Agis Tsouros

Health promotion and health systems: some unfinished business

One of the five action domains in the Ottawa Charter was Reorienting Health Services. In this paper, we reflect on why progress in this domain has been somewhat lethargic, particularly compared with some of the other action domains, and why now it is important to renew our commitment to this domain. Reorienting health services has been largely overlooked and opportunities missed, although good exceptions do exist. The occasion of the 25th anniversary of the Ottawa Charter represents an important opportunity for health promotion to: (i) renew its active voice in current policy debate and action and (ii) enhance achievements made to date by improving our efforts to advocate, enable and mediate for the reorientation of health services and systems. We outline six steps to reactivate and invest more in this action domain so as to be in a better position to promote health equitably and sustainably in todays fast changing world. Though our experience is mainly based in the European context, we hope that our reflections will be of some value to countries outside of this region.

City health development planning

The objective of this evaluation was to review the evolution and process of city health development planning (CHDP) in municipalities participating in the Healthy Cities Network organized by the European Region of the World Health Organization. The concept of CHDP combines elements from three theoretical domains: (a) health development, (b) city governance and (c) urban planning. The setting was the 56 cities which participated in Phase III (1998-2002) of the Network. Evidence was gathered from documents either held in WHO archives or made available from Network cities and from interviews with city representatives. CHDPs were the centrepiece of Phase III, evolving from city health plans developed in Phase II. They are strategic documents giving direction to municipalities and partner agencies. Analysis revealed three types of CHDP, reflecting the realpolitik of each city. For many cities, the process of CHDP was as important as the plan itself.

Health Promotion International: special supplement on European Healthy Cities

‘Health’ encapsulates a policy conundrum. Population health is by and large still associated with the institutions and activities of ministries of health and the health services sector. On the other hand, accumulating evidence on powerful social determinants of health (Wilkinson & Marmot, 2003; WHO Commission on Social Determinants of Health, 2008) is increasingly recognized in the multi-sectoral approaches to health promotion originally highlighted in the Ottawa Charter (WHO, 1986). The relevance of urban settings and the importance of action at the local and community levels have also gained prominence in the minds of public health leaders.

‘Social, innovative and smart cities are happy and resilient’: insights from the WHO EURO 2014 International Healthy Cities Conference

This paper provides a brief overview of, and elaborates on, some of the presentations, discussions and conclusions from Day 4 of the ‘WHO EURO 2014 International Healthy Cities Conference: Health and the City - Urban Living in the 21st Century’, held in Athens, Greece on 25 October 2014. The Internet of Things (IoT) is made of sensors and other components that connect our version of the world made of atoms, i.e., humans/our bodies, our devices, vehicles, roads, buildings, plants, animals, etc., with a mirror digital version made of bits. This enables cities and regions to be self-aware and dynamically reconfigurable in real- or near-real-time, based on changes that are continuously monitored and captured by sensors, similar to the way the internal biological systems of a living being operate and respond to their environment (homeostasis). Data collected by various IoT sensors and processed via appropriate analytics can also help predict the immediate future with reasonable accuracy, which enables better planned responses and mitigation actions. Cities and regions can thus become more adaptable and resilient in face of adversity. Furthermore, IoT can link atoms (humans) to other atoms (humans) (again via bits), resulting in the formation of ‘smart(er) communities’ that are socially connected in new ways and potentially happier. Cities, but also less urbanised regions and the countryside, could all benefit from, and harness the power of, IoT to improve the health, well-being and overall quality of life of the local populations, actively engage citizens in a smarter governance of their region, empower them to better care for one another, promote stronger social inclusion, and ensure a greener, sustainable and more enjoyable environment for all. Technology can also help reverse the ‘brain drain’ from the countryside and smaller towns to larger metropolises by making the former more attractive and connected, with better services akin to those found in larger cities. The article also discusses some ways of measuring and benchmarking the performance of smart cities and their impact on well-being. However, it should be emphasised that technology is not a panacea and that other factors are equally important in creating happier and healthier cities and regions.

Evaluating the impact of healthy cities in Europe

Background : Cities are engines of health development and not merely settings for health promotion. However, political scientists contest the extent of their powers and the scope of their influence. Methodology : Assuming local governance is a locus of decision-making about intermediate determinants of health, then there are three methodological challenges to evaluating its impact: first, accounting for context; second, addressing multiple, interactive interventions; and third identifying mechanisms for change. ‘Realist’ evaluation is more appropriate for this task than traditional paradigms of public health research. Review : Commissioned evaluations of the first three phases (1987-2002) of the WHO European Healthy Cities Network are reviewed against the three methodological challenges. Conclusions : These evaluations are stronger in identifying necessary city structures and processes but weaker, as are the Network cities themselves, in identifying change mechanisms which convert sector interventions into health gains. This lacuna is addressed in Phase IV (2003-2008) of the Network by the themes of healthy urban planning and health impact assessment.

Prevalence and determinants of current and secondhand smoking in Greece: results from the Global Adult Tobacco Survey (GATS) study

Objectives Greece is one of the leading tobacco-producing countries in European Union, and every year over 19 000 Greeks die from tobacco-attributable diseases. The aim of the present study was to provide nationally representative estimates on current and secondhand smoking prevalence in Greece and their determinants. Design Cross-sectional. Setting Greece. Participants A total of 4359 individuals participated in the Global Adult Tobacco Survey (GATS), a household survey of adults ≥15 years old (overall response rate 69%). They were selected through a multistage geographically clustered sampling design with face-to-face interview. Primary and secondary outcome measures In 2013, we investigated the prevalence of current and secondhand smoking and their determinants. Univariate and logistic regression analysis was used in order to identify possible risk factors associated with the prevalence of current and secondhand smoking. Results The prevalence of current smoking was 38.2% (95% CI 35.7% to 40.8%), and the mean number of cigarettes smoked per day was 19.8. Multivariate analysis confirmed that male gender (OR=3.24; 95% CI 2.62 to 4.00), age groups (25–39, OR=4.49; 95% CI 3.09 to 8.46 and 40–54, OR=3.51; 95% CI 1.88 to 5.87) and high school education (OR=1.97; 95% CI 1.41 to 2.74) were independently associated with the current smoking. Remarkably, responders with primary or less education had the lowest prevalence of current smoking (p<0.001). The prevalence of exposure to secondhand smoke at work, home and restaurants, was 52.3%, 65.7% and 72.2%. In total, 90.0% (95% CI 87.8% to 91.9%) of Greek population is exposed to tobacco smoke (current smoking and secondhand smoke). Conclusions Our results revealed an extremely high prevalence of current smoking and exposure to secondhand smoke among the adult population and a positive gradient between education and current smoking. These findings are alarming and implementation of comprehensive tobacco control and prevention strategies could be impactful in fighting the tobacco epidemic in Greece.

Twenty-seven years of the WHO European Healthy Cities movement: a sustainable movement for change and innovation at the local level

Healthy Cities in Europe was launched with the ambitious aim to put health high onthe social and political agenda of cities. This ambition resonates well with the understanding today of the significance of the social, economic, environmental, cultural and commercial determinants of health and the fact that health is ultimately a political choice. What was remarkable from the start was that city leaders from across Europe enthusiastically embraced the concept of a healthy city as a whole-of-local-government responsibility. Paradoxically, 27 years on, such an understanding remains an elusive challenge for national governments, even though the evidence of the effects of these determinants of health is immensely stronger today than it was then. The evolution of healthy cities in Europe can be seen as the history of modern public health through a local lens, covering 27 years of major political developments in Europe and globally, major changes in how health and sustainable development are understood and dealt with as well as majorchanges in the social and public health landscape of the WHO European Region. The WHO European Healthy Cities Network was for

Healthy Cities Phase V evaluation: further synthesizing realism

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.