Do healthy cities work? A logic of method for assessing impact and outcome of healthy cities

Abstract

In this article, we discuss an appropriate methodology for assessing complex urban programs such as the WHO European Healthy Cities Network. The basic tenets and parameters for this project are reviewed, and situated in the broader urban health tradition. This leads to a delineation of the types of questions researchers can address when looking at a complex urban health program. Such questions reach appropriately beyond traditional public health concepts involving proximal and distal determinants of health (and associated upstream, midstream, and downstream rhetoric). Espousing a multi-level, reciprocal pathways perspective on Healthy Cities research, we also adopt a distinction between impacts and outcomes of Healthy Cities. The former are value-driven, the latter intervention-driven. These approaches lead to the acknowledgment of a logic of method that includes situational and contextual appreciation of unique Healthy City experiences in a Realist Evaluation paradigm. The article concludes with a reflection of evaluation and assessment procedures applied to Phase IV (2003-2008) of the WHO European Healthy Cities Network and an interpretation of response rates to the range of methods that have been adopted.

Figure 1.

The connection between the “11 Qualities Healthy Cities should strive for” (inner circle, Hancock and Duhl, 1986) and priority areas for cities designated into Phase Four of the European WHO Healthy Cities Project (outer circle).

Figure 2

Levels and pathways of influence for determinants of health connected to impact and outcome parameters for Healthy Cities.

Figure 3.

Response to two research instruments for Phase Four (Annual Reporting Template ART and General Evaluation Questionnaire GEQ). ‘Old’ cities are those that were already designated by WHO at some point during Phase Three. ‘New’ cities have been designated during Phase Four (and may have been designated in Phases One and Two but not Phase Three).

Figure 4.

Response to two research instruments for Phase Four (Annual Reporting Template ART and General Evaluation Questionnaire GEQ). New Independent States are those that gained nationhood since 1989 (predominantly in Central and Eastern Europe). Mediterranean nations are those on the Mediterranean rim. Some Mediterranean and NIS states are Organization for Economic Cooperation and Development (OECD) members (e.g., Turkey or Slovenia). Such nations are—for the purpose of geographical response classification—not included as OECD nations.