City Health Profiles:: How To Report On Health in Your City

City Health
Profiles:
how to report on
health in your city
City Health Profiles 1

ICP/HSIT/94/01 PB 02
Target 14
Text editor: Rosemary Bohr

Desktop publishing: Shirley Harelle
Cover design: Thora Feldam
This booklet provides advice on how to produce a city health profile. A

city health profile is a quantitative and qualitative description of the
health of citizens and the factors which influence their health. It iden-
tifies problems, proposes areas for improvement and stimulates action.
All appropriate sectors work together to collect, analyse, interpret and
present the information. Guidance is given on the analysis of data, pro-
duction of the report and the presentation and communication of the
report's findings. Detailed suggestions are made for the contents of a
city health profile.
Keywords
URBAN HEALTH
HEALTH STATUS
HEALTH SURVEYS methods
HEALTH PROMOTION
EUROPE
WHO Regional Office for Europe
This document may be freely reviewed or abstracted, but not for commercial purposes. For
rights of reproduction, in part or in whole, application should be made to the WHO Regional
Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen, Denmark. The Regional Office wel-
comes such applications.
The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the World
Health Organization concerning the legal status of any country, territory, city or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries.
The views expressed in this publication are those of the contributors and do not necessarily
represent the decisions or the stated policy of the World Health Organization.
2 City Health Profiles

Contents
Part I
Acknowledgements ........................................................... iv
Foreword ........................................................................... v
1. Introduction .................................................................. 1
2. Objectives and purpose ................................................. 3
3. Production ..................................................................... 7
4. Contents ........................................................................ 13
5. Analysis and interpretation of data ............................. 19
6. Presentation, dissemination and communication ....... 23
7. Monitoring and evaluation ........................................... 27
8. Follow-up ....................................................................... 29
Part II
9. Contents of the profile:

detailed suggestions ................................................. 33

Acknowledgements
T
his booklet was produced for the WHO Healthy Cities
Project by the WHO Healthy City Project Technical
Working Group on City Health Profiles.
The Working Group
Dr Mark MacCarthy, Camden (Chairperson)
Dr June Crown, South-East Institute of Public Health,

England (principal technical adviser and responsible
for drafting the report)
M Jacques Berthou, Rennes
Dr Ann Marie Connolly, WHO Regional Office for Europe
Dr Patrick Doorley, Dublin
Dr W.G.M. de Haes, Rotterdam
Dr S. Fontanelli, Bologna
Mr Kieran Hickey, Dublin
Dr I.A. Krasilnikoff, St Petersburg
Dr Hans van Oers, Rotterdam
The generous support of Mutualit Franaise in the

production of this booklet is gratefully acknowledged.

Foreword
C
omprehensive city health profiles represent key
products of the Healthy Cities project. They provide
the evidence and the credibility for serious efforts to
promote health at the local level. They act as the basis for
advocacy, the setting of priorities and accountability for health.
Profiles are about the health of people and about the conditions
in which they live. They are essential tools for change and
thus must be an integral part of local decision-making and
strategic planning processes. The preparation of profiles creates
unique opportunities for intersectoral work and community
and media involvement. This booklet is intended to provide
guidance and a reference frame to cities, towns and
municipalities that belong to the Healthy Cities movement.
The WHO Healthy Cities project office is planning a series of
follow-up publications covering issues such as: tools for
assessing a population's health; innovative examples of and
approaches to designing profiles and evaluating the impact of
city health profiles.
Technical documents based on commissioned expert input alone

are relatively easy to produce, but they may be more academic
and lack the practical touch. Books in the Healthy Cities docu-
ment series are based on thorough consultation and experi-
ence through information exchange processes involving a wide
range of expertise especially from the primary users. This book
was prepared through consultation with a technical working
group to ensure that it is a truly practical and appropriate
guide for those working in Healthy City projects. The final
text was agreed only after consultation with the full WHO
Healthy City network at a technical symposium held in Poznan
(Poland) in September 1994.
I should like to express my gratitude to Ann Marie Connolly

for coordinating the preparation of this booklet, to June Crown

for her technical expertise as the principal technical adviser
and her work in preparing the text, and to Mark McCarthy,
who chaired the technical working group so successfully and
who facilitated the work of the group through hosting a meet-
ing in Camden. I appreciate very much all the work and ad-
vice from the technical working group. I would also like to
give special thanks to Mutualit Franaise for their very gen-
erous support which made the production of this booklet pos-
sible.
Agis D. Tsouros, MD, PhD

Coordinator Healthy Cities project

Part I
Preparing a
City Health Profile

1. Introduction
A
city health profile is an invaluable tool for every
participant in a Healthy Cities network. It provides a
lively, scientifically-based account of health in the city;
it can stimulate public interest and political commitment; and it can
identify targets for the future and monitor progress towards them.
All WHO Healthy Cities have agreed to produce profiles by

the end of 1995. This document aims to help them do this. It draws
on the experience of cities which have already prepared profiles as
well as the advice of an expert group.
The Healthy Cities network has developed a set of healthy

cities indicators which are incorporated into the suggestions for
profiles. Indicators and profiles together should help in the develop-
ment of city health plans, which in turn can lead to a review of the
indicators.
Indicators are measures of health and of the factors which

influence health. They can provide a basis for comparisons
between cities.
Profiles include both indicators and other health-related

measures with an analysis of the information. They identify in
writing and graphs health problems and their potential solutions
in a specific city.
City health plans set out strategies and programmes of

intervention to improve health in the city, define targets and
timetables for achieving proposed actions and identify monitoring
arrangements.
It is important that the preparation of a city health profile is not

seen as a burdensome requirement imposed by WHO for member-

ship of the Healthy Cities project. A profile can help cities in many
ways: the collaboration which is needed to produce it can help
cement alliances for health; the information it contains can highlight
health problems and bring partners together to find solutions; and
the presentation of the profile can stimulate public and media inter-
est and improve general understanding of health issues.
We realize that participating cities vary widely in the resources

they can devote to the preparation of profiles and in the amount and
quality of information currently available. This book does not aim to
give a prescription or rigid instructions for the preparation of a
profile but to put forward suggestions and ideas which will give
cities a starting point. To be relevant to a city a profile will always
depend on local involvement, interpretation of the data in a way that
is sensitive to social and cultural differences, and proposals for
change that are credible and feasible.
A good profile describes a city and the factors affecting its

citizens health in a way that they will instantly recognize, and sets
out proposals for change that will generate enthusiasm and energy.
It should provide a focus for both community involvement and
political support.

2. Objectives and
purpose
A
citys health profile is a quantitative and qualitative
description of the health of the citizens and the factors
which influence their health. It identifies problems,
proposes areas for improvement and stimulates action.
Objectives
A city health profile should:
summarize health information relevant to the city
identify health problems in the city
identify factors that affect health in the city
identify suggested areas for action to improve health
act as a stimulus for making health changes in the city
set targets for achievements related to health
act as a stimulus for intersectoral action
identify needs for new data on indicators of health
inform the public, politicians, professionals and policy-makers
about matters that affect health, in an easily understandable
form
make health and its determinants visible
record the local communitys views on health issues in the
city.
The main purpose of a city health profile is to

stimulate action to improve health by:
providing accurate, up-to-date, unbi-
ased and independent information
about the citizens health

providing accurate, up-to-date, unbi-
ased and independent information
about the determinants of health in the
city
analysing the information with respect
to its impact on health
identifying courses of action to improve
health
inviting community participation in
planning for health
inspiring all relevant groups to take
action to improve health
setting targets to monitor progress.
A
ll the cities participating in the Healthy Cities move
ment have committed themselves to improving the
health of their citizens. The city health profile is a tool
to assist in this work.
Although a citys health profile is usually produced by groups

of professionals in the city, its contents should be useful to and
endorsed by policy-makers and the public as well as professionals. It
should form a valuable channel of communication between politi-
cians, experts and citizens and facilitate open discussion of health
problems.
One of the most important instruments in the struggle for

health is information, which can be used to secure community
interest and political commitment. It can also measure progress in
improvement in health. The city health profile is a vital source of
information.
The information can only be effective, however, if it is of high

quality. Whatever its source, it must be checked for accuracy and be
as up-to-date as possible. The group responsible for gathering the
information should have high professional standards and ensure that
all the data are selected and analysed independently. However well

meaning, the inclusion of biased data from persuasive pressure
groups will unbalance the report and detract from its overall impact.
A citys health profile should describe clearly current know-

ledge of the citizens health and of the many aspects of the citys life
that influence it.
The analysis should lead logically to the identification of possi-

ble areas of action, with some indication of relative priorities.
The presentation of the information and the analysis should be

compelling, so as to galvanize the population and policy-makers
into taking action. The style of the document should be cohesive,
encouraging all groups to see the contribution they can make and to
facilitate the development of alliances for health across the commu-
nity.
A citys health profile is not a one-off document. A series of

profiles should be planned for publication at regular intervals.
Ideally they should be produced annually, especially in larger cities,
but where resources are limited a two-year cycle may be more
appropriate. Regular publication enables targets for progress to be
set, the implementation of recommendations to be monitored, and
achievements measured, recorded and celebrated.
If all these aspects can be successfully incorporated, a citys

health profile can become a valuable and powerful instrument of its
health strategy.

3. Production
E
ach city will face different problems in producing a
health profile. The priority is to make progress and not
let the best be the enemy of the good. Ideally you
should:
identify a lead agency to manage the

production of the citys health profile
involve all relevant agencies at an early
stage
identify the available budget and hu-
man resources
identify target audience(s) and decide
how many versions of the profile are
needed
set a timetable for production and
dissemination
decide on content and the longer-term
programme
identify existing relevant data sources
consider the availability of local assist-
ance (schools, universities, voluntary
groups)
include recommendations.
Lead agency
In most cities, the initiative to produce a health profile comes
from one agency or department which takes the lead in producing it.
This agency should be acknowledged by others in the city as the
appropriate group and should take responsibility for coordinating or
managing the production of the profile. The Healthy Cities coordi-
nator will often take this role, and will aim to secure political sup-

port for production of the profile as part of the commitment to the
Healthy Cities project.
Involvement of relevant agencies

It is important, however, that the profile is not the work of
only one agency. At an early stage, contact should be made with
other relevant groups in the city, using formal and informal contacts.
Collaborators should, wherever possible, include statutory agencies
responsible for health services, environmental health, housing, social
services and education. Voluntary agencies concerned with health
and health-related issues are also valuable partners. A steering
group for the project can support the production team. Ideally this
would include representatives of formal agencies which can contrib-
ute resources or information together with, if possible, one or two
enthusiasts chosen for their personal commitment and ability to
inspire others.
However, it is sometimes difficult to get going. It may be

necessary for the first profile to be produced by only one or two
agencies, with others being encouraged to join in in subsequent
years. It is better to get started, with high quality information wher-
ever possible and perhaps with some gaps, than to wait until every
possible partner is ready to collaborate.
Identify resources
The preparation of a citys health profile takes time, and print-
ing and distribution need money. It is important at an early stage to
identify a budget for the project which includes the available finan-
cial and human resources, contributions in kind (paper, printing) and
sources of income (advertising, sponsorship).
All those contributing resources should be asked to make clear

at the outset exactly what they can make available. The production
team should work within this and not put pressure on contributors
to exceed their capacity. All contributions should be acknowledged
in the publication. (However, caution should be exercised about
accepting sponsorship from producers of products that are danger-
ous to health such as tobacco companies.)

Cities should not be deterred by having to produce a profile
with limited resources. Some of the best city health profiles have
been produced very cheaply.
Target audience
One of the first tasks is to decide on the target audience for the
citys health profile. A document which is suitable for health profes-
sionals may not be suitable for policy-makers and may be too tech-
nical for the general public. It may be necessary to produce a
number of versions of the document. For instance, it may be possi-
ble to produce a short, accessible version for the public together
with a more comprehensive document, fully referenced with statisti-
cal information, for professionals. Decisions about the target audi-
ence may determine the number of copies needed and may thus be
influenced by the budget.
Timetable
The group responsible for production should, at an early stage
in the process, set a timetable with agreed dates for interim stages
and completion. It is useful to fit the publication of a citys health
profile to key organizational points for participating agencies, such
as planning or budget-setting cycles. The intention of this is to draw
attention to health problems and possible areas of action when the
next phase of activity and resource allocation within the city is
under discussion.
Content and long-term programme

The participants should agree on the frequency of production
of the citys health profile. Ideally these should be produced annu-
ally, especially in larger cities, but where resources are limited a
two-year cycle may be more appropriate. The first profile is likely to
include a comprehensive statistical description of health in the city.
If annual profiles are to be published it may not be necessary to
reproduce all the statistics each time, especially when there is little
change or surveys have not been repeated so that there is no new
data. It is, however, worth including annual figures for population
and vital statistics if these are not readily available elsewhere, as
they provide valuable reference material.

The first profile should try to be as comprehensive as possible
and cover a broad range of health problems and issues. Subsequent
profiles can focus in depth on a few health issues, which may each
be allocated a chapter in the publication. It is helpful to decide on
and announce the special topics for the next two to three editions.
This has the advantage of reassuring people with an interest that
their topic is not forgotten. In addition, the knowledge that a topic
is in preparation may generate surveys or offers of relevant informa-
tion.
Data sources
The formal agencies in the city will have access to the major
data sources and national statistics. Much of this information is not
collected specifically for health and health care purposes. It is
nevertheless of great value in describing the population and the
determinants of health. Statistics derived from the use of health
services are also valuable, although they have to be interpreted with
care since they may reflect access to care and inequitable demand
and supply rather than population morbidity and need. Local statu-
tory and voluntary organizations may also have data from surveys
and other sources which will enhance the citys health profile. The
conclusions drawn from such data must take account of their epide-
miological and statistical quality.
Local assistance
Gaps in information or areas where local studies would be
valuable may become evident when the work is being planned.
Assistance can sometimes be obtained from collaborators such as
schools, universities and institutes of higher education or voluntary
bodies, which may carry out surveys or other investigations for
inclusion in the profile. If properly designed and supervised, with
concern for scientific rigour, such projects can greatly enhance the
profile, encourage participation and understanding and offer useful
educational opportunities.
Recommendations
Finally, review the contents of the citys health profile, decide
on priority areas for action and put forward recommendations.
These should be firmly based on the evidence that has been pre-

sented, not just the current aim of a persuasive pressure group, and
should identify the agency responsible for taking action. It is helpful
to propose quantified targets for implementation which can give
people a sense of achievement and confidence when they are at-
tained.
not be available. Examples are hospital admissions by selected ICD codes
and primary care attendances by cause.
Other primary care measures may be valuable, as this is the level

where the vast majority of morbidity is managed. The arrangements vary
from country to country, so each city should try to develop measures
appropriate to its own system.
Statistics from statutory procedures: examples include compulsory

admission to hospital because of mental illness or physical infirmity
statistics from registration procedures. The main examples are statutory
notification of infectious diseases and cancer registration.

4. Contents
This section should be read in conjunction with Part II
E
very city will produce its own individual profile, with
contents that reflect the availability of data and the local
priority concerns. The first profile should try to be as
comprehensive as possible, but it should include in particular those
health issues which are of immediate concern or importance to the
citizens at that time.
There is no prescription for a citys
health profile: each city will choose its
own topics.
All profiles should include a basic
description of the population (number,
age structure) and vital statistics (birth
and death information).
Other areas for consideration for inclu-
sion are:
health status
lifestyles
living conditions
socioeconomic conditions
physical environment
inequalities
physical and social infrastructure
public health services and poli-
cies.
The basic demographic and vital statistics are so fundamental
to the description of the city that we would expect them to be
included in the statistical section of all profiles. They are usually
well and universally defined and so form useful indicators for com-

parisons between cities.
Some indicators can only be obtained if considerable resources

are available, for example through special surveys, so it may not be
possible for all cities to include them.
Some characteristics of the city may change only slowly, so

data may sensibly be collected and analysed every three or five
years. More frequent surveys would waste resources and perhaps be
disheartening to local people because of the small changes recorded.
Cities are not homogeneous: health and its determinants vary

across them, and it is useful to obtain some of the statistical data by
locality and perhaps to represent it graphically to help pinpoint areas
which have special needs. We would expect every city health profile
to include some examples in each of the following sections. A more
detailed list of possible topics can be found in Part II.
Population
The starting point for the profile must be the size of the city
and the demographic description of the population. This information
is usually available from national or regional censuses. It can often
be broken down by localities, and future trends and projections can
be included.
Health status
There is no single indicator of the health of a population. Most
of the measures are of death and illness rather than positive health.
These are nevertheless useful measures which have the advantage of
widespread use over many years. Their advantages and limitations
are well known. The main areas to be included are:
(a) vital statistics: measures of births, deaths by age group

and cause, and ratios which allow comparison with other places;
(b) measures of morbidity: measures of illness in the

population, which can be obtained by special epidemiological
studies or by indirect measures such as disease registration
(notifiable diseases, cancer) or use of health services.

Lifestyles
There is good epidemiological evidence on the influence of
lifestyles on the major causes of morbidity and mortality across
Europe. Cities should include information on these whenever possi-
ble, as they represent areas for local preventive action. They in-
clude:
smoking
alcohol
misuse of drugs
exercise
diet.
Housing
Adequate housing has long been recognized as an important
prerequisite for health. The patterns of tenancy (home ownership,
private and public rented housing) vary considerably from country
to country, so there will be different data sources which will be well
known within the city. Information may be available on:
the numbers of homeless people in the city

physical characteristics of housing
density of occupation.
Socioeconomic conditions
Living conditions are also influenced by socioeconomic fac-
tors. Information on these can come from a variety of agencies, and
will depend on national and local distribution of responsibility for
services. Items for inclusion might include:
education
employment
income
crime and violence
cultural participation.

Physical environment
The physical environment of the city has a major effect on both
health status and the citizens perception of health. A variety of
measures are available, and statistics can usually be obtained from
the local environmental health services on:
air quality
water quality
water and sewage services
noise pollution
radiation
open spaces
infestations
food quality.
Inequalities
Any assessment of a citys health will reveal that different
groups of citizens experience very different states of health. If the
status of the most deprived could be brought closer to that of the
most affluent, many of the citys health targets would be achieved. It
is therefore extremely important that the citys health profile identi-
fies and if possible quantifies the inequalities in and determinants of
health. Many of the statistics set out above can be analysed accord-
ing to population characteristics to demonstrate the gradients across
groups.
Physical and social infrastructure

A citys infrastructure influences and in some respects deter-
mines living conditions, the physical environment and lifestyles in
the city. This section of a citys health profile may be more descrip-
tive and qualitative rather than statistical and quantitative. It may
include information about transport, communications and city
renewal and planning. Social infrastructure topics may include
training opportunities, descriptions of community development
projects and evidence on social isolation.

Public health policies and services
The interpretation of public health varies across Europe. Here,
we mean services and policies which aim broadly at health promo-
tion or disease prevention. It may be useful to include a list of those
policies which exist and a commentary on the effectiveness of their
implementation. Areas for inclusion may be grouped according to:
policies and services aimed at disease prevention in the popu-

lation
educational policies and services
environmental policies and services.
Although no city health profile will include comprehensive

information on all these subjects, a profile which presents some
evidence on most of them will give a good account of health status
and the factors that affect it and will make a powerful contribution
to the identification of health problems and development of plans.

5. Analysis and
interpretation of data
Key Wherever possible, expert advice

points should be sought on the analysis and
interpretation of the data in the citys
health profile.
Criteria should be agreed for the
assessment of data submitted for
inclusion in the profile.
Statistical information is usually best
presented as rates or ratios.
Trends and projections are useful for
developing plans.
Comparisons with national figures or
with data from other cities can iden-
tify areas for detailed examination.
Graphical presentation adds interest
to the report.
W
henever possible, the team producing the citys
health profile should include or be supported by
people with training and expertise in statistics,
epidemiology and analysis of the data used, and who can advise on
the selection, technical use and interpretation of the data. Without
this expertise, statements may be made which are misleading, con-
clusions may be drawn which are without foundation and the work
may be brought into disrepute.
Selection of data
Criteria for selection of data for inclusion in the profile should
include:
relevance to health
statistical validity

statistical reliability
availability of historical trend data
potential for projection into the future
relationship with other health data (social isolationalcohol
health; povertyhousinghealth)
availability of comparative data within the country at national,
regional or city level and with foreign cities and countries.
Analysis of data
Each city will obtain guidance on the most appropriate meth-
ods of analysis of its particular data sets, taking account of factors
such as sample size and response rates. There are some general
points which it may be useful to consider.
Raw numbers of events are rarely useful: they should be

included in the text, to enable readers to assess the data.
Whenever possible, rates should be used which relate the
event to the population, e.g. deaths per 1000 inhabitants,
immunizations per 1000 children under 5 years, cervical
screening per 1000 women in the target age group.
Ratios such as the standardized mortality ratio allow compari-

sons to be made between populations with different demo-
graphic characteristics for example, comparison of death
rates between a town with many retired elderly people and an
industrial town with a younger population.
Trends are usually interesting and informative. Care must be

taken, however, to ensure that the data have been collected
uniformly during the period in question (definitions, data
sources, sampling, etc.) so as to ensure that like is being
compared with like.
Projections of data into the future are difficult and need

expert assistance. Account has to be taken of likely changes in
the population structure, etc. Straight line projections are
virtually never correct.

Calculations derived from the data can be of considerable
interest and assist in assessing priorities. For example:
potential years of life lost: this measures the gap between age
at death from a specific cause and general life expectancy. It
shows up the burden of deaths in young people from, for
example, accidents, where the numbers may be relatively small
but each event represents 50 years foreshortening of life;
avoidable deaths: designation of certain causes of death
as avoidable may relate to failures in prevention (coronary
heart disease, stroke), screening (cervical cancer) or medical
care (appendicitis).
Analysis of deaths in these categories may identify useful

areas for action.
Comparisons with similar cities or with regional or national

figures can provide valuable insights and generate questions
about the causes of significant differences, which may lead to
action.
It is often helpful to present data graphically as histograms or
pie-charts or on maps. When this is done, at least one version
of the profile should include the data from which the illustra-
tion is derived. Presentational tricks (different scales used in
comparisons, etc.) should never be used.
Readers who have not been involved in the preparation of the
report may wish to know how the data has been analysed. At
least one version of the profile should include technical de-
tails of statistical tests, sample sizes, response rates, etc. In
this version, the more detailed tables of data may also be
included as an appendix for those who wish to examine the
figures in depth.

Data sources
The sources and availability of data will vary widely from city
to city. The production team should, between them, be able to
generate a useful list of sources, including:
national surveys undertaken by government departments,

statistical services or other agencies on a regular basis
census data
city council statistics
Healthy Cities indicators database
university departments of medicine, public health, social
science, economics or education
institutes of epidemiology
health service data derived from hospital or primary care
facilities
environmental monitoring services
voluntary agencies
commercial organizations (e.g. for tobacco, alcohol or food
sales)
statutory health examinations (e.g. school, military)
local surveys.

6. Presentation,
dissemination and
communication
Presentation
Key
points Medium
Format, size
Layout
Illustration
Readability
Identity
Dissemination and communication

Distribution
Number of copies
Leaflets
Locations
Communication
Formal public meetings
Informal public meetings
Media
Launch
H
owever impressive the contents of a citys health
profile may be, the profile will only serve a useful
purpose if it is read and understood. Effort put into the
presentation and dissemination of the profile and communication of
its messages is never wasted. Each city will know how to attract the
attention of citizens, taking account of local culture and tastes. In
this section, we set out some pointers which may help to generate
ideas in cities.

Presentation
An early decision is needed on the medium in which the profile
is to be produced. Every city is likely to want a written version.
Some Healthy Cities have produced very successful video versions
of health profiles to complement written versions. Local voluntary
groups may be able to assist in preparing Braille or taped versions
for people with visual impairment.
The format and size of each version should be decided. Techni-

cal advice is valuable at this stage, as small differences in page
number can have major implications for price because of printing
and paper size considerations. If a version is to be distributed by
post, paper thickness should also be decided, to minimize weight
and postal costs.
The layout and presentation of pages should be decided.

Issues to consider might include typeface, colour of text print and
figures (clear, dark and large print is much easier for older people
and those with visual handicaps to read). Clear diagrams and figures
can also be easily photocopied.
Page layout do you want double or single columns, and a

figure or illustration on each page?
Will statistical tables be incorporated in the text or presented
as an appendix?
Will technical definitions be included as footnotes or a glos-
sary?
Illustrations can contribute to the attractiveness and accessibil-

ity of the profile. Decisions should be taken on the types of diagram
to be used, the inclusion of photographs and the use of cartoons.
Action should be taken at an early stage on the preparation of the
illustrations, so that production is not held up.
The text can be measured for readability to take account of

range of vocabulary, length of sentences, etc. Local educationalists
can advise on an appropriate level. It is also worth looking at popu-
lar local newspapers to obtain guidance.

Readers should be able to recognize the identity of the docu-
ment. It is worth including both on the cover and in the text a well
known logo or city symbol.
Dissemination and communication

The production of the profile is not an end in itself. Energy and
resources also have to be invested in communication to ensure that
the need for change is recognized, that interest is sustained and that
action is taken.
Distribution
The distribution of the profile will be influenced by the number
of copies available. If there are several versions of the profile, care
must be taken that the right version reaches the right target audi-
ence.
A small leaflet highlighting some key points of the profile can

usually be produced quite cheaply. This can include information on
how to obtain a copy of the full report. City councils often have
distribution systems for other purposes such as electoral registration
or local tax collection and leaflets may be sent round to all house-
holds with these at minimal cost.
Copies of the citys health profile should be sent to as many

public places as possible, for example:
libraries
schools
hospitals (the video can be shown in waiting areas)
primary care premises and clinics
leisure and sports centres
churches.
Communication
The citys health profile must make an impact on the public,
policy-makers and opinion-formers. Arrangements should be made
for presentations at:

formal public meetings of health boards and committees
informal public meetings for voluntary organizations, local
community groups and the general public.
A press release should be prepared and distributed before

publication day. This can be followed by a press conference and
interviews on local radio or television. Some local media repre-
sentatives may be willing to prepare articles or programmes on
health subjects to coincide with publication if they are given notice
of the proposed date.
It may be useful to organize a launch event to attract attention

to the profile, perhaps involving local personalities such as sports
stars. Some cities have also arranged health fairs, events in shop-
ping centres and widely publicized health competitions.

7. Monitoring and
evaluation
C
onsiderable effort and resources go into the production
of a citys health profile. It is strongly recommended
that the profile should be evaluated, both because this
is good practice and because it shows to other groups and bodies
that high standards are being set.
There are many approaches to monitoring and evaluation. Each

city will choose its preferred approach, but in selecting a method
attention should be paid to its validity. Although evaluation methods
are complex, it is possible to undertake simple studies which are
entirely satisfactory. Some resources should be set aside for moni-
toring and evaluation when the budget for the project is set.
It is not generally possible to use outcome measures such as

morbidity or mortality, as it is hard to make a direct connection
between the publication of a city profile and changes of this kind. It
is usual, therefore, to evaluate the production and content of the
citys health profile and its impact.
Evaluation of the production and content
Production
Was the timetable adhered to?
Was the budget adhered to?
Was the distribution satisfactory?
Were the arrangements for the public presentation and launch of
the profile satisfactory?

Profile content
Was the information which was required located and was it
accurate?
Were the illustrations clear and appropriate?
Were the conclusions based on evidence?
Were recommendations clearly spelled out?
Were the readability standards met?
Impact
The aim of the exercise is to improve the health of the popula-
tion. It is difficult, however, to measure this outcome, especially in
the short term, and even more difficult to ascribe cause and effect.
The impact of the profile must therefore be judged by various other
proxy measures.
Were public meetings well attended?

Did the profile have good media coverage?
Was there a good response in terms of requests for copies of the
profile or return of questionnaires enclosed with it?
Did the policy-making bodies endorse the recommendations?
Did the policy-making bodies produce plans in line with the
recommendations?
Were the plans implemented?
If plans or projects are developed as a result of the profile,

these should also be evaluated. It may then be possible to assess
resulting changes in lifestyles or health. Wherever possible, these
should be reported in subsequent profiles to encourage future work.
Each profile should include a short introductory section on the

impact of the previous profile and any action arising from it.

8. Follow-up
P
roducing a citys health profile will almost always estab
lish alliances between sectors and generate enthusiasm
for the promotion of health in the city. The profile itself
will identify areas for action and suggest possible partnerships.
It is important that the production of the citys health profile is

not seen merely as a task and an end in itself, but as part of a dy-
namic process. The momentum achieved should, if possible, be
maintained. Partnerships for health should be nurtured.
The profile itself should explicitly be part of a cycle, containing

reviews of earlier achievements and recommendations for future
action. It should be used regularly as a means of communication
with the public and policy-makers until it is replaced by the next
edition. The expectation is that over the years a citys health profile
will become an influential part of public health policy and activity.
The production of a citys health profile will not necessarily be

easier as time goes by, but there will be satisfaction in noting the
progress which it will record. The document should sustain and
develop interest in health and act as a mechanism to ensure account-
ability for health in the city.

Part II
Contents of the profile:

detailed suggestions

Note
P
art II supplements Chapter 4 of Part I. It contains
examples from a range of existing city health profiles.
They are a limited sample of the types of data that could
be used in health profiles and the ways in which these could be
presented.
Full details of the source of the examples used are listed at the
end of the booklet.

9. Contents of the profile:
detailed suggestions
T
his list is not intended to be prescriptive but to provide
a menu from which cities may select items for inclu
sion in their profiles. Neither is it comprehensive: as
they work on profiles, cities will identify other topics for inclusion.
Some items of information are almost universally available,

have agreed definitions and are therefore valuable for comparisons
between cities and countries. They are marked with an * and should
normally be included in at least the first health profile produced in
each city.
Population
85+ Example 1.
8084
Age pyramid
Male Female 7579
7074
6569
6064
5559
5054
Age
4549
4044
3539
3034
2529
2024
1519
1014
59
04
6 4 2 2 4 6
% of total population

* Total number of citizens on a specified date
* Age and sex structure of the population by 5-year age bands
* Percentage of children (01, 14, 514 years)
* Percentage of older people (over 65, over 75, over 85 years)
Historic trends and future population projections
Ethnic origin of major population groups (this may not be
relevant in cities which have not experienced significant
immigration)
Health status
Vital statistics
*Birth and fertility rates
* Death rates
* Standardized mortality ratios (compared with national figures)
for all causes and selected causes of death
* Perinatal mortality rate
* Maternal mortality rate
* Abortion rate
Example 2.
% Above Scottish Average
Standardized mortality
ratios for major causes
of death in Glasgow
Heaart Disease
Lung Cancer
Respiratory
All Causes
Disease
Cancer
Stroke

Years of life lost (this is derived from mortality statistics and
represents the difference in years between age at death from
specific causes and national life expectancy)
Avoidable deaths (deaths from conditions where there are
effective forms of prevention and/or treatment)
Example 3.
Trends in standardized
mortality ratios for 0
64 year age group, by
sex, all causes
Measures of morbidity
Use of health services. Although information derived from the
use of health services does not necessarily reflect the popula-
tions needs, it nevertheless provides evidence about some
illnesses that would otherwise not be available. Examples are
hospital admissions by selected ICD codes and primary care
attendances by cause.
Other primary care measures may be valuable, as this is the

level where the vast majority of morbidity is managed. The
arrangements vary from country to country, so each city
should try to develop measures appropriate to its own system.
Statistics from statutory procedures: examples include com-

pulsory admission to hospital because of mental illness or

physical infirmity statistics from registration procedures. The
main examples are statutory notification of infectious diseases
and cancer registration.
Example 4.
Measures of perceived health and wellbeing

Measures of perceived health and wellbeing. There are several
validated instruments which measure individuals assessments
of their own health. Information of this kind usually requires a
special survey.
Example 5.
Long-term illness

Lifestyles
The following are the major lifestyle factors for which there is
good evidence of a relationship with health.
Smoking
Example 6.
Lifestyle factors

Direct measure: population surveys identifying trends
in tobacco consumption and smoking levels in groups
such as women and young people
Indirect measure: hospital admissions for smoking-
related diseases (coronary heart disease, lung cancer,
bronchitis)
Indirect measure: information from suppliers and
retailers on tobacco sales (this may only be available
nationally or through customs and excise authorities)
Example 7.
Variations in smoking rates in
districts of Rotterdam
Percentage smokers per neighbourhood, 1987 1991

Alcohol
Direct measure: population surveys (as above)
Indirect measure: hospital admissions for alcohol-related
conditions (alcohol-related violence, cirrhosis)
Indirect measure: police records of drunk driving
Indirect measure: information from suppliers and retailers (as
above)
Example 8.
Alcohol consumption in districts of Nancy

Misuse of drugs
There are few satisfactory direct measures, except where
addiction to hard drugs must be registered and this is usually
not comprehensive. Information may be obtained from drug
clinics, needle-exchange schemes or hospital data.
Exercise
Direct measure: population surveys (as above)
Indirect measure: attendance at sports centres, swimming
baths, etc., and participation in team sports
Diet
Direct measure: population surveys (as above) or more de-
tailed food consumption/expenditure studies
Direct measure: anthropometric assessment of population
samples (height and weight)
Indirect measure: information from major local food suppliers
on trends in sales of low-fat milk, wholemeal bread, fish and
red meat
Housing
Information may be available on the number of homeless

people or those in temporary accommodation in the city.
Physical characteristics of housing

Availability of basic amenities (hot water, toilet, kitchen)
Occupation density
Number of persons per household
Number of persons per room
Number of persons sharing a bathroom
Number of persons sharing a kitchen
Number of single-person households

Example 9.
Home environment

Socioeconomic conditions
Many socioeconomic factors are known to be associated with

health status.
Education
Proportion of children still in full-time education at 14, 16 and
18 years
Literacy rates
Participation in adult education programmes
Employment
Numbers of people registered as unemployed, by sex and age
Major employers and industries in the city
Income
Range of income levels (obtained from population surveys,
fiscal records or benefit claimant records)
Crime and violence

Police statistics on crimes of violence against the person
(assault, mugging, homicide)
Car and domestic theft conviction rates
Example 10.
Unemployment can
seriously damage
your health . . .

Cultural participation
Availability of cinemas, sports events, theatres, concerts and
other entertainment
Attendance at art galleries, museums and exhibitions
Physical environment
Air quality
Average and peak levels of pollutants (N0x, C0 2, 03,
particulates)
Morbidity, hospital admissions from pollution-induced respira-
tory diseases
Water quality
Levels of chemical and biological pollutants
Outbreaks of waterborne diseases
Water and sewerage services

Proportion of households with mains water supply and sew-
age disposal
Noise pollution
Monitoring of noise (average and peak levels)
Radiation levels
Open spaces
Areas of designated public open space per hectare
Infestations
Notifications of infestations by rodents, insects, etc.
Food quality
Data from environmental services routine monitoring of food
sources and distribution centres
Outbreaks of food poisoning and other foodborne diseases

Example 11
Quality of water
Quality of water in the Neva River and tributaries
in the area of St Petersburg
12.0
10.0
8.0
Water pollution index

6.0
4.0
2.0
Ochta
Izhora 0.0
Karpovka 1993
Bolshaya 1991 1992
Neva 1989 1990
Nevka 1987 1988
1986
Inequalities
Much of the data in other sections can be analysed according to

population characteristics to draw attention to inequalities in health
and in the factors which influence health.
Example 12.
Inequalities in health variations in standardized mortality ratios
in Hampstead, Bloomsbury and Islington (London)Example 13.
Main factors
influencing health
and illnessPhysical and social infrastructure
Physical infrastructure
Transport systems (public and private)
Communications: the number of households with telephones,
including households with children and elderly people living
alone (as a measure of social isolation)
Urban renewal: rehousing programmes, slum clearance,
commercial development
City planning: coordination of leisure, cultural and education
facilities and public open spaces within urban renewal pro-
grammes City Health Profiles 53
Example 12.
Inequalities in health variations in standardized mortality ratios
in Hampstead, Bloomsbury and Islington (London)
Physical and social infrastructure
Physical infrastructure
Transport systems (public and private)
Communications: the number of households with telephones,
including households with children and elderly people living
alone (as a measure of social isolation)
Urban renewal: rehousing programmes, slum clearance,
commercial development
City planning: coordination of leisure, cultural and education
facilities and public open spaces within urban renewal pro-
grammes

Social infrastructure
City council employment and training programmes
Devolution of budgets for city services and works to localities
Development of and involvement in community groups
Public health policies and services

The policies and services included in this section are those
whose prime aim is the promotion of health or the prevention of
disease.
Example 13.
Main factors
influencing health
and illness

Services aimed at individuals
Immunization (uptake rates, infectious disease notifications)
Cervical and breast screening (uptake rates, morbidity and
mortality statistics)
Family planning services (uptake, abortion rates)
Stress management services
Educational policies and services

Health education in schools
AIDS awareness programmes
Smoking education
Alcohol education
Drug misuse education
Nutrition education
Environmental policies and services

Smoking in public places
Statutory authorities nutritional policies
Statutory authorities alcohol policies
Air and water quality controls

List of examples and
their sources
Example 1.
St Petersburg City Health Profile (draft), p. 4.
Example 2.
Black, D. & Womersley, J., ed. Glasgows health: old prob-
lems new opportunities. A report of the Director of Public Health,
Dr G.D. Forwell. Glasgow, 1993, p. 24.
Example 3.
Black, D. & Womersley J., ed. Glasgows health: old problems
new opportunities. A report of the Director of Public Health.
Glasgow, 1993, p. 25.
Example 4.
Copenhagen Healthy City project. Your district your health:
Inner Nrrebro. Copenhagen, 1992, p. 20.
Example 5.
Copenhagen Healthy City project. Your district your health:
Example 6.
Dublin Healthy City project. Dublin 1992 a healthy city?
Dublin, 1992, p. 38.
Example 7.
van Oers, J.A.M., Garretsen, H.F.L., Verbeek, H.A., ed. A
healthy view on Rotterdam and the Rotterdam population. Report
No. 9302, 1993.
Example 8.
Nancy Ville-Sant. Les indicateurs de sant dans la ville.
Nancy, 1992, p. 25.

Example 9.
Copenhagen Healthy City project. Your district your health.
Example 10.
Black, D. & Womersley, J., ed. Glasgows health: old prob-
lems new opportunities. A report of the Director of Public Health.
Glasgow, 1993, p. 14.
Example 11.
St Petersburg City Health Profile (draft) p. 54.
Example 12.
Hampstead District Health Authority, Bloomsbury and Isling-
ton Health Authority, Camden and Islington Health Authority.
Public Health Report, 1991. Camden, 1991, p. 18.
Example 13.
Copenhagen Healthy City project. Your district your health.
(By courtesy of the Danish Institute of Clinical Epidemiology)

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City Health

City Health Profiles 1

Text editor: Rosemary Bohr

This booklet provides advice on how to produce a city health profile. A

WHO Regional Office for Europe

2 City Health Profiles

2. Objectives and purpose ................................................. 3

5. Analysis and interpretation of data ............................. 19

6. Presentation, dissemination and communication ....... 23

7. Monitoring and evaluation ........................................... 27

9. Contents of the profile:

City Health Profiles 3

The Working Group

Dr Mark MacCarthy, Camden (Chairperson)

Dr June Crown, South-East Institute of Public Health,

M Jacques Berthou, Rennes

Dr Ann Marie Connolly, WHO Regional Office for Europe

Dr Patrick Doorley, Dublin

Dr W.G.M. de Haes, Rotterdam

Mr Kieran Hickey, Dublin

Dr I.A. Krasilnikoff, St Petersburg

Dr Hans van Oers, Rotterdam

The generous support of Mutualit Franaise in the

4 City Health Profiles

Technical documents based on commissioned expert input alone

I should like to express my gratitude to Ann Marie Connolly

City Health Profiles 5

Agis D. Tsouros, MD, PhD

6 City Health Profiles

City Health Profiles 7

All WHO Healthy Cities have agreed to produce profiles by

The Healthy Cities network has developed a set of healthy

Indicators are measures of health and of the factors which

Profiles include both indicators and other health-related

City health plans set out strategies and programmes of

It is important that the preparation of a city health profile is not

City Health Profiles 9

We realize that participating cities vary widely in the resources

A good profile describes a city and the factors affecting its

10 City Health Profiles

The main purpose of a city health profile is to

City Health Profiles 11

Although a citys health profile is usually produced by groups

One of the most important instruments in the struggle for

The information can only be effective, however, if it is of high

12 City Health Profiles

A citys health profile should describe clearly current know-

The analysis should lead logically to the identification of possi-

The presentation of the information and the analysis should be

A citys health profile is not a one-off document. A series of

If all these aspects can be successfully incorporated, a citys

City Health Profiles 13

identify a lead agency to manage the

City Health Profiles 15

Involvement of relevant agencies

However, it is sometimes difficult to get going. It may be

All those contributing resources should be asked to make clear

16 City Health Profiles

Content and long-term programme