Intersectoral approaches to health promotion in cities

Abstract

The health problems facing the world today increasingly require complex solutions in which public health interventions must work across sectors and levels of organization. Cities - where two-thirds of the global population is expected to live by 2030 - especially face challenging health conditions like cardiovascular disease, diabetes, obesity, avian flu, infant mortality, and depression and social conditions like concentrated poverty, rising inequality, and declining public infrastructures. These problems demand that effective health promotion measures must integrate efforts within the health care, education, environmental protection, housing, nutrition and economic development sectors. In this chapter, I will examine intersectoral approaches to health promotion, describe the rationale and characteristics of this strategy, and then examine the strategies used to evaluate intersectoral work and the methodological and organizational challenges to evaluation that this approach poses. I define intersectoral health promotion interventions as organized activities that seek to improve well-being by influencing multiple determinants of complex health problems that operate across sectors and levels of organization (WHO, 1986a, 1997). Sectors are functional areas such as education, employment and health care; levels describe hierarchical arenas of social interaction such as individuals, families, communities and jurisdictions. Intersectoral interventions seek to make changes in different systems in order to achieve defined public health goals. These goals can address one or multiple health problems. In some cases the health outcomes of intersectoral interventions are unintended or secondary benefits of initiatives designed to achieve economic, educational or other goals. Planners and implementers of intersectoral interventions need to appreciate the unique challenges their approach poses to evaluation while evaluators need to grasp the contextual influences on implementation if they are to design valid, implementable and policy-relevant evaluation studies. Since successful evaluation requires practitioners and evaluators to find a common language so they can collaborate, this chapter is addressed to both. Even though intersectoral work is used in both urban and non-urban settings, this chapter focuses on examples from cities because so many people already live in cities, rapid urbanization is further concentrating the world's population in urban areas, and because urban complexity creates unique opportunities and challenges for both implementation and evaluation of this approach. Complexity is evaluators' greatest challenge - if interventions had only a few dimensions, influenced only a single outcome, and operated in uniform and easily described environments, the job of evaluators would be easy. Intersectoral health promotion in cities presents complexity on every front. Thus, understanding the contextual variables that influence cities and intersectoral interventions becomes an evaluator's first task, a prerequisite for solving the more familiar tasks of choosing outcomes, designing evaluation studies, collecting data and interpreting findings. © 2008 Springer Science+Business Media, LLC.