Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK.
Liveability. What a cool, trendy word that immediately paints a vibrant picture in your mind. We know instinctively what it means as it conjures up an image of a healthy environment, an active lifestyle and personal wellbeing. No surprise, therefore that its used in advertising to sell everything from domestic products to real estate. If, on the other hand, we talk about the social determinants of health, most people don’t really know what we mean and they switch off. But, liveability gives us a common language to explain how there is so much more to health than just medicine.
This was a recurring theme at the conference on Creating Active and Liveable Societies hosted by the Centre of Excellence for Public Health in Belfast with a host of international experts.
Billie Giles-Corti is a champion of liveability. The Economist intelligence unit had, for a number of years, pointed to Melbourne, her home city, as the top city in the world to live. (although recently overtaken by Vienna). If she talks about liveability, people immediately understand what she means. So, what is a liveable city? By their definition “Liveable communities are safe, socially cohesive and inclusive, and environmentally sustainable. They have affordable housing that is linked (via public transport, walking and cycling infrastructure) to employment; education; shops and services; public open space; and social, cultural and recreational opportunities. “
They set out to create metrics of liveability. These metrics, while measured scientifically, were relevant to city government, and could be integrated into policy. One of their metrics is a walkability indicator which estimates the proportion of people who live within 400m walking distance from a bus stop. It’s a simple concept but creates a metric that is measurable, repeatable, meaningful and can be used in policy and planning for public transport. And this metric is geographically portable so can be applied to different cities. Each may set their own target standards but they each use a common metric.
Policy research doesn’t tend to interest academics but one benefit of these metrics is to help create a scientific enterprise. And, in terms of getting their message across, these metrics can be used in designing integrated urban transport systems. As we all know, what gets measured, gets done.
Rodrigo Reis from Washington University, St Louis explained the broader domains of a healthy lifestyle and, in particular, the importance of the built and natural environment. He pointed out that, if we work only through a health lens, it will be hard to sell the idea so we need to think more widely. And, we may need to go beyond our current parameters of research and our perception of evidence. Some of the of the best examples of effective interventions for improving health have not been published in the peer reviewed literature- so we may need a wider understanding of what is the best evidence. He cited, as an example, the Bus Rapid Transport system in Curitiba in Brazil as one of the most effective health interventions. We may need to integrate evidence from randomised controlled trials in one area with other types of evidence in other domains. But, getting evidence into practice can also be a challenge so we need to look beyond that evidence and engage with other sectors.
Our model of putting research directly into the research- practice- policy cycle doesn’t always work. Ruth Jepson from Edinburgh underlined how its not just about simply providing evidence, we need to think about different ways of moving it into practice. There may be, according to Jepson, too much focus on academia and institutions and not enough on what happens at ground level. Not every public health intervention has or needs a randomised controlled trial and we may have settle with “good enough” evidence. Its not a linear relationship, we need to view the policy-practice- research cycle as a system. Its about interconnectedness and adaptive interaction (like the human body where all the bits work together).
Returning to research, Sarah Rodgers from Liverpool gave us practical illustrations from research with which she has been involved. By integrating different datasets from very different sources they could relate, for example, the number of alcohol retail outlets to alcohol related harm using geo coded alcohol outlet data. And, by tracking the progress of a housing renovation project and morbidity data, they could demonstrate the health benefits of this housing intervention.
Jim Sallis, from Univ California, San Diego (https://profiles.ucsd.edu/james.sallis ) had four recommendations: Do policy relevant research, use research methods relevant to policy makers, actively disseminate findings and, engage in advocacy. But the key step in creating liveable cities is to communicate research results to city leaders, a step in dissemination that is often forgotten. Researchers need to get better at communicating useful results in accessible ways.
Move away from straight line thinking. Policy decisions are a much more messy process than a direct linear relationship. Policy is less evidence based and more evidence informed. And, we need to accept that policy makers are unlikely to seek out answers in the peer reviewed literature. Academic papers tend to be in depth and in detail but they need short non technical reports in simple language. These reports may not get the same academic recognition as research papers but they can have much more impact. Academics and policy makers prioritise different types of knowledge so researchers need to speak in the language that others can hear and understand. Researchers need to create user friendly messages.
Finally, reflecting on the language of physical activity, Jim Sallis, said that we seem to have moved away from natural play related physical activities that we remember as children to encouraging people to “work-out”. We need to lose the “work” part and re-find the fun.
In conclusion, however, it all needs to be joined up. Having listened to a range of views from planners, environmentalists, physical activity advocates, local community groups and the health lobby, it was clear that this is a shared challenge. There is little to be gained, for example, in designing and building modern energy efficient cities, creating ideal social environments, and promoting healthy living if, to appease our travel needs, we put a big tarmac ribbon down the middle, fill it with cars pumping out fumes and pollutants, and make people spend hours sitting inactive in traffic.