RIVM invited 250 professionals for the study, who either participated in the RIVM Congress 'Make Way for Health' (November 2015) or who were already known from other RIVM projects. A Healthy City demands inter-domain collaboration. Accordingly, 100 professionals with different backgrounds, varying from Municipal Public Health Service  and spatial planning professionals to other experts from the environmental, health, or spatial planning domains were involved.

Characteristics of a healthy city according to professionals

The professionals  completed the following sentence. 'For me, a healthy city is...'. This resulted in a list of 350 characteristics that, taken together, form a diverse palette of the healthy city. By removing characteristics that were similar to others in the list, it was possible to reduce the list to 88 characteristics, a more workable number for the next phase of the study. In the follow-up study, the participants were asked to rate these characteristics according to their importance for a healthy city.

The 12 most important characteristics:

1. where children can play outdoors
2. where you can easily get around by bicycle
3. with good air quality
4. where you can easily get around on foot
5. where people feel safe
6. with green areas for recreation
7. with safe bicycle paths
8. that encourages an active lifestyle
9. that is safe
10. that approaches health from various sectors, such as spatial planning, traffic, municipal health services et cetera
11. that has sufficient quality facilities for engaging in sports and exercise
12. in which vulnerable persons are given adequate support

A striking aspect, by the way, was that many of the 350 characteristics offered by the group of over 100 professionals seemed to reflect an ideal image of a green and safe environment with ample open space that encourages mobility, reminiscent of the VINEX (locations designated for urban development in the proximity of large cities) neighbourhoods built in the 1990s. Obvious urban characteristics such as the proximity of urban facilities, the liveliness of urban life, or multifunctional use of the available space were either not mentioned or considered unimportant.

Clustering and rating characteristics

The next step in this study was clustering and rating the 88 characteristics. 50 of the 100 professionals took part in this part of the study. More specifically, the characteristics that were 'very related to each other' had to be clustered, and the resulting clusters were then given an appropriate name. With the help of a computer program (Conceptsystems Global Max), it was then possible to calculate how often characteristics were grouped together in the same cluster by the professionals, and therefore which characteristics belonged in the same cluster. In addition, the average rating assigned to each characteristic was also calculated. The results were summarised in a ‘concept map’ in which a Healthy City was defined in terms of 12 different concepts, each of which represents a unique aspect of the Healthy City. These 12 clusters were described and ranked by the professionals as follows (clusters higher on the list were given a higher ranking):

1. Bicycle-friendly
2. Social networks
3. Age-friendly city
4. The caring city
5. Healthy and safe
6. Sustainability and climate
7. Healthy buildings
8. Integrated health policy
9. Care and income
10. Inspiring city
11. Future-oriented and sustainable
12. Irregular 'frayed' patterns

Main clusters

Each cluster consists of between four and nine of the 88 characteristics. These clusters can be grouped into four main clusters:

1. Social characteristics (4 clusters and 31 characteristics; main theme: A city where people help each other.)
2. Spatial planning (5 clusters and 36 characteristics; main theme: A city where children can play outdoors.)
3. Policy (2 clusters and 13 characteristics; main theme: A city with health as a central goal.)
4. Culture (1 cluster and 8 characteristics; main theme: A city to be proud of.)

Concept map with clusters and characteristics

The clusters and characteristics are illustrated in a so-called concept map . In this interactive digital presentation, you can click on the clusters to see which characteristics it contains. The size of the circle in the illustration indicates the importance attached to the characteristic in question.

We have also indicated which characteristics are summarised in which clusters with the help of a table. A striking aspect here is that 7 of the most important 12 characteristics of a healthy city are found in the main cluster, 'Spatial planning', and 4 are found in the main cluster, 'Social characteristics'. The only one of the top-12 characteristics not included in these two clusters is 'A city that approaches health from various sectors, including spatial planning, traffic, municipal health services et cetera'. This characteristic is included in the main cluster, 'Policy'.

Score per domain

The professionals were divided into three domains: health, spatial planning, and environment. In most cases, this classification was based on their own description of their domain. In some cases, the professionals could not indicate what their primary domain was, as there is already a great deal of collaboration taking place between the various domains. In such (exceptional) cases, the project team ended up making a choice between one of the three domains.

A striking conclusion obtained from scoring the various domains in this way was that there is a high degree of agreement between the different domains on what the most important characteristics of a Healthy City are. All three groups came up with a similar top-12 list. For example, the characteristics 'where children can play outdoors' and those referring to bicycling always had the highest ratings in this top 12. However, people from the spatial planning or environmental domain used the statement ‘where you can easily get around by bicycle’ in their top 12, whereas people from the health domain used ‘a city where sports and physical activity are taken advantage of as preventive measures for remaining healthy’.  The agreement between the various domains on what is considered important seems to be much greater than generally assumed.

The concept maps per domain have roughly the same subdivision into the four main clusters. The main clusters correspond roughly to how (local) government bodies address the healthy city theme. In fact, they seem to reflect the organisational structure of the government/municipal service entities.
 
Health professionals attach a relatively high degree of importance to social characteristics and policy. They give the highest rating to the characteristic, 'a municipal government that focuses on health as a central goal'. Spatial planning professionals attach roughly the same degree of importance to physical, social, cultural, and policy aspects. Healthy transport/mobility is the cluster that is ranked highest by them, and they also think it's important for a city to ''be in sync with the wishes and needs of the residents'. Environmental professionals attach a relatively high degree of importance to sustainable mobility: 'a city with good public transport' was given the highest-rating by them. They also considered safety and tranquillity to be slightly more important than the other professionals.

Conclusion: on the way to a Healthy City

It turns out that there is a high degree of agreement between professionals on what the most important characteristics of a Healthy City are, regardless of whether the professionals are from the environmental, health, or spatial planning domain. The names attached to the clusters by professionals differ per domain, which means that for us, it's worth making an effort to get to know one another’s discourse better. The characteristics ranked the highest in our study were ‘easily getting around by bicycle’ and 'where children can play outside'. The level of agreement provides a great many opportunities for collaboration.

At the end of October 2016, the concept map was used by a group of professionals as a basis to generate ideas aimed at making the Healthy City a reality. In addition, RIVM wishes to use this method in the near future in order to  investigate what residents consider important in this respect. It is interesting to find out whether similar results will be found, or whether residents will find different characteristics  important.