Investment in formal and informal networking and cooperation

Nurturing Healthy Cities

D: Investment in formal and informal networking and cooperation

D.1 Cities must give executive and political commitment for the attendance of the project coordinator and nominated politician at WHO business meetings and symposia. At each, the city should be represented, as a minimum, by the coordinator and politician responsible.

D.2 Cities should ensure that their Mayor (or lead politician) attends the Mayors’ meetings at start of the phase (1998) and midway through it (in the year 2000).

D.3 Cities should be connected to the Internet and electronic mail, and ideally should have access to video-conferencing facilities.

D.4Cities should participate actively in different networking activi- ties (thematic, sub-regional, strategic, twinning, etc.) during the phase, including the development of close links with national networks. Cities should demonstrate practical contributions to these networks throughout the phase.

Source: de Leeuw 2001

Creating evidence for Healthy Cities

Formulation of the above definition, and identification of European Healthy City objectives, has not made things easier. In its operational version, the definition could imply almost anything. Possibly this aspect of Healthy Cities has scared away more traditional academics and research funding; what these actors would call ‘anecdotal’ evidence (i.e. proof that comes about by pure luck) indicates that thousands of cities have enthusiastically embraced the idea, and that probably hundreds of thousands of people in those cities are involved in this miracle pro- gramme. Then, when trying to comprehend the recipe, they find out that each city or town may be doing radically different things under the same banner. This, of course, is not what most scientists like. Scientists like controlled conditions, and randomised assignment of interventions to extremely homogeneous experimental and control groups (‘matching’). Nothing of the kind would probably ever be found in Healthy Cities.

Or wouldn’t there? Some authors have argued that the diversity of perspectives of the Healthy Cities movement is its strength, and that precisely this strength should be mapped and understood. Such mapping has been going on since the very beginning of the programme, in 1986. Enormous collections of ‘best prac- tices’ have been amassed, which lead a rather successful life in themselves as sources of inspiration of Healthy City officers and community leaders (e.g. Price and Tsouros 1996).

Nur turing Healthy Cities 147 Still, inspiration by a good story is only one piece of evidence. Epidemiologists would be tempted to refute a story as proof of the efficacy of an intervention; they would go for the randomised control trials, hard numbers, small α‘s and even smaller p-values. This seems to be a conflict never to be resolved.

Tones (1997) has endeavoured to bridge this apparent gap between a good story and the validated numbers. He calls for a ‘judicial perspective’ on evidence.

Just as much as any reasonable scientist in the footsteps of Karl Popper would acknowledge that truth is transient (i.e. only true until the theory upon which it is based is falsified), Tones asserts that particularly in the health sciences and health promotion the belief of a notion of truth is only created on the bases of a number of different sources of information. Rather than taking a pure scientific view, Tones asserts that evidence is needed to guide the actions of intervention devel- opers and decision-makers, not just those of scientists. This view is shared by Nutbeam and Vincent (1998) and McQueen and Anderson (1999). Intervention developers and decision-makers by their very nature draw upon a variety of sources of information, and Tones’ perspective therefore mimics that of a court of law. He calls it the ‘judicial perspective’. The outlook calls for ‘proof beyond rea- sonable doubt’ derived from witness accounts, expert testimony, scientific work, and circumstantial evidence. However, it is of course not obvious what relative weight different actors would attribute to different sources of evidence; a politi- cian might sooner decide to take action on the basis of the expressed satisfaction by his constituency, whereas an intervention developer would want to have proper information on cost-effect ratios.

One perspective worth mentioning here is how differently scientists and policy- makers present scientific data required for policy change. Jasanoff (1990) and Shackley and Wynne (1990) have investigated differences in such presentation:

scientists present research materials not committing themselves to many certain- ties. Scientists, external observers to the game of transforming scientific findings into policy realities, are addicted to probabilities and unable to make unequivocal statements. Policy-makers using the very same research materials tend to use totally unambiguous statements as to the certainty of the outcomes of investiga- tions. One lesson to be learnt for the debate on whether Healthy Cities ‘work’ or not is therefore to identify and interpret the messenger. Apart from framing the message itself we have demonstrated elsewhere (de Leeuw 1993) that networking and power distribution among participants in the policy game determine the out- put of the policy formulation process. This is consistent with observations by Kingdon (1995) and Stone (1997) who assert that policies are the result of seem- ingly irrational processes which can only be understood as functions of symbolic exchanges between institutions (people, agreements, bodies) in the policy arena.

Applying this notion of a variety of sources of evidence to the Healthy City concept developed above, we can now induce the following: adequate evidence to answer the question whether Healthy Cities ‘work’ can only be provided once all components of the Healthy City vision are judged positively from the various sources of evidence required.

148 Evelyne de Leeuw

One possible way, then, to solve the problem that we have created is to build a matrix in which these components are each assessed. A rather preliminary attempt to do this is presented in Table 9.1. We have reviewed in a rather superficial way the just over 1000 annotated entries in the bibliographies produced by the WHO Collaborating Centre for Research on Healthy Cities (Polman et al.1992; Sanders et al.1994; Salgado and de Leeuw 1998), and all twelve issues of the Research for Healthy Cities Newsletterpublished by same. Yet, a validated meta-analysis of the available data is still to be produced.

In line with Tones’ (1997) argument, we have juxtaposed sources of evidence to components of the Healthy City definition presented above. Typically, a wit- ness account would be a story from a community group, expert testimony might come from committed welfare workers or family practitioners, scientific work normally would be published in serious academic journals (with SSCI impact fac- tors!), and circumstantial evidence could be provided, for instance, by structural changes documented by maps, papers, and local perceptions.

The realm of research in, with, for and on Healthy Cities seems to have much to gain from a rigorous use of the matrix presented here.

One thing becomes strikingly clear when reviewing Table 9.1. In spite of what some academics seem to believe, there is a considerable body of evidence arguing in favour of Healthy City components; the field which is most diverse in provid- ing conclusive evidence is that of community action (e.g. Minkler 1997; Bracht 1999; Boutilier et al.2000).

On the other hand, we would argue that answering the question of whether Healthy Cities ‘work’ is not the simple sum total of various positive and negative expressions of evidence. As stated above, we believe that such information only becomes convincing evidence through the interpretation by the end users. Clearly, as the call for further production of evidence does not weaken there is also a need for what we might call ‘synergistic evidence’: particularly the meaningful re- combination of sources of evidence in a larger framework would produce a more profound insight into the adequacy, efficacy and efficiency of Healthy City projects.

It is further worth pointing out that the uniqueness of Healthy Cities does not lie in their application of models of community action, or of determinants-based health education campaigns, or of a policy-driven urban perspective. Goumans (1998) has demonstrated that in their operational functions, Healthy Cities can be divided as falling into three models: the health model, the citymodel, and the visionmodel. In the health model, Healthy Cities use the WHO vision in order to develop and implement innovative health promotion interventions. In the city model, Healthy Cities feel enabled to use the concept to develop and improve intersectoral urban policies for health. And finally, in the vision model, the Healthy City becomes a vehicle to enhance the health of the city (economically, ecologically, psychologically, etc.) rather than only that of its population. This means that the question whether the Healthy City (as a generic concept) ‘works’

could never be answered: evidence in its synergy would have to demonstrate how each city reaches the specificity of its own objectives.

Source of evidence Healthy CityWitness accountsExpert testimonyScientific workCircumstantial componentevidence Strategic and systemic–xoxxox–xxx Determinants of health–xx–xxoxxxoxx Community action–xxxoooxoxxoxx Equity in health––oxo––x Sustainable developmentoxx–xxoxxoxx Notes – no adequate ruleo few negative datax few positive data oo considerable negative dataxx considerable positive data ooo conclusive negative dataxxx conclusive positive data

Table 9.1.General estimate of availability of sources of evidence for Healthy City components

150 Evelyne de Leeuw

A REVITALISED AGENDA FOR RESEARCH IN, WITH, FOR AND ON HEALTHY CITIES

In 1992, a group of research experts gathered in Maastricht to develop a Healthy Cities Research Agenda (de Leeuw et al.1992). It should be noted that the group of ‘research experts’ was made up of individuals with strong academic back- grounds, but not always in academic positions. Housing executives, senior community centre managers and independent business consultants were invited to be members of the expert group in order to facilitate outcomes of the meeting that were to be scientifically profound, but also socially relevant (cf. for instance, the debate in the public health training literature in the 1990s where it was purported that schools of public health were to be centres of relevance rather than only cen- tres of excellence: Barnard and Köhler 1994; de Leeuw 1994). Figure 9.2 was one of the most important outcomes of that meeting. The figure acknowledges that the type of research into Healthy Cities is dependent on community needs, willing- ness and possibilities to fund specific projects, and on the composition of the research team: epidemiologists may want to study different issues than those of interest to political scientists, for instance. That very context creates a domain in the central rectangle of the figure in which level of analysis is connected to the phenomenon under study (or rather, the preferred type of research product). The expert meeting also established the observation that researchers at the time were not doing enough to market their work and its outcomes. There was a call for fur- ther ‘vulgarisation’ of the research process, its mission, and its outcomes in order to connect better with political, community and funders’ needs for proper research action; consistent with earlier findings (Tarenskeen 1991) it was agreed that ‘practical’ people such as politicians have problems understanding and inter- preting information provided to them by scientists. They seek refuge instead in information gathering from sources such as tabloids and incidental talks with

bac kground

needs/prob lems

oper ations

individual/group organisation municipality province nation international

evaluation maintenance

research team outcome and ouput

community action needs

funders' priorites political priorities

'empirical cycle'

Fig. 9.2. A model to structure Healthy City research needs

Source: de Leeuw et al.1992

Nur turing Healthy Cities 151 their constituencies. There is frustration on both sides: epidemiologists, for instance, complain that politicians do not take their analyses seriously whereas politicians deplore the inability of epidemiologists to explain clearly what the problem really is. ‘Vulgarisation’ of research should bridge that gap (cf. also de Leeuw 1993). Other authors have in addition argued that it is not just the out- comes of research that should be vulgarised, but also that the formulation of the primary research question should be developed in closer contact with practice (Kok and Green 1990). This observation takes us to the expert meeting establish- ing that there is a marked difference between research in, with, for and on Healthy Cities.

This differentiation between research in, with, for and on is not merely a semantic one. It denotes the delineation of roles in the research endeavour, and follows roughly the same parameters I have set out elsewhere for the respective roles of bureaucrats, scientists and community representatives in the initiation and implementation of community action for health (de Leeuw 2000).

Research onHealthy Cities would be the typical, almost clinical, perspective on the research enterprise. It would regard issues and situations in the urban envi- ronment as separable from reality, as if a true experiment in a petri dish were possible. No involvement of local politics, consultation with inhabitants, nor any form of exploratory research are deemed necessary in Research on Healthy Cities. Pure epidemiological research, involving measures of morbidity, mortality and odds ratio calculations would be an example of such research.

Research for Healthy Cities does not necessarily have to take place in the Healthy City itself. This research type could be regarded as foundation-building inquiry that would contribute to the adequate and responsive operations of Healthy City activities. Fundamental research into cognitions, attitudes and beliefs which could contribute to intervention development could be regarded Research for Healthy Cities. Experimental social psychological investigations into, for instance, risk perception and ways in which to modify such ideas, could be exemplary for this type of Healthy City research.

Research withHealthy Cities would be the type of inquiry hinted at above, in which the formulation of the research problem is established in close collabora- tion between academics and research principals. It should be observed, though, that in our view Research with Healthy Cities still distinguishes between an acad- emic world and something ‘out there’ which should be structured and reconstituted in order to suit a more traditional scientific paradigm in which the randomised control trial is still considered the penultimate in appropriate scien- tific technology. The American Journal of Health Promotion, for instance, uses an evidence rating with which its reviewers would be enabled to judge whether research materials provide proper evidence:

● conclusive evidence (*****) is: the cause–effect relationship between inter- vention and outcome is supported by a substantial number of well-designed studies with randomised control groups;

152 Evelyne de Leeuw

● whereas weak evidence (*) is that research in which evidence supporting relationships is fragmentary, non-experimental and/or poorly opera- tionalised.

Such a position would consequently mean that policy research by definition yields weak evidence: in policy studies experimental and control groups are virtu- ally impossible.

Research inHealthy Cities, finally, would best meet the needs of communities and politicians; however, such interactive and exploratory research is not easily brought under such standards as routinely (or arrogantly, sic) applied by main- stream quantitative experimentation-driven research institutions and their funders. Research in Healthy Cities, by definition, is respectful of community concerns, even if this would mean that a randomised control trial would be totally besides the point. Fortunately, however, there is an emerging scientific tradition that takes account of such issues.

EVIDENCE AND RESEARCH

These observations led to the conclusion that there was a strong need for further application of so-called Fourth Generation Evaluation to Healthy Cities research (Guba and Lincoln 1981, 1989). Such evaluation is developed in close discourse with research clients. Fourth Generation Evaluation assumes the following steps in the research development process:

1. contracting 2. organising

3. identifying stakeholders

4. developing within-group joint constructions

5. enlarging joint stakeholder constructions through new information/increased sophistication

6. sorting out resolved claims, concerns and issues 7. prioritising unresolved items

8. collecting information/adding sophistication 9. preparing agenda for negotiation

10. carrying out the negotiation 11. reporting, and

12. recycling.

Guba and Lincoln not only postulate a new generation of evaluation approaches.

They have also ascertained what the moral and ethical position of the research endeavour should be: the academic community should work with its clients through the entire inquisitive process, from problem identification and phrasing until the implementation of processes of change, their evaluation, and beyond.

Nur turing Healthy Cities 153 Though these observations hold true in the twenty-first century, the judicial evidence perspective introduced above adds a new dimension, and would neces- sarily lead to a revitalisation of the research agenda.

We can now acknowledge that such a meaningful framework must serve a number of clients and purposes. Researchers, politicians, and probably most prominently communities are the clients, whereas the purpose of a reference framework is primarily to produce evidence, which (when used with the canons of good reasoning and principles of valuation) answers the question why, when asked of a judgement, decision, or action.

This has implications for a new Healthy Cities Research Agenda: it is not suf- ficient merely to take into account the agendas, wishes and constraints of communities, politicians, and research principals, but we would have to add to our agenda a more profound recognition of the fact that evidence may come from a variety of (sometimes unexpected) sources. The central cube in what we could call the ‘2000βversion’ of the Healthy City Research agenda (i.e. a version that is still subject to change and debate) connects the various scientific perspectives and levels of analysis from the original model with the range of sources of evidence identified above (see Figure 9.3).

For different stakeholders in the Healthy City research process, then, the

‘2000β version’ would provide an opportunity to connect perceptions and per- spectives among Healthy City participants into a validated strategic manoeuvre in social entrepreneurship (cf. de Leeuw 1999).

MONITORING, ACCOUNTABILITY, REPORTING AND IMPACT ASSESSMENT (MARI)

Healthy Cities need to show their communities, their politicians and their partners that their work yields real results. Showing results, that is being accountable, can be done in different ways. It is a true, and shared, responsibility for Healthy City

research team outcome and ouput

community action needs

funders' priorites political priorities

'empirical cycle'

levels of analysis

scientific perspectivesevidence sources of Fig. 9.3. Healthy City research agenda: the 2000βversion

154Evelyne de Leeuw

operators and researchers. We feel that the research community should nurture the Healthy City movement more than it has done so far. Until now, academia has looked upon Healthy Cities with justifiable criticism. Good research, however, would intend to support Healthy City endeavours, and identify their weak points with constructive critique.

In Phases I and II of the Project cities were required to produce Health Profiles and City Health Plans. For the first (1986–92), second (1993–8) and third phase (1998–2002) of the Healthy City programme cities had to demonstrate political commitment to Health for All and the Healthy City vision, appropriate resource allocations to secure a full-time project coordinator and support staff in a Healthy City Office, and commitment to specific objectives leading to the establishment of local health policies. In the first phase, among the most important of such objectives was the establishment of an urban health profile (Doyle et al. 1996;

Garcia and McCarthy 1994; WHO/EURO 1998). In the second phase, designated cities were supposed to be working on the creation of City Health Plans (e.g. de Leeuw 1999), and the third phase committed Healthy Cities to the production of a City Health Development Plan and a process of more rigorous internal and exter- nal monitoring and evaluation. The mere production of such reports was a major step towards accountability in itself. Profiles and Health Plans showed the need for action in health, social and sustainable development. However, a city would need to go beyond such needs assessments in order to show that its activities have an impact.

Impact can be determined in different ways. Traditionally, the impact of health interventions was measured in terms of morbidity and mortality outcomes: the presence or absence of death and disease are considered relatively simple proxies for health status in a specified area. However, description of morbidity and mor- tality measures is in no way an indicator for the degree to which health, well-being and quality of life are currently enjoyed or pursued by communities and cities. Health determinants analyses, and sound and responsible approaches towards influencing determinants of health, would provide relevant and important information on the impact of Healthy City interventions.

Such sound and responsible approaches have now been identified as core prin- ciples of the Healthy Cities Project. Cities designated for participation in the Third Phase of the Project have subscribed and committed themselves to such principles.

However, mere commitment and good will are no longer sufficient. The Healthy Cities movement has expanded enormously. At last count, more than 5000 cities globally and over a thousand in the European Region alone have declared themselves Healthy Cities. This puts a responsibility on the group of forerunners: officially WHO designated cities will have to show the way forward.

Studies into Healthy Cities dynamics will play an important role in this process.

Research in, with, for and on Healthy Cities has always been a crucial compo- nent of the European Project. In the First Phase, cities were invited to contribute to our overall knowledge by filling out a ‘Healthy Cities Questionnaire’. The