European Journal of Public Health, Vol. 27, Supplement 2, 2017, 19–24
ß The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckv104 Advance Access published on 14 July 2015
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Definitions of urban areas feasible for examining urban
health in the European Union
Jürgen Breckenkamp1, Lesley Patterson2, Martina Scharlach3, Wolfgang Hellmeier4,
Arpana Verma2
1 Department of Epidemiology & International Public Health, Bielefeld School of Public Health (BiSPH), Bielefeld
University, Bielefeld, Germany
2 Manchester Urban Collaboration on Health, Centre for Epidemiology, Institute for Population Health, Manchester
Academic Health Science Centre, The University of Manchester, Manchester, UK
3 Niedersächsisches Landesgesundheitsamt, Hanover, Germany
4 NRW Institute for Health and Work (LIGA.NRW), Düsseldorf, Germany
Correspondence: Arpana Verma, Manchester Urban Collaboration on Health, Centre for Epidemiology, Institute for
Population Health, Manchester Academic Health Science Centre, The University of Manchester, Manchester M13 9PT, UK,
Tel: +44 (0)161 275 5206, e-mail: [email protected]
Introduction: As part of the EU-funded project, European Urban Health Indicator System (EURO-URHIS), a
definition of urban areas (UAs) and of urban populations was needed to be able to identify comparable UAs in
all member states. Methods: A literature review on existing definitions, as well as those used by other relevant
projects, was performed. A survey of national experts in public health or land planning was also conducted. An
algorithm was proposed to find UAs, which were feasible for the focus of EURO-URHIS. Results: No unique general
definition of UAs was found. Different fields of research define UAs differently. None of the definitions found
were feasible for EURO-URHIS. All of them were found to have critical disadvantages when applied to an urban
health project. An ideal definition for this type of project needs to provide a description of the situation without
recourse to administrative boundaries yet inform the collection of routine data for urban health monitoring.
These requirements were found to contradict each other and were not met in any existing definition. An
algorithm was developed for the definition of UAs for the purpose of this study whereby national experts
would select regions which are urban as an agglomeration or as a metropolitan area and which are potentially
interesting in terms of public health; identify the natural boundaries, where countryside ends and residential or
commercial areas of the region begin (e.g. by aerial photos); identify local government boundaries or other official
boundaries used for routine data collection purposes which approximate the natural UA as closely as possible and
list all administrative areas which are contained in the larger UA. Conclusion: The aggregation of all administrative
areas within the original region formed the UA which was used in the project.
.........................................................................................................
Iand the proportion is predicted to rise to 77% by 2025.
Improve the presentation of urban health data to policy makers,
to enable and facilitate policy-making and to increase their
impact on public health policy.
Disseminate the project results.
Review and appraise the published literature on the health of
urban populations and the related urban health indicators.
Identify relevant data sources and summarize individual member
states’ current use of measures of urban health, to compile a
cross-EU inventory, which will allow transnational comparisons
and benchmarking.
Although there is a widely accepted, intuitive concept of UAs and
their populations, a definition of ‘urban’ and ‘urban population’
which is consistent and relevant for public health policy making
had yet to be developed. Different definitions for UAs exist in
other fields of research which are dealing with urban regions and
their respective populations. These rely strongly on the general
concepts in their field of research and reflect the goals and
questions of their projects. It is not known if they are relevant to
for public health.
The following examples illustrate this:
In Belgium, 97.2% of the total population is defined as urban.5
This definition is helpful in identifying areas which are really rural,
but it does not identify the regions that are likely to experience
urban health problems.
In Germany, according to the definition used by the United
Nations (UN), all communes (Kreise and kreisfreie Städte) with a
population density 150 inhabitants per square kilometre are
defined as urban.5 Of all the 54 communes of North RhineWestphalia (NRW), only two had a population density below this
threshold (Kreis Höxter: 128.0 inhabitants per square kilometre,
Hochsauerlandkreis: 141.5) in 2005. These communes represent
2.4% of the NRW population (N = 420 749).6 Again, this
definition of UAs does not identify those regions where special
urban health problems are likely to occur. However, in NRW,
Background
n Europe, about 72% of the population lives in urban areas (UAs),
1
The
United Nations Population Fund alluded to the beginning of ‘an
urban millennium’ with over 50% of the world’s population living
in UAs by 2008.2 Conditions of life and the health of the population
differ between urban and rural regions within a country. It is known,
e.g. that the prevalence of obesity is increasing worldwide and the
dietary changes that are associated with urbanization are highly significantly implicated in this.3 Despite this, a monitoring of urban
health is still lacking and not much is known about the particular
aspects of health in UAs of Europe.
There is a need for tools which enable health politicians to
understand the determinants of health and to assess and influence
health service provision in cities. Because this situation is
shared across the European Union, the EU Public Health Programme
Workplan of 2005 identified the development of an urban health
indicators system as an essential part of a comprehensive and
integrated EU health information and knowledge-based system.4
The aims of this part of the project European Urban Health
Indicator System (EURO-URHIS) were to:
20
European Journal of Public Health
there are areas with special health problems which can be recognized
if an alternative definition of urban is used. NRW health reports give
statistics for a region called ‘Ruhr-City’ and compare these to the
rest of the state. ‘Ruhr-City’ is defined as a region between the rivers
Ruhr and Rhine consisting of several big cities. The agglomeration
proper (or conurbation) is characterized by population density of
more than 2000 inhabitants per square kilometre and a total
population of 5.3 million.
To be usable in EURO-URHIS, a definition of UAs and populations had to be applicable across all member states to identify areas
where urban health problems are more likely to occur in each
country. Existing definitions and accepted classifications, e.g.
EUROSTAT NUTS (nomenclature des unités territoriales pour les
statistiques) had to be considered and the need to identify the most
appropriate administrative level for the purpose of providing health
information in accordance with contemporary urban health
problems.7
Against this background, this article provides an overview of definitions of UAs and populations used both at the national and
European levels, and of their advantages and disadvantages.
Results of the research were used to define a procedure of
selecting UAs for the EURO-URHIS project.
Methods
Three different approaches were taken to identify existing definitions
of UAs and to verify which of these are prevalent in the existing
projects’ descriptions.
First, a literature search was performed from different points of
view, such as geography, statistics, administration and spatial
structure. Furthermore, studies looking at ‘what is urban’ were
compiled. Search terms were used in varying combinations, e.g.
‘urban’, ‘area’, ‘definition’, ‘health’ and ‘audit’. The search term
‘Europe’ was included to identify specifically European projects
that were of relevance. The search was performed using PubMed
and included articles from 1998 to the then current date, 2006.
Direct searches on the Internet were also performed using the
same search criteria.
Second, as a further way of gathering information, experts in
regional planning within European states were informed about the
objectives of EURO-URHIS and were asked to identify some UAs in
their countries. With a short questionnaire, they were asked to name
one or more cities or ‘agglomerations’, which they would consider
important from the public health point of view. The experts were
also asked to provide a rationale for their decision.
Third, we searched for projects where cities have formed a
network to work on common problems to identify their
underlying definition of participants of the network.
Based on these findings, a list of definitions of UAs was produced
giving their advantages and disadvantaged with respect for their use
in EURO-URHIS. An algorithm to identify UAs was developed.
Results
The definitions found were categorized into those which are
generally defined and used internationally, those based on
objective criteria which are valid only in a national context and
the subjective selections which lack a formal definition.
General definitions are used by the UN to categorize cities by their
number of inhabitants (table 1). Geographers describe UAs using
indicators for population numbers and density. They also take into
account the centrality of a city for the surrounding areas with respect
to, e.g. public transport and/or industrial importance. The identification can also be based on the distance between the houses.
Definitions based on administrative boundaries are available for
Europe from the European Statistical Office.
National definitions rely mainly on the number of inhabitants,
but the minimum number of people that defines a city differs
between countries. Those definitions are also used by UN and the
World Health Organization (WHO).
Subjective definitions were obtained from the expert interviews
where people named the UAs in their country that they felt to be
suitable for an analysis of urban health. This process also identified
the expert’s opinion on health problems in these areas.
Definitions found in the literature
Geographers identified UAs by the number of inhabitants, most
commonly expressed in absolute numbers and per square
kilometre. Other factors mentioned were the urban way of life; the
importance of public transport; the nature of the population
structure and social conditions as well as the economic
importance of an area (see ESPON project: table 3).8–10
Linked with the geographer’s definition is the aspect of density of
buildings. A common definition of urban, used officially in nearly 50
countries worldwide, is a maximum spread of 200 m between buildings.11 Sweden, e.g. provides this as its definition (table 2).
Areas with high population or building density can be identified
by aerial photographs which give a very good impression of the
region and the parting line between urban and rural areas. These
are often referred to as agglomerations or conurbations, but the
boundaries seen do not necessarily correspond to the administrative
jurisdiction of any given area. This means that a visually perceived
urban conurbation may not relate to the specific mass of the statistical units routinely collected either within or partly around the area.
Besides, this definition characterizes too many regions as being
urban to be useful to identify health problems related to
population density.
From the administrative perspective, there is no common
definition of UAs or cities all over Europe. Administrative
organizations vary from country to country because spatial
structure and planning are organized in different ways and the
importance of a town or city is often very much related to the surrounding areas. Against the background of the worldwide view, even
the UN suggests the use of national definitions rather than
standardized ones. The categorization of a city as small or large or
‘important’, e.g. from the economical view, depends on the country
considered and the importance of the agglomeration or conurbation
for the respective country.
An important approach to a common definition of area units in
the European Union has been made by EUROSTAT using the ‘nomenclature des unités territoriales pour les statistiques’ (NUTS).7
NUTS forms a hierarchical classification based on normative
criteria (administrative structure) and subdivides a state into a
whole number of NUTS 1 regions, each of which is in turn
subdivided into a whole number of NUTS 2 regions which in turn
are subdivided into NUTS 3 regions.11 Below NUTS 3, there are
Local Administrative Units (LAU). The following minimum and
maximum thresholds are given by the NUTS regulation: NUTS 1:
3 million–7 million, NUTS 2: 800 000–3 million and NUTS 3:
150 000–800 000 inhabitants. Exceptions are possible, e.g. in
Germany, the states (Länder) represent the NUTS 1 level, which
contains NRW with 18 million inhabitants.
The NUTS boundaries correspond to administrative units. But
members of the same NUTS or LAU level may differ substantially
in their importance for the surrounding areas and may belong to an
agglomeration (conurbation) or may form an UA by themselves.
Furthermore, the population in regions at the same NUTS/LAU
level vary substantially between different member states and even
within countries.
The URBAN AUDIT project uses the EUROSTAT definitions,
which aims to present statistical data for cities and their
surroundings throughout the EU.12 The area units refer to the
NUTS 5/LAU 2 level (see below) and extend to the 27 European
Definitions of UAs
21
Table 1 Definitions of UAs and cities used by UN
Name of area
definition
Urban agglomeration
‘The built-up or densely populated area containing the city proper, suburbs and the continuously settled commuter areas.
It may be smaller or larger than a metropolitan area; it may also comprise the city proper and its suburban fringe or
thickly settled adjoining territory’.
‘The set of formal local government areas that normally comprise the UA as a whole and its primary commuter areas’.
‘The single political jurisdiction that contains the historical city centre’.
Metropolitan area
City proper
Cities
Metacities
Megacities
Intermediate cities
Small cities
More than 20 million inhabitants
10 million and more inhabitants
1–5 million inhabitants
Less than 500 000 inhabitants
Source: United Nations—habitat.1
Table 2 Definitions of urban populations in selected countries
country
definition
Albania
Germany
Netherlands
Sweden
Towns and other industrial centres with more than 400 inhabitants
Communes (Kreise and kreisfreie Städte) with a population density equal or greater than 150 inhabitants per square kilometre
Municipalities with 20 000 inhabitants or more
Build-up areas with at least 200 inhabitants and where houses are at most 200 m separated from each other
Source: United Nations World Urbanization Prospects.5
member states. Urban Audit cities are selected simply on the basis
that, for each member state, cities should present 20% of the
country’s population and be spread across the country concerned.
Three spatial levels have been defined in the Urban Audit project:
(i) the administrative town/city, (ii) the kernel and (iii) the larger
urban zones. The town/city has been defined as ‘administrative
town/city’. Typically, these administrative units are responsible for
the local government. In most countries, the administrative town/
city concept corresponds to the LAU level 2. The exceptions to this
across the EU member state countries are the towns/cities in
Belgium, France, Portugal, the United Kingdom, Ireland, Cyprus
and Malta (6/27).
The concept of ‘functional urban zones’ (see ESPON: table 3) has
been used as a proxy for ‘larger urban zones’. The underlying idea
was to group areas at NUTS level 3 or LAU level 1, which are
adjacent and which are linked by some common economical and
social functions. It was stressed as an advantage that the data availability (regional statistics) is relatively high. The disadvantage of this
concept is the consideration of administrative (functional) zones
instead of UAs.12
There are some projects that work on the analysis of the European
spatial structure. Among these projects, there are NUREC,13,14 ESPON,8
15
GEOPOLIS
and the research project Les Villes Européennes – Die
Städte Europas (available in French or German only).16 Some of
the goals and definitions of these projects are given in table 3.
Network projects
Some projects were found which were based on networks of cities.
These included METREX (Network of European Metropolitan Regions
and Areas), 17 EUROCITIES (Network of 130 major European cities,
founded in 1986)18 and URBACT (integrated Urban Development
Transnational Exchange) with sub-projects, e.g. urban health.19
There were also health-related networks like ‘Closing the Gap’ on
health inequalities (2004–2007),20 MÉGAPOLES, a network of EU
capital cities founded in 1997,21 or the WHO’s ‘healthy cities and
urban governance’ programme with 1200 cities and towns from
more than 30 countries in the WHO European Region.22 None of
the identified networks had produced or used a clear definition of
urban (areas) to decide on the acceptance of a city to the networks.
The networks describe their goals and invite cities to become
members of these networks if they are interested in those goals.
According to these mechanisms, cities or agglomerations in the
networks vary in size and are irregularly dispersed across Europe.
Result of the expert interviews
The expert interviews resulted in responses from 10 countries,
received from 7 experts from ESPON and 4 members of EUROURHIS. Eighteen UAs were identified as 7 cities and 11 agglomerations. The recommendations offered different selection criteria
taking into account the respective national situation. These were
densely populated areas (the United Kingdom, Germany and
Greece); cities from all parts of the country (Czech Republic); the
biggest cities (Netherlands, Slovenia, Lithuania, Norway); the capital
city only (Malta) and two cities in Luxembourg. None of the theoretical definitions found in the literature were capable of inclusively
covering all the expert proposals.
UAs for use in EURO-URHIS
Information from all the sources described above have been
systemized and checked for their feasibility to define UAs. No
definition was found which could be used without modification.
All of them had some disadvantages which excluded them from
application to EURO-URHIS (table 4).
Based on the findings and on the decision of UN and WHO to use
different national definitions for their comparisons and due to the
fact that EURO-URHIS aims to identify UAs relatively evenly
distributed in the European Union, it seemed reasonable and
necessary that EURO-URHIS also used national definitions. It was
found that general definitions based on identical numbers or density
of house or population in each member state would mainly identify
UAs in the western part of EU.
Based on the findings, the following algorithm for identification
of UAs for EURO-URHIS was defined:
The selection of UAs in a country should be made by the national
person who is member of the EURO-URHIS project and each
should perform the following steps:
(1) Select regions which are urban as an agglomeration or as a
metropolitan area and which are potentially interesting in
terms of public health.
22
European Journal of Public Health
Table 3 European urban research projects
Project
Goals, definitions and results
ESPON, European Spatial Planning
Observation Network
To analyze the potential for polycentric development in Europe (27+2 countries), 1595 so called Functional
Urban Areas (FUAs) with a minimum of 20 000 inhabitants were identified consisting of a core area and
surrounding areas that are economically integrated with the centre. Using indicators on population,
transport, tourism, manufacturing, knowledge and decision making in the private and public sector, 76 FUAs
were categorized as Metropolitan European Growth Areas (MEGAs).9
330 agglomerations with at least 100 000 inhabitants were defined by the built-up areas and comprise 8300
administrative units.11,12 The Network was founded in 1989. Thus, the project is limited to the former 15
countries of the EU.13
178 agglomerations (conurbations) were identified according to their built-up areas and described based on 15
indicators including population and its development, number of passengers at the airport, international
trade, financial importance, etc. (Europe = 15 countries + Switzerland and Norway).16
UAs are defined as urbanized districts, in which no houses are separated more than 200 m from the closest
neighbourhood building. In 2000, the database comprised 42 000 UAs with about 100 000 local units
worldwide.15
NUREC, Network of Urban Research
in the European Union
(Community)
Les Villes Europennes—Die Städte
Europas
GEOPOLIS
Table 4 Possible ways for the selection of UAs in EURO-URHIS and their advantages and disadvantages for the analysis of urban health
Selection criteria
Advantages
Disadvantages
Capital cities
Clearly defined; in most countries the
biggest city
Biggest cities (two or three) per country by
number of inhabitants
In most countries clearly defined
Areas with a maximum spread between
buildings of 200 m
Correct from the geographical and spatial
point of view; used in a lot of other
projects
Agglomerations (conurbations) named by
URBAN AUDIT
Almost clearly defined, with data available
Common national agglomerations or conurbations (eg Rhine-Ruhr-Area, Randstad)
Prominent areas with historical, economical
backgroundInteresting in terms of health
needs
Clearly defined
Special structure because of high administrative
functions,Does not necessarily identify the area with
the most urban health problems
Big differences, e.g. Riga and Daugavpils in Latvia
(731 762 and 110 379) in comparison with Rome and
Milan in Italy (2 546 804 and 1 256 211)
Usually not comparable with administrative borders/
health authoritiesNot necessarily identical with the
regions, which are linked to the core city
economically
Based on the cities which are part of URBAN AUDIT.
Cities are not necessarily the biggest ones of the
countryNo link to public health aspects
Do not always have a central administration/health
authorities
NUTS/LAU
UAs named by analytical projects
Have been used before; identical with administrative borders
(2) Identify the natural boundaries, where countryside ends and
residential or commercial areas of the region begin (e.g. by
aerial photos).
(3) Identify local government boundaries or other official
boundaries used for routine data collection purposes which approximate the natural UA as closely as possible.
(4) List all administrative areas which are contained in the
larger UA.
This algorithm identified areas in many European countries as
urban and belonging to the target group of EURO-URHIS because
urban health problems are likely to be present.
The number of UAs per country chosen for study was dependent
on the population size of the respective country, as identified
according to the algorithm defined above, within each country
according to the following criteria:
Table 5 Number of UAs per country
Population of country
Number of UAs
Less than 5 million
Between 5 and 20 million
Between 20 and 60 million
60 million or more
1
2
3
4
Big differences in number of inhabitants and areas; not
always politically relevant
Agglomerations and cities are mixed up
Discussion
Our literature search came up with the result that no general
definition of an UA exists but that every field of research has its
own definition according to the interests and the study
questions. Furthermore, none of the definitions found were
applicable to the aims of EURO-URHIS. Geographical approaches
lack a link to administrative boundaries and therefore would make
it very difficult to collect health data. Statistical approaches only
concentrate on cities and may miss agglomerations which form
an UA.
An ideal definition on areas for urban health would have to
include some properties which are contradictory. As we were
looking for health aspects of an urban population, we would have
liked to include population density as well as social criteria like
higher percentages of elderly people and people living alone as
well as structural indicators like public transport, density of
physicians and hospitals. These requirements would best be
fulfilled by a definition used by geographers. Properties like those
listed above might well be found outside of the administrative
boundaries of a city. To be able to describe the health status of
the population, we need statistical data, which should ideally be
collected routinely without the need for special data collection
projects. Therefore, we need a definition based on administrative
Definitions of UAs
or governmental boundaries. Areas usually do not fulfil both
requirements.
The European nature of EURO-URHIS gives further restraints. A
definition based on a fixed number of inhabitants would find UAs
mainly in the western part of Europe, whereas in the smaller
countries of Eastern Europe, the cities are also smaller. Problems
of UAs concerning health may also arise in cities of East Europe
despite lower population numbers within them. It seems reasonable
therefore to conclude that the relative size of a city compared with
the surrounding regions and to the country as a whole is more
important for the classification as an UA than a defined absolute
number of inhabitants. The same consideration holds for indicators
like centrality and economical importance of a city for the surrounding areas. Again they cannot solely be described with reference to
absolute population numbers but have to take into account the
national situation. In addition, the areas we are dealing with
should constitute some kind of administrative unit because this is
a necessary condition for the application of our results to health
policy decision making.
This link between the cities and their countries is also
acknowledged by other institutions like WHO and UN, in that
they also use country specific definitions to categorize the cities in
Europe and the world. Projects working with networks of cities in
several countries go even further. They do not at all give general
definitions as condition for the participation but offer partnership to
cities which feel that they need to deal with the question which is
treated in the respective project.
On the basis of these results, it was coherent to take a similar
view for EURO-URHIS. By involving national experts to define the
UAs in their country, we make sure that we get cities connected
to some of their surrounding areas not only geographically but
also by their various aspects of urban life. Even if all the UAs in
the project will not be comparable in absolute numbers, they are
similar in their role within their respective country and therefore
comparable according to the differences to the more rural areas
around them.
This pragmatic approach was seen by EURO-URHIS to be
optimal. By formulating standardized appropriate criteria and
leaving the decision to local experts, certain necessary standards
are upheld while maintaining the unique characteristics of the
countries and their regions. Although this pragmatic approach
was relevant to the purposes of the work in EURO-URHIS, and a
similar approach might be taken in other contexts, the definition
used is not generalizable and is likely to be subject to observer
variation.
Acknowledgements
We are grateful for the help provided by the EURO-URHIS project
teams in each of the beneficiaries’ institutions. (Full details of all
project partners can be found on http://urhis.eu/euro-urhis1/.)
Funding
This research project was co-funded by EU Commission, under the
Community Action in the Field of Public Health (HD2005/3.3.1/
2003-2008) as part of the EURO-URHIS project (grant agreement
no. 205119) and the project beneficiaries.
Conflicts of interest: None declared.
Key points
The term ‘urban area’ is often used but not clearly defined.
There are some general definitions of urban areas
(UAs) which are based mainly on indicators about
23
population, housing density and economic aspects of a
region.
Some definitions define UAs in relation to the country
where the region belongs to. The categorization is mainly
based on population numbers within administrative
borders.
Many research networks of cities are built on voluntary
partners without a formal definition of criteria.
For the EURO-URHIS study, UAs were defined according to
an algorithm by national experts starting with an identification of metropolitan areas and restricting these to governmental administrative boundaries.
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