Promoting health in the urban context

by Joachim Westenhöfer, Hamburg University of Applied Sciences (HAW Hamburg), Competence Center for Health

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Urbanization is one of the worldwide megatrends characterizing the development of mankind. At the beginning of the 20th century, only about 10 per cent of the world population lived in urban areas. By 2015, this proportion had risen to 54 per cent, and it is expected to increase further to 60 per cent by 2030 and 66 per cent by 2050. The proportion of people living in cities has also risen continuously in Germany in recent years and decades. In Germany, more than three quarters of all people currently live in cities and this proportion is expected to rise to 78.6 per cent by 2030. This means that cities and the urban setting are highly relevant to the health of their inhabitants. 

People’s health is affected by a variety of determinants: in addition to individual factors that cannot be changed, such as age, sex and genetics, individual lifestyle and health behaviour play an important role. Health behaviour is understood to be any behaviour that influences the likelihood of diseases occurring. This includes in particular abstinence from smoking, moderate alcohol consumption, adequate physical activity, a balanced, healthy diet and proper stress management.  However, the lifestyle and health behaviour of individuals cannot be seen in isolation from their social, cultural and physical context. Social networks, social support and social cohesion in the neighbourhood play an important role. The local infrastructure, such as transport connections, supply and shopping, cultural amenities and opportunities for participation and involvement also affect the behaviour and lifestyle of individuals and groups. Overarching factors, such as general living and working conditions and even global environmental factors, in turn have an impact on the immediate environment and individual behaviour. 

Lifestyle and health behaviour are also influenced by sociostructural factors. The socioeconomic status is of particular importance in this context. People with low occupational status, low income and/or low education levels tend to die earlier, suffer more frequently from health impairments (e.g. stroke, chronic bronchitis, back pain, depression, obesity) and often adopt less favourable health behaviour (smoking, increased alcohol consumption, unhealthy diet, physical inactivity) (Robert Koch Institute, 2015). The living and residential environment is another important sociostructural factor. Socially disadvantaged districts or neighbourhoods have particularly complex social, economic, infrastructural and building problems. These neighbourhoods are usually inhabited by many socioeconomically disadvantaged people, such as unemployed people, migrants, single parents and families with many children. There is often a lack of recreational spaces, play areas and sports facilities. In addition, there are environmental health risks and burdens (e.g. dense traffic situations, increased noise pollution and pollutant emissions, accidents) as well as a poorer safety situation (e.g. crime, poorly lit footpaths). 

These considerations clearly show that human health cannot be seen in isolation as the sole responsibility of individuals. Rather, health is created by people within the settings of their everyday life, i.e. where they “learn, work, play and love”, as the 1986 Ottawa Charter for Health Promotion puts it. Accordingly, health promotion measures should also focus on the settings of people’s everyday life in order to reach them. This approach is known as the setting approach. The setting approach is also suitable for reducing social disparities in health and health resources. 

Urban neighbourhoods are the living and residential environment of city dwellers and are thus a highly relevant setting for health promotion. Theories on the impact of the residential environment on health and mortality assume that there is a correlation between the socioeconomic and ethnic composition of the population in a neighbourhood, the social environment and the physical environment. The social environment includes factors such as prevailing norms and values, social cohesion and social relations, safety or violence. The physical environment comprises various factors such as environmental pollution, quality of buildings and housing, access to food and leisure resources, nature and aesthetic aspects. The social and physical environment, in turn, have an impact on the subjective perception of a neighbourhood by its inhabitants, on fluctuation in the neighbourhood and on health behaviour. 

The correlations between social and physical environmental factors in neighbourhoods, the associated health behaviour and health status are the subject of intensive research. With regard to the physical environment, it has been shown that more nature is associated with a lower prevalence of overweight and obesity and better health. These positive health determinants include green spaces (urban green spaces of a certain minimum size), greenery (forests, nature parks and cultivated agriculture) and blue spaces (water bodies such as rivers, streams and lakes). Under the keyword of “obesogenic environment”, a variety of environmental factors are discussed that contribute to people becoming overweight and/or obese. These include residential environmental factors that influence nutrition and/or eating and physical activity habits. One of these factors is the concept of the food desert, i.e. a residential environment with limited access to healthy food, but easier access to unhealthy food such as fast food and junk food. For example, a study in Cologne showed that fast food restaurants are more commonly found in deprived neighbourhoods compared to socially advantaged neighbourhoods. Similarly, access to alcohol and tobacco is more frequent in socially disadvantaged neighbourhoods in purely quantitative terms (addictive environment). 

The opportunities for people to engage in physical activity in the neighbourhood are of particular importance. Easy access to and availability of playgrounds and sports facilities is a key factor. Again, physical factors such as distance and accessibility, but also social aspects such as an inviting and target group-oriented design, social usage profile (who is there, when and how?) and subjective feeling of safety are of major importance. The walkability of neighbourhoods, municipalities and cities is also increasingly being discussed and investigated as an important design element. Even if this concept is by no means used and understood consistently, it is still understood to mean a design of urban (and municipal) spaces that generally promotes physical activity.

To promote and maintain the health of residents, it is advisable for neighbourhoods (as for many other settings) to take measures at two levels: at the behavioural level and at a level related to the social context. At the behavioural level (behavioural prevention), attempts are made to motivate and enable people to adopt healthier behaviour through information, education, counselling or training, for example a healthier diet, adequate physical activity or proper stress management. Measures related to the social context focus on the design and change of the residential, living and working environment. This may involve identifying and reducing health risks such as noise exposure, air pollution or heavy traffic in the neighbourhood, but also identifying and exploiting potential for health promotion. 

As mentioned above, natural elements such as green spaces and blue spaces can have a positive effect on people’s health. Inviting places can promote social interaction and social cohesion. Measures related to the social context can ultimately also facilitate health-promoting behaviour or make it possible in the first place. 

An example of this is designing urban neighbourhoods to promote physical activity, which has moved into the focus of prevention research under the keyword of “walkability” (a pedestrian-friendly or generally exercise-friendly approach). The reason for this is the fact that physical inactivity is described as one of the major public health problems of the 21st century. Physical inactivity is not only the cause of chronic and degenerative diseases, but it also leads to a decrease in interaction with the neighbourhood and consequently to a decrease in social participation. By contrast, adequate physical activity is associated with improved well-being and mental health. Good walkability requires that interesting destinations (e.g. public transport stops, shopping facilities, health services) are within walking distance, that footpaths are sufficiently wide and unobstructed, that paths are well lit at night, that road crossings are pedestrian-friendly and not car-oriented, and that the neighbourhood and paths are perceived as clean and safe. The availability of attractive seating and, last but not least, accessible and usable toilets also contribute to the walkability of public spaces.

The “Gesundheitsförderung und Prävention im Setting Quartier“ (“Health Promotion and Prevention in the Neighbourhood Setting”) research network is investigating health disparities among residents in six Hamburg neighbourhoods with different socioeconomic status. A survey of 799 residents in the six neighbourhoods showed that there are differences between the neighbourhoods in terms of walkability. The survey showed that there is a clear need to improve walkability in deprived neighbourhoods. However, even better walkability in socially more advantaged neighbourhoods is no guarantee for adequate physical activity and exercise. Better walkability seems to be a necessary condition for more physical activity rather than a sufficient condition for it. 

It has been shown that the design of urban neighbourhoods has a considerable impact on the residents’ health. Nevertheless, urban planning and health promotion are two disciplines that are often not linked, let alone systematically cooperate. It therefore seems imperative that future urban planning measures take systematic account of the health consequences of such planning. The aim should not only be to reduce health burdens in planning, but also to pursue the goal of expanding and improving health-promoting potentials and resources. 

We will systematically investigate and develop this approach in a further research project on “Health Impact Assessment in Urban Planning”. Health impact assessment (HIA) is a tool to assess the compatibility of measures taken outside the actual health sector with health concerns. The aim is to increase the chances of social participation and a healthy and fulfilling life, as well as to reduce social inequalities. This requires changes on at least two levels: urban planning authorities need to rethink their understanding of health, and health services need to be put in a position to take a well-founded stand in the urban development process and to introduce health issues. It is also important to involve the residents concerned in planning and design processes through participatory processes to ensure that the result can meet the interests and needs of those affected. The aim of our new project is to investigate, together with colleagues from Erfurt University of Applied Sciences, what impediments there are to the systematic consideration of health and health-promoting aspects in urban planning processes and measures, how an HIA can be integrated into municipal processes in the easiest and most resource-saving way possible, and how previous impediments to implementation can be reduced. We will initially focus on the aspect of walkability to address a central public health problem of the present.