A Method for Assessing “Broad View of Health”

Among Healthy Cities and Communities Participants

Robert E. Aronson, Dr.P.H.,UNC-Greensboro

Michelle C. Kegler, Dr.P.H.,Emory University

Barbara L. Norton, M.P.H.Univ. of Oklahoma

Heather Paulsen, M.A.Center for Civic Partnerships

Healthy Cities & Communities Movement

The Healthy Cities movement was born in 1986 when the World Health Organization (WHO) initiated a pilot initiative in 11 European cities. By 1998 there were over 6500 self-declared “healthy cities” and close to 40 cities directly sponsored by the WHO. Within the U.S. statewide initiatives have been launched in the states of Indiana, Colorado and California, along with countless individual cities.

Healthy Cities projects work with communities to foster health-promoting environments through inter-sector cooperation, extensive community participation, and the design and implementation of action-based plans.

Healthy Communities Principles

A broad definition of “health”

A broad definition of “community”

Shared vision from community values

Address quality of life for everyone

Diverse citizen participation and widespread community ownership

Focus on “systems change”

Build capacity using local assets and resources

Benchmark and measure progress and outcomes

Norris T, Pittman M. The Healthy Communities Movement and the Coalition for Healthier Cities and Communities, Public Health Reports, Vol. 115, 2000, p. 122.

What is a “broad view of health”?

A “definition of health” that is holistic, and applies to individuals as well as contexts;

A perspective of the “determinants of health” that recognizes and emphasizes the contribution of lifestyle and environment.

Broad Definition of Health

Health is more than the absence of disease.

Health can be described as an optimum state of well being, including: mental, physical, emotional and spiritual.

Health includes a sense of belonging to community and experiencing control over one’s circumstances and fate.

Health applies not only to individuals, but also to contexts, such as organizations, cities and communities.

What is a Healthy City or Community?

“A healthy [community] is one that is continually creating and improving those physical and social environments and expanding those community resources which enable people to mutually support each other in performing all the functions of life and in developing to their maximum potential.”Hancock T, Duhl L. 1986. Healthy Cities: Promoting Health in the Urban Context. Copenhagen: WHO Europe, p. 24.

What Makes Populations Healthy?

50%

20%

10%

20%

Life Choices andBehavior

Socioeconomic factors

Medical care

Genetic endowment

Source: Health and Welfare Canada

Broad Perspective on Determinants of Health

Biologic and genetic factors

Behavior and lifestyle

Social environment and relationships

Physical environment and living conditions

Health care system

Assessing “Broad View of Health”

“members of the steering committee must grasp and articulate the root and multi-causal nature of community health problems to ensure that issues beyond behavioral risk factors are addressed.”

Kegler MC, Twiss JM, Look V. Assessing community change at multiple levels: The genesis of an evaluation framework for the California Healthy Cities Project. Health Education and Behavior, Vol. 27(6): p. 768, 2000.

Assessing “Broad View of Health” in California Healthy Cities and Communities

Seen as an aspect of the evaluation of change among members of the local steering committee/local coalition.

Administered as a part of the steering committee/coalition survey during years 1 and 3.

Question structured as a paired comparison activity to identify individual and composite rank ordering of “determinants of health.”

Ways to collect rank-order data

Ask research participants to number items sequentially, in order of importance.

Ask research participants to compare two items at a time and select the most important item until all items are compared with every other item (paired comparison).

Our Survey Question

This next question asks you to think about the relative importance of different factors that affect the health of individuals.

8. The following is a list of pairs of items, all considered by some to be important factors

that influence the health of individual persons. (Although some of the pairs may sound repetitive, no pair of items appears more than once.) For each pair of items, please circle the item which you think is a more important influence on health. Please circle only one from each pair.

Our Survey Question (Continued)

Lifestyle decisions vs. Genetics/heredity

Quality health care vs. Supportive relationships

Living conditions vs. Genetics/heredity

Quality health care vs. Genetics/heredity

Living conditions vs. Lifestyle decisions

Genetics/heredity vs. Supportive relationships

Living conditions vs. Supportive relationships

Supportive relationships vs. Lifestyle decisions

Quality health care vs. Lifestyle decisions

Quality health care vs. Living conditions

Univariates on “Determinants of Health” (n=309)

Which is a more important influence on health....

Lifestyle decisions vs. Genetics/heredity

85.1% 14.9%

Quality health care vs. Supportive relationships

56.0% 44.0%

Living conditions vs. Genetics/heredity

82.5% 17.5%

Quality health care vs.Genetics/heredity

75.1% 24.9%

Living conditions vs. Lifestyle decisions

25.9% 74.1%

Univariates on “Determinants of Health” Continued

Which is a more important influence on health....

Genetics/heredity vs. Supportive relationships

33.7% 66.3%

Living conditions vs. Supportive relationships

46.3% 53.7%

Supportive relationships vs. Lifestyle decisions

32.0% 68.0%

Quality health care vs. Lifestyle decisions

38.5% 61.5%

Quality health care vs. Living conditions

53.7% 46.3%

Pairs with the most disagreement

Quality health care vs. Supportive relationships

56.0% 44.0%

Living conditions vs. Supportive relationships

46.3% 53.7%

Quality health care vs. Living conditions

53.7% 46.3%

What is the resulting rank order?

Can the aggregate responses to all ten of these pairs be converted into a rank order of the five items?

Using the software ANTHROPAC 4.0, a composite rank-order can be determined….

but

…we must further analyze the data to determine the degree of agreement with the rank order.

Analysis of Paired Comparison Data Using Anthropac

Using the software Anthropac, the data is converted into the following files:

• Individual dominance matrices

Matrix of item by item dominance scores (for each pair which is more important) for every respondent (309 matrices)

• Aggregate dominance matrix

Single matrix of item by item dominance scores based upon an average of all individual dominance matrices

• Unrandomized respondent by item matrix

If the order of the pairs were randomized, an unrandomized matrix containing respondents in rows and pairs in columns is generated.

• Composite Rank Order

This file is an item-vector that averages the respondent-by-item matrix across all respondents, and produces a z-score for each item (Torgerson, WS, 1958. Theory and Methods of Scaling. New York: John Wiley.).

Composite Rank Order of Determinants of Health

Rank Item z-score __________________________________________

1 Lifestyle decisions 0.50

2 Quality health care 0.13

3 Living conditions 0.02

4 Supportive relationships-0.03

5 Genetics/heredity -0.63

Interpreting this Composite Ranking

Does the rank ordering indicate a “broad view of health?”

What kind of variability is there in this rank ordering?

Does the rank order differ from community to community?

What kinds of changes might we expect to see after three years of involvement in the Healthy Cities and Communities project?

Next Step in the Analysis: Consensus

Use ANTHROPAC’s “Consensus Analysis” function to determine if a single or multiple rank order solutions are possible.

“Consensus Analysis” is a factor analytic approach that examines patterns of agreement between respondents.

EIGEN VALUES FROM CONSENSUS ANALYSIS

Factor Value Percent Cum%Ratio

__________________________________________________

1 89.939 48.2% 48.2%1.594

2 56.435 30.2% 78.5%1.404

3 40.195 21.5% 100.0%

Average correlation among respondents = 0.169

Respondent reliability = 0.984

Range of individual factor loadings: (-0.891, 0.891)

Interpreting Consensus Outputs

There is little agreement between respondents on the rank-order of the determinants of health.

We cannot consider the composite rank-order to be a meaningful indicator of “how people involved in the CA Healthy Cities and Communities initiative view the determinants of health.”

There are likely to be two or more common ways to rank-order these items within our sample.

Even analyzing results community-by-community, shows little consensus on rank-order in all but six communities.

What’s Next

We can look to see if there is greater consensus among respondents from the year 3 survey.If there is consensus in the year 3 survey results, we can assess the composite rank order in terms of a “broad perspective on the determinants of health.”If there is no consensus, we can still examine the univariates for each pair of items from the year 3 survey to see if there are any changes.

References for these Methods

Borgatti. 1992. ANTHROPAC 4.0. Columbia: Analytic Technologies.Bernard HR. 1994. Research Methods in Anthropology. Thousand Oaks: Sage Publications.De Munck VC, Sobo EJ, eds. 1998. Using Methods in the Field. Walnut Creek: Altamira Press.Weller SC, Romney AK. 1988. Systematic Data Collection. Qualitative Research Methods, Vol. 10. Newbury Park, CA: Sage Publications.