Creating Healthy Living Environments and Actual Evidence of Community Health Promotion and Prevention
The content of WP 6 focuses on the influence of the living environment on health and health behaviour and related possible measures to reduce health inequalities at the local level. The PFA highlights the importance of the municipal setting and the HiAP approach to reduce health inequalities. A decrease in health inequalities can only succeed if all the macro, meso and micro levels are addressed. The macro level is concerned with issues affecting society as a whole (at the political level); at the meso level, the focus is on institutions and social networks, and at the micro level, the focus is on the individual. However, a systematic and planned approach should always be adopted [15
]. One approach, suitable for measures of varying scope and useful on projects at the micro, meso and macro levels, is the Public Health Action Cycle (PHAC). The PHAC represents an ideal process flow, which is therefore not always transferable in all points of a concrete measure or intervention [16
]. Nevertheless, the value of this model lies in the necessity and significance of its individual process steps and its use in comparing different health promotion measures. The PHAC can be used to identify and analyse different patterns of dealing with health problems and then evaluate their effectiveness and impact on the health equity dimension [17
]. The process consisting of the four steps of analysing, planning, implementing, and evaluating can be reasonably supported by the use of quality criteria. The literature review related to the quality criteria yielded 16 criteria. They apply to the four phases and, to a lesser extent, to the overall process of the PHAC. Figure 2
shows the PHAC related to identified quality criteria applied to the individual phases of the cycle resp. spanning all phases.
The PHAC originated in political science and was adapted and further developed for health policy actions and processes [16
]. The action cycle differentiates a health-related intervention into four individual process categories: (1) identification of the fundamental problem to be addressed by the intervention, (2) strategy development in which an intervention suitable for treatment is developed, (3) implementation of the intervention and (4) evaluation of the activities carried out. The 16 central quality criteria for good practice are divided into three categories: fundamental quality criteria for the creation of healthy living environments, process criteria applying to individual PHAC phases and general criteria covering the PHAC.
The influencing factors at the macro and meso levels play a key role as downstream action to tackle risk factors. Accordingly, health inequalities should be seen as a cross-cutting dimension to be taken into account in the development, implementation and evaluation of any activity. This also applies to the social determinants of health (see, e.g., the model of Whitehead and Dahlgren 1991 [18
]). Benach et al. (2013) [19
] described four scenarios that can contribute to reducing health inequalities:
The healthy living environment approach avoids the individualisation of social problems resulting from social inequality. The creation of healthy living environments is supposed to strengthen individual health in two ways: on the one hand, health-promoting behaviours are improved irrespective of income, origin and educational background [20
], and on the other hand, health is promoted by strengthening resilience factors and reducing environmental risk factors. As a result, through the participatory orientation of such measures, people are empowered to influence their living conditions and living environments by themselves. It is of utmost importance to involve particularly vulnerable groups and to apply appropriate methods, as this is not yet well established.
The measures within WP 6 pursue a setting-based approach that is steered from the municipal level. The setting-based approach is one of the core strategies in health promotion and is a central strategy in tackling health inequalities [21
]. The municipality represents an umbrella setting, which includes other settings, such as neighborhoods, schools or associations, and provides different access points for interventions. “Municipality” as a term thus describes not only a geographical or political space, but also a social space. This provides resources for health promotion through the possibility of merging and coordinating social networks and through the development of a health-promoting overall policy that allows organizational development in municipal administrations and institutions. The Ottawa Charta (1986) [22
] already describes the support of communities and local authorities as a central node for health promotion (in strengthening citizen autonomy and control over the determinants of their own health). Particular attention must be paid to explicitly take into account the individual needs of each municipality
However, the creation of healthy living environments can only succeed if other areas besides the health sector are involved in the process. This approach, with the main goal of reducing health inequalities, is called Health in All Policies (HiAP) and was coined by the WHO. Since health inequalities are strongly determined by social inequalities, all policies related to social cohesion and the reduction of social disparities, such as labour, social or educational policies, are relevant. An area of relevance at the federal rather than the EU level is spatial planning, with healthy urban development having the potential to reduce health inequalities [23
To reduce the impact of different policy fields on health inequalities, population vulnerability has to be studied rigorously. In various policy areas, such as the environment or urban planning, this is not common or an explicit objective, as all people are considered to be equal. Neither environmental standards nor noise or air action plans consider population vulnerability. The implementation of a population vulnerability principle as an additional guiding principle for (environmental) politics could support the aim of reducing health inequalities through a HiAP approach [26
]. The community offers the chance for more health equity, especially if the approach of proportionate universalism is taken into account.
In the following, the central findings with regard to existing evidence of municipal health promotion are summarized in order to substantiate the significance of the municipality for health promotion and to make possible starting points transparent. Although the creation of healthy living environments is generally considered beneficial, it is difficult to provide sufficient empirical evidence of their effectiveness [27
]. This is mainly due to the complexity of the approach and the various influencing factors, especially given that interventions often aim for long-term change. In addition, there are challenges in evaluation designs and methods. Measuring the success of interventions becomes more difficult as the complexity of the intervention increases, since the impact often only becomes visible in the long term and project durations frequently end after one or two years. In the meantime, those affected are exposed to many other social and other environmental factors that can mitigate or change the health-promoting effects. A direct causal link between the health-promoting interventions and the effects on individual health is therefore often not possible.
Evidence of the effects of risk and protection factors offers important starting points for context-oriented and setting-based interventions at the local level. Compared to the epidemiological evidence, there is little but growing evidence of the effects of environmental interventions. For example, the promotion of equal environments can “disrupt the usual transformation of socioeconomic inequalities into inequalities in mental well-being” [28
] (p. 80).
Some intervention studies show that the following strategies are of great importance in this context. Potentially effective strategies for designing healthy living environments include capacity building [15
], transport and walkability [29
], green spaces [31
], healthy schools and kindergartens [32
], municipal planning and control [24
] and urban planning measures [33
]. Especially capacity building within intersectoral cooperation seems to play a major role in creating healthy living environments. Quilling and Kruse (2018) [15
] showed in a rapid review that capacity building in particular is of central importance. Fifteen publications (including [34
]) on the topic of municipal health promotion were included in the content analysis [15
]. The programme “Communities That Care” (CTC), for instance, shows evidence on the relevance of capacity building, where capacity building is both one of the main goals and one of the main effects of the interventions. An integral part of the CTC programme is an individual tailoring of measures based on municipal data on specific health problems and risk factors for citizens. In addition, the training of actors and the provision of supporting materials play a central role for capacity-building effects [41
Transport accounts for 29% of CO2
emissions. Promoting public transport, road safety and active mobility infrastructures (cycling, walking) can reduce accidents, improve air quality, increase physical activity and facilitate access to community facilities. One central approach to active mobility is the walkability concept. Walkability is understood to mean the ‘movement-friendly’ design of a residential quarter [29
]. This includes the existence of good walking, cycling and hiking paths, traffic safety, playgrounds and residential areas, good accessibility to sports facilities, usable green spaces and a stimulating aesthetics of the surroundings [30
Green environments create the health benefits of staying in nature or in parks and in the countryside [31
]. Proven benefits include improved human health, physical activity, self-esteem and reduced short-term sleep duration (associated with obesity) [42
]. Green school grounds with open playgrounds, trees and shrubs also improve the quality and quantity of the children’s physical activity [43
]. Green space interventions were most effective in a dual approach combining physical improvement with social engagement and participation to reach new target groups [45
Urban planning measures and control— this strategy addresses health inequalities through city administration and planning, including investment in active mobility, environmental and regulatory controls (e.g., alcohol outlet density in deprived communities) [24
]. In the field of environmental planning, there are a number of environmental standards developed to protect human health. Examples of urban development projects that promote the health of their residents include the redesign of infrastructure to meet the needs of the elderly (Age-Friendly City, City of Unley, Australia) [46
], of children (Bendigo in Victoria, Australia, UNICEF City, St. Lukes Anglicare) [47
] and women (the Women Work City housing complex in Vienna) [33
There are various evidence-based approaches for implementing health promotion in the community. The expert opinions also show that municipal health promotion is considered to be of central importance for reducing health inequalities.