Health Issues in Urban Areas

HEALTHY SETTING
INTRODUCTION
Currently, more than half of the world’s population lives in an urban area. It is estimated that by 2050, more than two-third of the world’s population will be living in towns and cities (WHO 2015). Rapid urbanization leads to significant changes in our standards of living, lifestyles, social behaviour and health. Living in urban area offer many opportunities, including potential access to better health care. However, today’s urban environments can concentrate health risks and introduce new hazards.

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Health problems in cities include issues of water, environment, violence and injury, non-communicable diseases such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases, unhealthy diets and physical inactivity, harmful use of alcohol. (Eckert & Kohler 2014; WHO 2015). The prevalence of non-communicable diseases such as cardiovascular diseases and respiratory diseases are worsened by pollution. Urban air pollution kills around 1.2 million people each year around the world (WHO 2015). A major proportion of urban air pollution is caused by motor vehicles, although industrial pollution, electricity generation and in least developed countries household fuel combustion are also major contributors. Mass marketing in urban areas, availability of unhealthy food choices and accessibility to automation and transport all have an effect on lifestyle that directly affect health (WHO 2015). These environments tend to discourage physical activity and promote unhealthy food consumption. Community participation in physical activity is poor due to by a variety of factors including overcrowding, high-volume traffic, and heavy use of motorized transportation, poor air quality and lack of safe public spaces and recreation or sports facilities (WHO 2015). Apart from that, urbanization affects the spread of diseases including tuberculosis, malaria and HIV/AIDS. Incidence of tuberculosis in New York City is four times the national average. While in the Democratic Republic of the Congo, 83% of people with tuberculosis live in cities.
Setting like recreational park in urban area is supposed to be a place for healthy activities such as jogging, exercise and some sports. However, for some people they use this park for negative behaviour such as sexual misconduct including indecent exposure, offensive touching, sexual acts, or prostitution. This behaviour may lead to unintended pregnancy and subsequently some of them will desperately dump the baby especially among teenagers.
THE CONCEPT STRATEGY OF HEALTHY SETTING
Healthy Settings as one of health promotion approaches, involve a holistic and multi-disciplinary method which integrates action across risk factors. The goal is to maximize disease prevention via a “whole system” approach. This approach begins in the WHO “Health for All” strategy and, more specifically, the Ottawa Charter for Health Promotion. Key principles of Healthy Settings include community participation, partnership, empowerment and equity.
The best-known example of a successful Healthy Settings programme is Healthy Cities. This programme initiated by WHO in 1986 and have spread rapidly across Europe and other parts of the world. Building on this experience, a number of parallel initiatives based on similar principles were established during the late 1980s and early 1990s within a number of smaller settings such as villages, schools, or hospitals.
The Healthy Settings movement came out of the WHO strategy of “Health for All” in 1980. The Ottawa Charter for Health Promotion (1986) clearly explained this approach. These documents were important steps towards establishing the holistic and multifaceted approach embodied by Healthy Settings programmes, as well as towards the integration of health promotion and sustainable development. Then, in 1992, the Sundsvall Statement called for the creation of supportive environments with a focus on settings for health. The Jakarta Declaration in 1997 subsequently emphasized the value of settings for implementing comprehensive strategies and providing an infrastructure for health promotion. Nowadays, various settings are used to facilitate the improvement of public health throughout the world.

Figure 1: Ottawa Charter for Health Promotion (WHO 1986)
WHO defined setting for health as the place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and wellbeing (Health Promotion Glossary 1998). A setting is where people actively use and shape the environment and it is also where people create or solve problems relating to health. Settings can normally be identified as having physical boundaries, a range of people with defined roles, and an organizational structure. Examples of settings include schools, work sites, hospitals, villages and cities. Health promotion through different settings can take many forms and these often involve some changes to the physical environment or to the organizational structure, administration and management. Settings can also be used to promote health as they are vehicles to reach individuals, to gain access to services, and to synergistically bring together the interactions throughout the wider community.
Healthy setting programmes took off predominantly in Europe and the Americas following the Ottawa Charter and Jakarta Declaration. The primary form of implementation has been the Healthy Cities programmes. Through pilot projects and expansion efforts, many other Healthy Settings have been established throughout the two regions. Today, efforts have been made in all WHO regions to expand the movement. Other settings include villages, municipalities and communities, schools, workplaces, markets, homes, islands, hospitals, prisons, universities and healthy ageing (Figure 1).
Approach in healthy settings involves a focus on both structure or place and agency or people. It should be understood that a setting not only as a medium for reaching ‘captive audiences’ but also as a supportive context and environment which directly and indirectly impacts wellbeing. Apart from that, it is a commitment to integrating health and wellbeing within the culture, structures and routine life of settings.

Healthy City is defined as a one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential (Hancock and Duhl 1988). Healthy Cities Initiative features political commitment in multi-sector to health and well-being in the most ecological sense; commitment to innovation; community participation; and the resultant healthy public policy. Health and well-being must be planned and built ‘into’ cities and presented as everyone’s business. Political endorsement is important in ensuring inter-sectorial collaboration. Systems for participatory decision-making must be developed to ensure that all voices are heard, especially those of marginalised people (Baum 1993). Healthy Cities is essentially an empowerment process that embeds the Ottawa Charter’s core definition of health- “The process of enabling people in a community or city to increase control over and improve all the many different factors that affect their health” (WHO 1986). Healthy Cities is based on the recognition that city and urban environments affect citizens’ health, and that healthy municipal public policy is needed to effect change (Ashton 1992). In the early stages of the Healthy Cities approach, 11 key parameters were identified for healthy cities, communities, and towns (Hancock and Duhl 1988):

A clean, safe, high-quality environment (including housing).
An ecosystem that is stable now and sustainable in the long term.
A strong, mutually supportive and non-exploitative community.
A high degree of public participation in and control over the decisions affecting life, health, and well-being.
The meeting of basic needs (food, water, shelter, income, safety, work) for all people.
Access to a wide variety of experiences and resources, with the possibility on multiple contacts, interaction, and communication.
A diverse, vital, and innovative economy.
Encouragement of connections with the past, with the varied cultural and biological heritage, and with other groups and individuals.
A city form (design) that is compatible with and enhances the preceding parameters and forms of behaviour.
An optimum level of appropriate public health and sick care service accessible to all.
High health status (both high positive health status and low disease status).

Hancock (1993) conceived of a Healthy Cities and Communities model in which human health and wellbeing – or human capital – is the ultimate outcome of a sustained, integrated effort to build community (social) capital, environmental capital and economic capital (See Figure 2).

Figure 2: Healthy Cities Model
Healthy Cities approach built on community involvement; political commitment, in which the local government is a major player; partnerships between sectors; and enabling, healthy public policy to create conditions for health. These approaches build on local capacity, by building on assets, strengths and resources. The application of the concepts, principles and practice of health promotion at the local level is important. Central to local health promotion is the key role played by local government. Many of the major determinants of health are within the scope of local government.
WHO (1997) offers a systematic strategy for progressing through three phases of development of a Healthy Cities initiative in their document, Twenty Steps for Developing a Healthy Cities Project. Three main phases are start-up, initiative organisation and areas for action and strategic work. Twenty Steps makes it clear that the role of a Healthy Cities initiative is to offer effective advocacy to promote healthy public policy.
Figure 3: Twenty Steps for Developing a Healthy Cities Project
LESSONS LEARNED
Healthy Cities Europe
As the site of the first pilot Healthy Cities initiatives by WHO in the mid-1980s, Europe has in many ways served as the engine house of Healthy Cities concepts and approaches. WHO Europe has developed a legacy of theory and practice; strategy and methodology, buttressed by a huge bureaucratic initiative. Typically, the European approach has featured large cities, in which local governments play a key role as both planner and health provider. Many HC initiatives are administered at the senior corporate level of a city (such as Copenhagen or Dublin). The European Healthy Cities approach has typically involved the establishment of a peak intersectoral working group, supported by a project team.
The European Healthy Cities approach has progressed through several phases: First phase 1986-1992; Second phase 1993-1998; Third phase 1998-2002; Fourth phase (2002 onwards). Only the European region of WHO has had rigorous entry requirements to the Healthy Cities initiative. For all phases of HC initiative, member cities have had to demonstrate: (i) a political commitment to Health for All and the Healthy Cities vision; (ii) that they have adequate resources to employ a full-time initiative coordinator and support staff in a HC office; and (iii) commitment to specific objectives leading to development of local health policies (De Leeuw, 2001).
During the first phase of the Healthy Cities initiative, a primary objective for all cities was to establish an Urban Health Profile through completion of a Healthy Cities Questionnaire. This phase produced the well-regarded document, “Twenty Steps for setting up Healthy Cities Initiative” which is described in detail below. The second phase objective for cities was to create a City Health Plan. ‘A City Health Plan is a policy document including the Health Profile identifying health challenges, their determinants, and roles various actors should play in targeting those challenges’ (de Leeuw, 2001, pp. 37-38). This phase produced a plethora of case studies and models of good practice. The third phase objectives were to produce a City Health Development Plan, and engage in rigorous internal and external monitoring and evaluation. A City Health Development Plan builds on Phases I and II in that it ‘identifies strategic development issues, incorporating also urban planning, sustainable development and equity concerns on a longterm basis’ (de Leeuw, 2001, p. 38).
In Phase III of European HC initiatives, City Health Development Plans were required to embody a more rigorous internal and external monitoring and evaluation process to identify the impact of actions identified in Health profiles and City Health Plans. WHO established an extremely comprehensive (some would argue over-bureaucratic and unwieldy) requirement that HC initiatives would assess their performance against ‘health determinants analyses, and sound and responsible approaches towards influencing determinants of health’ (De Leeuw, 2001, p. 41). Initial annual reports were eventually received from 25 out of 40 cities: many struggled with the human resources needed to complete the reports. Over 1000 HC-related activities were reported. However, ‘very few of those activities showed a strategic perspective, thus underscoring [a] degree of ‘projectism’ in cities… that would hinder the development of healthy urban policies’ (De Leeuw, 2001, p. 42) and thus City Health Development Plans in Phase III. It was anticipated that the requirement to produce these Annual Reports might help create a cultural shift away from ‘projectism’ towards a more strategic planning approach.
Phase IV of Healthy Cities (2003 – 2007) has attempted to address health development comprehensively, with an emphasis on partnerships, determinants and governance. This phase has also focused on developing knowledge, tools and expertise on core developmental themes of healthy urban planning, health impact assessment and healthy ageing:

Healthy urban planning. Urban planners should be encouraged to integrate and supported in integrating health considerations in their planning strategies and initiatives with emphasis on equity, well-being, sustainable development and community safety.
Health impact assessment. Health impact assessment processes should be applied within cities to support intersectoral action for promoting health and reducing inequality. By combining procedures, methods and tools, health impact assessment provides a structured framework for mapping how a policy, initiative or initiative affects health.
Healthy ageing. Healthy ageing works to address the needs of older people related to health, care and the quality of life with special emphasis on active and independent living, creating supportive environments and ensuring access to sensitive and appropriate services.

(WHO 2003)
Healthy Cities and Communities – USA
The Healthy Cities scene in Europe compares interestingly with that in the United States. Leonard Duhl noted that whilst the Europeans made Healthy Cities a bureaucratic initiative, the Americans have seen it as a pseudo-anarchic process (personal correspondence, 10 September 2004). The approach adopted in the United States, for instance, has been driven more at a grassroots level, reflecting the realities of an individualistic cultural tradition of ‘life, liberty and the pursuit of happiness’ and small government (National Civic League, 1998: 287), from which the collective notions of the Ottawa Charter may be viewed by some with suspicion (Baum, 1993). Furthermore, with a somewhat chaotic private health care system, much government attention in the US is focused on ensuring access to basic health care, rather than addressing, at the intersectoral community level, the social determinants of health advocated in Healthy Cities (Wolff, 2003). The long and ‘embedded’ history of the involvement of health care industry in US health policy also needs to be considered. Wolff argued that the term ‘healthy communities’ is a problem in a country like the US, in which ‘health’ is dominated by privatized health care industry. Although many community organizations may be working along the lines of the Ottawa Charter to enhance population health through civic engagement and community building, they may not in fact identify ‘health’ as a primary goal of their efforts. Intersectoral collaboration has frequently been harder to achieve in the US than in countries such as Australia or Canada, in which government is expected to provide some sort of leadership (Twiss and Duma 2003, Wolff 2003).
Taiwanese and Chinese examples
In contrast to European, American and Australian experiences, the Taiwanese expression of Healthy Cities reflects a strong Confucian tradition of the integration of politics and academe. Many senior government personnel met during Dr Iain Butterworth’s visits to Taiwan in 2004 and 2005 – including the Ministers for Health and Culture – had held academic positions. As a result, strong national government support existed for forging collaboration across sectors. As a relatively new democracy with a culture evolving as a reaction to mainland China, there also exists a strong commitment to grass-roots civic engagement and participation. In comparison, Chinese Healthy Cities-style initiatives might be characterised by central government-mandated edicts to establish initiatives and for various sectors to participate. Western notions of democratic participation led by grass-roots activists with the potential to advocate and dissent do not translate readily or easily into a description of a Healthy Cities initiative led and driven by a more centralised, interventionist state.
In Shanghai, one of the approaches for healthy setting includes availability of Healthy Path Building and people were encouraged to do ‘Walking 10,000 Steps Everyday’. Apart from that, there were constructions of exercise sites in communities and training personnel for sports instruction. Other activities include ‘Healthy Rhythm’, ‘Stair Climbing’, ‘Three calisthenics’ and ‘Three Balls’ Activities
During the 3rd round of Shanghai Healthy City Initiative evaluation conducted in 2011, the short version of the International Physical Activity Questionnaire (IPAQ) was administered among 3,999 Shanghai residents. The result showed that 81.2% of the respondents were physically active (37.0% were highly active), and 73.6% of the residents investigated were active in walking (13.4% were highly active).
REFERENCES
Eckert, S. & S. Kohler 2014. Urbanization and health in developing countries: a systematic review. World Health & Population 15(1): 7-20.
WHO. 2015. Urbanization and health. World Health Organization, Bulletin of the World Health Organization (BLT). http://www.who.int/bulletin/volumes/88/4/10-010410/en/ (Accessed 1/3/2015).
WHO (1986). Ottawa charter for health promotion. Available: http://www.euro.who.int/AboutWHO/Policy/20010827_2. Accessed 3 March 2015.