Evaluating Speaker-Listener Cognitive Effort in Speech Communication Through Brain-to-Brain Synchrony: A Pilot Functional Near-Infrared Spectroscopy Investigation.

PURPOSE: We explore a new approach to the study of cognitive effort involved in listening to speech by measuring the brain activity in a listener in relation to the brain activity in a speaker. We hypothesize that the strength of this brain-to-brain synchrony (coupling) reflects the magnitude of cognitive effort involved in verbal communication and includes both listening effort and speaking effort. We investigate whether interbrain synchrony is greater in native-to-native versus native-to-nonnative communication using functional near-infrared spectroscopy (fNIRS). METHOD: Two speakers participated, a native speaker of American English and a native speaker of Korean who spoke English as a second language. Each speaker was fitted with the fNIRS cap and told short stories. The native English speaker provided the English narratives, and the Korean speaker provided both the nonnative (accented) English and Korean narratives. In separate sessions, fNIRS data were obtained from seven English monolingual participants ages 20-24 years who listened to each speaker's stories. After listening to each story in native and nonnative English, they retold the content, and their transcripts and audio recordings were analyzed for comprehension and discourse fluency, measured in the number of hesitations and articulation rate. No story retellings were obtained for narratives in Korean (an incomprehensible language for English listeners). Utilizing fNIRS technique termed sequential scanning, we quantified the brain-to-brain synchronization in each speaker-listener dyad. RESULTS: For native-to-native dyads, multiple brain regions associated with various linguistic and executive functions were activated. There was a weaker coupling for native-to-nonnative dyads, and only the brain regions associated with higher order cognitive processes and functions were synchronized. All listeners understood the content of all stories, but they hesitated significantly more when retelling stories told in accented English. The nonnative speaker hesitated significantly more often than the native speaker and had a significantly slower articulation rate. There was no brain-to-brain coupling during listening to Korean, indicating a break in communication when listeners failed to comprehend the speaker. CONCLUSIONS: We found that effortful speech processing decreased interbrain synchrony and delayed comprehension processes. The obtained brain-based and behavioral patterns are consistent with our proposal that cognitive effort in verbal communication pertains to both the listener and the speaker and that brain-to-brain synchrony can be an indicator of differences in their cumulative communicative effort. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.25452142.

Economic analysis of the 'Take Charge' intervention for people following stroke: Results from a randomised trial.

OBJECTIVE: To undertake an economic analysis of the Take Charge intervention as part of the Taking Charge after Stroke (TaCAS) study. DESIGN: An open, parallel-group, randomised trial comparing active and control interventions with blinded outcome assessment. SETTING: Community. PARTICIPANTS: Adults (n = 400) discharged to community, non-institutional living following acute stroke. INTERVENTIONS: The Take Charge intervention, a strengths based, self-directed rehabilitation intervention, in two doses (one or two sessions), and a control intervention (no Take Charge sessions). MEASURES: The cost per quality-adjusted life year (QALY) saved for the period between randomisation (always post hospital discharge) and 12 months following acute stroke. QALYs were calculated from the EuroQol-5D-5L. Costs of stroke-related and non-health care were obtained by questionnaire, hospital records and the New Zealand Ministry of Health. RESULTS: One-year post hospital discharge cost of care was mean (95% CI) $US4706 (3758-6014) for the Take Charge intervention group and $6118 (4350-8005) for control, mean (95% CI) difference $ -1412 (-3553 to +729). Health utility scores were mean (95% CI) 0.75 (0.73-0.77) for Take Charge and 0.71 (0.67-0.75) for control, mean (95% CI) difference 0.04 (0.0-0.08). Cost per QALY gained for the Take Charge intervention was $US -35,296 (=£ -25,524, € -30,019). Sensitivity analyses confirm Take Charge is cost-effective, even at a very low willingness-to-pay threshold. With a threshold of $US5000 per QALY, the probability that Take Charge is cost-effective is 99%. CONCLUSION: Take Charge is cost-effective and probably cost saving.

Methodology of the fatigue after stroke educational recovery group randomized controlled trial.

RATIONALE: Post-stroke fatigue affects up to 92% of stroke survivors, causing significant burden. Educational cognitive behavioral therapy fatigue groups show positive results in other health conditions. AIMS: FASTER will determine if educational cognitive behavioral therapy fatigue management group reduces subjective fatigue in adults post-stroke. DESIGN: Prospective, multi-centre, two-arm, single-blind, phase III RCT (parallel, superiority design), with blinded assessments at baseline, six weeks, and three months post-program commencement. With n = 200 (100 per group, 20% drop-out), the trial will have 85% power (2-sided, p = 0.05) to detect minimally clinically important differences of 0.60 (SD = 1.27) in fatigue severity scale and 1.70 points (SD = 3.6) in multidimensional fatigue inventory-20 at three months. OUTCOMES: Primary outcomes are self-reported fatigue severity and dimensionality (i.e. types of fatigue experienced - physical, psychological and/or cognitive) post-intervention (six weeks). Secondary outcomes include subjective fatigue at three months, and health-related quality of life, disability, sleep, pain, mood, service use/costs, and caregiver burden at each follow-up. DISCUSSION: FASTER will determine whether fatigue management group reduces fatigue post-stroke.Registered with the Australian New Zealand Clinical Trials Registry (ACTRN12619000626167).

The influence of neighbourhood equity on parkrunners in a British city.

Physical activity benefits both physical and mental health. Specific events may augment participation in physical activity at a population level. Parkrun is a popular, free, weekly, timed 5 km run or walk in public spaces located in five continents. However, these events may be distributed inequitably, possibly reinforcing inequities in health. As a prelude to a comprehensive analysis of a larger dataset, we explore a hypothesis that participation in parkrun is influenced by the socio-economic characteristics of both parkrunners and their park. Two parkruns, 4.5 km apart, were selected in the city of Sheffield in the United Kingdom. Defined by indices of multiple deprivation, Castle parkrun is located in an economically deprived neighbourhood and Hallam parkrun is in a prosperous area of the city. Parkrunners were defined by applying these same indices to the neighbourhood of home registration. Results: (i) the prosperous Hallam catchment area produced over five times more parkrun participants than Castle; (ii) compared with Castle, Hallam parkrun attracted more participants from both catchment areas; (iii) consequently, Hallam parkrun had seven times more participants than Castle parkrun. Conclusion: establishing parkruns in deprived areas is a necessary but not sufficient prerequisite for equity of participation in this heath promoting activity.

Parkruns are popular, free, weekly, timed 5 km runs or walks in public places across the world. They contribute to both mental and physical health. But they could also increase health inequality. Participants may already have the better health generally associated with above average incomes and home life in attractive neighbourhoods. Our pilot study compares two parkruns in the British city of Sheffield; one located in the city's poorer East End, the other in the richer West End.

The effect of the Take Charge intervention on mood, motivation, activation and risk factor management: Analysis of secondary data from the Taking Charge after Stroke (TaCAS) trial.

OBJECTIVE: To use secondary data from the Taking Charge after Stroke study to explore mechanisms for the positive effect of the Take Charge intervention on physical health, advanced activities of daily living and independence for people after acute stroke. DESIGN: An open, parallel-group, randomised trial with two active and one control intervention and blinded outcome assessment. SETTING: Community. PARTICIPANTS: Adults (n = 400) discharged to community, non-institutional living following acute stroke. INTERVENTIONS: One, two, or zero sessions of the Take Charge intervention, a self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. MEASURES: Twelve months after stroke: Mood (Patient Health Questionnaire-2, Mental Component Summary of the Short Form 36); 'ability to Take Charge' using a novel measure, the Autonomy-Mastery-Purpose-Connectedness (AMP-C) score; activation (Patient Activation Measure); body mass index (BMI), blood pressure (BP) and medication adherence (Medication Adherence Questionnaire). RESULTS: Follow-up was near-complete (388/390 (99.5%)) of survivors at 12 months. Mean age (SD) was 72.0 (12.5) years. There were no significant differences in mood, activation, 'ability to Take Charge', medication adherence, BMI or BP by randomised group at 12 months. There was a significant positive association between baseline AMP-C scores and 12-month outcome for control participants (1.73 (95%CI 0.90 to 2.56)) but not for the Take Charge groups combined (0.34 (95%CI -0.17 to 0.85)). CONCLUSION: The mechanism by which Take Charge is effective remains uncertain. However, our findings support a hypothesis that baseline variability in motivation, mastery and connectedness may be modified by the Take Charge intervention.

Taking Charge after Stroke: A randomized controlled trial of a person-centered, self-directed rehabilitation intervention.

BACKGROUND AND PURPOSE: "Take Charge" is a novel, community-based self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. In a previous randomized controlled trial, a single Take Charge session improved independence and health-related quality of life 12 months following stroke in Maori and Pacific New Zealanders. We tested the same intervention in three doses (zero, one, or two sessions) in a larger study and in a broader non-Maori and non-Pacific population with stroke. We aimed to confirm whether the Take Charge intervention improved quality of life at 12 months after stroke in a different population and whether two sessions were more effective than one. METHODS: We randomized 400 people within 16 weeks of acute stroke who had been discharged to institution-free community living at seven centers in New Zealand to a single Take Charge session (TC1, n = 132), two Take Charge sessions six weeks apart (TC2, n = 138), or a control intervention (n = 130). Take Charge is a "talking therapy" that encourages a sense of purpose, autonomy, mastery, and connectedness with others. The primary outcome was the Physical Component Summary score of the Short Form 36 at 12 months following stroke comparing any Take Charge intervention to control. RESULTS: Of the 400 people randomized (mean age 72.2 years, 58.5% male), 10 died and two withdrew from the study. The remaining 388 (97%) people were followed up at 12 months after stroke. Twelve months following stroke, participants in either of the TC groups (i.e. TC1 + TC2) scored 2.9 (95% confidence intervals (CI) 0.95 to 4.9, p = 0.004) points higher (better) than control on the Short Form 36 Physical Component Summary. This difference remained significant when adjusted for pre-specified baseline variables. There was a dose effect with Short Form 36 Physical Component Summary scores increasing by 1.9 points (95% CI 0.8 to 3.1, p < 0.001) for each extra Take Charge session received. Exposure to the Take Charge intervention was associated with reduced odds of being dependent (modified Rankin Scale 3 to 5) at 12 months (TC1 + TC2 12% versus control 19.5%, odds ratio 0.55, 95% CI 0.31 to 0.99, p = 0.045). CONCLUSIONS: Confirming the previous randomized controlled trial outcome, Take Charge-a low-cost, person-centered, self-directed rehabilitation intervention after stroke-improved health-related quality of life and independence. CLINICAL TRIAL REGISTRATION-URL: http://www.anzctr.org.au. Unique identifier: ACTRN12615001163594.

A scoping study of interventions to increase the uptake of physical activity (PA) amongst individuals with mild-to-moderate depression (MMD).

BACKGROUND: Depression is the largest contributor to disease burden globally. The evidence favouring physical activity as a treatment for mild-to-moderate depression is extensive and relatively uncontested. It is unclear, however, how to increase an uptake of physical activity amongst individuals experiencing mild-to-moderate depression. This leaves professionals with no guidance on how to help people experiencing mild-to-moderate depression to take up physical activity. The purpose of this study was to scope the evidence on interventions to increase the uptake of physical activity amongst individuals experiencing mild-to-moderate depression, and to develop a model of the mechanisms by which they are hypothesised to work. METHODS: A scoping study was designed to include a review of primary studies, grey literature and six consultation exercises; two with individuals with experience of depression, two pre-project consultations with physical activity, mental health and literature review experts, one with public health experts, and one with community engagement experts. RESULTS: Ten papers met the inclusion criteria and were included in the review. Consultation exercises provided insights into the mechanisms of an uptake of physical activity amongst individuals experiencing mild-to-moderate depression; evidence concerning those mechanisms is (a) fragmented in terms of design and purpose; (b) of varied quality; (c) rarely explicit about the mechanisms through which the interventions are thought to work. Physical, environmental and social factors that may represent mediating variables in the uptake of physical activity amongst people experiencing mild-to-moderate depression are largely absent from studies. CONCLUSIONS: An explanatory model was developed. This represents mild-to-moderate depression as interfering with (a) the motivation to take part in physical activity and (b) the volition that it is required to take part in physical activity. Therefore, both motivational and volitional elements are important in any intervention to increase physical activity in people with mild-to-moderate depression. Furthermore, mild-to-moderate depression-specific factors need to be tackled in any physical activity initiative, via psychological treatments such as Cognitive Behavioural Therapy. We argue that the social and environmental contexts of interventions also need attention.

Allogeneic Mesenchymal Stem Cells Ameliorate Aging Frailty: A Phase II Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

BACKGROUND: Aging frailty, characterized by decreased physical and immunological functioning, is associated with stem cell depletion. Human allogeneic mesenchymal stem cells (allo-hMSCs) exert immunomodulatory effects and promote tissue repair. METHODS: This is a randomized, double-blinded, dose-finding study of intravenous allo-hMSCs (100 or 200-million [M]) vs placebo delivered to patients (n = 30, mean age 75.5 ± 7.3) with frailty. The primary endpoint was incidence of treatment-emergent serious adverse events (TE-SAEs) at 1-month postinfusion. Secondary endpoints included physical performance, patient-reported outcomes, and immune markers of frailty measured at 6 months postinfusion. RESULTS: No therapy-related TE-SAEs occurred at 1 month. Physical performance improved preferentially in the 100M-group; immunologic improvement occurred in both the 100M- and 200M-groups. The 6-minute walk test, short physical performance exam, and forced expiratory volume in 1 second improved in the 100M-group (p = .01), not in the 200M- or placebo groups. The female sexual quality of life questionnaire improved in the 100M-group (p = .03). Serum TNF-α levels decreased in the 100M-group (p = .03). B cell intracellular TNF-α improved in both the 100M- (p < .0001) and 200M-groups (p = .002) as well as between groups compared to placebo (p = .003 and p = .039, respectively). Early and late activated T-cells were also reduced by MSC therapy. CONCLUSION: Intravenous allo-hMSCs were safe in individuals with aging frailty. Treated groups had remarkable improvements in physical performance measures and inflammatory biomarkers, both of which characterize the frailty syndrome. Given the excellent safety and efficacy profiles demonstrated in this study, larger clinical trials are warranted to establish the efficacy of hMSCs in this multisystem disorder. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov: CRATUS (#NCT02065245).

Allogeneic Human Mesenchymal Stem Cell Infusions for Aging Frailty.

BACKGROUND: Impaired endogenous stem cell repair capacity is hypothesized to be a biologic basis of frailty. Therapies that restore regenerative capacity may therefore be beneficial. This Phase 1 study evaluated the safety and potential efficacy of intravenous, allogeneic, human mesenchymal stem cell (allo-hMSC)-based therapy in patients with aging frailty. METHODS: In this nonrandomized, dose-escalation study, patients received a single intravenous infusion of allo-hMSCs: 20-million (n = 5), 100-million (n = 5), or 200-million cells (n = 5). The primary endpoint was incidence of any treatment-emergent serious adverse events measured at 1 month postinfusion. The secondary endpoints were functional efficacy domains and inflammatory biomarkers, measured at 3 and 6 months, respectively. RESULTS: There were no treatment-emergent serious adverse events at 1-month postinfusion or significant donor-specific immune reactions during the first 6 months. There was one death at 258 days postinfusion in the 200-million group. In all treatment groups, 6-minute walk distance increased at 3 months (p = .02) and 6 months (p = .001) and TNF-α levels decreased at 6 months (p < .0001). Overall, the 100-million dose showed the best improvement in all parameters, with the exception of TNF-α, which showed an improvement in both the 100- and 200-million groups (p = .0001 and p = .0001, respectively). The 100-million cell-dose group also showed significant improvements in the physical component of the SF-36 quality of life assessment at all time points relative to baseline. CONCLUSIONS: Allo-hMSCs are safe and immunologically tolerated in aging frailty patients. Improvements in functional and immunologic status suggest that ongoing clinical development of cell-based therapy is warranted for frailty.

Incidence of Transient Ischemic Attack in Auckland, New Zealand, in 2011 to 2012.

BACKGROUND AND PURPOSE: There have been few recent population-based studies reporting the incidence (first ever) and attack rates (incident and recurrent) of transient ischemic attack (TIA). METHODS: The fourth Auckland Regional Community Stroke study (ARCOS IV) used multiple overlapping case ascertainment methods to identify all hospitalized and nonhospitalized cases of TIA that occurred in people ≥16 years of age usually resident in Auckland (population ≥16 years of age is 1.12 million), during the 12 months from March 1, 2011. All first-ever and recurrent new TIAs (any new TIA 28 days after the index event) during the study period were recorded. RESULTS: There were 785 people with TIA (402 [51.2%] women, mean [SD] age 71.5 [13.8] years); 614 (78%) of European origin, 84 (11%) Maori/Pacific, and 75 (10%) Asian/Other. The annual incidence of TIA was 40 (95% confidence interval, 36-43), and attack rate was 63 (95% confidence interval, 59-68), per 100 000 people, age standardized to the World Health Organization world population. Approximately two thirds of people were known to be hypertensive or were being treated with blood pressure-lowering agents, half were taking antiplatelet agents and just under half were taking lipid-lowering therapy before the index TIA. Two hundred ten (27%) people were known to have atrial fibrillation at the time of the TIA, of whom only 61 (29%) were taking anticoagulant therapy, suggesting a failure to identify or treat atrial fibrillation. CONCLUSIONS: This study describes the burden of TIA in an era of aggressive primary and secondary vascular risk factor management. Education programs for medical practitioners and patients around the identification and management of atrial fibrillation are required.

Developing a framework for estimating the potential impact of obesity interventions in a European city.

Obesity is a global challenge for healthy populations. It has given rise to a wide range of public health interventions, focusing on supportive environments and lifestyle change, including diet, physical activity and behavioural change initiatives. Impact is variable. However, more evidence is slowly becoming available and is being used to develop new interventions. In a period of austerity, momentum is building to review these initiatives and understand what they do, how they do it and how they fit together. Our project seeks to develop a relatively straight forward systematic framework using readily accessible data to map the complex web of initiatives at a policy, population, group and individual level aiming to promote healthy lifestyles, diet and physical activity levels or to reduce obesity through medical treatments in a city or municipality population. It produces a system for classifying different types of interventions into groupings which will enable commissioners to assess the scope and distribution of interventions and make a judgement about gaps in provision and the likely impact on mean body mass index (BMI) as a proxy measure for health. Estimated impact in each level or type of intervention is based upon a summary of the scientific evidence of clinical and/or cost effectiveness. Finally it seeks, where possible, to quantify the potential effects of different types of interventions on BMI and produce a cost per unit of BMI reduced. This approach is less sophisticated but identifies the areas where more sophisticated evaluation would add value.

Is a healthy city also an age-friendly city?

Healthy Ageing is an important focus of the European Healthy Cities Network and has been supported by WHO since 2003 as a key strategic topic, since 2010 in cooperation with the Global Network of Age-friendly Cities and Communities. Based on the methodology of realist evaluation, this article synthesizes qualitative evidence from 33 structured case studies (CS) from 32 WHO European Healthy Cities, 72 annual reports from Network cities and 71 quantitative responses to a General Evaluation Questionnaire. City cases are assigned to three clusters containing the eight domains of an age-friendly city proposed by WHO's Global Age-friendly City Guide published in 2007. The analysis of city's practice and efforts in this article takes stock of how cities have developed the institutional prerequisites and processes necessary for implementing age-friendly strategies, programmes and projects. A content analysis of the CS maps activities across age-friendly domains and illustrates how cities contribute to improving the social and physical environments of older people and enhance the health and social services provided by municipalities and their partners.

Healthy Cities Phase V evaluation: further synthesizing realism.

In this article we reflect on the quality of a realist synthesis paradigm applied to the evaluation of Phase V of the WHO European Healthy Cities Network. The programmatic application of this approach has led to very high response rates and a wealth of important data. All articles in this Supplement report that cities in the network move from small-scale, time-limited projects predominantly focused on health lifestyles to the significant inclusion of policies and programmes on systems and values for good health governance. The evaluation team felt that, due to time and resource limitations, it was unable to fully exploit the potential of realist synthesis. In particular, the synthetic integration of different strategic foci of Phase V designation areas did not come to full fruition. We recommend better and more sustained integration of realist synthesis in the practice of Healthy Cities in future Phases.

Policymaking in European healthy cities.

This paper assesses policy development in, with and for Healthy Cities in the European Region of the World Health Organization. Materials for the assessment were sourced through case studies, a questionnaire and statistical databases. They were compiled in a realist synthesis methodology, applying theory-based evaluation principles. Non-response analyses were applied to ascertain the degree of representatives of the high response rates for the entire network of Healthy Cities in Europe. Further measures of reliability and validity were applied, and it was found that our material was indicative of the entire network. European Healthy Cities are successful in developing local health policy across many sectors within and outside government. They were also successful in addressing 'wicked' problems around equity, governance and participation in themes such as Healthy Urban Planning. It appears that strong local leadership for policy change is driven by international collaboration and the stewardship of the World Health Organization. The processes enacted by WHO, structuring membership of the Healthy City Network (designation) and the guidance on particular themes, are identified as being important for the success of local policy development.

European Healthy Cities evaluation: conceptual framework and methodology.

This paper presents the methodology, programme logic and conceptual framework that drove the evaluation of the Fifth Phase of the WHO European Healthy Cities Network. Towards the end of the phase, 99 cities were designated progressively through the life of the phase (2009-14). The paper establishes the values, systems and aspirations that these cities sign up for, as foundations for the selection of methodology. We assert that a realist synthesis methodology, driven by a wide range of qualitative and quantitative methods, is the most appropriate perspective to address the wide geopolitical, demographic, population and health diversities of these cities. The paper outlines the rationale for a structured multiple case study approach, the deployment of a comprehensive questionnaire, data mining through existing databases including Eurostat and analysis of management information generation tools used throughout the period. Response rates were considered extremely high for this type of research. Non-response analyses are described, which show that data are representative for cities across the spectrum of diversity. This paper provides a foundation for further analysis on specific areas of interest presented in this supplement.

Healthy cities as catalysts for caring and supportive environments.

'Caring and Supportive Environments' are fundamental to a social model of health and were a core theme of Phase V (2009-13) of the WHO European Healthy Cities Network. Deploying the methodology of realist evaluation, this article synthesizes qualitative evidence from 112 highly structured case studies from 68 Network cities and 71 responses to a General Evaluation Questionnaire, which asked cities to analyze city attributes and trends. A schematic model was developed to describe the interaction between action targeted toward children, migrants, older people and action on social and health services, health literacy and active citizenship-the six subtopics clustered within the theme Caring and Supportive Environments. Four hypotheses were tested: (i) there are prerequisites and processes of local governance that increase city capacity for creating supportive environments; (ii) investing in health and social services, active citizenship and health literacy enhance the social inclusion of vulnerable population groups; (iii) there are synergies between social investment and healthy urban planning; and (iv) these investments promote greater equity in health. The evaluation revealed many innovative practices. Providers of health and social services have developed partnerships with agencies influencing wider determinants of health. Health literacy campaigns address the wider context of people's lives. In a period of economic austerity, cities have utilized the social assets of their citizens. Realist evaluation can help illuminate the pathways from case study interventions to health outcomes, and the prerequisites and processes required to initiate and sustain such investments.

Stroke rehabilitation services in New Zealand: a survey of service configuration, capacity and guideline adherence.

AIM: To provide an up-to-date account of stroke rehabilitation services in all District Health Boards (DHB) in New Zealand in 2013. METHOD: An online survey was completed by clinicians at all 38 facilities in New Zealand providing rehabilitation services following acute stroke. RESULTS: There was some evidence of stroke rehabilitation specialisation, particularly in larger DHBs (seven of eight large DHBs provided a dedicated stroke rehabilitation unit or designated beds). Capacity was generally satisfactory with units accommodating all (68% of units) or most (further 29%) of stroke patients needing rehabilitation. Most units had guidelines for the management of common problems following stroke, apart from depression screening (7%), but intensity of therapy input remains below recommended levels. Post-discharge rehabilitation services are available in the majority of areas but significant delays (mean 14 days) are common in accessing these services. The results for New Zealand stroke rehabilitation services are broadly comparable with those from the recent Australian stroke rehabilitation service audit. CONCLUSION: Compared to previous surveys, New Zealand stroke rehabilitation services have shown progress. To maximise outcomes for stroke patients, improvements are still needed in provision of dedicated stroke rehabilitation units, rehabilitation intensity and access to prompt community rehabilitation in the community.

Healthy cities: promoting health and equity – evidence for local policy and practice: summary evaluation of Phase V of the WHO European Healthy Cities Network

This publication summarizes the evaluation of Phase V (2009–2013) of the WHO European Healthy Cities Network. The evaluation process was designed in collaboration with city representatives, academic institutions and public health experts. It adopted a realist synthesis approach, being responsive to the unique social, cultural, political,health and epidemiological circumstances in the 99 cities in the WHO European Healthy Cities Network and 20 accredited national networks. The evaluation findings are rooted in the enduring healthy city values such as equity, governance, partnership, participation and sustainability. Considering also the core Phase V themes, this publication focuses on policy and governance, healthy urban environments and design, caring and supportive environments, healthy and active living, national network performance and effects on health and equity. The evaluation finds good progress among cities and networks but differing in scale and quality. The healthy cities movement adds value and allows local governments to invest in health and well-being and address inequities through novel approaches to developing health.