Active living in healthy cities – an analysis of actions to promote physical activity by members of the European Healthy Cities Network

The built environment in cities and neighbourhoods, less physical demands in working life, and technological innovations have contributed to the increase in sedentary lifestyles in the last decades [1-3]. A sedentary lifestyle is a major threat to public health. Nearly two thirds of adult Europeans are not physically active at recommended levels [4] A review of population prevalence studies around the world by Bauman & Miller [5] indicates that approximately half of the studied populations are insufficiently physically active. The public health burden is very high. Physical inactivity causes an estimated 600 000 deaths per year in Europe [6]. In Great Britain, e.g., the monetary cost has been estimated at approximately 12 billion Euros annually – independently of the costs for overweight and obesity [7].

Strong scientific evidence shows that regular physical activity (PA) promotes health-related fitness, substantially lower rates of a large variety of chronic diseases, and prevent a number of disabling medical conditions [8].  In adult men and women, adhering to the current PA recommendation, e.g., lower the rates of all-cause mortality, coronary heart disease, hypertension, stroke, type 2 diabetes, metabolic syndrome, colon cancer, breast cancer, and depression [8]. In addition, more physically active people, compared to more sedentary people, have a higher level of cardiorespiratory and muscular fitness, a healthier body composition, and exhibit a biomarker profile that is more conducive for preventing cardiovascular disease, type 2 diabetes and enhancing bone health [8].

Clearly, there is substantial evidence and a range of motives to why governments at all levels ought to promote PA and create supportive environments for active living. Traditionally, efforts to promote PA have focused on providing information and intervening at the individual level. However, information-based interventions have not been effective in changing the sedentary trend, and individual behaviour change approaches are usually too small scale to make a difference at the population level [1, 2, 7]. There has also been a shift in focus in the last decade, from a situation whereby most interventions targeted exercise behaviour, to efforts at national, regional and local level to promote active living (although exercise is still an important component of an active lifestyle) [3]. Other trends include introducing socio-ecological models that target a large variety of sectors and arenas at different levels of society, and the increasing emphasis on making changes to the social- and built environment to improve conditions and remove barriers to active living [3].

Active living is a way of life that integrates PA into daily routines, such as walking and bicycling for transportation, taking the stairs, and using recreational facilities [3]. Since many pre-requisites of health and an active lifestyle are influenced by factors at community level, the role of local governments are vital to this process. However, investments in active living have been limited to date. Bauman and Miller [5]argue that:

“The potential of physical activity to contribute to the improvement of population health is under-recognised. The limited strategic development, lack of national physical activity policies, and limited commitment of resources to physical activity can be contrasted with much larger budgets for tobacco control and prevention and with substantial health sector resources allocated as a response to increases in obesity among adults and children.” (p 140)

In order to provide necessary support and leadership to local governments, the European Healthy Cities Network was established in 1986 by the WHO. The network aims at engaging local governments in health development processes, including making efforts to plan and implement actions in favour of active living. The network emphasises the vital importance of creating and improving the physical and social environments, as well as expanding community resources, to make a long-term and sustainable difference to public health [9]. To date, 79 cities participate in the European network, while more than 1200 other cities take part in related national networks. A survey was sent out to member cities during spring 2008 to evaluate phase IV.

This article analyses and summarizes the work done by member cities to plan and implement actions to promote active living. The aim is to facilitate the sharing of experiences of member cities and to document “added value”. The information gathered in the phase IV evaluation of the WHO Healthy Cities Network is important to improve knowledge of trends, goals and the nature of strategies and actions taken by member cities.

Methodology

The analysis was based on feedback from the following questions:

–          In planning your neighbourhoods how did you promote walking, cycling and physical activity?

–          How does your city’s active living programme link to public health concerns, especially about obesity and heart disease?

–          How does your city identify and reach out to sedentary people in your population?

–          Is the active living approach incorporated into your city’s plan and strategies for urban development?

–          How does your city measure and monitor levels of physical activity in the population?

Relevant information was also found in a wider examination of questions, e.g., “How did you support older people with age-friendly urban environments?”, and “What were the three most important healthy urban planning issues in your city?”.

Data analysis

A checklist was developed to analyse survey responses and to categorize actions. The checklist included the following items: Actions and strategies? Approaches? Policy-documents? Goals? Settings/levels of actions? Actors/Organisations involved? Types of physical activity behaviour? Target groups?

The author analysed the responses by ordering the content (the actions) into themes and dimensions. The dimensions represented higher-order constructs and included many actions and a number of themes that emerged in the analysis.

Results

Of the 79 member cities, 56 responses were included in the analysis. 22 members did not respond to the survey. One response was incomplete.

Type of physical activity behaviour promoted

As outlined in table 1, member cities promoted both behaviours related to active living and more sport-related behaviours. Among the responses were actions aimed at facilitating walking and cycling to conduct daily errands and for transportation, as well as actions promoting walking and cycling as recreation in free time. However, many members did not specify what type of active living behaviour they tried to promote.

Table 1. Types of PA behaviour promoted

Physical activity behaviours:
 

  • ·Overall physical activity & active living
  • ·Cycling for transportation
  • ·Walking for transportation
  • ·Recreational walking, e.g., long walks
  • ·Recreational cycling
  • ·Exercise & sports, e.g., gym, riding, ice-hockey, team sports, running
  • ·Outdoor leisure, e.g., fishing
  • ·Free play
  • ·Physical education in schools
  • ·Rehabilitation, e.g., hydrogymnastics

 

 

Target groups

Member cities described a number of target groups to promote active living. Among the most frequently mentioned target groups were: elderly, children, disabled, sedentary groups, and citizens in deprived neighbourhoods. Many members failed to mention any specific target groups, or targeted the whole population. Others stated “vulnerable groups” as target groups with no further information. The identified target groups are outlined in table 2.

Table 2. Target groups cited by member cities

Target groups:
 

  • ·Elderly
  • ·Children
  • ·Sedentary citizens
  • ·Disabled
  • ·Ethnic minorities
  • ·Parents with children in trolleys
  • ·Women
  • ·Citizens in deprived areas
  • ·Unemployed
  • ·Social benefit receivers
  • ·Worksite populations
  • ·The whole population

 

Goals and objectives

As can be seen in table 3, there were a wide range of goals cited by member cities in relation to active living, walkability and cyclability. There were goals related to the renewal of city centres and urban open space, such as enhancing city attractiveness, visual appeal and creating human-friendly environments. This, in turn, may be important to encourage tourism and one member city argued that enhancing the attractiveness of the city might encourage new business establishments. Other goals concerned social issues, such as fostering social cohesion and contacts, promoting equality, preventing segregation, and “reclaiming the streets” for social events. Regarding equality, one member wrote:

“Equity exists as an explicit theme in the work of the Sports Services centre of the city in promoting physical activity: providing special swimming hours for immigrants (Muslim women), providing reduced gym prices for everyone + 60 years and free use of the public physical activity facilities for everyone + 70.”

There was also evidence of social engagement and democratic influence by trying to involve citizens in the urban planning:

“The local people in the districts/communities participate actively in the city planning processes for better, greener and comfortable environment. The young people are often consulted e.g. where and what kind of skating area is the best and they are invited to the establishment [opening] of the sites.”

Transport-related goals included reducing traffic volume and speeding of motor vehicles, improving safety in traffic, reducing noise, in addition to the “universal” goals of accessibility and mobility for non-motorists. In terms of active living, salient goals concerned promoting PA, raising awareness of the benefits of active living, and raising awareness of existing recreational facilities in parks and neighbourhoods. Finally, climate-related goals included preventing climate change, promoting sustainable development, and reducing air pollution.

Table 3. Goals and objectives stated by member cities

Goals & objectives:
 Urban renewal:

  • ·Enhance city attractiveness
  • ·Visual appearance
  • ·Promote access to services and shops

 

Transportation:

  • ·Improve connectivity for non-motorists
  • ·Increase mobility and accessibility
  • ·Reduce traffic volume
  • ·Reduce speed of motor vehicle
  • ·Reduce noise
  • ·Improve public transport

 

Sustainable development:

  • ·Promote sustainable development
  • ·Increase the proportion of urban green areas
  • ·Prevent climate change
  • ·Reduce air pollution

 

 Social issues:

  • ·“Reclaim the streets” for social events
  • ·Foster social contacts and cohesion
  • ·Foster social capital and democratic involvement
  • ·Prevent segregation
  • ·Promote equality

 

Active living:

  • ·Raise awareness of benefits of active living
  • ·Raise awareness of recreational facilities
  • ·Improve walkability and cyclability
  • ·Promote physical activity & active living
  • ·Improve safety
  • ·Encourage outdoor recreation

 

Other:

  • ·Improve public health
  • ·Promote tourism
  • ·Encourage new business establishments 

 

 

Actions cited by member cities

The analysis identified a variety of actions at different levels. Overall, there was an emphasis on actions targeting the built environment, including actions to promote walkability and cyclability by improvements to the physical infrastructure. In addition, many member cities stated that the promotion of walking and cycling was integrated in their traffic plan, e.g.:

“The traffic plan focuses very much on pedestrians and cyclists. There is a commissioner for cyclists and one for pedestrians. There is an inter-sectoral working group for the issues of pedestrians”

The results are presented according to dimensions below. Table 4 outlines examples of actions stated by member cities. The list of actions is not exhaustive. Rather, the aim is to describe a large variety of existing actions.

Table 4. Levels of actions cited by member cities.

Built environment:Children & Schools:

– Build safe routes to school

– Improve road safety around schools

– Improve and build new playgrounds

– Improve and build new school yards

– Introduce playground markings

Parks & green structures:

– Protect, develop and extend urban green areas and parks

– Develop neighbourhood gardens

– Make sports facilities and equipment more available in parks

– Open up land to the public adjacent to urban areas

Cyclability:

– Build new and/or develop existing cycling infrastructure

– Introduce cycle priority lanes

– Build new, and improve existing, path and pedestrian crossings

– Build green trails between suburbs and city centre for cycling

Community facilities:

– Build recreational facilities in neighbourhoods

– Build community centres for elderly

– Build gyms suitable for the need of the elderly

– Install more benches in urban areas, including in public transport system

 Urban planning:

– Influence urban planning so that new neighbourhoods are built with services, public transport, green areas and recreational facilities within proximity (one scheme according to zero carbon principles)

– Renovate deprived areas

– Introduction of building ban

– Ban on the expansion of buildings in ecologically valuable areas

– Develop urban leisure zones

– Develop more attractive open space

Walkability:

– Equip buildings and services with ramps for the disabled

– Build pedestrian zones in city centre

– Build new and improve existing junctions

– Introduce low curbs on sidewalks

– Introduce “Woonerven” schemes *

– Open up cul-de-sacs (dead-ends) to promote connectivity for non-motorists

Safety & Traffic:

– Introduce new, and repair and improve existing, street lighting

– Introduce road signs for non-motorists

– Introduce speed bumps

– Narrow road space for cars

– Equip pedestrian crossings with sound signals and extended time

– Build new or improve public transport system

Social environment:Community events:

– Recreational- and sport events on city streets

– Annual events (health days, risk factor screening, day of cycling)

Community schemes & programmes:

– Community walking groups

– Walking-buddy for elderly

 – Walking school bus

– Exercise programme for vulnerable groups (unemployed, disabled, elderly etc)

– Free bike scheme & bike sharing

– Physical activity promotion in preschool, including swimming classes

Neighbourhood cycling schemes

– Cycling courses for beginners

– Schemes to promote cycling to work

– special swimming hours for immigrant women

– Community clubs for elderly

– Involve NGO:s

Financial incentives:

– Free entrance to gyms for elderly

Other:

– “Active” role models for elderly

– Private sector initiatives for exercise

– Improve winter maintenance of sidewalks and cycle paths

Information & Communication:- Mass-media campaigns

– Social marketing programmes 

– Leaflets & newsletters

– NGO:s “passing the word”

– Community & citizen involvement

– Open lectures & workshops

– Develop city cycling map

– Road safety guide to elderly

Other settings:

Health care:

GP advice

Exercise prescription

Family counselling (obesity in children)

Weight control groups (adult obesity)

 

University

 

– Research initiatives as a basis for future action

* Schemes whereby pedestrians and cyclists have legal priority over motorists. Motorists must adjust their speed to non-motorist. Usually introduced on a certain street or residential block

Built environment

The dimension built environment included the themes “children & schools”, “parks & green structures”, “Community facilities”, “Urban planning”, “Traffic & Safety”, “Cyclability”, and “walkability”. Salient actions were “improving existing or building new green areas and parks” (35 measures), “investing in bicycling infrastructure” (N=41), “investing in infrastructure for walking” (N=49), and “providing or improving community facilities for sports or recreation” (N=26). Other actions cited by member cities concerned traffic-calming and reducing motorized traffic (N=22) and designing people-friendly urban open space (N=20). In addition, developing public transport services was an important action: Approximately 15 cities cited actions taken to build new or improving public transport, while nine actions concerned establishing services and shops in the vicinity.

Relatively few member cities reported actions to promote safe routes to school (7 actions) or designing neighbourhoods to promote active living for children. Furthermore, only five actions concerned renovating or developing playgrounds, while even fewer member cities reported on actions taken to improve school yards (N=2).

Social environment

The dimension social environment included the themes “community events”, “community schemes and programmes”, “financial incentives” and “other”. Actions based in the social environment commonly involved schemes, activities and events organised by community groups, sport clubs or other NGO:s. For the purpose of this analysis, event is defined as an activity occurring infrequently or annually (e.g., cycle to work day), while schemes or programmes is regular or typically weekly activities (e.g., exercise classes). Salient actions were “organising community schemes and programmes” (21 actions), “organising community or sport events” (N=14). A popular action cited by some member cities was to close inner-city roads for traffic to organise sport events. Few member cities reported actions taken in the social environment to promote walking and cycling to school, e.g., “walking school bus” (N=4).

Information and communication

The dimension information and communication included the themes “media campaigns”, “community campaigns”, “information”, “health education for adults”, and “guides for mobility”. Information- and communication-based measures included producing leaflets and newsletters (9 actions), media advertising or campaigns (N=12), or other forms of community campaigns (N=6). Health education for adults (lectures, workshops) was mentioned as an action by seven member cities. More novel actions included producing road safety guides for elderly (N=1) and using social marketing principles (N=1).

Other settings

The health care sector was the dominant arena under the heading “other settings”. Actions in the health care sector (N=25) included screening, advice giving, family counselling, and exercise referral schemes. Member cities often reported the health care sector as an arena to identify and reach out to sedentary groups and to initiate prevention programmes for the chronically ill.

Barriers to active living

Several member cities experienced barriers to the urban planning for active living, including difficulties in integrating health perspectives into the process of regenerating city areas, lack of funding, and pressure from other sectors on the local government to allow exploitation of green areas or urban open space. Political commitment is important. One member stated that:

“Within the framework of physical activity the experience is that a top-down commitment to the overall agenda and an adequate funding is facilitative. Lack of these factors is obstacles.”

In addition, a substantial number of member cities mentioned that their work towards active living is not (yet) sufficiently integrated with other sectors or policy developments. Only eight member cities mention a specific integrated programme for active living. More common are frameworks or programmes tackling overweight and obesity in adults or children (N=18). However, some cities mention national strategies to promote PA.

Evaluation

Most content on evaluation originated from the question regarding how member cities measure and monitor levels of PA in the population. The evaluation efforts used by member cities to identify sedentary people and to evaluate the effects of interventions are mainly by household- or transport surveys. Furthermore, many member cities monitor citizens’ participation in community schemes and social events. However, a large proportion of members (N=28) did not evaluate or monitor levels of PA in the population at all, while one member city mentioned that the national survey they used did not have sufficient sample size to analyse subgroups of citizens.

Discussion

The main finding of this study is that most member cities reported actions initiated to promote active living, with an emphasis on actions targeting the built- and social environment. A majority of actions related directly to improving walkability and cyclability, but a variety of PA behaviours were promoted (see table 1). It is important to distinguish between different PA behaviours since they most likely are influenced by different correlates [2]. Although most cities mentioned existing policy relevant for the promotion of active living, such as plans and strategies for urban development, bicycling, and sustainable development, few cities appeared to have a specific and integrated strategic framework for the promotion of active living. More common were frameworks or programmes to tackle obesity in adults or children.

The results indicated relatively few actions to promote active living among children. In the evaluation, only seven member cities stated actions taken to create safe routes to school, five actions concerned playgrounds, and only two actions related to school yards. The lack of actions is surprising, given the recent attention to societal barriers to active living for children [10, 11] and evidence for the effectiveness of promoting PA to children through school-based interventions [12]. However, one reason may be that schools in many countries are governed by national authorities, which make school-grounds a non-issue for local governments. Another possibility is that actions to invest in community playgrounds and child-friendly neighbourhoods are “hidden” under the theme “community facilities”.

Interestingly, as outlined in table 3, there were a range of different goals directly or indirectly related to urban planning for active living. Among those goals were: fostering social cohesion and relations, promoting mobility and accessibility, enhancing city attractiveness and appeal, promoting sustainable transport systems, and encouraging tourism. Further to this issue, community involvement in the urban planning of actions was cited as an example of promoting democratic influence. It seems like a wise “win-win” strategy to continue to integrate the issue of active living and public health with other important social-, environmental- and economical goals that concern the local government. The potential for “win-win” approaches to achieve goals of the transport, health and environment sectors has been emphasised in a previous publication of European case studies [13]. 

Although some member cities use indicators and monitor PA by household- and travel surveys, most member cities lack thorough methodology to evaluate effectiveness of strategies and actions. A better understanding is needed of how to promote PA in sedentary groups, and member cities must work towards providing evidence that actions taken actually promote health-enhancing PA. This finding is in line with the results of the analysis of case-studies in European countries [13].

The popularity of socio-ecological models in recent years to promote active living is clearly evident in the scientific literature [2, 3]. However, in this evaluation, few member cities seemed yet to have adopted a socio-ecological model to plan or implement actions. This is supported by the fact that only eight member cities reported having a specific and integrated programme for active living. Having said that, promising is the approach taken by member cities to create supportive environments for active living, which is a cornerstone in socio-ecological models. One reason for the lack of socio-ecological models might be lack of funding and resources to initiative such model, rather than lack of evidence-based knowledge.

Limitations

A possible limitation to this analysis is underreporting, i.e., member cities failing to report on all measures adopted for active living. A second limitation is the lack of detailed information on strategies and actions in the feedback, which makes it difficult to develop a deeper understanding of the context of the actions (what?) and the processes involved (how?). A third limitation to this study might be the fact that 22 member cities in the network did not complete the phase IV evaluation. However, it is unlikely that the drop-out did affect the overall findings.

Future challenges

The findings in this study provide information on what member cities do well to promote active living, as well as information on areas of improvement. Without attempting to be exhaustive, the list below outlines some of the future challenges for member cities.

- Cycling infrastructure between cities: One may argue that the race for investing in bicycling infrastructure in cities is about to be won, given the rate at which such infrastructure is built at the moment. Much less work has been done on, and resources invested in, building bicycling infrastructure between cities and communities. Only one member city (Belfast) specifically mentioned investing in bicycling infrastructure between two cities. The WHO Europe has produced evidence-based guidance for cycling infrastructure and policies [14, 15]. Furthermore, the Swedish Road Administration [16] has recently established a model to guide the planning of bicycling infrastructure outside communities. The conclusion was that communities within 5-15 km of each other should be connected by car-free bicycling infrastructure. It may also be cost-beneficial to build cycle paths to improve accessibility to popular sites outside urban areas. The variance in distance in the recommendation depends on the size of the communities, the number of people living in proximity to the route, the number and use of popular sites along the route (e.g., beach, sport complex, forest, church), the potential for tourism, and whether it is possible to use closed road- or train infrastructure (e.g., the cost to build bike trails is dramatically lower if the trail can be built on a closed train embankment).

- Improve methodology for urban planning: Another challenge is the improvement of methodologies for “active planning”. GIS-methodology has a high potential to identify community needs and barriers in the environment. As an example, we might look at the issue of segregation. Today, the term “segregation” is often used to refer to a whole neighbourhood, mainly based on socio-economic status or some kind of an index. Many member cities indeed mentioned actions taken to create supportive environments for active living in segregated areas. Most of those measures were probably justified and for the best of public health, but little is known of the segregation inherent in the physical and social structures between areas or within areas. More affluent areas might even be more segregated than segregated areas in terms of accessibility to e.g., playgrounds, sport facilities or parks. A way forward would be to geocode all address points of the citizens, relevant aspects of the built environment as well as the sites and services in the city to establish accessibility among different groups to facilities and infrastructure for active living. GIS-methodology can identify barriers to active living inherent in the structures of the built and natural environments, and provides the opportunity to give much more specific answers to the question: Which citizens or which areas are segregated in terms of opportunities for an active lifestyle? There is a high potential to influence politics and policy by putting accessibility to active living on a geographical map. 

- Let an ecological model guide the urban planning of parks and green structures: As mentioned earlier, building new or developing existing parks and other green structures was one of the most frequently mentioned actions adopted by member cities. Relatively few member cities, however, seemed to have conducted audits beforehand or based the planning on a model. An important future planning issue, therefore, concerns creating activity-friendly parks and green areas. It is important to improve knowledge of how to optimize design of parks and green areas to fulfil a variety of needs of people and groups. A useful ecological model for such planning have been proposed by Bedimo-Rung et al [17].The model emphasises the importance of geographical aspects of the park and surrounding areas, and usability of the park for a variety of citizens. It also focuses on aesthetics, safety, maintenance, rules, and accessibility.

- More focus on active living for children: Relatively few actions taken by member cities related to children. Factors hindering active living for children include: dangerous routes to school, densification of neighbourhoods with exploitation of children’s play areas, speeding vehicles, and large increases in traffic volumes. Other factors may be lack of maintenance of school yards and community playgrounds [2, 3]. A recent Swedish study [18] using GIS-methodology showed that very few children had safe routes to school for independent active transportion. The share of children with safe routes to school ranged from only three percent in the least safe city (Säffle), to 36 percent in the safest city (Helsingborg). The magnitude of the problem is even worse when considering children’s independent mobility to other services in the city. It is important to note that the needs of children in terms of PA cannot be met by only providing special places or facilities for play, sports, and exercise. The health and development of children is influenced by their opportunities to explore their neighbourhood and community. This is also an important goal in the Convention on the Rights of the Child. Special attention is thus needed to remove barriers in society for active living for children.

- More resources needed: Lack of resources was one of the most frequently cited barriers to the promotion of active living among member cities, and it is important that funding and other resources are increased. This is often due to how resources are distributed within a certain sector. The transport sector is a good example of a sector with unevenly distributed resources to different modes of transport: Resource allocation for walking- and bicycling transportation seldom reaches 10 percent of the total budget for transportation at any level, despite the fact that walking and cycling contribute to a large proportion of trips in Europe every year. In Sweden, walking and cycling does not even receive 1 percent of the funding out of the 22-23 billion SEK annual government spending on transportation, despite the fact that approximately 30 percent of all trips are by foot or bicycle [19]. One way to increase resources for active living could be to make decision-makers more aware of the health consequences and related costs involved in travel choices and effects of governmental policies on transport and mobility. Another obstacle to overcome may be resistance from professionals within the transport sector itself to engage in transport planning for bicycling, as described by Spolander [19]. Health impact assessments and advocacy are likely to play important roles in making changes, but barriers exist on many levels at the same time. Systematic analyses are needed to gain insights into what needs to be done and to secure higher funding.

The future active city

Given the increasing public health burden of physical inactivity, future investments in active living is likely to increase. But what will the future active city look like, and what strategies and actions will be implemented in 10 years time? With the promising efforts taken by many member cities in mind, the future active cities will most likely be more successful in securing a higher share of resources. They will have an integrated strategy with goals, indicators and actions for active living and inter-sectoral collaboration is common. They are also likely to use health impacts assessments at an early stage of relevant urban planning projects. Furthermore, the future active cities rely on annual or bi-annual household surveys, validated against objectively measured PA, to gather important information on which groups to target for health promotion, and use GIS-methodology in the urban planning of active living to identify groups or neighbourhoods with low accessibility to active living. Community involvement is a natural step at all levels of urban planning and when implementing schemes and programmes for active living. The staff involved in the planning or implementation of actions is regularly trained to possess the right skills and expertise needed. Evaluation is a natural step of planning, programming, implementation and follow-up of policies, strategies and actions.

The main question remains, however: How do we get there? Perhaps the city of Kadikoy, Ukraine, already provided one part of the solution:

“…after carrying out new pedestrian zones, new cycling paths etc, people started to demand more and more physical activity areas, more pedestrian areas, more cycling paths, more walkable areas, by sending official letters to the Municipality”

Article submitted to Journal of Public Health

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