WHO Healthy Cities

The WHO Healthy Cities Program has been around since the mid-1980s and but is not as well known in the United States as it perhaps should be. The program is focused on “health development through a process of political commitment, institutional change, capacity-building, partnership-based planning and innovative projects” (http://www.euro.who.int/en/what-we-do/health-topics/environment-and-health/urban-health/activities/healthy-cities). Healthy city activities typically focus on fostering collaborations and partnerships to promote health with a refreshing mix of interventions—policies, programs, and plans. Activities that won Healthy Cities Awards in recent years include schools that promote urban health, injury and violence prevention activities, best practices in public toilets, and healthy urban transportation (http://www.alliance-healthycities.com/htmls/awards/index_awards.html).

It’s hard to find exactly how many cities participate but the WHO European office claims that over 1,400 European cities take part in 30 national networks. As the network is global, presumably the overall numbers are much larger. An Alliance for Healthy Cities brings some of these cities together: http://www.alliance-healthycities.com/htmls/about/index_about.html 

The WHO European office has a useful healthy cities checklist that shows the wide range of topics of interest to the program from ecosystem health and public participation to diversity and economic vitality. You can read the whole list at http://www.euro.who.int/en/what-we-do/health-topics/environment-and-health/urban-health/activities/healthy-cities/who-european-healthy-cities-network/what-is-a-healthy-city/healthy-city-checklist. 

Design for Health on Flickr: Sets and Collections

Cyclist: Photo by Ann Forsyth

The Design for Health photostream now has hundreds of photos organized into “sets” such as “pedestrians” or “markets” and collections such as “Landscape”. Hundreds more photos will be added in the coming month. Check it out at http://www.flickr.com/photos/designforhealth/

Design for Health on Flickr

Urban Agriculture in Beihai, China. Photo by Ann Forsyth. Soon to be available on Flickr.

Design for Health now has a Flickr photostream at http://www.flickr.com/photos/designforhealth/. It will eventually contain all the images now available in the DFH web site under image resources: http://designforhealth.net/resources/imageresources.html. However, we will gradually add others from around the world. Most images are by Ann Forsyth except where noted specifically (for example some are from Kevin Krizek).

Research Summaries: Some Links

For practitioners interested in integrating health research into planning and design, the task can be daunting. There are many articles that touch on the topic of the connection between people, health, and place but with varying levels of relevance, research quality, and cost (and many can be quite expensive to those who don’t have university library subscriptions). Into the gap have come a number of organizations creating practice-oriented research summaries.

InformeDesign summarizes many articles, and has an easy search interface, which is very helpful: http://www.informedesign.org/Default.aspx. To find syntheses that evaluate the balance of evidence one needs to go to other sources.

UCLA HIA-CLIC has some helpful summaries of research organized by sector (e.g transportation) and pathway (e.g air quality) http://www.hiaguide.org/sectors-and-causal-pathways. Not every issues has information—a number are forthcoming—but it’s generally a helpful site.

Design for Health’s research summaries are now 3 or 4 years old: http://designforhealth.net/resources/researchsummaries.html. This is more of a problem in the area of physical activity and food—where there has been a lot of recent research—than in the other topics where there are fewer new studies. For those wanting to get updated research there are larger topical pages listing other resources: http://designforhealth.net/resources/generalhealthissues.html and a list of web sites by topic is available at http://designforhealth.net/resources/websites.html.

UN Habitat Reports on Health

UN Habitat produces and distributes a large number of reports, many related to health with numerous publications on water infrastructure, social inclusion, disaster management, housing issues, and climate change. Although you can buy printed reports that isn’t always necessary as many can be found for free.

Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings (2010), produced in collaboration with the World Health Organization, provides a good overview of the history and current situation in terms of cities and health. Topics cange across the natural and build environment, social and conomic issues, food secutiy, health services, and general urban governange http://www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=3049

Diagram from Hidden Cities

Collection of Municipal Solid Waste , Key issues for Decision-makers in Developing Countries (2011) grapples with an important problem in public health. Written in a very accessible style it answers practical questions about how too extend solid waste collection to a wider population. http://www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=3231

A Global Assessment on Women’t Safety (2008) focuses on tools for enhancing safety including public education, adviacey, participatory approaches, and changing public spaces. It’s part of a series of reports on this topic http://www.unhabitat.org/pmss/listItemDetails.aspx?publicationID=2848

Planning for Healthy Places with Health Impact Assessments

A screenshot of the online slide show

A few years back the American Planning Association in association with the National Association of County and City Health Officials created the online course Planning for Healthy Places with Health Impact Assessments at http://professional.captus.com/Planning/hia/default.aspx. Don’t be put off by the initial survey that you have to fill in to get into the site—it’s short and you don’t need to be an APA member to access it! Sponsored by the Centers for Disease control and Prevention the initial course was developed by Rajiv Bhatia, Laura Biazzo, MPH, Division of Nutrition and Physical Activity of the Centers for Disease Control and Prevention, Brian Cole, Andrew Dannenberg, Carrie Fesperman, and Candace Rutt.

With Christine Green from APA and Nisha Bochwey from the University of Virginia I’ve worked to update the program (without changing the voiceover except for one short additional module!)—Christine is the maven of resources and Nisha did a stellar job on quizzes. There are a lot of new examples. The computer generated voice is a bit weird but the content is a good introduction to HIA—and thanks to the CDC it’s free.

What’s in a Name?

Plan available directly from the
City of Bloomington

Recently, I was looking at the Pew Health Impact Project web site and noticed a featured HIA: the Xcel Energy Corridor: http://www.healthimpactproject.org/resources#reports

This is an excerpt from a plan featured on the Design for Health web site (one of the 19 Minnesota communities in Phase 1 of the project). On Design for Health site it is listed under the place name (Bloomington) and plan name (Alternative Transportation Plan) at http://www.designforhealth.net/cases/bloomington.html

Whatever the name it’s great to have these examples featured in multiple places.

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Food Resources

Food stall in Stockholm. Photo: Ann Forsyth

How people get access to healthy food is a concern to many. I’ve recently had some requests for information. Design for Health resources include an "issues sheet" with ideas for incorporating food into planning and a research summary. Links include a food security assessment, also featured on an earlier blog http://healthymetropolis.blogspot.com/2010/11/tools-food-security-assessments.html

The APA's national healthy communities center has a food interest group is also a terrific resource as are its numerous publications on this issue: http://www.planning.org/nationalcenters/health/food.htm

Visuals: What Does a Rapid HIA Look Like?

This blog has dealt earlier with the logistics of doing an HIA but what does a workshop look like? One source is the Arden Hills Healthy City Planning Workshop Summary Report Appendices. This document contains images of each stage of the half-day workshop. Go to http://designforhealth.net/pdfs/cases/HIA_ArdenHills_Appendices_3June2010.pdf and look at pages 33-36. More information about the process is available at: http://designforhealth.net/cases/ardenhillsworkshop.html.

Images from Arden Hills workshop. Photos: Design for Health.

Tools: What is a Rapid HIA?

On the face of it Rapid HIAs are quick, but that's not the whole story. A rapid HIA while faster than a full, environmental impact assessment-style HIA, still takes some time. It is also different to some other quick HIA types such as desktop screening or scoping exercises.

Students performing a practice health impact assessment
at the School of Planning and Architecture, Vijayawada

Fundamentally a rapid  HIA is an interactive workshop—taking half a day or a day--that brings together stakeholders to identify and assess health impacts. However, additional time is needed to engage stakeholders in identifying key concerns and interest groups, to prepare background docuemtns for the workshop, have participants read those docuemtns, and write up the results. The good news is that a lot of the background information is similar to typical analyses that are standard in many planning and public health processes. Background information on health is available from several sources. Examples of completed HIAs are online.

Several toolkits are also available.

Design for Health  has two versions. The most recent Rapid HIA toolkit was ublished in 2008 but will be updated over the coming year. It draws on a number of previous examples, including the famous Merseyside model.  In 2010 DFH conducted a rapid HIA, termed a Healthy City Planning Workshop. This took a more flexible approach than the 2008 toolkit and also adapted worksheets from a number of recent HIAs. The reports from the workshop include basically all the information used to run and report on the HIA workshop--the actual information packet provided to participants in advance; the agenda of the meeting, copies of handouts, worksheets, and presentations from the workshops; a series of photos keyed to parts of the agenda; and the workshop’s summary report. This makes the report usable as a toolkit.

The Merseyside Guidelines for Health Impact Assessment (2001) published by the International Health IMPACT Assessment Consortium, is often cited as the most widely used HIA model in England. 

Human Impact Partners, Oakland provides several relevant tools including a number of guides and worksheets: http://www.humanimpact.org/hips-hia-tools-and-resources. Be sure to scroll down the page because a lot of the more interesting material is at the bottom.

Resources: Health, Place, and Children

Children, because they are still growing and developing, often suffer from different or additional health risks compared with adults. There are many useful resources on this topic--I list a few below specifically tailored to health and places.

Feeding chickens. Photo: Heather Forsyth

• Children's Health Protection 
  Sponsored by the U.S. Environmental Protection Agency (EPA), this Web site has a terrific search feature for looking up publications related to where children live, learn, and play. Their Children’s Environmental Health section has additional resources:including a site on indicators called America’s Children and the Environment.
• Guide to Community Preventive Services
  This resource from the Centers for Disease Control and Prevention (CDC) provides a study titled “Community Interventions to Promote Healthy Social Environments: Early Childhood Development and Family Housing,” which gives recommendations from reviews of HUD Section 8 Housing Vouchers, Rental Vouchers and preschool programs based on early childhood development intervention success. There’s also a section on adolescent health, focused on broad health topics.
• Effective Interventions to Tackle Inequalities in Children's Health
  This London Health Commission report provides a summary of “what works” —or what appears to work—in relation to the aims and interventions proposed in the draft children and young people's strategy; examines other interventions with strong evidence of effectiveness in reducing inequalities in child health; and identifies where there are gaps in the evidence.

Some additional resources are available at http://www.designforhealth.net/resources/children.html

Resources: Planning and Active Living

Active living, the idea that it’s good to build exercise into daily life, has been big news in planning for a while but I still get questions about how to incorporate active living into plans. A decade ago, when it was a fairly new idea, there was the hope that if we built places where people were more prone to do activities like travel walking, that they’d keep exercising as well, increase their total activity, and reduce weight. It turns out to be a bit more complicated than this as I noted in my blog on high density and overweight adolescents in China. Research is quite mixed in its findings—there’s a lot of variation in how people respond to environments. Programs, policies, prices, education, and attitudes all shape how people use environments. But as a bottom line it is useful to provide options for people to be active in different ways so that when they want to do so they can. 

So how can you help provide options? Several web sites provide case studies of communities have done this work.

Mexico City Cycle Day, 2011

• Active Living by Design has been around since 2001 and has a useful web site. The group has worked with a number of cities and countied and provides case studies linked to an onsite map: http://www.activelivingbydesign.org/communities.
• The APA has a webinar with some practice examples: http://www.planning.org/nationalcenters/health/education/webinars/activecommunity.htm
• Design for Health also highlights some alternative transportation plans including ones by Bloomongton and St. Louis Park. Some of the questions in the DFH Comprehensive Plan Review checklists also target active living—noted in a column: http://www.designforhealth.net/resources/checklists.html

Tools for Conducting an HIA on a Comprehensive Plan

I’ve recently had a number of queries about how to conduct a health impact assessment on an existing comprehensive plan. This is a great thing to do because it can help prioritize changes in an update: http://healthymetropolis.blogspot.com/2010/12/when-in-planning-or-policy-process-does.html. How to conduct an HIA is a big topic, but fortunately there are a lot of resources available with more coming online over the next year.

One place to start is the set of Comprehensive Planning Checklists on the Design for Health web site: http://www.designforhealth.net/resources/checklists.html. They are based on evidence--though there is stronger evidence for the “essential for health” sections than the “good for health” ones. Each question has a column that explicitly states which area of research it is based on and these are described more fully in online research summaries (see next point). These checklist are also broken into standard categories for comprehensive or general plans in the United States. Two other resources, highlighted in an earlier blog, may be useful: the Australian Healthy Urban Development Checklist and British Delivering Healthier Communities in London.

Research Summaries that form the basis of the DFH checklists that are available for free: http://www.designforhealth.net/resources/researchsummaries.html. The current versions reperesent work up to about 2007 or 2008 and in fast developing areas--such as food--we’ll be preparing updates in the next year. For extra information in the interim you might look at the "pathways" section of HIA-CLIC http://www.hiaguide.org/sectors-and-causal-pathways/pathways.

Model of Downtown Tianjin in the
Tianjin planning museum.
Photo: Ann Forsyth.

For advice about what to do after you have used the checklist and done your evaluation, the Design for Health web site has Information Sheets linked to the research summary topics that have examples and cases:
http://www.designforhealth.net/
resources/planningissues.html

In addition, a course on Planning for Healthy
 Places with Health Impact Assessments by the American Planning Association in association with the National Association of County and City Health Officials, is also a good place to start: http://professional.captus.com/Planning/hia/default.aspx. It is currently being updated by a team including Christine Green and Kimberly Hodgson at APA, Nisha Botchwey from the University of Virginia, and myself, with advice from Dee Merriam of the CDC. The update will substantially expand the resources section so there will be lots more information than this brief note can provide.

How Do People Connect Places and Health in Practice?

I am often asked how to connect health and place, practically. There are two main ways of thinking about this--one relates to topics and another to methods.

In terms of topics there are several lists available. Most end out looking like the following list, adapted from Design for Health (http://www.designforhealth.net/resources/generalhealthissues.html). However other, quite similar, lists exist (http://www.hiaguide.org/sectors-and-causal-pathways/pathways). They mix health issues and environmental features mainly because different issues are thought about in those terms. They also play out differently for various groups including children, seniors, people with low incomes, and so on.

Self-build housing in Beihai, China

• Accessibility to places, people, and services that can promote health
• Air quality
• Disasters--including climate change
• Environment + housing quality related to pollutants
• Food quality
• Healthcare access
• Mental health--often related to stress (e.g. plants can reduct stress)
• Noise
• Physical activity options
• Safety—from accidents and crime
• Social capital/connections--with complicated relations to place
• Water quality

A range of methods help practitioners make these connections:

1. Policy and Program Collaborations: The UN Healthy Cities Program is an example, focusing on building awareness and collaboration among partners including governments and universities.
2. Health Impact Assessments: These are actually a range of tools, both participatory and technical, aiming to link local knowledge and health research/data maximize health benefits+ minimize health risks for all groups. They can be done on a range of policies, programs, and plans, not only ones affecting places.
3. Quality of Life Tools: This is a term for a range or preexisting tools and methods that focus on the connection of people and place, and connections between people. Examples include safety audits, food security assessments, and asset maps. Various social development tools such as anti-racism trainings with a place-based approach, also fit in this category.
4. Healthy Community Plans and Designs: Such proposals translate health research into practice at scales from the building to the region.

Tools: The National Collaborative for Childhood Obesity Research Measure Registry

Recently I highlighted work of the National Collaborative for Childhood Obesity Research (NCCOR). a group spearheaded by the National Institute of Health, Centers for Disease Control, and Robert Wood Johnson Foundation. They have now released a new tool, or rather a registry of measures related to diet and physical activity: http://tools.nccor.org/measures/. I was part of the team on this project. My role was cataloging some of the physical activity measures, a mix of “questionnaires, instruments, diaries, logs, electronic devices, direct observations of people or environments, protocols, and analytic techniques.” Overall there are over 700 measures.

Example of Straight Line and Network
Buffers Created Using GI

The main search page at http://tools.nccor.org/measures/ allows users to search by domain (e.g. Individual dietary behavior, food environment…), measure type, age of people measured (though as this information seems to have been unevenly cataloged I found it not so useful for environmental measures), and context or type of place. Measures with reliability and validity information, as well as those used in studies of children and adolescents, were given priority. However, for the domain of physical activity environments this would have limited the measures too much so these are drawn from a wider range of sources.

Research: High Density and Overweight Adolescents

I typically don’t report on scholarly studies in this blog but recently came across a nicely designed study that makes a larger point—that the links between health and place are complex. Fei Xu, JieQuan Li, YaQiong Liang, ZhiYong Wang, Xin Hong, Robert S Ware, Eva Leslie, Takemi Sugiyama, and Neville Owen have produced a report  on the Nanjing High School Students’ Health Survey, published in the Journal of Epidemiology and Community Health in 2010 (64, 1017-1021, http://jech.bmj.com/content/64/11/1017). Titled: “Residential density and adolescent overweight in a rapidly urbanising region of mainland China” the study used data collected from 2,375 adolescents in 2004 to examine the relationship between (large-scale) district level densities and weight.

New high rise behind village
residences in suburban Shanghai, 2010

Densities are reported per square kilometer but in range from 5 persons per hectare to 307.  The study divided the sample into high, medium, low density residents. Youth in the middle and higher density areas (that is over > 35 person per hectare) were roughly  twice as likely to be overweight.

The relationship was reduced a bit but still significant after controlling for TV time, study time, recreation, age, gender, and parents education. Physical activity data came from self reports through a version of the International Physical Activity Questionnaire (IPAQ) that only asked about some kinds  of activities. Given a lack of data on overall physical activity and food intake the authors speculate on a number of reasons for this difference e.g. youth in higher density and potentially higher income areas eating more, higher density areas having less recreational space, or (and here I am paraphrasing quite loosely) that higher density areas may just be too convenient with too much internet access so youth don’t have to expend much energy getting places. The high densities in China are also quite high compared with the US and Australia in particular, where much research has been done. They are also increasing rapidly—the authors report overall densities in Nanjing, presumably including some rural districts, increasing from 14 persons per hectare in 1997 to 23 in 2007.

The study is interesting because in many studies of adults, those in higher densities walk more for transportation (though they may not walk more overall) and some find they are thinner (though not all studies measure this or find it to be true, including my own). In this study of youth, with a large group and fairly good measures, those in higher densities are chubbier. While it is important not to make too much of one study, this is yet another example of the complexity of the relationship between health and place, and the importance of social factors.

Tools: The Pedestrian and Bicycling Survey (PABS)

I’ve recently been involved creating a new survey for measuring transportation behavior, particularly walking and cycling.  The Pedestrian and Bicycling Survey (PABS) is a mail out/mail back survey designed to be an inexpensive means for local governments to learn about nonmotorized transportation use in their communities.

An important component of the design of the PABS was creating a probabilistic sampling approach that would be relatively straightforward to administer and, if desired, could be carried out in house (within municipal agencies). While other sampling approaches—such as snowball sampling across the internet—can achieve a large number of responses, the probability of any person being asked to take the survey is not known making it a challenge to generalize from the sample to the wider population.

Pedestrians in suburban Hong Kong

Documentation includes a report outlining how the survey was developed and the results of reliability (repeatability) sampling. A manual provides step by step guidance about how to use the survey too. The survey is provided at the end of both documents and is available in English and Spanish. Materials are available for download at http://transweb.sjsu.edu/project/ 2907.html (scroll down to find the manual).

Future plans include creating a more modular version so users can mix and match sections to suit the questions they need answered. Updates will be available at http://www.designforhealth.net/health/PABS.html.

Tools: The National Collaborative for Childhood Obesity Research Catalog of Surveillance Systems

The National Collaborative for Childhood Obesity Research is a group spearheaded by the National Institute of Health, Centers for Disease Control, and Robert Wood Johnson Foundation. The Catalog of Surveillance Systems is a new product, also sponsored by the USDA. The catalog provides a searchable database of ongoing monitoring systems related to health. It includes both public systems such as the Census of Agriculture and National Vital Statistics System and private ones such as the Nielsen Homescan and InfoUSA.com. In all, 77 systems are represented.

The database can be filtered by keywords related to the level (person to community to policy), scope (local, state, national), key health variables, age groups, ethnicity, research design, and cost to use.

Each system has an individual entry including information on distinctive characteristics, sampling, key variables, costs, whether information is linked to geographical databases or to other surveys, example publications using the data, and other resources.

This is an extremely useful database and can provide a quick point of entry for those interested in assessing what data are available.

Mapping Health Issues with GIS: Participatory Approaches

Participatory GIS is a growing field. For those interested in integrating participatory GIS into healthy planning, several web sites provide helpful illustrations of the potential.

Public Participatory GIS based in a company called Vertices in New Brunswick, New Jersey, (http://www.ppgis.info/) provides illustrative maps on topics from bike crashes to a calculator for calories burned walking different routes. Not all maps are local, for example the public health maps rangr from alcohol sales places in New Orleans to food sales in Philadelphia.

Transparent Chennai (http://www.transparentchennai.com/), at the Institute for Financial Management and Research, uses GIS but with a focus on topics such as squatter settlements, environmental hazards, and other aspects of quality of life. What is particularly handy about this site is one can build a map from different kinds of information including environmental, political, infrastructural, and social issues: http://www.transparentchennai.com/buildamap/. This site really shows the potential for a fairly integrated yet still user driven experience that could be particularly helpful for those interested in working with communities on issues of health and place.

Part of a map from Transparent Chennai

Map Kibera (http://mapkibera.org/) started in 2009 by several NGOs in a large squatter settlement in Nairobi Kenya, reportedly was an inspiration for Transparent Chennai. The site has a lot of information apart from maps, showing how different kinds of information—spreadsheets, a blog, twitter, a wiki, and so on—can be linked.

For a more technical, expert-led approach to using GIS see the DFH Threhold Analysis HIA  and research oriented NEAT-GIS and LEAN-GIS protocols. These can however be used in a participatory setting. The Arden Hills Rapid HIA used similar maps as background information, for example (see report appendices).

My thanks to Azhar Tyabji, at the Institute for Financial Management and Research, for leading me to his colleague Nithya V. Raman (and her team’s) work on Transparent Chennai.