Geoff Green

Age-friendly cities of Europe.

This article summarizes how members of the European Healthy Cities Network have applied the ‘healthy ageing’ approach developed by the World Health Organization in their influential report on Active Ageing. Network Cities can be regarded as social laboratories testing how municipal strategies and interventions can help maintain the health and independence which characterise older people of the third age. Evidence of the orientation and scope of city interventions is derived from a series of Healthy Ageing Sub-Network symposia but principally from responses by 59 member cities to a General Evaluation Questionnaire covering Phase IV (2003–2008) of the Network. Cities elaborated four aspects of healthy ageing (a) raising awareness of older people as a resource to society (b) personal and community empowerment (c) access to the full range of services, and (d) supportive physical and social environments. In conclusion, the key message is that by applying healthy ageing strategies to programmes and plans in many sectors, city governments can potentially compress the fourth age of ‘decrepitude and dependence’ and expand the third age of ‘achievement and independence’ with more older people contributing to the social and economic life of a city.

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.

European Healthy Cities evaluation: conceptual framework and methodology

This paper presents the methodology, programme logic and conceptual framework that drove the evaluation of the Fifth Phase of the WHO European Healthy Cities Network. Towards the end of the phase, 99 cities were designated progressively through the life of the phase (2009-14). The paper establishes the values, systems and aspirations that these cities sign up for, as foundations for the selection of methodology. We assert that a realist synthesis methodology, driven by a wide range of qualitative and quantitative methods, is the most appropriate perspective to address the wide geopolitical, demographic, population and health diversities of these cities. The paper outlines the rationale for a structured multiple case study approach, the deployment of a comprehensive questionnaire, data mining through existing databases including Eurostat and analysis of management information generation tools used throughout the period. Response rates were considered extremely high for this type of research. Non-response analyses are described, which show that data are representative for cities across the spectrum of diversity. This paper provides a foundation for further analysis on specific areas of interest presented in this supplement.

Partnership structures in the WHO European Healthy Cities project

The development of new partnership structures for public health is an important goal of the World Health Organizations Healthy Cities project which covers a network of European municipalities. A review was carried out of the partnership structures and key changes arising from the project, based on the responses of 44 cities to a structured questionnaire, interviews with 24 city representatives and publications from the project from 1988 to 2003. Cities reported elaborate partnership mechanisms usually combining formal and informal working methods. Differences between cities could partly be related to differences in the way that local government is organized within countries and partly differences in local choices and circumstances. A relationship between the effectiveness of partnership arrangements and delivery of key elements of the project was discernable. Most cities reported having changed their processes for decision-making and planning for health as a result of membership of the WHO European Healthy Cities Network. One of the most potent stimuli for these changes was the action to which a city had committed as part of its membership of the Network.

Developing a Model to Estimate the Potential Impact of Municipal Investment on City Health

This article summarizes a process which exemplifies the potential impact of municipal investment on the burden of cardiovascular disease (CVD) in city populations. We report on Developing an evidence-based approach to city public health planning and investment in Europe (DECiPHEr), a project part funded by the European Union. It had twin objectives: first, to develop and validate a vocational educational training package for policy makers and political decision takers; second, to use this opportunity to iterate a robust and user-friendly investment tool for maximizing the public health impact of ‘mainstream’ municipal policies, programs and investments. There were seven stages in the development process shared by an academic team from Sheffield Hallam University and partners from four cities drawn from the WHO European Healthy Cities Network. There were five iterations of the model resulting from this process. The initial focus was CVD as the biggest cause of death and disability in Europe. Our original prototype ‘cost offset’ model was confined to proximal determinants of CVD, utilizing modified ‘Framingham’ equations to estimate the impact of population level cardiovascular risk factor reduction on future demand for acute hospital admissions. The DECiPHEr iterations first extended the scope of the model to distal determinants and then focused progressively on practical interventions. Six key domains of local influence on population health were introduced into the model by the development process: education, housing, environment, public health, economy and security. Deploying a realist synthesis methodology, the model then connected distal with proximal determinants of CVD. Existing scientific evidence and cities’ experiential knowledge were ‘plugged-in’ or ‘triangulated’ to elaborate the causal pathways from domain interventions to public health impacts. A key product is an enhanced version of the cost offset model, named Sheffield Health Effectiveness Framework Tool, incorporating both proximal and distal determinants in estimating the cost benefits of domain interventions. A key message is that the insights of the policy community are essential in developing and then utilising such a predictive tool.

Intersectoral Planning for City Health Development

The article reviews the evolution and process of City Health Development Planning (CHDP) in municipalities participating in the European Network of Healthy Cities 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 77 cities which participated in Phase IV (2003–2008) of the network. Evidence was gathered principally from a General Evaluation Questionnaire sent to all Network Cities. CHDPs are strategic documents giving direction to municipalities and partner agencies. Analysis revealed a trend away from “classic” CHDPs with a primary focus on health development towards ensuring a health dimension to other sector plans, and into the overarching strategies of city governments. Linked to the Phase IV priority themes of Healthy Aging and Healthy Urban Planning, cities further developed the concept and application of human-centered sustainability. More work is required to utilize cost–benefit analysis and health impact assessment to unmask the synergies between health and economic prosperity.

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.

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.

Is a healthy city also an age-friendly city?

Healthy Ageing is an important focus of the European Healthy Cities Network and has been supported by WHO since 2003 as a key strategic topic, since 2010 in cooperation with the Global Network of Age-friendly Cities and Communities. Based on the methodology of realist evaluation, this article synthesizes qualitative evidence from 33 structured case studies (CS) from 32 WHO European Healthy Cities, 72 annual reports from Network cities and 71 quantitative responses to a General Evaluation Questionnaire. City cases are assigned to three clusters containing the eight domains of an age-friendly city proposed by WHOs Global Age-friendly City Guide published in 2007. The analysis of citys practice and efforts in this article takes stock of how cities have developed the institutional prerequisites and processes necessary for implementing age-friendly strategies, programmes and projects. A content analysis of the CS maps activities across age-friendly domains and illustrates how cities contribute to improving the social and physical environments of older people and enhance the health and social services provided by municipalities and their partners.