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This is, therefore, one example of how local governments and nongovernment institutions can collaboratively apply a tool to collect relevant evidence and develop appropriate interventions and targets to resolve health inequities in their cities. En- gaging a wide group of stakeholders and strategically communicating the results to policy-makers proved key in obtaining the support for further action.
Conclusions: Key Elements for Strategic Communication
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HEART seems to favor the option of using—improving and adapting where pos- sible—existing sources of information as the most strategic alternative.
The use of a previously agreed value could be useful to portray existing differ- ences; Urban HEART shows how the different units of analysis behave in relation to the agreed standard and organizes them into three groups. The standard can be the mean of the total area under scrutiny, or a national or regional average; the use of goals such as the MDGs or national goals has also proven useful. In the example from Ulaanbaatar, officials were able to use national and international goals where appropriate to benchmark performance on various indicators.
Having a simple and consolidated way to communicate differences does facili- tate understanding of existing health inequalities and the urgency for action. One of the strengths of Urban HEART is a summary chart that shows the differences for all the analyzed variables simultaneously using a simple three-color classification (see a monochromatic version in Fig. 10.2).
Second, strategic communication requires a recognition that social structures in urban areas are the main determinant of health inequity. The final report of the CSDH clearly states this, revisiting a time-honored finding of public health (WHO 2008a). Moreover, overwhelming evidence suggests that health services alone are insufficient to improve health (Broyles et al. 2000; Annett 2009; Choy and Duke 2000; Webb et al. 2001). Hence, communication of health inequalities to policy- makers must adopt a framework that recognizes the crucial role of the social deter- minants, and takes into account the risk factors and interactions of multiple sectors in the urban environment as they impact on communicable and noncommunicable diseases as well as violence and injuries. Several of the tools analyzed, accomplish this objective by complementing the description of the differences in health out- comes with analysis of social, economical, and political variables that can explain, or suggest, their structural determinants.
Once again, the selection and availability of information is a challenge that needs to be overcome based on the context. For instance, a political indicator such as voter participation rate can be very useful to explain health differences, but not in all contexts. Nevertheless, omitting the governance dimension can jeopardize deeper understanding of the roots of health inequalities and blur the process of selecting the proper intervention.
Third, the evidence collected should be linked clearly to actionable interventions and policies. The use of data disaggregated by socioeconomic group, by geographi- cal area or neighborhood, inclusion of information on social determinants, and eas- ily understandable presentations facilitates the development of guidance on multi- sectoral action and community participation as key strategies. In addition, guidance on the process of moving from the assessment of the health inequalities to the selec- tion of interventions and policies could be a useful path for effective strategic com- munication, although prescriptive, one-size-fits-all approaches should be avoided.
Urban HEART uses a two-pronged strategy, presenting the policy cycle as an orientation on how to transit from the assessment to the response, and provid- ing a set of evidence-based interventions organized into five different strategies:
(1) incorporate health in urban planning and development; (2) emphasize and
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strengthen the role of urban primary health care; (3) strengthen the health equity focus in urban settings; (4) put health equity higher on the agenda of local govern- ments; (5) pursue a national agenda. By providing sources and examples of inter- ventions, it also facilitates the selection of proper actions and, therefore, real stra- tegic communication. For instance, WHO has prepared a compilation of evidence that support interventions to address healthy nutrition and promote physical activity (Ni Mhurchu et al. 2010; Spahn et al. 2010; Michie et al. 2009), which are included in Urban HEART.
Fourth, tools to assess health equity in urban settings could be an effective aide to strategic communication, as long as the tool follows the characteristics explained.
In addition to that, such tools should be simple and user-friendly. A wide variety of stakeholders including local and national government officials, civil society and other independent agencies should be able to apply it for decision-making and im- pact assessment purposes. Moreover, implementation should be operationally fea- sible and sustainable. This is facilitated, for instance, when the evidence can be gathered from routinely available data within existing institutional mechanisms.
Finally, for strategic communication to effectively contribute to tackling health inequity, an instrument needs to promote sustainability of action and therefore to go beyond providing a set of principles and recommendations. Therefore, political commitment is required as a crucial ingredient of successfully addressing health in- equities rooted in unfair distribution of resources among populations. For instance, one city that piloted Urban HEART has made the application of the tool compulsory by ordinance. This expresses the political commitment of a city to establishing a permanent mechanism to disentangle and respond to its health inequities.
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