ARTIGO ORIGINAL

Evaluation of Portuguese community health projects and initiatives within the European and national healthy cities network

Avaliação de iniciativas e projetos comunitários de saúde em Portugal inseridos na Rede Europeia de Cidades Saudáveis e Rede Nacional de Municípios Saudáveis

Ana Isabel Rito^1,2*; Rafael Cardoso²; Inês Portugal²; Joana Baleia²; Sofia Mendes²; Margarida Bica²

¹ Departamento de Alimentação e Nutrição do Instituto Nacional de Saúde Doutor Ricardo Jorge, Av. Padre Cruz, 1649-016 Lisboa, Portugal

² Centro de Estudos e Investigação em Dinâmicas Sociais e Saúde, Fábrica da Pólvora de Barcarena, 2730-036 Oeiras, Portugal

Endereço para correspondência

 

ABSTRACT

Introduction: Following the World Health Organization European Healthy Cities Network, the Portuguese Healthy Cities Network was formally created by municipalities equally committed to promote equity, health and quality of life through local action.

Objectives: To evaluate the health promotion strategies and initiatives implemented at municipality level in the Portuguese Healthy Cities Network and to confirm if these were in line with the requirements of the Health 2020 policy integrated on Phase VI of European Healthy Cities Network (2014-2018).

Methodology: An exploratory-descriptive methodological design was used and a semi-structured questionnaire, developed by the World Health Organization Regional Office for Europe, was applied to the 29 municipalities of the Portuguese Healthy Cities Network (2013) invited to participate. 22 (75.8%) healthy cities met the criteria and were included.

Results: Programmes on promotion of physical activity were the most frequently implemented across the Portuguese Healthy Cities Network (81.8%). All municipalities (100%) reported that children (>5 years) were the main targeted group of Portuguese Healthy Cities Network initiatives, followed by elderly (95.5%), adolescents (86.4%) and adults (86.4%). Low levels (27% - 32%) of initiatives that engaged other stakeholders, were reported as well as there was lack of research projects related to health matters and established partnerships by the scientific community. Overall, there was a perception of a positive impact of the Portuguese Healthy Cities Network programmes as 50% of the municipalities reported a remarkable improvement in health and quality of life of the population.

Conclusions: Although life-course initiatives addressing the major burden of diseases were implemented, a more comprehensive approach is needed to follow Health 2020 principles. Development and reinforcement of the Portuguese Healthy Cities Network programmes is still a challenge. It should cover different population groups in order to tackle social inequalities and it also demands new partnerships, new forms of communication, as well as monitoring and evaluation mechanisms in place.

Keywords

Community health programmes, Healthy cities, Municipalities, Portuguese Healthy Cities Network

 

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RESUMO

Introdução: A Rede Europeia de Cidades Saudáveis da Organização Mundial da Saúde integra a Rede Portuguesa de Municípios Saudáveis cujo o objetivo comum é o de promover a saúde e a qualidade de vida, combatendo as desigualdades sociais, através de programas municipais.

Objetivos: O estudo pretendeu avaliar as estratégias e iniciativas de promoção de saúde implementadas a nível municipal na Rede Portuguesa de Municípios Saudáveis e verificar se estas estão alinhadas com os requisitos da Política de Saúde 2020 integrada na Fase VI da Rede Europeia de Cidades Saudáveis.

Metodologia: Foi utilizada uma metodologia exploratória-descritiva e aplicado um questionário semiestruturado, desenvolvido em colaboração com Organização Mundial da Saúde/Europa, e aplicado nas 29 cidades da Rede Portuguesa de Municípios Saudáveis (2013) convidadas a participar. 22 (75,8%) municípios cumpriram os critérios, tendo sido incluídos.

Resultados: Os resultados mostraram que os programas que abordavam a promoção da atividade física foram os mais implementados (81,8%) na Rede Portuguesa de Municípios Saudáveis. Todos os municípios (100%) reportaram que o grupo das “crianças > 5 anos” foi a população-alvo mais abrangida nos programas da Rede Portuguesa de Municípios Saudáveis, seguida pelo grupo dos “idosos” (95,5%), "adolescentes" (86,4%) e "adultos" (86,4%). As iniciativas de carácter multissetorial foram reportadas em apenas 27% dos municípios, bem como projetos de investigação relacionados com a saúde e parcerias com a comunidade científica (32%). No geral, o impacto percepcionado pelos municípios dos programas implementados da Rede Portuguesa de Municípios Saudáveis foi positivo, já que 50% dos municípios apontaram uma percepção de melhoria no estado de saúde e na qualidade de vida da população.

Conclusões: Seguindo os princípios da Saúde 2020, foi confirmado que várias iniciativas, direcionadas a todas as etapas do ciclo de vida focadas na redução da morbilidade, foram implementadas, no entanto foi deficiente a observação da implementação de abordagens mais abrangentes e multissectoriais, abrangendo diferentes grupos populacionais, com o intuito de combater as desigualdades sociais. Reforça-se ainda ser fundamental o recurso a parcerias e a novas formas de comunicação, bem como a mecanismos de monitorização e avaliação de carácter científico dos programas.

Palavras-chave

Programas de saúde comunitários, Cidades Saudáveis, Municípios, Rede Portuguesa de Municípios Saudáveis

 

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INTRODUCTION

In 1987, the World Health Organization (WHO)/Europe launched the Healthy Cities Project with the participation of 11 pilot cities (1), inspired and supported by the “WHO European Health for All strategy” and the Health 21 targets (2). This project emerged as an acknowledgement of the importance of the local and urban dimensions in health promotion, and the role of the governments in developing health policies (3, 4). It engages local governments in health development through a process of political commitment, institutional change, capacity-building, partnership-based planning and innovative projects. Today, the WHO European Healthy Cities Network (WHO EHCN) is composed by nearly 100 cities and 30 national networks, which together cover about 1400 municipalities (5).

The primary goal of the WHO EHCN is to place health as a top priority on the social, economic and political agenda of city governments. Health is a common matter to all sectors, and local governments are in a privileged leadership position, with power to protect and promote their citizens’ health and well-being (6). From the very beginning, the network’s activities have been organized into four-year phases with specific priorities (7). This would serve as a model to guide and overcome the challenging tasks involved in the process of becoming a healthy city (8). In 2014-2018 (Phase VI) Health 2020 principles were adopted which brings new evidence and puts increased emphasis on the right to health, equity, well-being and health in all policies through whole-of-government and whole-of-society approaches. It is based on four pillars: the life course; focused action to address the major burdens of disease; b people-centred health, care and public health systems; resilient communities and supportive environments. Health 2020 makes the political, moral and economic case for action and provides clear roles for local and community leadership as well as a platform for horizontal collaboration and national-local cooperation (9). Following the WHO EHCN, the Portuguese Healthy Cities Network (PHCN) was formally created on October 10th 1997, being nowadays made up of 55 municipalities equally committed to promote equity, health and quality of life through local action. Major aims of the PHCN include providing a stimulating forum for sharing and discussing health issues and developing joint solutions to common problems, implementing several health-related initiatives at local level (10).

Given that Phase VI (2014-2018) of the WHO Healthy Cities considers municipalities as a strategic vehicle to implement Health 2020 (9,11) at local level and the importance of holistic and comprehensive approaches, an evaluation of the initiatives, programmes and policies undertaken within the Portuguese Healthy Cities Network (PHCN), was needed, in order to measure progress and adjust programmes and policies at local level.

OBJECTIVES

The aim of this study was to evaluate the initiatives and programmes implemented within the PHCN through the lens of the Phase VI of the WHO Healthy Cities and to feed policy making to the development and re-positioning of health promotion strategies at the municipality level in Portugal.

METHODOLOGY

An exploratory-descriptive methodological design was selected and applied through a semi-structured questionnaire directed at all PHCN city coordinators. An invitation letter, which explained the overarching goals and aims of the study, was sent out to all municipalities (n=29 in 2013) of the PHCN. The questionnaire was answered in a self-administrated manner.

The questionnaire was developed in collaboration with the WHO Regional Office for Europe and adapted from a previous questionnaire developed by the Pan American Health Organization (12). The questionnaire encompasses the following dimensions: 1) areas of intervention and description of the ongoing initiatives; 2) political and institutional aspects; 3) training activities and relationship with the scientific community; 4) evaluation and perception of impact.

Out of the 29 participating cities of the PHCN, 22 (75.8%) were included - Amadora, Bragança, Golegã, Figueira da Foz, Lagoa, Loures, Lourinhã, Miranda do Corvo, Montijo, Odivelas, Oeiras, Palmela, Ponta Delgada, Porto Santo, Ribeira Grande, Seixal, Serpa, Torres Vedras, Vendas Novas, Viana do Castelo, Vila Franca de Xira and Vila Real. The remaining 7 were excluded because they didn’t meet at least one of the following criteria: 1) replying neither via e-mail nor via phone call to the invitation; 2) having underway activities; 3) getting approval in time to participate in the study.

RESULTS

1) Areas of intervention and description of the ongoing initiatives within the PHCN

According to the results regarding the areas of intervention, programmes intending to promote physical activity were the most frequently implemented across the PHCN: 18 municipalities (81.8%) reported such programmes (Table 1). On the other hand, programmes aiming to promote breastfeeding and health environment were reported as non-existing by the municipalities (54.6% and 27.3%, correspondingly) (Table 1).

Table 2 shows the settings where PHCN programmes were implemented. All the 22 PHCN municipalities (100%) were running programmes in communities, schools and kindergartens by the time the questionnaire was applied. Social centres (90.9%) were reported by the municipalities as the second most common setting.

By analysing the answers of the questionnaire, it was perceived that most of the municipalities (86.4%) developed community programmes through both short-term actions (directed at emerging problems) and long-term actions (towards determinants of health and/or quality of life of the population).

All PHCN participant municipalities (100%) reported “Children (>5 years)” as the main target population for initiatives, followed by elderly (95.5%), adolescents (86.4%) and adults (86.4%) (Table 3). Disabled persons and immigrants were the least reported population groups, only addressed in almost half of the PHCN municipalities (45.5% and 40.9%, respectively).

The Internet (63.6%) was highlighted as the most frequently communication channel used to disclose the municipalities’ activities, followed by social networks (45.5%) and brochures (31.8%). TV was the least used platform (4.5% of the PHCN municipalities reported its use).

2) Political and institutional aspects

Out of the 22 municipalities, 3 (13.6%) of these reported that their community-based programmes were implemented incorporating national public policies. Data revealed that most of the PHCN municipalities (77.3%) engaged in initiatives which involved different stakeholders.

Multiple players were involved in PHCN programmes. The Ministry of Health and Sports and Recreational Clubs were the most reported as partners (around 32% each) in the community programmes.

3) Training activities and relationship with the scientific community

Most of the cities (90.9%) reported that the training programmes for municipality staff, technicians and health professionals were conducted sporadically. The majority (54.5%) of the municipalities did not run research projects related to health matters and did not have established partnerships by the scientific community.

4) Evaluation and perception of impact

The general impact of the PHCN programmes was perceived positively in most cases as 50.0% of the municipalities reported a remarkable improvement in health and quality of life of the population.

Half of the municipalities considered “urban infrastructures for physical activity” and the existence of “parks and other green areas” as the key elements for the success of programmes which promote healthy eating and active lifestyle.

DISCUSSION

The evaluation of the PHCN programmes offers new key elements to improve concepts, strategies and local policies. It provides an important contribution to re-positioning the PHCN initiative.

Among the areas addressed in the PHCN programmes, the promotion of physical activity has been pointed out as a priority. This vision is aligned with the new physical activity strategy for the WHO European Region (13) and the WHO Global action plan for the prevention and control of noncommunicable diseases 2013-2020 (14). These policies call on governments to work across sectors, and together with stakeholders to incorporate physical activity in the lifestyle of all citizens. This is particularly challenging in Portugal, as only 35% of adults reported sufficient levels of physical activity and only 9% engaged in daily vigorous-intensity (exercise/sports) and a few times a week by 26% of the population (15).

All municipalities reported that Children (>5 years) followed by elderly, adolescents and adults were the targeted group of PHCN initiatives. Other cities from the WHO EHCN invested their intervention frequently among elderly, disabled people, children, and citizens in deprived neighbourhoods (16). In the German Healthy Cities Network child and youth health were the core areas of intervention (17). This represents that not only Portuguese cities, but also other European cities showed interest in covering the main life-course groups also highlighted on the Health 2020 principles, focusing action to address the most prevalent diseases.

Overall, there was a perception of a positive impact of the PHCN programmes as half of the municipalities stated a remarkable improvement in health and quality of life of the population. Nevertheless, there was no specific scientific evaluation reported. The majority of the municipalities did not run research projects related to health matters and did not have established partnerships with the scientific community. Plümer et al. stated that this was also a necessity felt in most of the Healthy Cities Networks of other countries (17). Additionally, professional training programmes which could strengthen the municipality structure in response to the most urgent health matters were also almost non-existent.

Although PHCN’s agenda has a b focus on tackling social inequalities, which is also highlighted in the Phase VI framework of the WHO Healthy Cities (9) and in the strategy for health and well-being – Health 2020 (11), this study showed that there is still a lack of programmes addressing specific groups, as only 9-12 municipalities reported to implement initiatives, targeting people with disabilities, immigrant communities and rural areas. However, other countries with the objective of reducing inequalities in deprived neighbourhoods implemented some measures by developing social services and a more inclusive public realm, through physical activity programmes for the disabled and walking schemes in disadvantaged areas (18, 19).

The results reveal that few PHCN programmes were considered as contributors to the national public health agenda. There is evidence of constant need to link each PHCN experience (micro level) with public polices (macro level), while simultaneously appraising the unique and diverse contribution inherent in each of these experiences (10). The articulation of the community programmes developed by the PHCN and the public policies would create and strengthen technical, political and institutional conditions to overcome instabilities, particularly financial. Moreover, the whole-of-government approach suggested by the Health 2020 principles was also shown to be in an incipient stage. There was some reportage (around 30%) of partnerships with Ministry of Health, Local Stakeholders (such as Sports Institutions) and Non-Governmental Organizations suggesting that there is still opportunity for comprehensive strategies to be implemented. Thus, the PHCN still shows the need for future alliances and relationships with social actors and dynamic institutions, such as cultural, youth, academic, and business-oriented institutions, which would contribute to the development of policies for social integration. PHCN could also be inspired by the successful examples of some WHO EHCN’s countries (e.g. Spain, Belgium, Norway and Croatia) that have already achieved a wider impact, influencing the policy of their regional and national governments (20).

This study suggests that some topics need further attention for the establishment of the Health 2020 policy:

- Strengthening the identity of the PHCN through its concept and tools and renew the methodology of its programmes, e.g. information concerning emergent and innovative themes should be created and published;

- Collaboration in line with the technological advances and the new forms of social participation;

- Permanent training for professional involved in PHCN initiatives and continuous research to support the ongoing initiatives;

- Monitoring and evaluation mechanisms, documenting obstacles and critical elements to the success of the programme to improve the population’s health and wellbeing.

CONCLUSIONS

Although life-course initiatives addressing the major burden of diseases were implemented, a more comprehensive approach is needed to follow Health 2020 principles. Development and reinforcement of the PHCN programmes is still a challenge. It should cover different population groups in order to tackle social inequalities and it also demands new partnerships, new forms of communication, as well as monitoring and evaluation mechanisms in place.

 

ACNOWLEDGMENTS

The authors want to express their gratitude to Rita Garcia and Patricia Abreu for their contribution and inputs in this study. Additionally, the authors would like to thank for the prestigious contribution in this study to the PHCN, namely Dr Mirieme Ferreira, for her availability and cooperation as well as to all the collaborators and city coordinators of the PHCN.

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Endereço para correspondência

Ana Isabel Rito

Departamento de Alimentação e Nutrição do Instituto Nacional de Saúde Dr. Ricardo Jorge,

Av. Padre Cruz,

1649-016 Lisboa, Portugal

rito.anaisabel@gmail.com

 

Recebido a 13 de novembro de 2018

Aceite a 24 de março de 2019