Healthy Cities in Queensland, Australia: The Cambooya Shire Experience

An Australian community demonstrates that rural health issues must become holistically centered.

disease control and environmental management projects.

An Alternative Health Perspective
It would be inappropriate to discredit the advances of a social health policy and technological improvements made by a characteristically reactive health care system. In Australia, as in many industrialized nations, the costs to support primary care are tremendous. Fraught with inefficiency, it has been noted that further spending to improve such an approach would only yield increased health benefits to a few (Frank, 1995). Distinct factors, other than the health care system, have been identified as influential on a population's health status and many researchers have advocated their incorporation into public health approaches.
For example, in a study that compared Japanese and Swedish populations, Marmot and Smith (1989) found that health was directly related to equitable distribution of affluence rather than the prosperity of countries as a whole. Additional factors of health may include: socioeconomic status and levels of social equity (Houle, Knighton, & Berthelot, 1996); improvements to physical environments and living standards (Mustard & Frank, 1991); health in early development and maternal care (Walker, 1994); and, natural immunity and genetic predisposition (Clark, 1995). This shift in public health ideology has let to a discourse saturated with the more modern philosophies of increased community participation, ecological approaches to health promotion and illness prevention, and health planning at local levels. The benefits of prescribing a Healthy Cities approach to health planning is that it embraces a range of factors which determine people's health (Labonte, 1991) and provides a framework to address how each of these and their interactions can contribute to healthy and sustainable communities.
With its roots in the Lalonde report of 1974, which identified environment and lifestyle as important health determinants (Witty, 1991), the Healthy Cities project began in 1986 with confirmation by the World Health Organization programs and conferences and the Organization's European Regional Office for Health Promotion (Tsouros, 1991). Mainly a result of the Ottawa Charter (1986) principles and the initiatives of the Health for All 2000 strategy, the idea of Healthy Cities is an attempt to look holistically at health in an urban setting (Duhl, 1992). It strives to encourage health promoting activities that rely on the precepts of intersectoral collaboration (Baum, 1992) and community participation to improve the quality of life for local community members. Moreover, the Healthy Cities concept is a process and not just an outcome (WHO, 1995). In this context, it constitutes a method for placing health firmly on the agenda of local governments facilitated by commitments and partnerships between the public, health professionals, and elected decision makers. Rarely, however, has the process been initiated in a rural setting. This paper examines the implementation of Healthy Cities principles and concepts in Cambooya Shire, a rural district in Queensland, Australia; it also considers the role of ecological health perspectives in rural community decision-making.

Getting Started in Cambooya Shire
Cambooya Shire is located approximately two hours west of the City of Brisbane and borders the southern boundary of Toowoomba City in rural Queensland, Australia. According to Noel Locker (personal communication, October 18, 1997), the Shire (an administrative region similar to municipal or county boundaries in North America) has an estimated population of over 4,000 split into four towns and covers an area of approximately 630 square kilometers. It is characterized as predominately agricultural with movement towards intensified rural residential developments. The Shire also offers a few social amenities including tennis courts and a cricket club. Regardless of the atmosphere of rural living and the "quietness" associated with distance from major urban centers, a few members of local government identified a growing aggravation among the Shire population that community concerns and needs were not being properly addressed.
One area of particular concern is health. Cambooya Shire residents do not have local access to many health-related services, such as a medical practitioner, pharmacy, aged welfare and housing, facilities for youth, and health promotion to maintain public health awareness and information access. These community health service deficiencies have been confirmed by Queensland Health (a state government agency) who admit that insufficient progress has been made to improve the accessibility to health services in rural Queensland and that policies to address equity issues have been lacking due to social, cultural, and economic barriers (Queensland Health Council, 1991). Shire residents have also identified concerns about public transport for youth and the elderly, and inadequate communication between citizens among neighboring towns.
Compelled by a desire to ensure that public health considerations are incorporated into future decision making, Cambooya's Environmental Health Officer recommended to the local government council that it apply for an encouragement grant. An application was sent to Healthy Cities and Shires Queensland, an organization responsible for overseeing the implementation of Healthy Cities projects in Queensland, and a healthy shire working party was formed to implement the project (Locker, 1995). Although the council was not successful in its application for a support grant, community commitment to a healthier shire never wavered. In December 1996, council approval was sought to proceed with the development of a Municipal Public Health Plan (MPHP) and the formation of the working party. Healthy Cities and Shires Queensland subsequently recognized the community's commitment and the working party received enough funding to initiate the project.

The Process of Developing a Municipal Public Health Plan
The process used to guide Cambooya Shire towards the development of a Municipal Public Health Plan (MPHP) was proposed by Healthy Cities and Shires Queensland (Chapman & Davey, 1995) and consists of seven stages ( Figure 1). According to cities that have already completed the MPHP process, progress towards project completion may be characterized by continual movements backwards and forwards between many of the stages (see, for example, The City of Gold Coast Community Health Plan, 1997). With implementations in several of Queensland's largest urban areas, the process has proven to be easy to follow and comprehensive in design (Baum & Brown, 1989). However, implementation of the process in a rural setting was novel.  (Chapman & Davey, 1995).
The first stage (Doing the Groundwork) is typified by a commitment from local government to proceed with the development of the MPHP and an understanding that the plan, once completed, would become an important component of their overall corporate plan. It has been documented that, in larger cities, resistance to changes in existing corporate plans has arisen due to modifications in local council organizational interrelationships and hierarchies (Brisbane City Council, 1995). The relative size and rural flavour of the Cambooya Shire council were key factors in avoiding such resistance. Council members not only endorsed the ideas and approaches promoted by healthy cities and shires framework, but also offered both professional and administrative support for the project. This form of support is the backbone for the development and successful implementation of a healthy cities plan.
The formation of a working party (workgroup) to manage the process (stage two) was achieved through specific attention to maintaining a collaborative process involving consistent consultation with community organizations, schools, local associations, and eventually, with the Queensland Center for Public Health. After an initial meeting conducted by a representative from Council and the local Environmental Health Officer, it was decided that any person willing to make a 12 to 14 month commitment would be able to sit on the working party. Those unable to fulfill the obligation, but still interested in participating with the process, could be called upon when extra assistance was required.
The atmosphere of the rural setting allowed for an uncomplicated amalgamation of both community members and Council representatives into an effective working party. The party was diverse with a variety of expertise, age groups, and level of dedication to the project. Once the managerial issues were decided, the working party outlined strategies for the creation of partnerships and alliances with local and regional health and welfare authorities, and advocated the formation of sub-committees consisting of working party members to research and develop approaches for issues as they arose.
To assess the public health needs of the shire (step three), the working party chose to develop and distribute a questionnaire to investigate various community characteristics (such as "age" and "persons per household") and ascertain which health issues were of special importance to the community (Appendix A). After a community-wide mail out of 1000 surveys, 165 responses were returned to the working party for analysis. Although the response rate was too low to reveal statistically significant results, the information was useful to derive a general indication of the prominent public health issues and their relative degree of importance to the community. Questionnaires were distributed using the four villages that make up Cambooya Shire as units for stratification. The responses revealed a tendency for respondents to list each issue as having 'high importance' which may have been the consequence of poor questionnaire design. Unfortunately, the working party had already distributed the questionnaire before consultation with the Queensland Center for Public Health and changes were not possible.
Questionnaire reponses were grouped into three categories of low, medium, and high issues of importance and added to derive raw scores for each issue. Mean scores for each issue were calculated and ordered according to the number of standard deviations from the mean. Issues of high priority, as selected by the working party, were those with scores higher than the mean score of 3.8 on a five point scale and included: community security (4.3), Immunization (4.2), environmental management (4.1), and employment and school transport (4.0). However, it is important to note here that issues with a lower score were not discarded; rather, the working party forwarded the list to the local governement council and would address them once further funding could be secured. Among the respondents, 34% reported having dependents under the age of 17 years, and 45% of respondents over 41 years had no dependents.
Open-ended questions provided space for respondents to clarify which issues in Cambooya Shire were of particular personal importance and to provide suggestions for addressing the issues raised. Not surprisingly, and again likely due to poor questionnaire design, many of the same issues (immunization, security, school transport) took priority. A majority of respondents indicated the Shire Letter (a letter distributed by local government council), school newsletters, and a newspaper from the closest major city as their primary sources of local information. Over 60% of the respondents indicated a dissatisfaction with these sources with the main complaint being a lack of "local" news content. The working party viewed the responses as community-based solutions to community-based concerns-a concept inherent to the Healthy Cities and Shires process.
Cambooya Shire is still working through the remainder of the process (stages five through seven) and is maintaining contact with the Queensland Center for Public Health in preparation for the creation of the Municipal Public Health Plan (Noel Locker, personal communication, November 2000).

Small Wins for Large Gains
Cambooya Shire, aware of the principles of Healthy Cities, decided to adopt a socio-ecological approach to community health planning by remaining committed to community participation. Although the Shire council offered its support for the project by providing administrative assistance and general office facilities, the voluntarism and devotion of the local Environmental Health Officer and working party members has been a primary determinant in the continuation of their Healthy Cities and Shires project (Locker, 1995).
Although the working party adopted the framework provided by Healthy Cities and Shires Queensland, it was realized that small "wins" along the way could maintain motivation and demonstrate the possibilities of a coordinated approach. For example, in coordination with the annual campdraft (an Australian-style rodeo), the working party decided to organize a "Health Expo" to promote public participation in community health planning and the principles of the Healthy Cities approach to health. A medical practitioner, several personnel from various government departments, and community organizations were made available to display educational materials and promote the Cambooya Shire as a viable, healthy community. The idea of a Health Expo seemed to spark interest from the community toward the activities proposed by the working party and, in turn, instilled motivation among party volunteers.
The working party has also addressed the issue of communication-a priority listed in the previous section. The only available printed media available to Shire residents originates from the neighboring City of Toowoomba. In an effort to increase communication among community members, and as a tool for the dissemination of working party activities, a local newsletter entitled On Our Selection News was created. The newsletter is a joint initiative between the working party and the editor of the Clifton Courier (Clifton is located approximately 45 minutes South of Cambooya), and was delivered free of charge to the residents of Cambooya Shire. Distribution had risen from 800 to over 1500 households within the first two weeks, potentially rekindling community dialogue.

A Changing Health
The way in which communities are defined as urban, rural, and remote will influence and sometimes may even determine contradictions in the patterns of morbidity and mortality. Defining the term "rural" has proven to be an elusive objective; there is no clear and unambiguous statement of the parameters by which rural is defined (Humphreys, 1998). Empirical investigations among so-called rural communities in Australia, based on ongoing studies and reviews of available morbidity and mortality data, suggest that the overall health of rural and remote communities is worse than those living in larger metropolitan areas (Australian Institute of Health & Welfare, 1998). Studies of rural social indicators, such as unemployment, education, subsidized housing tenancies, and disruptions to family, support the results from prior empirical investigations overall declines in human wellbeing in rural areas (Walmsley & Weinand, 1997). Although not completely obscure, the reasons for rural health disparities remain puzzling.
Approaches to remediate health inequalities vary considerably between the doctrines of traditional biomedical and ecological health perspectives. Research has pointed to the influence of the biomedical model on public perceptions of valued health care services (Humphreys & Weinand, 1991). For many small, relatively isolated communities, such as those within Cambooya Shire, the past focus on health has concentrated largely on procuring and retaining the services of a local doctor and care facility. However, the preliminary results from the working party questionnaire lend support to a growing awareness of an ecological public health perspective. For example, respondent interest in the maintenance of environmental quality, employment, communication within the community, and transport issues as components to a healthier community, are very much aligned with a changing perspective of health and well-being. In essence, the Healthy Cities process represents a marked departure from traditional biomedical health policies and has enabled the citizens of Cambooya Shire to create their own definitions of what constitutes a healthy community.
The effort of the working party to create a Municipal Public Health Plan, using the Healthy Cities process, has identified an alternative to the traditional biomedical course to achieving a healthy community. The process is a method of activity identification and prioritization, such as those mentioned previously, that guides communities such as Cambooya Shire towards the creation of their own MPHP (Chapman & Davey, 1995). The product, however, is a document consisting of goals and strategies, as chosen through the cooperation of the community and local councils, that directs local government planning actions from an ecological health perspective.

Conclusion
The nature of this exercise has been the descriptive analysis of an implementation of the Healthy Cities framework in rural Queensland. The project researched and described is reaching the latter stages of completion. Although it is difficult to establish a thorough evaluation of the project, it is still a useful exercise to expose both the achievements and challenges associated with policy change. One crucial aspect of this project will be its impact on the health and well-being of Cambooya Shire residents. The Healthy Cities model provides a practical procedure to implement health policies at a local and thus manageable level. Moreover, the implementation of a Municipal Public Health Plan into council planning activities will promote health as a resource for everyday living.
Numerous changes are apt to take place as a result of Cambooya Shire's MPHP. The local government council and community have shown a demonstrated devotion and commitment to placing health firmly on the agenda of local governance and represent a new approach to health planning and environmental safekeeping. Relationships have been founded and partnerships forged between the community, professionals in health, and decision-makers. Cambooya Shire is an interesting addition to the flourishing network of Healthy Cities in Queensland and in Australia, especially in light of its rural character and holistic perspectives on health. The knowledge gained through the evaluation of the process in Cambooya Shire will improve the ability for other shires and rural localities to plan for and become healthy.