HEAL THY CITIES - HEALTHY ISLANDS PROGRAMME
The WHO programme "Healthy Cities - Healthy Islands" for the Western Pacific Region has been developed in response to the need of Member States to integrate efforts of various stakeholders in improving the health of people living in urban areas and islands. The objectives of the programme are: (1) to minimize health hazards in urban areas/islands through the integration of health and environmental protection measures in the physical and economic planning process; (2) to enhance the quality of the physical and social environment supportive of health in urban and island settings; (3) to increase public awareness towards healthier behaviour, lifestyle and habits; (4) to improve the provision of health services through developing appropriate health care systems in urban areas and islands; and (5) to upgrade country capabilities and develop policies to improve health in urban areas and islands through better intersectoral coordination and public participation. ******************************************************************************
This document was prepared by Dr Takehito Takano, Professor, Health Promotion/International Health, The Graduate School of Tokyo Medical and Dental University, in collaboration with the Healthy Settings and Environment Focus of the Building Healthy Communities and Population Division of the WHO Regional Office for the Western Pacific. ******************************************************************************
The documents in the Healthy Cities - Healthy Islands Series are published informally by the Healthy Settings and Environment Focus of the Building Healthy Communities and Population Division of the WHO Regional Office for the Western Pacific. The findings, interpretation and conclusions are entirely those of the authors.
Printed and distributed by:
World Health Organization Regional Office for the Western Pacific P.O. Box 2932, 1000 Manila Philippines
Telephone No.: (632) 528 8001 Facsimile: (632) 521 1036 E-mail: postmaster@wpro.who.int
WHorWPRO LIBRARY MANILA, PHILIl'PINES
10 jUL 2002
Contents Page
1 INTRODUCTION 2 EVALUATION FRAMEWORK 2.1 Evaluation Framework 2.2 Evaluation with People in the Community ~ "Doing Research Together"
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2 2 3
3 CITY HEALTH PROFILES 3.1 Baseline Indicators for Healthy Cities 3.2 City Health Profiles 3.2.1 Practical Methods: General Outline for Developing Healthy City Profile 3.2.2 Examples • Table of Contents • Information / Data to Collect • City Health Profile Working Group Membership
5 5 6 6 7
4 NEEDS AND RESOURCE ASSESSMENT 4.1 Community Health Needs Survey 4.1.1 Practical Methods • Conducting Household Interview Survey • Details on How to Train Interviewers 4.1.2 Examples • Interviewer/Recorder Manual • Sample Questionnaire 4.2 Resource Mapping Walk 4.2.1 Practical Method: General Procedural Outline of the Resource Mapping Walk
11 11 11
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15 15
5 ANALYSIS AND CONSENSUS BUILDING 5.1 Health Determinant Analysis 5.2 Geographic Information System
17 17 18
ANNEX Example of Baseline Indicators
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1
INTRODUCTION
Healthy Cities projects aim to improve the health of city dwellers through improved living conditions and better health services in association with various urban development activities. An underlying intention of a Healthy Cities project is to bring together the partnership of the public, private and voluntary sectors to focus on urban health and to tackle health issues in a broad participatory way. To make Healthy Cities projects more influential to the population health in the long-term, we should have substantial evidences on the health status of city dwellers, various health determinants that impact their health, community's view on Healthy Cities, community-based practices, legislations, and operations ofthe Healthy Cities projects. It is obvious that evaluation activities are necessary to obtain these evidences relating to Healthy Cities. The importance of evaluation has already been emphasized in the Regional Guideline for Developing a Healthy Cites Project. It is generally considered that there are two different meanings of evaluation. One is a classical evaluation and the other is a newly developed evaluation framework. The classical evaluation is usually conducted after the project. This classical evaluation is not sufficient when dealing with a complicated process and a complex web of interactions of urban problems. Healthy Cities requires a new evaluation framework because the Healthy Cities project requires a comprehensive strategy and deals with a package of policies. The underlying intention of Healthy Cities is to bring together the partnership of the public and private sectors and community to focus on urban health and to treat health issues in a broad way. The evaluation framework for Healthy Cities should be based on that viewpoint. The following chapters introduce an evaluation framework for Healthy Cities with some examples actually conducted in selected cities in the Western Pacific Region. Practical methodologies for data collection, surveys, community studies, and analysis are given based on experiences in the regIOn.
2 2.1
EVALUATION FRAMEWORK
Evaluation Framework
The newly developed evaluation framework is comprised of four parts: (1) city health profiles;
(2) needs and resource assessments; (3) analyses and consensus building; and (4) periodical monitoring. This framework is in line with the Regional Guidelines for Developing a Healthy Cities Project.
Evaluation Framework Analysis and Consensus Building
(1. I..k.no, 2(00)
Profiles of the health status and environmental conditions of the city are necessary to support each step of the progress of Healthy Cities projects. They provide a statistical foundation for the development of communities as well as of the country. A city health profile provides baseline data. It gives substantial data enabling an understanding of health issues in the particular city's background. It is used to identify priority issues to be focused upon by action plans for Healthy Cities. A city health profile is updated periodically. This updating process is a part of monitoring. The changes in the profile according to the progress of Healthy Cities projects can be considered as outcomes of the projects. Making a health profile will bring the following benefits, including: • • • • Giving comprehensive views about health and environment Providing current status, trends from the past, and future projections Facilitating information sharing among various sectors Involving multiple sectors in collaboration
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• • • •
Supplying baseline data Enabling evidence-based decision-making Serving as an essential tool for a planning cycle Raising awareness of health and environment
Development of a health profile must be done under an appropriate evaluation framework. Needs-resource assessment is a first step to directly review community needs, existing resources and past experiences. Measures to conduct needs-resource assessment usually comprise of household surveys and resource mapping. It is indispensable to employ a participatory style in conducting surveys and mapping through the participation of community residents and professionals of various levels and sectors. A systematic survey based on scientifically proven methods ensures the accumulation of reliable data for planning and decision-making. The next step is analysis and consensus building. Analysis is a process to analyse obtained indicators, outcomes ofI he surveys, and profiles of the city as well as the projects. Expertise in analysis is required. The results of the analyses should be presented in forms appropriate for information sharing among the community and multiple concerned sectors. These results contribute to consensus Building for making the most desired policies/activities. The other component is Periodical monitoring. Monitoring helps the project achieve its goals in the most efficient manner. For example, airplanes and ships alike cannot reach their destinations without proper navigation - they need to know their current locations, destinations, and speed all the time. In the same way, monitoring plays a navigating role in propelling program development. The city health profile supports the planning cycle. It is necessary for all these stages: Plan, Do and See. Evaluation provides substantial data and well-thought-out resolutions delineated from the analyses. It proposes solutions to urban health issues according to a particular city's circumstances. It helps understanding of a comprehensive view of a city's health situation and leads to a comprehensive strategy. A city health profile enables us to see visible outcomes brought about years after the intervention of Healthy Cities projects.
2.2
Evaluation with People in the Community "Doing Research Together"
The evaluation framework requires participation by the public as well as many concerned sectorsThe Process of evaluation offers Opportunities for capacity building, community development, and intersectoral collaboration. Institutional capacity will be expanded in the city. The evaluation activities with people in the community working together for Healthy Cities are typical of "Doing Research Together". Community participation for making baseline data is a very important process for creating awareness, and also a good opportunity for encouraging involvement of the people. It is worthwhile to involve professionals who have the ability to work with community people and to carry out appropriate arid understandable general research together with those people for the development of the program. It is necessary for the Healthy Cities planners to acquire the ability to analyse the relationship among various factors in both physical and social environments III the context of health status in order to demonstrate visible outcomes from the Healthy Cities project/programme.
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The outcome of these research activities is persuasive to the public as well as to administrators, the private sector, and other people. Using objective data is an important point to involve other sectors and to obtain high political support for Healthy Cities projects. Analysis on the basis of evidential data is essential to formulate the most effective plan for the Healthy Cities program, to involve various sectors, and to obtain visible outcomes. In addition, it helps the members of the Healthy Cities team recognize the validity of what they are doing. The members who have done these research activities become more convinced that the Healthy Cities approach is valuable and effective.
Doing Research Together activities facilitates vision sharing and interpretation! clarification of the present situation. By conducting participatory research, participants, communities, and professionals would develop skills for: comprehensive planning, capacity building, and discovery of resources. Essential steps of Doing Research Together are: preparation, baseline work, fieldwork! survey, analysis, feedback, and disseminatIOn.
Preparation I I
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aseline
I
Analysis
[Feed l-(T:C:OT:-:ak-an-o-,~2()()=O)---
.. Dissemination)
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3 3.1
CITY HEALTH PROFILES
Baseline Indicators for Healthy Cities
The WHO Tenninology Infonnation System defines 'indicator' as 'A variable with characteristics of quality, quantity and time used to measure, directly or indirectly, changes in a health and health-related situation and to appreciate the progress made in addressing it. It also provides a basis for developing adequate plans for improvement.' Baseline indicators are used for health profiles and provide appropriate platfonns for monitoring and evaluation. Many statistical resources to develop baseline indicators are already existing in the current administrative and other institutions. Several categories for baseline indicators were identified to be useful for Healthy Cities. They are: • • • • • • • • • • • Population Health Urban Infrastructure Environmental Quality Housing and Living Environment Community Action and Activities Lifestyles and Preventive Activities Healthcare, Welfare, and Environmental Health Services Education and Empowennent Employment and Industry Income and Family Living Expenses Local Economy Demographics
Situations in individual city's situation may differ. However, the efforts to fonnulate some indicators for each categories are useful in the evaluation framework. The ANNEX gives examples of individual indicators to be taken in each city's situation. Some indicators can be fonnulated by computing existing statistical data; some indicators require efforts to collect original data. Setting up a system to compile existing statistical infonnation stored in different sectors and institution is important for evaluation framework for Healthy Cities. Efforts to establish a system to collect original data that are required for baseline data but are not found in the existing statistical infonnation sources are valuable because a new system can be a part of periodical monitoring. By reporting the needs of a city, describing resources available in a city, and addressing the characteristics of a city, indicators give us a clear, objective image of that city. Because of the comprehensive nature of Healthy Cities, practitioners, decision-makers, and researchers need multi-faceted infonnation. Indicators help people share infonnation, particularly when people from different sectors sit at the same table. Indicators collected by community based assessment and evaluation reinforce the community's view. Indicators fonn a basis to develop baseline data and city health profiles. Collecting appropriate indicators is also an important part in establishing a Geographic Infonnation System (GIS) for Healthy Cities programs. This GIS enables us to make more accurate analyses, such as image diagnosis. These activities are essential to effective planning.
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3.2
City Health Profiles
A city health profile presents reliable information in a user-friendly and publicly understandable manner. This is a tool to facilitate information sharing among people of various departments or organizations, as well as community people concerned for a Healthy City. A city health profile gives a comprehensive view s and some background information on the health and environmental situations of the city. Developing a city health profile is identified as one of the steps in the development of a Healthy City project. The process of formation of a city health profile requires intersectoral collaboration. This process is beneficial for periodical monitoring step as well as for good planning and implementation of the Healthy Cities project.
3.2.1
Practical Methods: General Outline for Developing City Health Profiles
The following gives an example of practical step-by-step points that practitioners should consider, in developing a city health profile in a given city: (1) Convene multi-sectoral group meeting. (2) Understand goals and develop strategies and reach an agreement on them. (3) Get political support to achieve the goals. (4) Share expected outcomes and benefits. (5) Develop general administrative framework (e.g. a timeframe) and decision-making rules. (6) Develop a shared understanding and a common discussion platform by going over examples of city health profiles from other cities and some results of health determinants analysis. (7) Discuss what indicators should be included in the profile and how to collect them (who may have or could provide the information). (8) Make divisions of responsibility and form working groups according to tasks. Select a leader for each group. (9) Set deadlines for the collocation of data. (10) Meet and present collected data by each working group. (11) Put together the collected information. (12) Produce preliminary version ofthe profile. (13) Discuss the preliminary version for improvement. (14) Complete the final version.
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(15) Share the final version with concerned people and groups. (16) Set the date for reviewing the profile and data renewal.
3.2.2
Examples
Table o/Contents The following gives a general outline of city health profiles. Detailed contents should differ from city to city. Discussion based on this framework with multi-sectoral working group is useful.
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City's Experiences for Developing Healthy City • In the past, finished ones - impact, effects • Existing, carried out, on-going - how it is going • In the future Health and Environmental Conditions of the City 2.1 Health condition along with our life cycle 2.2 Factors affecting our health 2.2.1 Introduction - History / Culture 2.2.2 Demography 2.2.3 Lifestyle 2.2.4 Health care resource 2.2.5 Preventive activities 2.2.6 Community activities 2.2.7 Housing / Sanitation / Environment 2.2.8 Education / Employment / Agriculture / Industry / Productivity / Income 2.2.9 Land use / Urban infrastructure
2
3
Needs / Resources • (Results of household surveys) • (Results of mapping events) • (Others) Legislation and Regulation Future of Our City
4 5
In/ormation / Data to Collect The following table give examples of information to collect by categories. Some figures can be used for city health profile as they were; some figures are appropriate to be transformed by calculating rates or proportion. Some figures need to be adjusted, for example, by age distributions for comparison. Data sources and how they were collected are important to understand the real meaning of the figures. Note of the data source s are very useful to conduct monitoring smoothly. It is desirable to formulate a systematic process of collecting data from wide-range sources. This will facilitate periodical monitoring by systematic updating of city health profile.
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Example of Information I Data to Collect Introduction of Healthy City concept Creation of multi-disciplinary and multi-sectoral teams • Development of Healthy City steering committee Programs for improving health and sanitary conditions • Programs for community development, city development (Summary of experiences of the past and current programs) (Review impacts and effects of the programs) I List of projects by contents initiated List of projects by contents in progress • List of projects br contents completed .. Health condition • Number of death (by age and sex, by causes) • Mortality rate (crude death rate, infant mortality, maternal mortality, age specific mortality, cause specific mortality) Number of patients (by age and sex, by causes) Morbidity rate Communicable (incidence rate of food-, water- and vector-borne diseases, immunisable diseases, STDs) Non-Communicable (prevalence rate ofCVD, DM, obesity among school children) - InjurieslAccidents (motor vehicle accident) - Crime (cnmerate) Disabilities I I Occupational injuries ~ ______~________+-____~~(~su~b~·~e~ct~iv~e~he~a=l=th~co~n=d=i=ti~o=nL)__________________ I Background • Administrative units I History Villages, households, family, settlements Culture Topography I. History Culture , Climate ~-------. ..~I--~==~~~~ I I. Total population I Demography (with land area - knl) Population by age group and sex Age and sex I (population pyramid) Ethnic group Number of birth, birth rate i Fertility rate Marriage, divorce Teenage pregnancy • • Sin Ie mothers Lifestyle • Nutrition • Drug addiction • Smoking • Exercise • Famil relationship • Number of hospitals, clinics, pharmacies Health Care Resource • Number of health staff • Availability of hospital, community health services • Envirorunental services such as food inspector, enforcement , • Family planning i I • Maternal ant!."child health care services _______________________ Category City's experiences
• • •
• •
.~
• •
____
I. I. I·.
• • • • • •
L ______ 8
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Catee:orv Preventive Activities
• • • • • • • • •
•
Community Activities
• •
Housing Sanitation Environment
• • •
•
• • • • • • • •
• • •
• I
I 'I
EducatIOn Employment Agriculture Industry Productivity Income
• • • • • • • • • • •
I
•
Example of Information / Data to Collect Number of children receiving immunization Number of attendance to antenatal care Number of people receiving health information Screening rate for cervical and breast cancer Health education at school AIDS awareness programmes Smoking education Nutritional education Health education to community (inununization and breast feeding, prevention of TB/AIDSlDengue/ARIldrug abuse, skin diseases, hygiene and sanitation, etc.) Availability of school, community centre, sports facilities Community committee for health improvement (health volunteer, TBA, district committee for urban/rural development, etc.) Sources of health information (media, education materials) Sanitary Public Toilet Safe drinking water (% of house with safe water supply) ElectricitylTelephone (% of house with electricity supply/telephone) Use of refrigerator Use of boilers, stoves Living spaces Sewage treatment Waste treatment Solid waste collection Ambient air quality Water quality Sewerage services Solid waste (solid waste generation per person - kgs. per person, types of handling) Flood Green space/parks (km2 per 1,000 population) Number of flash floods \Jer year Education (school emolment rate, ratio student-classroom) Number of school Cultural participation Type of occupation of the residents Main industry Level of development Agricultural production Industry production Commerce and tourism Income (per capita income, % of urban poor) Car per 1,OOO-population ratio Employment/unemployment rate Poverty (% offamilies below national level) Squatters (number of s uatter households)
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I
,
I I I I I
I
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i
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Cateaory Land Use Urban Infrastructure
• • • • • • • • • • • • • •
Legislation and Regulation
Example of Information I Data to Collect Land use (for commercial, agriculture, industry, residential, open spaces, parks) Electricity Water supply Road system Public transport License public transport per 1,OOO-population Communication network system Market Disease prevention Food hygiene Building and housing Drinking water Air Noise
City Health Profile Working Group Membership The following people, group, agencies are candidates for a working group for city health profile: • • • • • • • • • • • • • • • • • • • • • • • • • • • Office of the mayor / governor Head of communities / villages Public health office District hospital Youth council Women's council City / community development committee Health promotion management team Elderly council Health promotion council City health monitoring agency City environmental and ecological control department City education department City water supply department City community service department City waste disposal centre City agricultural department City commerce department City industry department City transportation department City animal sanitation and control department City planning and statistics department City information and cultural department City social welfare department City housing department Policy department Ministry of health
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4 4.1 4.1.1
NEEDS RESOURCE ASSESSMENT
Community Health Needs Survey Practical Methods
Conducting Household Interview Survey
Household interview survey is a tool to fmd current family's health, sanitary and living condition, people's knowledge and skills and health needs. To involve community leaders, professionals, volunteers, and decision-makers of the communities is useful to share the idea of Healthy Cities. The community health needs survey itself Provides opportunities to gain skills of the community and to explore vision of the community to become Healthy Cities. Important steps to note are: (a) Have a small inaugural ceremony for core members (b) Decide the study area, sampling procedure, and the size of the sample population (c) Conduct sampling of the study areas (d) Contact to the community political leaders of the study areas and have consensus to conduct community health survey (e) Develop a questionnaire and protocol of health measurement (f) Ensure that all core members thoroughly understand the purposes, procedures, protocols, rules and other details of the project
(g) Decide major meeting dates all the way to the end (h) Prepare materials necessary for the survey (i) List all necessary activities and assign tasks (j) Make a list of interviewers, recorders, supervisors
(k) Conduct a pre-test (I) Feedback from the pre-test/adjustment of the protocol
(m) Prepare manual for interview, recording, data coding, and data entry (n) Print questionnaire and manuals (0) Train supervisor; on how to conduct a survey with the questionnaire and health measurement
(p) Train interviewer s about how to conduct household visits, interviews, and taking notes for the reports (q) Train data coding and data input procedures
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(r) Have a small ceremony to start real survey (s) Conduct household survey (t) Have a small ceremony to share experiences in the community (u) Store questionnaire sheets and coding sheets properly (v) Conduct data coding and data input (dual coding and dual data input) (w) Conduct data cleaning (x) Perform analyses (y) Information sharing among research team (z) Dissemination of the results for improvement
Details on How to Train Interviewers • Conduct workshops for interviewers and recorders. Explain the overall picture and how their roles fit in. Elaborate on details. Use of a play would provide an effective, visual way to teach how a good interview is conducted. In the play, show and explain what to do and what NOT to do in somehow exaggerated ways to clarify the points. Give them appropriate incentives for good jobs done. Give interviewers and recorders sufficient opportunities to practice under supervision. When practicing, form groups of 3 people - one for an interviewer, another one for in interviewee, and the other one for an observer. Rotate the roles for 2 times so that the three will play all the roles. An observer and an interviewee should pay careful attention to how interview is conducted and check out good points and not-so-good points. Give comments to an interviewer after hislher interview (starting with all good points, and state only one or two major weaknesses). This way, they could experience how to interview, how it feels to be interviewed, and how it should and should not be conducted from a third person's viewpoint. After the rotation, form new groups with different people and practice over and over. After the first round, to save time and energy, only a part ofthe questionnaire may be used instead of the entire questionnaire. Exemplary groups may be asked to do a demonstration in front of other groups. Conduct at least one field practice under supervision. Interviewers and recorders actually go into households in the community and conduct an interview. Form groups of three again, and this time, one will be an interviewers and the other two will be observers, and commentators. A meeting should be held after each field practice to discuss experiences and make further improvements. Supervisors should closely monitor their conducts and progress with words of encouragement. Make sure to encourage interviewers and recorders to report every minor question, problem, or concern to supervisors. Also give them an assurance that reporting mistakes will never result in punishment or penalty, and such information will remain strictly confidential.
•
•
•
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4.1.2
Examples
An Example of Interviewer IRecorder Manual- Points to remember when conducting interviews
Outlook • Wear appropriate clothes. • Have clean hands. • Combed hair. IuterviewlReviewing • Be polite and friendly (express respect and appreciation; greetings and thank you). • Introduce yourself. Explain why and how you are going to interview. Ask if interviewees have any questions before you begin the first question. • Smile and create a good atmosphere. *Interviewers • Read questions slowly and clearly. • Make sure that interviewees understand your questions and how to answer them (multiple choice? open-end answers? in numbers? give examples?); repeat your questions until they understand them, or ask them politely and friendly where they have difficulty understanding. • Give interviewees sufficient time to answer your questions; do not force them to answer in a short time. • Give a recorder enough time to write down the answer. Make sure that a recorder has finished putting down the answer before you move on to the next question. • Do not force the interviewee to give out the answer. • Do not skip questions. (Unless the interviewee does not want to answer the question.) • Do not ask questions that are not on the questionnaire. • Do not give your personal comments to answers. • Stay neutral and professional throughout the interview. *Recorders • Write the answer clearly and in a way that everyone understands what is written (i.e. avoid using abbreviations or drawings that only you can understand). Keep in mind that somebody will have to read your writing and put it into a database later on. • Make sure that the interviewer does not move on to another question before you finish writing the answer from the previous question. If it happens, do not hesitate to say, "just a moment, I am still writing the answer." • Stick to putting down the information; do not cut in the interviewer and start making comments unless absolutely necessary (e.g. the 'interviewer skipped a question or asked a different question). • (Do not forget to write ID numbers.) • Bring an extra pen in case one becomes out of ink. • Do not lose or damage filled questionnaires. • Do not give or show the questionnaires (filled and unfilled) to anyone not involved in the project. • After finishing the interview, make sure that all the questions have been answered and properly recorded by going through the filled questionnaire. • At the end of each day, bring all the filled questionnaires to supervisors and report any important news.
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Understanding Roles and Objectives • Read the questionnaire and practice out loud at least a few times before the interview day to understand the questions thoroughly; if you have questions or have difficulty in understanding them, ask your supervisors before you begin interviewing. • Know what to do; know what not to do. • Know how to complete your assigned tasks. • Know the objective of the interview. • Always report to your supervisors when problems or any concerns arise (supervisors are there to assist you and help you complete your tasks). • Do not be afraid to report mistakes (e.g. skipped questions, or incorrect recording). You should try not to make errors, but when you do make them, you should be honest about it; you will NOT be punished for mistakes you made during the interview/recording. Removal of incorrect information is important for the success of the project. • Understand and have pride that you are collecting important information that will help • improve the health of your fellow villagers. • Which villages? - an assignment list • Which households? - households with even numbers (--2,--4,--6,--8,--10) • Who is your partner for interview? 2 people - 1 subgroup • Share interview/recorder (note taker) responsibilities. • Bring the expected number of questionnaire forms. • Bring pens/pencils (place questionnaire forms/pens-pencils/guidelines into your bag before you start your visits)
Sample Questionnaire The following gives examples of areas of questions for household interview survey: General information 1.1 Number of family member by sex and age 2 Working condition 2.1 Type of work 2.2 Mainjob 2.3 Hours of work 2.4 Family income Education Health Education in the community 4.1 Participation to health education programs 4.2 Reason for participation 4.3 Reason for non-participation Information sources Lifestyles 6.1 Sleep, smoking, drinking, drugs Property 7.1 Machines, electric apparatus, cars 7.2 Domestic animals 7.3 Land and fields 7.4 House
3 4
5 6
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Sanitation 8.1 Access to water and water use 8.2 Sanitary habit 8.3 Garbage treatment Health 9.1 Child health 9.2 Immunization 9.3 Illness 9.4 Coping 9.5 Deaths
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10 Sanitation around house II Community-based health promotion group activities 11.1 How to conduct community-based health promotion activities 12 Family health 12.1 Health needs of families 13 Hcalth promotion for senior citizens 13.1 Practices for health promotion activities for senior citizens 14 Community's vision towards healthy town/communities 14.1 Image for healthy town 14.2 Essential elements for healthy town 14.3 Satisfaction to various environmental conditions 15 Knowledge and attitudes towards health promotion activities 15.1 Usefulness of the activities 15.2 Points to disseminate Healthy Cities activities
4.2
Resource Mapping Walk
"The Resource Mapping Walk" is a new approach to identitying needs, interest, and resources of the community. Simply put, it is a participatory community activity in which community members (or their representatives) including community leaders (e.g. a village head) actually walk around the community, and draw a map indicating points of interest, problems, and resources. For examples, dangerous spots for kids and the elderly can be spotted, or various resources of the community such as temples, beautiful nature, or fertile lands can be recorded. Along the way, they freely engage in discussions about their community - what is needed, how to develop the community, what resources are present, and other relevant issues. After coming back from the walk, they discuss new findings and impressions based upon the map created dunng the walk.
4.2.1
Practical Method: General Procedural Outline of the Resource Mapping Walk
(I) Meeting with Community Leaders A meeting with community leaders including a head of the community should be arranged. Administrative agendas such as the time and date. partIcipating members, facilitators, and
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other roles should also be discussed. A map of the community should be obtained if available, or created by depicting major roads, pathways, and geographical characteristics such as a river. (2) Preparing Necessary Items
The Mapping Walk requires a number of items. Examples include: a) blank maps of the community, preferably in size A3 or larger; b) drawing boards (or equivalents) to place the blank map to provide a stable surface for recording during the walk; c) pencils; d) erasers; and e) a camera, if so desired, to take photos of the activity and spots of interest. (3) The Walking Event
Before departing for the walk, participants should be gathered and an overview of the Resource Mapping Walk (e.g., purposes, procedures, and what participants are expected to do) should be provided. After the briefing session, a community head may lead the way into the community, and small groups will follow. A facilitator of each group throws questions to its members to elicit their opinions and provoke active discussions. A note taker takes notes and a drawer fills the map with geographical, verbal and other information. During the walk, a community head or any member may call all the participants to gather at a point of interest to discuss related issues (e.g., folk stories behind some landmarks, legends, or future plans) and develop a shared understanding among the participants. (4) After-Walk Discussion Upon the return from the walk. participants should be given opportunities to talk about their impressions of the walking activity, findings, opinions, needs, and other related topics. (5) Completing A Final Version of A Community Resource Map
Various information on maps provided by different groups during the walk should be sorted out, organized, and then put together into a final version of the map. (6) Exchanging and Sharing Information and Ideas Among Communities
The community resource map, discussion summary sheets, and other information particular to a community can be shared not only among its community members, but with other communities as well. As described, the Resource Mapping Walk provides a common platform on which information exchange among different communities can be pursued. In some respects, therefore, not only does the Resource Mapping Walk identify community resources, it also creates valuable community resources that can open many doors of possibilities for the future development of the community.
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5
ANALYSIS AND CONSENSUS BUILDING
Using substantial and objective data is an important point to involve other sectors and to obtain highly political support to Healthy Cities projects. The outcome of these research activities is persuasive to the public as well as administrators, people in the private sector, and other people. The analysis on the basis of evidential data is essential to formulate the most effective plan for the Healthy Cities program from the viewpoint of integration, to involve various sectors. This lead to demonstrate visible outcomes of the Healthy Cities program. In addition, it helps the members of the Healthy Cities team recognize the validity of what they are doing. The members who have done these research activities become more convinced that the Healthy Cities approach is valuable and effective.
5.1
Health Determinant Analysis
It is necessary to understand a causal web-like relationship of various factors affecting health in the urban environment for the effective Healthy Cities implementation. It is also necessary for the
Healthy Cities planners to acquire the ability to analyse the relationship among various factors in both physical and social environments in the context of health status. Some typical examples of these health determinants include water supply and sanitation, nutrition, health services, housing conditions, working conditions, lifestyles, population change, education, income, and so on. Health determinants are not only those which are related to the actions of individuals, such as health behaviours and lifestyles, but also factors such as income and social status, education, employment and working conditions, access to appropriate health services. and the physical environments. A body of research shows that health status is affected not only by single health determinants but also by combinations of health determinants. The involvement of multiple factors is common in the case of urban health issues. Conversely, a single factor tends to affect a number of health issues. And the factors, which influence health, are interactive. 'The combination of these health determinants creates different living conditions which impact on health. Improving these health determinants and their combinations leads to the improved health outcomes. However, actual contributions of health determinants are usually different from city to city. and from country to country. Therefore, it is necessary to understand these causal web-like relationships of various factors affecting health in your own city. And thus, it is necessary for the Healthy Cities planners to analyse the relationship among various factors in both physical and social environments in the context of the health status of the city,
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5.2
Geographic Information System
Visualization of health and environmental conditions by applying the Geographic Information System (GIS) is convenient, because it provides combined-information of statistics and location and makes database easily understandable. This method for analytic purposes is able to demonstrate a distribution of health, distribution of resources necessary for a city's development, and a diversity of environment conditions in cities, which influence the health of the residents. GIS enables us to further advance analysis for planning and policy-making. And there are some sophisticated applications. However, it is not necessary to use a computer when the main principle of this technique is applied. All we need is a handwritten map and coloured pencil. This is a very important point of this technique when it would be applied in the community. When considering, counting, and compiling indicators concerning health and environment of areas in the city for GIS application, community-based assessment and evaluation activities are necessary.
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ANNEX Example of Baseline Indicators Population Health ·• • • • • • • • • • • • • • • • • • • • Percentage of population who feel in good health Perceived overall quality of life Average scores oflife satisfaction Life expectancy at birth (male, female) Life expectancy at 20 (male, female) Life expectancy at 40 (male, female) Life expectancy at 65 (male, female) Disability-free life expectancy Number of cases of food poisoning per population Number of work-related injuries per population Number of traffic accidents-related injuries per population Childhood asthma hospitalisation rate Percentage of children with dental decay Percentage of population having any physical complaints Percentage of population perceiving stressfulness in daily life Students absenteeism rate Worker absenteeism rate Average annual attendance to hospitals and/or clinics Percentage of population consecutively regularly attending to hospitals and/or clinics for the same reason at least 6 months Rate of attendance to hospitals or clinics by major illnesses (hypertensive disease, acute respiratory disease, chronic respiratory disease, diarrhoeal-related disease, diabetes mellitus, dorsopathies, cerebrovascular disease, ischemic heart disease, mental disorders) Morbidity rates by sex and major illnesses (parasiticlinfectious disease, tuberculosis, malignant neoplasm, ischemic heart disease, cerebrovascular disease, respiratory-related diseases, diarrhoea-related diseases, mental ill-health) Percentage of population needing personal assistance in everyday personal care Percentage of elderly receiving allowance for disability Percentage of population with disability in moving around inside of houses Percentage of population with disability in moving around outside of houses Percentage of people with disability (motor function, visual and ocular function, auditory function, speech) Infant mortality rate Perinatal mortality rite Stillbirth rate Percentage of children weighing 2.5 kg or less than 2.5 kg at birth Under 5 years mortality rate Age-adjusted mortality rates of all causes (male, female) Mortality rates by sex and age groups Age-adjusted mortality rates by sex and major causes of death (parasitic/infectious diseases, tuberculosis, all causes of malignant neoplasm, ischemic heart disease, cerebrovascular disease, malignant neoplasm of the lung, malignant neoplasm ofthe stomach, malignant neoplasm of the liver, malignant neoplasm of the breast, malignant neoplasm of the uterus, pneumonia and bronchitis, motor vehicle accidents, suicide) Proportional mortality of age 50 and older (PMI 50) Proportional mortality of age 60 and older (PMI 60)
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Proportional mortality of age 80 and older (PMl 80) Proportional mortality of age 85 and older (PMI 85) Longevity differential index (standard deviation of the age-adjusted death rate as a function of age calculated by using a standard population) Traffic deaths per population Traffic deaths per daytime population Number of traffic accidents per kilometer of road Number of criminals per population (traffic violation excluded) Number of violent criminals per population Number of non-sexual assaults per population Number of sexual assaults per population Number of domestic violence per population Number of fires per buildings
Urban Infrastructure • • • • • • • • • • • • • • • • • • • Tap water service area Sewer diffusion rate Length of road per total land area Length of road per habitable land area City planning area as percentage of total land area Road area as percentage of total land area Length of guardrail per kilometer of public road Number of traffic signs per kilometer of public road Number of goods vans per kilometer of road Number of cars per kilometer of road Number of two-wheeled vehicles per kilometer of road Percentage of dwelling units located within 50 meters of a road 6 meters or more in width Percentage of houses which faces no road or road ofless than 2 meters in width Percentage of dwelling units more than 1 km. away from railway station and more than 500 m. away from bus stop Residential-zone area as percentage of total city-planning area Commercial-zone area as percentage of total city-planning area Industrial-zone area as percentage of total city-planning area Residential-zone area as percentage of habitable land area Electrification coverage rate
Environmental Quality • • • • • • • • • • • • Number of complaints per households relating to smoke Number of complaints per households relating to suspended particles Number of complaints per households relating to external noise Number of complaints per households relating to vibration Index of higher nitrogen oxide measurement Annual median of atmospheric nitrogen oxides (l1g/m3) 98% value of the daily average of nitrogen oxides Annual median of atmospheric sulphur dioxide (l1g/m3) Annual mean concentration of atmospheric sulphur dioxide (l1g/m3) Annual median of suspended particulate matter (SPM) and particles below 10 micrometer (PM I 0) (l1g/m3) Annual mean of suspended particulate matter (SPM) and particles below 10 micrometer (PM I 0) ().lg/m3) Annual median of atmospheric lead concentration (!lg/m3)
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Annual mean concentration of atmospheric lead (flgim3) Noise level Heavy metals in air, water, soil, dust, and food Microbiological quality measurements of the water supply exceeding zero faecal coliforms per 100 mi. as percentage of total number of measurements Nitrates quality measurements of the water supply exceeding 50 mg/L (N03) as percentage of total number of measurements Fluorine quality measurements of the water supply exceeding 1.5 mglL as percentage of total number of measurements Benzene quality measurements of the water supply exceeding 10 llg/L as percentage of total number of measurements Chlordane quality measurements of the water supply exceeding 0.2 llg/L as percentage of total number of measurements Normalized difference vegetation index area - averaged by a circle of 3 kIn. radius Normalized difference vegetation index area - averaged by a circle of 10 kIn. radius Normalized difference vegetation index area - averaged by a circle of 19 kIn. radius Distribution of plants and animals in communities
Housing and Living Environment • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Percentage of sub-standard dwelling units Percentage of population living in substandard dwelling units Percentage of dwelling units having direct sunshine 5 hours or more per day Percentage of older house Percentage of dwelling units with flush toilets Percentage of wooden houses not constructed with fire-retardant materials Percentage of households in detached houses Rate of change in the number of detached houses Percentage of households in apartment flats Rate of change in the number of apartment houses Rate of change in the number of dwelling units in high rise apartments with six or more floors Percentage of dwelling units on the sixth floor and above Owner-occupied dwelling units as a percentage of all dwelling units Rented dwelling units as a percentage of all dwelling units Living space per household Living space per person Average number of rooms per inhabitants Access to regular garbage removal system Average daily weight of waste per population Recycled waste as a percentage of total weight of waste collected City park area as percentage of total land area City park area as percentage of habitable land area City park area per population Safe, open outdoor space for children as percentage of habitable land area Access to safe drinking water Estimated number of homeless people Risk score indicating fragileness of buildings in case of earthquake Fire risk score in case of earthquake Microbiological quality of food Chemical quality of food
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Community Action and Activities
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Number of health volunteers per population Number of social support volunteers per population Number of environmental health volunteers per population Number of facilities available for meetings of community groups per population Visits at the community centres and other public facilities for community activities per population Number of sports facilities accessible to the public per population Number of indoor pool accessible to the public per population Recreational area per population Area of well-maintained gardens accessible to the public per population Length of bicycle paths per population Number of barrier-free design facilities accessible to the public Number of barrier-free design eating and drinking places Number of barrier-free design facilities for recreational use Number of barrier-free design facilities for educational use Availability of information regarding garbage recycling Existence oflocal guidelines or legislation for food safety, air quality, water quality, and hazardous substances Existence of environmental health information system accessible to the public Existence of health service information system accessible to the public Existence of social support service information systems accessible to the public Existence of health promoting lifestyles information systems accessible to the public Existence of monitoring and surveillance systems for environmental quality (air, water, soil) Existence of monitoring and surveillance systems for housing quality Existence of monitoring and surveillance systems for food quality Existence of Geographic Information System filing health and health determinants information accessible to the public Existence of local health profiles accessible to the public Existence of inventory of community-based non-profit groups working on health, social support, and environmental health Number of community-based non-profit groups for health, social support, and environmental health Existence of support programs for community groups Types of support programs for community groups (finance, allowance for attending meetings, provision of material, assistance for professionals, use of premises, printing documents, others) Progress in formulating training programs for community workers Existence of inventory of professionals on health promotion and environmental health available in advising community groups Number of recreational leaders per population Number of seminars on health promotion!nutrition and diet/physical fitness/relaxation! child care per population Progress in formulating training programs on skills for multi-sectoral work Number of consultations on health promotion/nutrition and diet/physical fitness/relaxation per population Existence of city (municipal) council and/or task group for health promotion and environmental health with the participation of residents Progress in formulating city (municipal) health plan Public awareness to city (municipal) health plan Progress in formulating city (municipal) health development plan Progress in formulating city (municipal) environmental health plan Representation of women in planning of the city health plan!city health development plan! city environmental health plan
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Clarification of health agenda in the city's long tenn development plan Progress in fonnulating city planning scheme considering health of the residents Progress in fonnulating emergency preparedness plans Progress in fonnulating multi-sectoral steering committee or task group for healthy city Progress in establishing Healthy City project office Existence of a full-time Healthy City project coordinator Public awareness to Healthy City project Progress in involvement to Healthy Cities networks
Lifestyles and Preventive Activities • • • • • • • • • • • • • • • • • • • • Current smokers as percentage of total population Per capita cigarette tax revenue Per capita alcohol consumption Percentage of population consuming more than 14 drinks per week Prevalence of substance use among youth (cigarettes, alcohol, drugs) Existence of smoking-control policies in public places Percentage of population not wearing seat belts Percentage of population exercising 15 minutes or more per week Percentage of population eating everyday meals regularly Patterns ofleisure-time activities Participation rate to general health check-up Participation rate to health check-up for stomach cancer Participation rate to health check-up for lung cancer Participation rate to health check-up for cervical cancer Availability of health check-up in foreign languages Percentage of pregnant women taking maternity health check-up regularly Participation rate to child health check-ups Participation rate of children to dental health check-ups Percentage of six year old children having received all compulsory vaccinations Availability of preventive health consultations in foreign languages
Healthcare, Welfare and Environmental Health Services • • • • • • • • • • • • • • • • • • • Accessibility to primary health care services Percentage of households identifying own family doctors Accessibility to primary health care services during evenings and holidays Availability of primary health care services in foreign languages Percentage of population covered by health insurance Per capita annual expenditure spent on curative medical care Number of medical doctors per population Number of public heath nurses per population Number of midwives per population Number of nurses per population Number of hospitals per population Number of general hospitals per population Number of clinics per population Number of hospital beds per population Number of beds in general hospitals per population Number of beds in clinics per population Number of hospitals and clinics per habitable land Number of clinics per habitable land Number of dentists per population
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Number of dental clinics per habitable land Number of pharmacists per population Number of pharmacies per population Number of pharmacies per habitable land Percentage of dwelling units located 500 meters or less than 500 meters from medical facilities Emergency ambulance car callings per population Emergency ambulance car callings per hospital Emergency ambulance car callings per hospital bed Percentage of population having access to an emergency medical service within 30 minutes Welfare-assistance recipients as percentage of total population Number of social workers per population Indoor environmental inspections per year per population Food inspections per year per population Number of environmental health officers per population Percentage of local government's budget allocated to health care services Percentage of local government's budget allocated to welfare services Percentage of local government's budget allocated to environmental health services
Education and Empowerment
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Number of students per elementary school Number of students per junior high school Number of students per high school Percentage of children leaving school after compulsory education Employment rate of junior high school graduates Employment rate of high school graduates Age-adjusted years of education Average years of education of people aged 25-29 Ratio of male and female age-adjusted years of education Growth rate of age-adjusted years of education Adult literacy rate Number of libraries per population Number of volumes owned by libraries per population Percentage of people registered for the use of lending service of libraries Local budget for education per population School meal provision at school Existence of education programs on healthy lifestyles (smoking, diet, leisure, sexuality, drugs, alcohol, driving, safety, etc.) Availability of education programs on healthy lifestyles in foreign language Existence of environment al health education programs Availability of environmental health education programs in foreign language Existence of maternal and child health education programs Participation rate to maternal and child health education programs by parents Availability of maternal and child health education programs in foreign language Percentage of health education programs using round-table discussion and/or participatory style Existence of basic food hygiene education programs for food producers, handlers, and sellers Existence of training programs for health promotion and environment health workers Existence of training programs on health promotion and environmental health for community leaders
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Employment and Industry • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Unemployment rates Unemployment rate among people aged 20-24 Unemployment rate among people aged 60-64 Workforce enrolment as percentage of population aged 15-65 People with disabilities in workforce as percentage of the total number of people with disabilities in working age (15-65) Primary industry workforce enrolment as percentage of total work force Secondary industry workforce enrolment as percentage of total work force Tertiary industry workforce enrolment as percentage oftotal work force Managers and officials as percentage of total work force Manufacturing industry workers as percentage of total work force Wholesale, retail trade, and eating establishment workers as percentage of total work force Professional and technical workers as percentage of total workforce Average number of workers per establishment (all industries) Small-scale establishments (less than 4 employees) as percentage of all businesses Small-scale establishments (less than 10 employees) as percentage of all businesses Average commuting time Percentage of workers using public transport for commuting Percentage of workers using private cars for commuting Construction industry firm as percentage of all businesses Manufacturing firms as percentage of all businesses Percentage of workers engaged in manufacturing Percentage of wholesale, retail trade, and eating establishments Percentage of workers engaged in wholesale, retail trade, and eating establishments Percentage of wholesalers in sales industry Percentage of retail shops in sales industry Retail shops per area Retail shops per population Retail shops per daytime population Percentage of eating and drinking establishments in sales industry Eating and drinking establishments per area Eating and drinking establishments per population Eating and drinking establishments per daytime population
Income and Family Living Expenses • • • • • • • • • • • • • • • • Annual per capita income Annual taxable income per taxpayer Annual taxable income per capita Annual taxable income per household Average annual earnings per household Standardized deviation of average annual earnings per household Family expenses for food as percentage of the total family expenses Family expenses for housing as percentage of the total family expenses Family expenses for education as percentage of the total family expenses Family expenses for leisure and hobby as percentage of the total family expenses Family expenses for fish consumption adjusted by the area-difference of food consumption Family expenses for meat consumption adjusted by the area-difference of food consumption Per capita balance of savings Per capita value of housing and land property Per capita value of consumer durables Percentage of families below the national poverty level
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Local Economy • • • • • • • • • • • • • • • • • • Local tax revenue as proportion to the total amount of revenue to the local government Per capita subsidy to local government from the national government Per capita local public debt Local government financial index Per capita local expenditure on health services Per capita local expenditure on welfare Per capita local expenditure on environmental health Per capita local expenditure on education Per capita local expenditure on civil engineering Growth rate of number of establishments Growth rate of total work force Rate of change in the number of manufacturing firms Rate of change in the number of workers engaged in manufacturing Rate of change in the number of workers in wholesale, retail trade, and eating establishments Rate of change in the number of retail shops Rate of change in the number of eating and drinking establishments Rate of change in the number of construction industry firms Housing units built per year
Demographics • • • • • • • • • • • • • • • • • • • • • • Population growth rate Night-time population density Ratio of male and female night-time population Daytime population density Age structure of the population Juvenile percentage of population Percentage of population 65 and over Percentage of population 75 and over Percentage of elderly 75 and over among the 65 and over population Birth rate Marriage rate Divorce rate Percentage of single parent families Number of children brought up without parents One-person private households as percentage of total number of households Aged one-person private households as percentage of total number of households Foreign residents as percentage of total population Daytime influx population as percentage of night-time popUlation Daytime influx population as percentage of daytime population Daytime efflux population as percentage of night-time population Ratio of daytime population to night-time population Annual entries and departures of the population
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