Design and validation of Iranian Child Health-Friendly Neighbourhood checklist: a mixed-methods study

Introduction

In 1986, the first International Conference on Health Promotion led to the declaration of the Ottawa Charter for Health Promotion as a recommended global strategy for achieving health for all by 2000 and beyond. The Ottawa Charter emphasised five key strategies, including creating a health-promoting setting as the second most widely recommended key action. The setting includes all the places where people live, work and learn. The Ottawa Charter supported the environment-based health promotion approach.1 In this regard, the WHO introduced healthy cities as the first idea of health promotion approach.2 The idea attracted global attention to public health and environmental health promotion, which was subsequently followed by relevant definitions such as a child-friendly city and its components to meet the needs of this age group around the world.3

The concept of a child-friendly city was first introduced by the UNICEF with the aim of protecting children’s rights in 1989.4 UNICEF offers seven areas of play and leisure, health, education, environment, conservation, social participation and innovation for measuring the qualitative concept of a child-friendly city.5 Children are the most vulnerable group in society and are more susceptible to environmental and social harm than other age groups.3

As stated by the WHO, a healthy city for children is a healthy city for all residents.2 The Urban95 initiative is an example that makes developing cities considering people 95 cm necessary (average height of 3 year-olds).6 Neighbourhoods can play a protective or threatening role for young children. Hence, cities, especially neighbourhoods, are of the utmost importance to the health and development of children.5 Creating protective and healthy environments requires a greater focus on the health aspect of one’s neighbourhood as child-friendly.

In recent years, various studies have been conducted across the world to provide appropriate tools for assessing cities and neighbourhoods, many of which have been designed using UNICEF’s Child Friendly City framework to measure strengths and weaknesses of environments.7–9 There is no universal standard tool for measuring the characteristics of child-friendly cities.8 Obviously, a suitable tool for measuring a child-friendly city should reflect various local and contextual factors such as the socioeconomic, political, environmental and organisational conditions of each country to ensure its suitability and feasibility to be implemented in the intended environment.9

Previous studies in this area showed that developing a health-friendly neighbourhood requires a thorough awareness of the neighbourhood’s circumstances and a comprehensive assessment of its current conditions.9–11 On the other hand, a majority of the existing evidence has examined this subject from the perspective of urbanisation, thus few studies are available from the health perspective in different populations.12–14 Similarly, studies conducted in Iran have examined cities from the perspective of urbanisation and architecture, child living context and indicators of child-friendly cities.15–18 This limited evidence implied the necessity of designing a comprehensive tool that includes different aspects of the child health-friendly neighbourhood. In addition, there has been less attention on already designed instruments for children younger than 6 years of age, while there are a variety of studies focused on adolescents.9 Accordingly, in the present study, we aimed to design and validate a checklist to assess the multidimensional components of a child health-friendly city to understand and quantify the principal needs of children based on the UNICEF’s Child Friendly City framework.

Methods

Results

Developing the conceptual framework of ICHFN

Integrating the results from the two studies in the qualitative phase showed more comprehensive categories and codes including the main category (dimensions), subcategory 1 (domains), subcategory 2 (indicators), subcategory 3 (subindicators) and codes (items). In addition, developing the conceptual framework for the ICHFN consisted of six dimensions, that is, neighbourhoods’ green spaces and parks, recreational centres, cultural centres, pedestrian passages and streets, healthcare centres and kindergartens. Each dimension included five domains, namely facilities and services, accessibility, security, safety as well as aesthetics and view. Figure 1 displays the conceptual framework for the ICHFN checklist.

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Figure 1

Iranian Child Health-Friendly Neighbourhood (ICHFN) conceptual framework. The framework conceptualised six dimensions, namely green space and park, recreational centre, passage and street, healthcare centre, cultural centre and kindergarten. Each dimension encompassed five domains of facilities and services, accessibility, security, safety and aesthetics and view.

Discussion

This study contributed to designing and validation of the child health-friendly neighbourhood checklist for children under 6 years old in Tehran. The final version of the checklist included 6 main dimensions, 5 domains, 42 indicators, 77 subindicators and 273 items that found to be feasible to assess a child health-friendly neighbourhood in the Iranian context following three phases of designing and validation. To the best of authors’ knowledge, this is the first checklist designed to assess child health-friendly neighbourhoods considering children of preschool ages applying a mixed-methods approach at a neighbourhood scale. Although there are conceptually similar characteristics between the ICHFN and UNICEF checklists, the ICHFN could be more feasible and applicable to the local and contextual characteristics of Iran. The examples of these contextually specific characteristics are services and facilities, accessibility, security, safety and aesthetics and view.

Promoting children’s health goes beyond accessibility to the paediatric healthcare service and includes attention to environmental factors, for example, living environment, peer interactions and play, that substantially affect children’s health.27 Therefore, a reliable and validated assessment tool with the purpose of identifying potential environmental factors that impact children’s health could be of significant benefit to assess the weaknesses and strengths when designing the health-promoting interventions at the neighbourhood level.8 The ICHFN checklist could be considered a promoted and calibrated version of UNICEF’s Child Friendly City framework, designed for the age group of children under 6 years old. While conceptually similar to the UNICEF tool,19 this tool has been designed to be more comprehensive based on local conditions and the age group of children. More specifically, domains of services and facilities, accessibility, security, safety and aesthetics and view have been incorporated into each domain of this instrument.

The comprehensiveness of the designed assessment tool is perspectives of both relevant stakeholders and mothers in the design process. In many previous studies, the proposed tools have been designed in the form of questionnaires,8 28–30 while our designed instrument was developed as a checklist. This enables the experts of diverse specialties, including urban planning specialists, public health experts, architects, urban designers or anyone familiar with the concept of a healthy city and child, to assess the neighbourhood environment based on detailed and specialised questions.

The neighbourhood environment affects various aspects of children’s health, for example, obesity, mental health and social interactions,31 emphasising how essential the factors at neighbourhood level are for the health of children.28 31 Previous studies demonstrated that the presence and activity of children in parks and green spaces reduced the child’s obesity, relieved their stress and increased their interaction with their peers.28 Moreover, it was shown that due to cars and other vehicles passing, young children might face challenges and feel unsafe playing in the neighbourhood.32 Studies on designing a child health-friendly neighbourhood assessment tool for children younger than 6 are limited, and a majority of studies mainly focused on adolescents.8 15 28 We included preschool-aged children’s mothers in addition to the specialists to explore their viewpoints. The parents’ perspectives are of pivotal importance as their opinions pertaining to the neighbourhoods’ safety, and available services may encourage or discourage the presence of the child in the neighbourhood.32 33

Study to design and validation of child-friendly city indicators in South Korea evaluated the indicators of a child-friendly city in six areas, that is, urban organisation, health and social services, play and leisure environment, educational environment, social participation and safety and protection environment.34 Saridar Masri designed a tool with youth participation to develop a child-friendly city planning strategy and emerged dimensions were ‘parks and green spaces, recreational centres, shopping centres, health services, access’.35 There are similar dimensions explored by the mentioned two studies that were consistent with the dimensions of the ICHFN checklist in the current study. Study by Rakhimova et al8 designed an instrument according to the UNICEF checklist considering children aged 6–14. The instrument consisted of six domains to assess neighbourhoods, including ‘home environment’, ‘health and social services’, ‘educational resources’, ‘safety, protection, and mobility’, ‘play and recreation’ as well as ‘community life’. Compared with the findings of the current study, there are similar domains; however, the discrepancy of some domains may be related to the contextual characteristics. Furthermore, the ICHFN checklist in the current study took a health-related approach, while the study by Rakhimova et al8 focused on the urban planning approach.

This research has some strengths and limitations. The first strength is that we explored diverse stakeholders’ perspectives including mothers and experts and subsequently designed a checklist to assess the neighbourhoods considering children under 6 years of age. In addition, this study took a multi-methods approach including qualitative, scoping review and quantitative analysis to design and validate the ICHFN checklist to capture more in-depth insights. The ICHFN checklist was prepared in the form of a checklist through which researchers, experts and decision-makers within the relevant fields could easily apply to assess the neighbourhood’s conditions regarding children’s health from the health promotion standpoint. The main limitation of this study is that we did not explore the perspectives of children nor the perspectives of fathers given that this could have required much time. Another limitation can be related to scoping review procedures that were completed without critical appraisal of the reviewed studies. The main purpose of the scoping review part was exploring the domains in scientific documents in addition to our participants’ viewpoints, and conducting a critical appraisal of the studies was not the main focus of our review.

This study designed and validated a comprehensive checklist to assess child health-friendly neighbourhoods with broader domains and subdomains which can affect the health of children of younger ages. To develop and implement health promotion interventions that support children’s health in today’s urban space, we need to develop indicators for evaluation based on which we can identify the extent of child health advocacy in local communities and take the necessary interventional measures. The complex nature of the environment and the multiple dimensions of child health confirm the necessity of using tools considering different parts of the neighbourhood that can affect the child’s health.