Why investigate urban health indicators?

Globally, the majority of people now live in urban areas.1 The European Urban Health Indicator System projects parts 1 and 2 (EURO-URHIS 1 and 2) have been developing tools to help policy-makers determine the health, and ways to improve the health, of urban dwellers. The focus of policy-makers should not just be on a narrow health perspective but also on the need to improve the environment, social status and quality of life of urban populations by all means possible. Descriptive studies at urban and sub-urban level which measure the extent of problems and monitor progress, and population-based interventions, are essential to ensure the sustainability of healthy urbanization and the wellbeing of urban citizens. Multidisciplinary, trans-sectoral research into evidence-based policy-making, i.e. from bench to populations, is the only way to bring about real health gain for the global urban resident. ‘Health is wealth’ must be the rallying cry for all urban policy-makers. In 1978, the United Nations (UN) recognized that the urban environment was a global challenge and created the Human Settlements Programme, or UN-Habitat, for sustainable settlement development and adequate shelter for all. Thirty years later, the urban population has now exceeded the rural population and become poorest subset of the World’s population.2 The movement of populations into urban areas (UAs) is due in part to the drive to achieve better general socioeconomic, cultural and environmental conditions. However, it has led to an expansion of urban environments known as ‘urban sprawl’. UAs can be split into many different zones depending on the functionality and density of the infrastructure and environment, e.g. urban heart or ‘city centre’, industrial and commercial zones, and suburban areas which are mostly residential or mixed function.3,4 The resultant variation in urban environments means it is often difficult to define the ‘city’ as distinct from the conurbation or larger urban zone as a whole. Health inequalities within the UA are sometimes as extreme as those observed between high and low-income countries.5 Urbanization is occurring most rapidly in low and middle-income countries. In addition, the majority of megacities (urban areas with a population of >10 million), and the fastest growing megacities are in developing countries.6 Positive environmental initiatives in UAs and megacities have been well-financed, especially by the European Commission, in the form of European Structural Funds, including the European Regional Development Fund, which identifies environmental protection and risk prevention among its key aims, as well as specific funds for housing improvement, and for access to green space and redevelopment of previously industrialized zones.7 As well as this, most of the major health agencies collect data on environmental factors from the UN agencies, e.g. World Health Organization (WHO), UN-Habitat; Organization of Economic Co-operation and Development (OECD) and EUROSTAT for the EU. However, most of these routinely available data can only be found at national level, which masks the differences that may exist between and within urban areas.8,9 An important recent initiative has mapped small-area level data for environmental agents and health conditions for public use.10 The broad range of natural, man-made, physical and social determinants of health means that successful environmental initiatives must involve many actors, including policy-makers and partners from disciplines such as architecture, urban planning, transport, education and recreation services. For these actors to develop evidence-based initiatives, they need access to urban and suburban level data in a timely manner with accurate estimates of exposure and outcomes. Health should be seen as both an outcome of good policy and a determinant for a healthy well-educated and diversely-skilled workforce. Therefore, collaboration between health and non-health policy makers is vital. Residential areas often have public health protection problems relating to current and previous land use. Historical data spanning decades are needed in the cases of some pollutants. Exposure to air and water pollution has often been measured in urban areas to reduce risk from air and water-borne agents. Social capital and cohesion correlate with health, and accordingly, data for neighbourhood and social environmental indicators are now collected routinely. The EURO-URHIS (www.urhis.eu) project funded by DG SANCO, identified urban health indicators and their availability. EURO-URHIS used a fusion of the American model described by Galea et al.11 and the European Community Health Indicators (ECHIs) shortlist with additions and omissions of indicators according to their importance in describing urban health. One of the key findings from the first project was the lack of routinely collected, comparable environmental indicators. Therefore, EURO-URHIS 2 aimed to develop methodology and validated tools useful to policy makers at all levels to enable them to make health gains for urban populations via evidence based policy decisions. There are a number of issues that primarily affect UAs, e.g. internationalization of metropolitan regions, ageing populations, rapid migration into and out the UAs and exposure to poor environmental factors. UAs have specific problems associated with health that are different to non-urban areas; which would not be identified through national or regional investigations. The WHO Healthy Cities programme promotes comprehensive and systematic policy and planning with a special emphasis on health inequalities and urban poverty, the needs of vulnerable groups, participatory governance and the social, economic and environmental determinants of health.12 In many urban areas, health policy is determined at local level. Policy makers therefore require data at urban area level to inform local policy decisions. Resource allocation in many countries is also at local level. National and international policy makers require data at UA level not only to inform evidence-based policy making, but also to evaluate the impact of policies. EURO-URHIS 2 has built on the existing knowledge base to collect, analyse and report on the prevalence of health problems in urban areas. This provides global, European, national and local urban health policy makers with a range of (aggregated) health measures and impact measures to help with decision-making. The timing of the project was critical, so as to build on the foundations of European health indicator systems made by EURO-URHIS 1, ECHI, Regional Health Indicator System (ISARE) and Urban Audit. The Urban Audit project has proved that it is possible to collect data at urban area level on a wide variety of indicators, thus enabling comparisons to be made. The comparisons of UAs across Europe will facilitate the exchange of experience and improve the quality of local urban policies3 or local policy makers. Other EU projects have investigated UAs for economic indicators, e.g. European Economic Research Consortium (ERECO). One of our partners has undertaken research in the field of Health Impact Assessments and has developed methodology and an evaluated tool specific to urban health to further their work on European Policy Health Impact Assessment. Four common questionnaires were developed by the consortium partners working together, relevant to the indicators required, and also developed methodologies to ensure comparability. Data was collated to create health profiles of individual UAs (available at www.urhis.eu health profiles). The results of the project were presented in the project’s final conference (available at www.urhis.eu final conference), on an interactive web-based platform (available at results.urhis.eu), and they will be published in relevant peer-reviewed publications. The project addresses many professional groups within urban society and environments, from policy-makers to public health professionals. The utility of the tools produced for policy makers is being addressed currently through qualitative methodology, with the overall aim to improve the quality of health in the urban environment. A series of workshops were organized within the project. The first three workshops concerned methodology development, while the last three workshops involved policy makers in discussion about the results and their usefulness for policy making. One of the key findings of the project is the complexity of urban policy and the variety of actors who take part in the decision making process. This is exemplified by the multi-disciplinary nature of urban health and the need to work across sectors and in non-health settings. Sustainability issues (including food, energy and water security), protection from the environment (including air and water pollutants, plans to protect the vulnerable from the effects of temperature extremes, social isolation and loss of social cohesion, etc.) are all important contributions to overall wellbeing and disease prevention. The 11th International Conference on Urban Health held in Manchester, March 2014 devoted many work streams to describing the need for crossing boundaries and the need for effective partnerships for improving the health of urban residents (www.icuh2014.com). The findings were also presented at the highly influential UN-Habitat’s World Urban Forum, Medellin, Columbia in April 2014 (http://wuf7.unhabitat.org/). Urban health is a discipline in which the wider determinants are a fundamental challenge for the next decade, century and millennium. This research project was co-funded by EU Commission, under the 7th Framework Programme (FP7/2007-2013) as part of the EURO-URHIS 2 project (grant agreement no 223711) and the project beneficiaries. We are grateful for the help provided by the EURO-URHIS and EURO-URHIS 2 project teams in each of the beneficiaries’ institutions. (Full details of all project partners can be found on http://urhis.eu/euro-urhis1/ & http://urhis.eu/). Conflicts of interest: None declared.