Review Article: Learning and knowledge-production for public health: a review of approaches to evidence-based public health

Abstract

Public health needs to be evidence-based if it is to be done correctly, which means that learning and knowledge-production for public health must be comprehensive and include knowledge from four different domains: distribution of health, determinants or causal web, consequences, and intervention methods. Specification of development trends in cardiovascular prevention points at four generations of preventive programs; these include a clinical, a bioepidemiological, a socioepidemiological, and an environmental and policy-oriented generation. Generations differ in focus and strategy, in knowledge base - the art of making an impact - and evaluation. Comprehensive public health programs often comprise components from different generations, leading to the need for an expanded model for research and evaluation. There is an urgent need for learning and knowledge-production using both quantitative and qualitative approaches for developing the evidence base for public health action. In addition, epidemiological knowledge is necessary for making appropriate priorities.

Keywords

program evaluation outcome assessment evidence-based medicine research design health promotion cardiovascular prevention review.

References

Cochrane A. Effectiveness and efficiency: random reflections on health services . London: Nuffield Provincial Hospital Trust, 1972.

Muir Gray JA Evidence-based healthcare. How to make health policy and management decisions . London: Churchill Livingstone , 1997.

Sackett DL , Richardson WS , Rosenberg W. , Haynes RB Evidence-based medicine. How to practice and teach EBM. Churchill Livingstone, 1997.

Levi R. Evidensbaserad sjukvård. Vård på säkrare grund. Lund: Studentlitteratur, 1998.

Silagy C. , Haines A. Evidence based pratice in primary care. London : Br Med J Books, 1998.

Davies JK , Macdonald G. Quality, evidence and effectiveness in health promotion. London: Routledge, 1998.

Green J. , Tones K. Towards a secure evidence base for health promotion. J Public Health Med 1999; 21: 133 - 9.

Macdonald G. , Veen C. , Tones K. Evidence for success in health promotion: suggestions for improvement. Health Educ Res 1997; 11: 367 - 76.

Perkins E. , Sinmnett I. , Wright I. Evidence based health promotion. Chichester: John Wiley and Sons, 1999.

10.

Scott D. , Weston R. Evaluating health promotion. Cheltenham: Stanley Thornes, 1998.

11.

Speller V. , Learnmouth A. , Harrison D. The search for evidence of effective health promotion. Br Med J 1997; 315: 361 - 3.

12.

Whitehead M. Assessing effectiveness: the quasi-judicious approach. Health Educ J 2000; 59: 1Y2.

13.

International Union for Health Promotion Education (editors). The evidence of health promotion effectiveness. Shaping public health in a new Europe. Brussels - Luxembourg: ECSC-EC-EAEC, 1999: 1 - 12.

14.

Dean K. Creating a new knowledge base for the new public health. J Epidemiol Community Health 1994; 48: 217 - 9.

15.

Eriksson CG , Granvik M. , Kindblad I. , Lindgren G. , Nyström L. , Rosén M. , et al. Health problems in a Swedish county - what can we learn from official sources? Soc Sci Med 1981; 15C: 143 - 51.

16.

Friis RH , Sellers TÅ Epidemiology for public health practice. Gaithersburg., Maryland: Aspen, 1996.

17.

Persson LÅ , Wall S. Epidemiology for public health. Umeå: Umeå University, Department of Public Health and Clinical Medicine, 2000.

18.

Liberatos P. , Link BG , Kelsey JL The measurement of social class in epidemiology . Epidemiol Revs 1988; 10: 87 - 121.

19.

Braveman P. , Krieger N. , Lynch J. Health inequalities and social inequalities in health. Bull WHO 2000; 78: 232 - 4.

20.

Gakidou EE , Murray CJL , Frenk J. Defining and measuring the health inequality: an approach based on the distribution of health expectancy. Bull WHO 2000; 78: 42 - 54.

21.

Krieger N. , Fee E. Measuring social inequality in health in the United States: a historical review 1900 - 1950. Int J Health Serv 1996 ; 26: 391 - 418.

22.

Krieger N. , Williams DR , Moss NE Measuring social class in US public health research: concepts, methodologies and guidelines. Annu Rev Public Health 1997 ; 18: 341 - 78.

23.

Mackenback JP , Gunning-Schepers LJ

How should interventions to reduce inequalities in health be evaluated?

J Epidemiol Community Health 1997; 51: 359 - 64.

24.

Mackenback JP , Kunst AE Measuring the magnitude of socio-economic inequalities in health: an overview of available measures illustrated with two examples from Europe. Soc Sci Med 1997 ; 44: 757 - 71.

25.

Murray CJL , Gakidou EE , Frenk J.

Health inequalities and social group differences: what should we measure?

Bull WHO 1999; 77: 537 - 43.

26.

Wagstaff A. , Paci P. , van Doorslaer E. On the measurement of inequalities in health . Soc Sci Med 1991; 33: 545 - 57.

27.

Gwatkin DR

Health inequalities and the health of the poor: what do we know? What do we do?

Bull WHO 2000; 78: 3 - 17.

28.

Braveman P. Combining forces against inequality and poverty rather than splitting hairs. Bull WHO 2000 ; 78: 78 - 9.

29.

Wall S. Epidemiology for prevention. Int J Epidemiol 1995; 24: 655 - 64.

30.

Diderichsen F. Health and social inequalities in Sweden. Soc Sci Med 1991; 31: 359 - 67.

31.

Vågerö D. Inequalities in health - some theoretical and empirical problems. Soc Sci Med 1991; 32: 367 - 72.

32.

Bartley M. , Blane D. , Davey Smith G. Sociology of health inequalities. Oxford: Blackwell, 1998.

33.

Macintyre S. The patterning of health by social position in contemporary Britain: directions for sociological research. Soc Sci Med 1986; 23: 393 - 415.

34.

Evans RG , Barer ML , Marmor TR Why are some people healthy and others not? New York: Aldine de Gruyter, 1994.

35.

Lynch JW , Kaplan GA , Shema SR Cumulative impact of sustained economic hardship on physical, cognitive, psychological, and social functioning. N Engl J Med 1997; 337: 1889-95.

36.

Lynch JW , Kaplan GA , Salonen JT Why do poor people behave poorly? Variations in adult health behaviour and psychosocial characteristics, by stage of the socioeconomic lifecourse . Soc Sci Med 1997; 44: 809 - 20.

37.

Kaplan GA People and places: contrasting perspectives on the association between social class and health. Int J Health Serv 1996; 26: 507 - 19.

38.

Macintyre S. , Maciver S. , S, Soloman A.

Area, class and health: Should we be focused on places or people?

J Soc Policy 1993; 22: 213.

39.

Davey Smith DOA. Individual social class, area-based deprivation, cardiovascular disease risk factors, and mortality: the Renfrew and Paisley study. J Epidemiol Community Health 1998; 52: 339 - 405.

40.

Marmot M. , Wilkinsom RG Social determinants of health. Oxford: Oxford University Press, 1999.

41.

Kuh D. , Ben-Slomo Y. A life course approach to chronic disease epidemiology. Oxford: Oxford University Press, 1997.

42.

Kawachi I , Kennedy BP , Wilkinson RG (editors). The society and population health reader. Volume I. Income inequality and health. New York: New Press , 1999.

43.

Wilkinson RG Unhealthy societies. London : Routledge , 1996.

44.

Muntaner C. , Lynch J. Income inequality, social cohesion, and class relations: a critique of Wilkinson's neo-Durkheimian research program . Int J Health Serv 1999; 29: 59 - 81.

45.

Coleman J. Social capital in the creation of human capital. Am J Sociol 1988; 94: 95-120.

46.

Coleman J. Foundations of social theory. Cambridge: Harvard University Press, 1990.

47.

Fukuyama F. The great disruption. Human nature and the reconstruction of social order . London: Profile Books, 1999.

48.

Putnam R. Making democracy work. Princeton: Princeton University Press, 1993 (sv.översättning 1996).

49.

Woolcock M. Social capital and economic development: toward theoretical synthesis and policy framework. Theory Soc 1998; 27: 151 - 208.

50.

Antonovsky A. Unraveling the mystery of health. San Fransisco: Jossey-Bass, 1987 .

51.

Ornstein R. , Sobel D. Healthy pleasures. 1989. (Sunda synder. Njut av livet för hälsans skull.) Göteborg: Natur och kultur , 1990.

52.

Raeburn J. , Rootman I. People-centered health promotion. New York: John Wiley & Sons, 1998.

53.

Green LW , Kreuter MW Health promotion planning. An educational and environmental approach . (2nd ed). Mountain View: Mayfield Publishing Company, 1991.

54.

Turshen M. The politics of public health. London: Zed Books, 1989.

55.

Wilkinson RG The culture of inequality. In: Kawachi I , Kennedy BP , Wilkinson RG , editors. The society and population health reader. Volume I. Income inequality and health. New York: New Press, 1999: 492 - 8.

56.

Härenstam A , Lundberg U , Lindbladh E , Starrin B , editor. On the Process of Disempowering - qualitative studies of social conditions, exclusion, welfare and health development. Umeå: Borea, 1999 (in Swedish).

57.

Asplund K. , Cohen D. , Emmelin M. , Eriksson C. , Janlert U. , Jonsson E. , et al. Community Intervention Programs to Prevent Cardiovascular Disease . Stockholm: SBU-rapport nr 134, 1997 (in Swedish).

58.

Cohen D. , Eliasson M. , Eriksson C. , Gilljam H. , Hedin A. , Hellénius ML , et al. Smoking Cessation Methods. Stockholm: SBU-rapport nr 138, 1998 (in Swedish).

59.

Lindholm L. Health economic evaluation of community-based cardiovascular disease prevention. Some theoretical aspects and empirical results (dissertation) . Umeå: Umeå University, Department of Epidemiology and Public Health, 1996.

60.

Jansson B. Cost of Injuries in Sweden - An exploratory study. Stockholm : Folkhälsoinstitutet 1994: 9 (in Swedish).

61.

Lindholm L. Public Health Actions and Economic Evaluation - Methods and Perspectives . Stockholm: Socialtstyrelsen, SoS-rapport 1999: 15 (in Swedish).

62.

Anderson R , Davies JK , Kickbusch I , McQueen DV , Turner J , editors. Health behaviour research and health promotion. Oxford : Oxford University Press, 1988 .

63.

Glanz K , Lewis FM , Rimer BN , editors. Health behavior and health education. San Francisco: Theory Res Pract 1990.

64.

Bracht N , editor. Health promotion at the community level. Newbury Park, CA: Sage Publications, 1990.

65.

Bracht N , editor. Health promotion at the community level. 2. New advances. London : Sage Publications, 1999.

66.

Eriksson C , editor. Reducing Social Inequalities in Health through Health Promotion and Disease Prevention. A Report on Research and Development at the National Institute of Public Health . Stockholm: Folkhälsoinstitutet , 1996: 90 (in Swedish).

67.

Whitehead M. , Dahlgren G.

What can be done about inequalities in health?

Lancet 1991; 338: 1059-63.

68.

Benzeval M , Judge K , Whitehead M , editors. Tackling inequalities in health. An agenda for action. London: King's Fund, 1995.

69.

Nutbeam D. Achieving best practice in health promotion: improving the fit between research and practice. Health education research: Theory Pract 1996; 11: 317 - 26.

70.

Farchi G. Multifactorial primary prevention trials of coronary heart disease . Rev Epidmiol Santé Publique 1984; 32: 219 - 24.

71.

Brännström I. Community participation and social patterning in cardiovascular disease intervention. Umeå: Department of Epidemiology and Public Health, 1993.

72.

Brännström I. , Weinehall L. , Persson LÅ , Wester PO , Wall S. Changing social patterns of risk factor for cardiovascular disease in a Swedish community intervention programme. Int J Epidemiol 1994 ; 22: 1026 - 37.

73.

SBU. Moderatly elevated blood pressure. J Intern Med 1995; 228 (suppl 737) (in Swedish).

74.

Hjermann I. , Velve Byre K. , Holme I. , Leren P. Effects of diet and smoking intervention on the incidence of coronary heart disease. Lancet 1981; 2: 1303 - 10.

75.

Wilhelmsen L. , Tibblin G. , Werkö L. A primary preventive study in Gothenburg, Sweden. Prev Med 1972 ; 1: 153 - 50.

76.

Wilhelmsen L. , Berglund G. , Elmfeldt D. , Tibblin G. , Wedel H. , Pennert K. , et al. The multifactor primary prevention trial in Göteborg, Sweden. Eur Heart J 1986 ; 7: 279-88.

77.

Multiple Risk Factor Intervention Trial Research Group (MRFIT). Multiple risk factor intervention trial risk factor changes and mortality results. J Am Med Assoc 1982; 248: 1465 - 77.

78.

Werkö L. Analysis of the MRFIT screens: a methodological study. J Intern Med 1995; 237: 507 - 18.

79.

De Backer G. , Kornitzer M. , Dramaix M. The Belgian Heart Disease Prevention Project: 10-year mortality follow-up. Eur Heart J 1988 ; 9: 238 - 42.

80.

UK Heart Disease Prevention Project: incidence and mortality results. Lancet 1983; i: 1062 - 5.

81.

Fortmann SP , Flora JA , Winkelby MA , Schooler C. , Barr Taylor C. , Farquhar JW Community intervention trials: reflections on the Stanford Five-City Project experience. Am J Epidemiol 1995; 142: 576 - 86.

82.

Green SB , Corle DK , Gail MH , Mark SD , Pee D. , Freedman LS , et al. Interplay between design and analysis for behavioral intervention trials with community as the unit of randomization. Am J Epidemiol 1995; 142: 587 - 93.

83.

Koepsell TD , Diehr PH , Cheadle A. , Kistal A. Invited commentary: symposium on community intervention trials. Am J Epidemiol 1995; 142: 594 - 9.

84.

Murray DM Design and analysis of community trials: lessons from the Minnesota Heart Health Program. Am J Epidemiol 1995; 142: 1369-72.

85.

Comstock GW Uncontrolled ruminations on modern controlled trials. Am J Epidemiol 1978; 108: 81 - 4.

86.

Cornfield J. Randomization by group: a formal analysis. Am J Epidemiol 1978; 108: 100 - 2.

87.

Farquhar JW The community-based model of life style intervention trials. Am J Epidemiol 1978; 108: 103 - 11.

88.

Sherwin R. Controlled trials of the diet-heart hypothesis: some comments on the experimental unit. Am J Epidemiol 1978; 108: 92 - 9.

89.

Stone EJ, Pearson TA, editors. Community trials for cardiopulmonary health: directions for public health practice, policy, and research. Ann Epidemiol 1997; 7 Suppl. 7: S1 - S124.

90.

Holm LE , Callmer E. , Eriksson CG , Haglund BJA , Kanström L. , Tillgren P. Community-based strategies for cancer prevention in an urban area: the Stockholm Cancer Prevention Program. J Natl Cancer Inst 1989; 81: 103 - 6.

91.

Kanström L. Community-based methods and tools to promote dietary changes - some experiences from the Stockholm Cancer Prevention Program. Sundbyberg : Karolinska Institutet, Department of International Health and Social Medicine: 1994.

92.

Lindqvist K. Towards community-based injury prevention. The Motala model. Linköping, Linköping University Medical Dissertation no 404, 1993.

93.

Schelp L. Epidemiology as a basis for evaluation of a community intervention programme on accidents. Thesis. Sundbyberg: Karolinska Institute, Department of Social Medicine , 1987.

94.

Hansson BS , Larsson S. , Bracht N. Early experiences from the Kirseberg Public Health Project in Malmö, Sweden. An alcohol prevention campaign. Health Promotion 1991; 6: 111 - 9.

95.

Holder HD , Howard JM , editors. Community prevention trials for alcohol problems. Methodological issues. London: Praeger, 1992.

96.

Commit. Community Intervention Trial for smoking cessation: summary of design and intervention. J Natl Cancer Inst 1991; 83: 1620 - 8.

97.

Commit. I. Cohort results from a four-year community intervention. Am J Public Health 1995; 85: 183 - 92.

98.

Commit. II. Changes in adult cigarette smoking prevalence. Am J Public Health 1995a; 85: 193 - 200.

99.

Catford J. , Parish R. ``Heartbeat Wales'': New horizons for health promotion in the community - the philosophy and practice of Heartbeat Wales. In: Seedhouse D , Cribb A , editors. Changing ideas in health care. Chichester: John Wiley & Sons, 1989: 127 - 41.

100.

Nutbeam D. , Catford J. The Welsh Heart Programme evaluation strategy: progress, plans and possibilities. Health Prom 1987; 2: 5 - 18.

101.

Shea S. , Basch CE , Lantigua R. , Wechsler H. The Washington Height-Inwood Healthy Heart Program: A third generation community-based cardiovascular disease prevention program in a disadvantaged urban setting . Prev Med 1992; 21: 203 - 17.

102.

Shea S. , Basch CE , Wechler H. , Lantiqua R. The Washington Heights-Inwood Healthy Heart Program: A 6-year report from a disadvantaged urban setting. Am J Public Health 1996; 86: 166 - 71.

103.

Brännström I. , Rosén M. , Wall S. , Weinehall L. Local health planning and intervention - the case of a Swedish municipality. Scand J Prim Health Care 1988; Suppl. 1: 57 - 64.

104.

Rosen G. A history of public health. Baltimore, Md: Johns Hopkins University Press, 1993.

105.

Green LW , McAlister AL Macro-intervention to support health behavior: some theoretical perspectives and practical reflections. Health Educ 1984 ; 11: 322 - 9.

106.

Green LW , Richard L. The need to combine health education and health promotion: the case of cardiovascular disease prevention. Int J Health Prom Educ 1993; 1: 1 - 17.

107.

Schmid TL , Pratt M. , Howze E. Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease. Am J Public Health 1995; 85: 1207 - 11.

108.

Ashton J , editor. Healthy cities. Milton Keynes: Open University Press, 1992.

109.

Hancock T. The evolution, impact and significance of the healthy cities/healthy communities movement. J Public Health Policy 1993; 14: 5 - 18.

110.

Springett J. Quality measures and evaluation of healthy city policy initiatives. In: Davies JK , Macdonald G , editors. Quality, evidence and effectiveness in health promotion. London: Routledge , 1998: 155 - 88.

111.

Ashton J. , Seymour H. The new public health. The Liverpool experience. Milton Keynes: Open University Press, 1988 .

112.

Beaglehole R. , Bonita R. Public health at the cross-roads . Cambridge: Cambridge University Press, 1997.

113.

Petersen A. , Lupton D. The new public health. Health and self in the age of risk. London: Sage publications, 1996.

114.

Haines A , Donald A , editors. Getting research findings into practice . London: Br Med J Books, 1998.

115.

Nutbeam D. , Harris E. Theory in a nutshell: a practitioners guide to commonly used theories and models in health promotion. Sydney: National Centre for Health Promotion, 1998.

116.

House JS , Landis KR , Umbertson D. Social relationships and health. Science 1988 ; 214: 540 - 5.

117.

Berkman L. The role of social relations in health promotion . Psychosom Med 1995; 57: 245 - 54.

118.

Dalgard O. , Döhlie E. , Ystgaard M. , redaktors. Social Network, Health and Society. Oslo: Universitetsforlaget, 1995 (in Norwegian).

119.

Elder JP , Hovell MF , Laseter TM , Wells BL , Carlton RA Application of behavior modification to community health education: the case of heart disease prevention. Health Educ Q 1985; 12: 151 - 68.

120.

Farquhar JW , Fortmann SP , Maccoby N. , Haskell WL , Williams PT , Flora JA , et al. The Stanford fivecity project: design and methods. Am J Epidemiol 1985; 122: 322 - 34.

121.

Lefebvre RC , Lasater TM , Carlton RA , Peterson G. Theory and delivery of health programming in the community: the Pawtucket Heart Health Program . Prev Med 1987; 16: 80 - 95.

122.

McAllister A. , Puska P. , Salonen JT , Toumiletko J. , Koskela K. Theory and action for health promotion. Illustrations form the North Karelia Project. Am J Public Health 1982; 72: 43 - 50.

123.

Puska P , editor. Comprehensive cardiovascular community control program in Europe. Copenhagen : WHO Regional Office for Europe, EURO Reports and studies no 106, 1988.

124.

Nutbeam D. , Smith C. , Murphy S. , Catford J. Maintaining evaluation designs in long term community based health promotion programmes: Heartbeat Wales case study. J Epidemiol Community Health 1993; 47: 127 - 33.

125.

Walt G. Health policy. An introduction to process and power. London : Zed Books, 1994.

126.

Tones K. , Tilford S. Health education. Effectiveness, efficiency and equity. 2nd ed. London: Chapman & Hall , 1994.

127.

Lindholm L. , Rosén M. What is the ``golden standard'' for assessing population-based interventions? - problems of dilution bias . J Epidemiol Community Health 2000; 54: 617 - 22.

128.

Sanderson C. , Svanström L. Contributions of social medicine and systems analysis to formulating objectives for a community-based cancer prevention programme. Scand J Soc Med 1988 ; 16: 35 - 40.

129.

Sanderson C. , Svanström L. , Eriksson C-G. Development of strategies for evaluating a community intervention program for cancer prevention through dietary change . Community Med 1988; 10: 289-97.

130.

Altman DG A framework for evaluating community-based heart disease prevention programs . Soc Sci Med 1986; 22: 479 - 87.

131.

Jacobs DR , Leupker RV , Mittlemark MB Community-wide prevention strategies: evaluation design of the Minnesota Heart Health Program. J Chronic Dis 1986; 39: 775 - 88.

132.

Salonen JT , Kottke TE , Jacobs DR , Hannan PJ Analysis of community-based cardiovascular disease prevention studies - evaluation issues in the North Karelia Project and the Minnesota Heart Health Program. Int J Epidemiol 1986; 15: 176 - 82.

133.

Vedung E. Public policy and program evaluation. London: Transaction Publishers, 1997.

134.

Eriksson CG Focus groups and other methods for increased effectiveness of community intervention - a review. Scand J Prim Health Care 1988; Suppl. 1: 73 - 80.

135.

De Vries H. , Weijts W. , Dijkstra M. , Kok G. The utilisation of qualitative and quantitative data for health education program planning, implementation and evaluation: a spiral approach. Health Educ Q 1992; 19: 101 - 15.

136.

Steckler A. , McLeroy KR , Goodman RM Towards integration qualitative and quantitative methods: an introduction . Health Educ Q 1992; 19: 1 - 8.

137.

Baum F. Researching public health: beyond the qualitative-quantitative methodological debate. Soc Sci Med 1995; 55: 459 - 68.

138.

Green J. , Bitten N. Qualitative research and evidence based medicine. Br Med J 1998; 316: 1230 - 2.

139.

Laflamme L , Svanström L , Schelp L , editors. Safety promotion research. Stockholm: Karolinska Institutet, Department of Public Health Sciences, 1999.

140.

Meyer J. Qualitative research in health care: using qualitative methods in health related action research. Br Med J 2000 ; 320: 178 - 81.

141.

Dale J. , Kellerhear A. , Gliksman M. The public health researcher. A methodological guide. Oxford: Oxford University Press, 1997.

142.

Popay J. , Rogers A. , Williams G. Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative Health Res 1998; 8: 341 - 51.

143.

Mays N. , Pope C. Qualitative research in health care: assessing quality in qualitative research . Br Med J 2000; 320: 50-2.

144.

Pope C. , Ziebland S. , Mays N. Qualitative research in health care: analysing qualitative data. Br Med J 2000; 320: 114-6.

145.

Tones K. Beyond the randomised controlled trial: a case for judicial review . Health Educ Rev 1996; 12: 1 - 4.

146.

Macdonald G. A new evidence framework for health promotion practice. Health Educ J 2000; 59: 3-11.

147.

Nutbeam D. Health promotion effectiveness - the questions to be answered. In: International Union for Health Promotion and Education , editors The evidence of health promotion effectiveness. Shaping public health in a new Europe. Brussels - Luxembourg: ECSC-EC-EAEC, 1999: 1 - 12.

148.

Evans D. , Head MJ , Speller V. Quality assurance in health promotion: how to develop standards for good practice . London: Health Education Council , 1994.

149.

Haglund BJA , Jansson B. , Pettersson B. , Tillgren P. A quality assurance instrument for practitioners: an example from Sweden. In: Davies JK , Macdonald G , editors. Quality, evidence and effectiveness in health promotion. London: Routledge , 1998: 93 - 116.

150.

Overtveit J. Quality in health promotion. Health Promotion Int 1996; 11: 55-62.

151.

Kelly MP , Charlton B. The modern and the postmodern in health promotion. In: Bunton R , Nettleton S , Burrows R , editors. The sociology of health promotion. Critical analyses of consumption, lifestyle and risk. London: Routledge, 1995: 78 - 90.

152.

Kickbush I. Good planets are hard to find. Copenhagen: WHO, Healthy Cities Reports, 1989.