Health Challenges in Europe

This article synthesizes diverse official reports, statistics, and scientific papers that present demographic, economic, environmental, and social trends impacting on the health and quality of life of citizens living in European cities. A literature review led to the identification of some key challenges including an aging society, migration flows, inequalities in health, global change, and risk behaviors that should be addressed in order to promote urban health. Other challenges, such as food production and consumption, are also relevant, but not included. Cities that have participated in one or more of the phases of the WHO European Healthy Cities Network have implemented a number of policies, programs, and measures to deal with the challenges discussed in this article. Some contributions are presented to illustrate how health and quality of life in urban areas can be promoted by local authorities.     

Healthy Cities projects

This is a review article on "Healthy Cities". The Healthy Cities programme has been developed by the World Health Organization (WHO) to tackle urban health and environmental issues in a broad way. It is a kind of comprehensive policy package to carry out individual projects and activities effectively and efficiently. Its key aspects include healthy public policy, vision sharing, high political commitment, establishment of structural organization, strategic health planning, intersectoral collaboration, community participation, setting approach, development of supportive environment for health, formation of city health profile, national and international networking, participatory research, periodic monitoring and evaluation, and mechanisms for sustainability of projects. The present paper covered the Healthy Cities concept and approaches, rapid urbanization in the world, developments of WHO Healthy Cities, Healthy Cities developments in the Western Pacific Region, the health promotion viewpoint, and roles of research.     

Do Healthy Cities Work? A Logic of Method for Assessing Impact and Outcome of Healthy Cities

In this article, we discuss an appropriate methodology for assessing complex urban programs such as the WHO European Healthy Cities Network. The basic tenets and parameters for this project are reviewed, and situated in the broader urban health tradition. This leads to a delineation of the types of questions researchers can address when looking at a complex urban health program. Such questions reach appropriately beyond traditional public health concepts involving proximal and distal determinants of health (and associated upstream, midstream, and downstream rhetoric). Espousing a multi-level, reciprocal pathways perspective on Healthy Cities research, we also adopt a distinction between impacts and outcomes of Healthy Cities. The former are value-driven, the latter intervention-driven. These approaches lead to the acknowledgment of a logic of method that includes situational and contextual appreciation of unique Healthy City experiences in a Realist Evaluation paradigm. The article concludes with a reflection of evaluation and assessment procedures applied to Phase IV (2003-2008) of the WHO European Healthy Cities Network and an interpretation of response rates to the range of methods that have been adopted.     

Utility-driven evidence for healthy cities: problems with evidence generation and application

The question whether the WHO Healthy Cities project 'works' has been asked ever since a number of novel ideas and actions related to community health, health promotion and healthy public policy in the mid 1980s came together in the Healthy Cities Movement initiated by the World Health Organization. The question, however, has become more urgent since we have entered an era in which the drive for 'evidence' seems all-pervasive. The article explores the nature of evidence, review available evidence on Healthy Cities accomplishments, and discusses whether enough evidence has been accumulated on different performances within the realm of Healthy Cities. A main point of reference is the European Healthy Cities Project (E-HCP). Building on the information gathered through documentary research on the topic, it is concluded that there is fair evidence that Healthy Cities works. However, the future holds great challenges for further development and evidence-oriented evaluations of Healthy Cities. There are problems with (1) the communication of evidence, (2) the tension between the original intention of the Healthy Cities Movement and its current operations, and (3) the complex nature of Healthy Cities and the methodological tools currently available.     

Developing healthy local communities at local government level: lessons from the past decade

Abstract: There have been many approaches by the health sector to developing healthy communities based on local government areas in Australia in the past decade. Each has struggled with the need to establish realistic goals and to find ways of working more effectively with local government. This paper outlines four of these approaches–Healthy Cities, the Healthy Localities project, municipal health plans, and programs to address specific health problems or issues. Although the picture is one of huge diversity in the ways in which the issue is defined and action taken, a number of dimensions to a healthy community are emerging. However, if we are to be able to monitor change within and between the health of communities over time, indicators need to be developed and goals set. This will require a shift away from defining goals and targets in terms of populations (people), towards goals based on changes in organisations and systems. Engaging local government in this process will be vital and will require the health sector to develop a better understanding of the ways in which local government defines its role in creating healthy communities. It will also involve learning from local government the strategies that they have found most effective in dealing with complex problems that require action at many levels.     

Healthy Cities and change: social movement or bureaucratic tool?

Healthy Cities is seen as a vision, project and movement. Itswide appeal leaves it open to losing touch with the core valuesenvisaged by the origtnators of Healthy Cities. This paper considersthe outcomes Healthy Cities should aim for in Australia andthe processes by which they can be achieved It identifies thepolitical ideology underlying the Ottawa Charter as social democraticand collectivist. Economic rationalism, individualism and misplacedprofessionalism are discussed as blocks to achieving HealthyCities. It is suggested that professional workers seeking topromote health should operate within a 'health promotion winners'triangle' as many do currently. The paper concludes by arguingthat Healthy Cities should ensure complacency does not permita taken-for-granted economism, individualism and professionalismto dominate agendas for change and suggests ways in which collaborationswith forces inside and outside bureaucracies may assist theprocesses of achieving healthier cities.     

Why urban health cannot be ignored: the way forward

Urban health is an increasingly relevant and challenging field of action for the European region, and indeed the whole world. Urban health and action at the local level represent a high priority for the European Office of the World Health Organization. The success and appeal of the Healthy Cities concept to politicians, to professionals, and to community activists has resulted in a continuing growth of the movement both within and outside Europe. More than 1200 cities and towns are now involved in the 26 national Healthy Cities networks and several regional networks in Europe. Working directly and closely with a relatively small network of selected fully committed cities (over two 5-year phases: 1988 to 1992 and 1993 to 1997) has proved to be a valuable tool for strategic growth and a source of know-how, legitimacy, and continuous learning. No plan or strategy for health can be serious without systematically addressing poverty, vulnerability, and access to care. The WHO Healthy Cities programme gives emphasis on addressing equity and the social determinants of health through explicit political commitment and integrative policy making and planning.     

Preparing for Climate Change: A Perspective from Local Public Health Officers in California

Background

The most recent scientific findings show that even with significant emission reductions, some amount of climate change is likely inevitable. The magnitude of the climate changes will depend on future emissions and climate sensitivity. These changes will have local impacts, and a significant share of coping with these changes will fall on local governmental agencies. Public health is no exception, because local public health agencies are crucial providers of disease prevention, health care, and emergency preparedness services.

Methods

This article presents the results of a survey of California’s local pubic health officers conducted between August and October 2007. The survey gauged health officers’ concerns about the public health impacts of climate change, programs in place that could help to mitigate these health effects, and information and resource needs for better coping with a changing climate.

Results

The results of this survey show that most public health officers feel that climate change poses a serious threat to public health but that they do not feel well equipped in terms of either resources or information to cope with that threat. Nonetheless, public health agencies currently implement a number of programs that will help these agencies handle some of the challenges posed by a changing climate.

Conclusions

Overall, the results suggest that local public health agencies in California are likely in a better position than they perceive to address the threats associated with climate change but that there is a larger role for them to play in climate policy.     

WHO Healthy Cities and the US family support movements: a marriage made in heaven or estranged bed fellows?

The family support movement in the US emerged at about the sametime that the WHO Healthy Cities project was gaining momentumin Europe, and the underlying principles and ecologic frameworksof the two have much in common. However, while many ‘HealthyCities’ in Europe have included activities that benefitfamilies, this has not been made a major focus. There seemsto be little awareness of experience gained in the US in termsof establishing programs with limited or no government funding,using volunteers, and developing social marketing and advocacystrategies to sustain long term viability. Similarly, citiesand states in the US are struggling to develop networks of familysupport programs and they appear to be doing this without thebenefit of experience gained in Healthy Cities projects on howto engage political leadership, develop public policies, establishintersectoral councils, fund a coordinator position, mobilizeneighborhoods, and evaluate community wide health promotionprograms. The purpose of this paper is to examine how thesetwo movements might join forces and learn from each other.     

The health of cities and their citizens (urban development and municipal public health). 2008 SESPAS Report

The policy of continued improvement in citizens' health, further to the definitions provided in the latest World Health Organization reports, entails a huge undertaking on the part of local administrations in issues that not only affect health management but also involve a change in other health-related policies, such as urban development and planning. Until now, urban development has been reluctant to incorporate the criteria defined by health strategies into its field of knowledge. However, there is a lack of research in public health, which could specify the clear effects of the environmental on citizens' health and enable criteria applicable to spatial planning to be defined. The present article reflects on certain experiences acquired in our environment of processes that bring together these two views of health, ranging from urban and environmental policies in indicator-based reports to a series of good practice. The integrated municipal action of San Fernando de Henares in the Healthy Cities project has also been significant.     

Healthy Cities Evaluation: the co-ordinators perspective

The Healthy Cities Project is based on the development of healthypublic policies by local governments. The study aim of someproject teams in different countries has been to find out whatprocesses are involved in the development of these policies,how decisions are made, and who and what they are influencedby. The Valencian Community Healthy Cities Network conductedan evaluation process, part of which is presented in this paper.The aim was to find out the concepts and opinions of the projectco-ordinators concerning the opportunities and problems forhealthy municipal policies, and to analyse the municipal organizationwith a view to detecting structural opportunities for interdepartmentalwork. Interviews were conducted with the people responsiblefor the project in 13 cities and the relevant documents analysed.When discussing their health concept and actions for health,few of the co-ordinators mentioned the ideas contained in theOttawa Charter. The established health programmes were ratherbased on personal/ individual changes and topic approach thansetting-based strategies. The structural and strategic opportunitiesfor interdepartmental work, as well as the active participationof the community in the healthy policies decision-making processneed to be strengthened, as they are perceived to be insufficient.Personal relationships and political differences between thedifferent actors appear to play an important role in the opportunitiesfor the implementation of intersectoral policies.     

Healthy cities: overview of a WHO international program

Health is the outcome of all the factors and activities impinging upon the lives of individuals and communities. The last decade has seen an emerging understanding within development circles that living conditions are greatly affected by local action, by the work of local government, and by community groups and organizations. In addressing health and environmental issues and making interventions, an integrated approach, based on 'settings', exemplified in the Healthy Cities approach, has proved most effective. A Healthy City project can involve people and organizations in the programs and activities that are needed for better health, and enables a city or neighborhood to mobilize the human and financial resources required to address many health and quality of life issues. The WHO program involves implementating city projects and networks in all regions of the world and serves as a vehicle for many health programs, including major disease control initiatives. Healthy City projects allow Ministries of Health to develop stronger partnerships with local government organizations (such as the Union of Local Authorities and its members, "Local Agenda 21" initiatives, and others). One focus for the program is the development of 'multi-'multi-city action plans' for major global priority issues, including AIDS, sanitation, women's health, and violence, to ensure that major public health programs are strengthened by wider community participation. It is recognized that city networking--at national, regional, and international levels--now must be better exploited by individual cities and municipalities to solve local health problems.     

Healthy Cities projects in Europe

The WHO Healthy Cities Project has been developed in Europe to place health high on the agenda of city decision-makers. It has promoted comprehensive local strategies for health and sustainable development. Cities endorse principles and strategies, establish project infrastructures, work on specific goals, products, changes, and outcomes, and invest in formal and informal networking and cooperation. Consistent research and development efforts are contributing towards a more evidence-based policy making and to the emergence of a framework to meet the demands of the new public health movement.     

Global environmental health and sustainable development: the role at Rio+20

The Rio+20 United Nations Conference on Sustainable Development represents a crucial opportunity to place environmental health at the forefront of the sustainable development agenda. Billions of people living in low- and middle-income countries continue to be afflicted by preventable diseases due to modifiable environmental exposures, causing needless suffering and perpetuating a cycle of poverty. Current processes of economic development, while alleviating many social and health problems, are increasingly linked to environmental health threats, ranging from air pollution and physical inactivity to global climate change. Sustainable development practices attempt to reduce environmental impacts and should, in theory, reduce adverse environmental health consequences compared to traditional development. Yet these efforts could also result in unintended harm and impaired economic development if the new "Green Economy" is not carefully assessed for adverse environmental and occupational health impacts. The environmental health community has an essential role to play in underscoring these relationships as international leaders gather to craft sustainable development policies.     

Challenges and Opportunities for Urban Environmental Health and Sustainability: the HEALTHY-POLIS initiative

Cities around the world face many environmental health challenges including contamination of air, water and soil, traffic congestion and noise, and poor housing conditions exacerbated by unsustainable urban development and climate change. Integrated assessment of these risks offers opportunities for holistic, low carbon solutions in the urban environment that can bring multiple benefits for public health. The Healthy-Polis consortium aims to protect and promote urban health through multi-disciplinary, policy-relevant research on urban environmental health and sustainability. We are doing this by promoting improved methods of health risk assessment, facilitating international collaboration, contributing to the training of research scientists and students, and engaging with key stakeholders in government, local authorities, international organisations, industry and academia. A major focus of the consortium is to promote and support international research projects coordinated between two or more countries. The disciplinary areas represented in the consortium are many and varied, including environmental epidemiology, modelling and exposure assessment, system dynamics, health impact assessment, multi-criteria decision analysis, and other quantitative and qualitative approaches. This Healthy-Polis special issue presents a range of case studies and reviews that illustrate the need for a systems-based understanding of the urban environment.     

What makes for sustainable Healthy Cities initiatives?--A review of the evidence from Noarlunga, Australia after 18 years

This paper examines the factors that have enabled the Healthy Cities Noarlunga (HCN) initiative to be sustainable over 18 years (1987-2005). Sustainability related to the ability of the initiative to continue to operate continuously in a manner that indicated its existence was accorded value by the community and local service providers. The analysis is based on a narrative review of 29 documents related to HCN, including a number of evaluations. Nine factors emerged as important to ensuring sustainability: strong social health vision; inspirational leadership; a model that can adapt to local conditions; ability to juggle competing demands; strongly supported community involvement that represents genuine engagement; recognition by a broad range of players that Healthy Cities is a relatively neutral space in which to achieve goals; effective and sustainable links with a local university; an outward focus open to international links and outside perspectives; and, most crucial, the initiative makes the transition from a project to an approach and a way of working. These sustainability factors are likely to be relevant to a range of complex, community-based initiatives.     

Monitoring Millennium Development Goals in Brazilian municipalities: challenges to be met in facing up to iniquities

The Healthy Cities and Agenda 21 programs improve living and health conditions and affect social and economic determinants of health. The Millennium Development Goals (MDG) indicators can be used to assess the impact of social agendas. A data search was carried out for the period 1997 to 2006 to obtain 48 indicators proposed by the United Nations and a further 74 proposed by the technical group for the MDGin Brazil. There is a scarcity of studies concerned with assessing the MDG at the municipal level. Data from Brazilian health information systems are not always consistent or accurate for municipalities. The lack of availability and reliable data led to the substitution of some indicators. The information systems did not always provide annual data; national household surveys could not be disaggregated at the municipal level and there were also modifications on conceptual definitions over time. As a result, the project created an alternative list with 29 indicators. MDG monitoring at the local community can be important to measure the performance of actions toward improvements in quality of life and social iniquities.     

Sustainable funding of health initiatives in Wonju, Republic of Korea via a tobacco consumption tax

Wonju is the first municipality in the Republic of Korea to fund the Healthy City project through municipal revenues from the local tobacco consumption tax. We investigated the process of the local tobacco consumption tax being approved as the main source of financing for the local Healthy City project. We also examined the sustainability and sufficiency of the funding by looking at the pricing policies instituted for cigarettes, smoking prevalence, cigarette consumption and revenues from local tobacco consumption as well as the budgetary allocations among programs in the city. The strong initiative of the mayor of Wonju was one of the factors that enabled the earmarking of the local tobacco consumption tax for the Healthy City Wonju project. He consulted academic counselors and persuaded the municipal government and the City Council to approve the bill. Despite the increasing price of cigarettes in Korea, adequate funding can be sustained to cover the short-term and mid-term programs in Wonju for at least 5 years of the mayor's term, because the smoking rate is persistently high. Analyzing the effects of strong leadership on the part of local authorities and the balance between revenues from the tobacco tax and the prevalence of smoking in the face of anti-smoking policies would be helpful for other countries and communities interested in developing sustainable Healthy Cities projects.     

Healthy Cities Australia: the evaluation of the pilot project in Noarlunga, South Australia

This paper reports on the evaluation of the Healthy Cities (Noarlunga)Project which was one of the three original pilot cities inthe Australian Healthy Cities Project. The evaluation nethodologyused is outlined the project's organization and activities,and the data (from a variety of sources) used to assess itsachievements are discussed. These data were collected from arange of local informants including comnuinity members and froman analysis of the local print media. The implications of theevaluation findings for the development of the Healthy Citiesmovement are discussed.     

Addressing climate change through health promotion in Australia

Climate change is arguably the biggest global health threat of the 21st Century. While the spread of vector‐borne diseases and the health impacts of extreme weather events dominate discussions about health and climate change, there are also a range of other issues that are central to the health promotion community. Concerns such as food security; mental health; Indigenous health; and water quality are increasingly familiar. It is also undeniable that a shared vision of most health promoters to achieve environmental sustainability and to promote health equity is challenged by the threat of climate change. Health professionals are well positioned to address this threat, but action needs to be swift and sustained.