HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
Participatory research to enhance vision sharing for Healthy Town initiatives in Japan
1Research and Planning Committee, Tokyo Citizens' Council for Health Promotion, Tokyo, Japan, 2Health Promotion/International Health, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan and 3WHO Collaborating Centre for Healthy Cities and Urban Policy Research c/o Health Promotion/International Health, Graduate School of Tokyo Medical and Dental University, Tokyo, Japan
Address for correspondence: Professor Takehito Takano, Health Promotion/International Health, Graduate School of Tokyo Medical and Dental University, Tokyo 113-8519, Japan E-mail: whocc.hlth{at}tmd.ac.jp
SUMMARY
This paper presents the results of a participatory research project conducted by the Tokyo Citizens' Council for Health Promotion (Citizens' Council) to enhance vision sharing, thereby aiding the implementation of Healthy Town initiatives. The Citizens' Council conducted a survey to elucidate citizen interests and expectations regarding Healthy Towns. The project had three stages: (i) a survey; (ii) dissemination of the results; and (iii) evaluation of the impact of the survey's findings. The survey was conducted among ordinary citizens, community group members, health promotion practitioners and members of the Citizens' Council. Responses from 476 ordinary citizens, 400 community group members, 316 health promotion practitioners and 387 members of the Citizens' Council were received and analyzed. Major criteria that respondents required of a Healthy Town were: adequate sports facilities and walking/jogging trails (44.5%); easy access for senior citizens, small children and people with disabilities (42.2%); and parks, clean rivers and other natural features (33.1%). Prioritized criteria given by specific respondent groups were (i) a town with little crime and few traffic accidents (ordinary citizens: 37.2%) and (ii) a town where people help each other (health promotion practitioners: 36.7%; members of the Citizens' Council: 31.5%). Factor analysis revealed that the structure of citizen views on criteria for a Healthy Town had the following three dimensions: (i) health conducive physical living environment; (ii) social networks and mutual help; and (iii) societal discipline/rules and good access to services. The research results were disseminated to the general public, community groups and members of the Citizens' Council. The results substantiated citizen views, which were then incorporated into plans towards realizing Healthy Towns initiatives. This research effort generated a vision of the creation of Healthy Towns by the participation of citizens in a megacity.
Key words: community participation; evaluation; Healthy Cities; participatory research
INTRODUCTION
Vision sharing among community members and groups is considered key to implementing Healthy Cities projects [Tsouros, 1990
; Baum et al., 1997; World Health Organization (WHO) Western Pacific Regional Office, 2000]. Cities have tried to integrate citizens' views into city health plans (Costongs and Springett, 1997; Strobl and Bruce, 2000), but without systematic intervention it is not possible to implement vision sharing in larger cities in a way that takes into consideration the wide array of groups within the community. Gathering citizen views on healthy cities by surveying representative sample populations within a large city can provide opportunities for citizens to share their vision.
The health promotion movement has been advanced in Tokyo through close cooperation between the public and private sectors by the Tokyo Citizens' Council for Health Promotion (Citizens' Council), which was established in 1991 (Takano, 1995). According to the articles of incorporation of the Council, its purpose is to actualize Healthy City Tokyo. A multisectoral approach was adopted because the Citizens' Council's membership of >500 includes ordinary citizens as well as representatives from community groups, government bodies, academia and the private sector, including various areas such as health, welfare, general planning, culture, labor and economy, construction, education, and other health-related fields. Under the Board of Executives of the Citizens' Council, the following four specialized committees were set up to conduct individual programs: the Research and Planning Committee, the Public Relations Committee, the Organizational Development Committee and the Facilities Committee.
The large size of Tokyo's population (11.6 million in 1991) made it necessary to implement initiatives in individual communities to meet their local needs. To encourage activities in individual communities, the General Assembly of the Citizens' Council decided in February 1997 to implement the Healthy Town initiative (Tokyo Citizens' Council for Health Promotion, 1997). The needs and resources of individual communities in Tokyo vary, therefore leaders in those communities needed information based on their unique citizenry to create their respective programs. The Research and Planning Committee was assigned the role of conducting research activities to collect, analyze and disseminate necessary information for the Healthy Town initiative. In this paper, ‘town’ means a residential area inside a city.
The sharing of citizen views on a Healthy Town is considered the basis for its development. However, no such data on citizen views were available, therefore information gathering was the first step. The Citizens' Council adopted the research style of employing ‘community participation’. ‘Community participation’ refers to the series of processes of planning the protocol and questionnaire, implementing the survey and data collection, analyzing the data, and sharing the results with concerned people from various backgrounds, including the general public. This helped to ascertain the views of citizens from various backgrounds and offered opportunities for people from different sectors to strengthen their understanding of common issues. In this paper, we refer to ‘participatory research’ as research that: (i) is conducted jointly between concerned community members and researchers; (ii) involves community members in the process of planning, implementation, analysis, discussion, dissemination and evaluation of the research project; and (iii) helps the community concerned to obtain information that facilitates better planning and improved activities.
The Research and Planning Committee of the Citizens' Council played a key role in the research process. The 24 members of the committee were from academia, citizen groups, municipal governments, the Tokyo Metropolitan Government and the private sector. Since the establishment of the Citizens' Council, it has conducted evaluations of the megacity's needs in selected areas and disseminated the obtained information to the members of the Citizens' Council as well as to the general public (Tokyo Citizens' Council for Health Promotion, 2000). In response to the General Assembly's 1997 decision, the Research and Planning Committee developed plans for the research programs, conducted a survey and analyzed the data. In a joint meeting, the four specialized committees consulted on the project, which was then reviewed by the Board of Executives. The final report was discussed at the General Assembly of the Citizens' Council in February 1999. The four specialized committees and members of the Citizens' Council disseminated the research results.
The aim of this paper is to present the survey results of citizen expectations for a healthy town and to determine the value of participatory research in a megacity based on the research project by the Tokyo Citizens' Council for Health Promotion.
METHODS
Implementation of the survey
A questionnaire was developed to survey citizens' views on Healthy Towns. Survey recipients comprised the following four groups: (i) a representative sample of Tokyo citizens; (ii) a representative sample of health promotion community group members; (iii) a sample of participants in training programs for community health promotion practitioners organized by the Tokyo Metropolitan Health Promotion Center; and (iv) a representative sample of Citizens' Council members. A total of 2974 questionnaires were distributed.
The questionnaire asked respondents about the following: gender, age, occupation, years of residence in current area, size of household, general state of health, general care of one's health, practices to promote one's health, smoking, involvement in community group activities, health topics of most interest, image of a Healthy Town, necessary elements in a healthy town, level of satisfaction with, and assessment of, one's town from the viewpoint of a Healthy Town, overall grading of one's town's achievements in being healthy for adults and children, and opinion regarding the government's ideal role in the promotion of health.
Analysis of the responses
The percentage of responses to individual items in the questionnaire was calculated by respondent group. Differences among respondent groups were analyzed using the Steel–Dwass all-pairs comparison to calculate statistical significance in pairs of multiple comparisons. Factor analysis was performed to estimate fundamental dimensions that underlie subjects' responses on images of a Healthy Town, elements in a Healthy Town, and activities and resources found in the town. Items selected as part of the respondents' images of a healthy town were given a score of one, and items not selected were given a score of zero. Responses regarding the elements for a healthy town were given a score according to the degree of necessity indicated: necessary, 4; relatively necessary, 3; relatively unnecessary, 2; unnecessary, 1. Responses regarding the activities and resources found in the town were given a score of one for those selected, and a score of zero for those not selected.
Dissemination of the survey results
Results of the baseline survey were compiled into a survey report and were delivered at the General Assembly of the Citizens' Council in February 1999. The report was also released to the people who requested the information through the secretariat of the Tokyo Citizens' Council for Health Promotion and its network, including 101 citizens, 79 community health promotion groups, 45 local health promotion councils and 62 municipal offices.
Follow-up evaluation
A follow-up questionnaire survey was conducted by the Citizens' Council in November 1999 to evaluate the activities of the Citizens' Council. In the survey, members of the Citizens' Council were asked to indicate how they had used the report on citizen views on Healthy Towns. The 327 responses obtained from both individuals and groups were analyzed.
RESULTS
Questionnaires were completed and submitted by 1579 subjects. Respondents included 476 Tokyo citizens, 400 health promotion community group members, 387 participants in the training programs for community health promotion practitioners and 387 members of the Citizens' Council. Male respondents numbered 473, and 1059 respondents were female; a total of 47 respondents did not indicate their gender.
The 60–69 years age group accounted for the largest proportion of respondents (34.5%); the second largest proportion was in the 50–59 year age group (23.6%). With respect to respondent occupation, 32.7% were housewives, 16.3% were full-time employees, 15.5% were part-time employees and 14.9% were self-employed. Approximately three-quarters (75.7%) of respondents reported that they had lived in the same area for 
15 years, and 28.6% lived in two-person households, 22.8% in three-person and 19.1% in four-person households. With respect to marital status and family structure, 70.4% were married, 45.7% had family members aged 65 years and 13.9% had school-age children in their household.
Responses regarding the respondent's current status showed that 85.2% reported that they were either quite healthy or healthy. There were no differences among the respondent groups.
Table 1 shows health issues of interest and involvement in community group activities according to respondent group. More than half of the respondents reported a particular interest in the following issues: waste and recycling (64.2%); mental health (59.7%); air and water pollution (59.5%); preventing older people becoming bed-ridden (58.5%); food safety (55.2%); and cancer (55.2%). With respect to active involvement in community group activities, 36.4% were involved in physical activities such as tennis, gate ball (Japanese-style croquet) and walking, 34.6% were active in volunteer personal development activities, such as social-welfare-related activities, empowering others and mentoring youth, and 32.6% were active in cultural activities, such as composing Haiku poems, playing the Japanese game of Go, music or cooking.
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Table 2 shows the criteria required of a Healthy Town by respondent group. At least 30.0% of respondents in each group reported that they required the following from a Healthy Town: adequate sports facilities and walking/jogging trails so that they can enjoy sports (44.5%); a town that is easily accessible for senior citizens, small children and people with disabilities so that they can move around (42.2%); a town with parks, clean rivers and other natural features (33.1%); a town free of environmental pollution, such as air and noise pollution (31.9%); and a town with little crime and few traffic accidents (30.0%).
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Table 3 shows the results of factor analysis of respondents' criteria for a Healthy Town. Six factors with an eigen value of >1.0 were selected. The individual factors represented the following dimensions: factor 1, a town meeting citizen needs for vigorous activity (positive value) and a town conducive to a relaxed lifestyle (negative value); factor 2, a town with health conducive physical infrastructure (positive value) and a town with the social infrastructure for health (negative value); factor 3, a town with societal discipline/rules; factor 4, a town with good access to information; factor 5, a town satisfying collective needs (positive value) and a town satisfying individual needs (negative value); and factor 6, a town with social network activities.
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Figure 1 plots factor loadings for factors 2 (x-axis) and 3 (y-axis) of 13 items. Items were categorized into three groups: (i) criteria relating to a health conducive physical living environment; (ii) criteria relating to social networks and mutual help; and (iii) criteria relating to a society in which discipline/rules are observed and there is good access to services.
Regarding the government role in the promotion of health, 60.0% answered that health promotion is a joint effort between the individual and the government, while 32.2% responded that the government bears the sole responsibility for providing conditions for health promotion. This distribution pattern was similar among both male and female respondents.
Table 4 summarized the responses of members of the Citizens' Council to a follow-up survey examining how they had used the survey report.
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DISCUSSION
Citizen perspectives on a Healthy Town were elucidated through a survey of ordinary citizens, community group members, health promotion practitioners and members of the Citizens' Council. The following three components emerged as key concepts in participants' visions of a Healthy Town: better physical living environment, social networks and mutual help, and societal discipline/rules. Elements that create a health-supportive physical environment were commonly viewed as essential for a Healthy Town by all respondent groups. Social networks and mutual help were much valued by people involved in community-based, health-related programs. Societal discipline/rules were much valued by ordinary citizens. This participatory research created a vision towards Healthy Towns in Tokyo, a megacity. Follow-up evaluation revealed that the survey report was used for information sharing and as a reference in the planning of the Healthy Town initiative.
All respondent groups valued the following elements of a health-supportive physical environment: sports facilities and walking/jogging trails; barrier-free architecture; parks, clean rivers and other natural features; and a pollution-free environment. People's intuitive understanding of what is necessary for citizens to lead a healthy life related closely to the concept of ‘supportive environments’ (Nutbeam and Harris, 1995; Division of Health Promotion Education and Communication WHO, 1998). The awareness of Tokyo citizens extended beyond classic considerations of clean air and water to include healthier settings that facilitate healthy behaviors, psychologically sound lifestyles and socially healthy daily living. Tokyo citizens widely acknowledge that a health-supportive physical environment is an important aspect of a Healthy Town.
Social networks were considered an important element in a Healthy Town by those participating in community-based programs; however, comparatively less interest was shown by ordinary citizens. More of the people participating in community group activities identified a town where people are actively involved in recycling and volunteer activities as a Healthy Town than ordinary citizens did. More of those who participated in health-related activities identified a town where people help each other as a Healthy Town than ordinary citizens did. This correlates with research on social support, which is now understood to have a positive impact on health (House et al., 1988; Bennett et al., 2001; Eng et al., 2002). Our results suggested that relative importance recognized by people depended on what social activities they participated in.
Societal discipline/rules were valued as an element of a Healthy Town by ordinary citizens, while people involved in community-based health-related programs showed less concern regarding this matter. It is noteworthy that little crime and few traffic accidents were considered by one-third of ordinary citizens as criteria for a Healthy Town. This proportion was greater than that who said a Healthy Town was one where even if people fall sick, they can rest assured because there are family doctors, etc. Our results suggested that a Healthy Town should consider not only access to medical care, but also community safety. Recent promotion of Safe Community initiatives (Itoh et al., 2000) may have had an influence on people's attitudes. Joint promotion of the Safe Community initiatives and Healthy Town initiatives at the community level would probably be well received by ordinary citizens.
Divergent views on a Healthy Town emerged in the responses of ordinary citizens. The health of a city is associated with a wide range of factors, including both physical and social environmental factors (Detels and Breslow, 1984; Division of Health Promotion Education and Communication WHO, 1998), and their interrelationship is of concern (Takano and Nakamura, 2001). The three major identified components of a healthy town reflected views of the subjects in Tokyo. Components may vary according to the community; however, in the process of vision sharing in a large city, this participatory research style would be shared. Healthy Towns are not realized by a single facet, but rest on the dynamics of multifaceted physical and social environments as well as people's participation in community activities.
This survey provided an opportunity for Tokyo citizens to share their vision of a Healthy Town. The articulation of a collective vision of a healthy community was considered participatory action research for developing Healthy Cities and Healthy Towns (Minkler, 2000). It was considered that in larger cities it is more difficult to spread information and ideas, and to increase project visibility (Tsouros, 1990). However, our follow-up survey revealed that the survey report edited by the Citizens' Council was used to disseminate data on divergent views of Tokyo citizens on a Healthy Town and to create collective visions for Healthy Town initiatives in communities.
Evidence-based discussions involving the participation of various groups help to develop Healthy Town initiatives that many citizens can support. Some Healthy Town initiatives emerged in Tokyo on the basis of the results of this participatory research project (Suginami City, 2001). It was generally agreed that the reports contained a wide variety of rich and useful data. Although the contents did not always satisfy all readers, many found useful components related to their individual needs. The report and other related activities, including capacity-building seminars and workshops with community members, provided opportunities to share evidence and stimulated actions toward Healthy Town initiatives.
This participatory research conducted in Tokyo revealed that the following three major dimensions should be part of a Healthy Town: (i) better physical living environment; (ii) social networks and mutual help; and (iii) societal discipline/rules. The results were shared among the general public, community groups and members of the Citizens' Council. This research effort contributed to generating a vision toward Healthy Towns in a megacity. The results substantiated citizen views that could be reflected in plans for Healthy Towns.
ACKNOWLEDGEMENTS
The survey was conducted between April 1997 and March 1999 as a program of the Tokyo Citizens' Council for Health Promotion, upon the initiative of the Working Group for the Survey for a Healthy Town (Research and Planning Committee, Tokyo Citizens' Council for Health Promotion).
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