The Effectiveness of Healthy Community Approaches on Positive Health Outcomes in Canada and the United States

Healthy community approaches encompass a diverse group of population based strategies and interventions that create supportive environments, foster community behavior change and improve health. This systematic review examined the effectiveness of ten most common healthy community approaches (Healthy Cities/Communities, Smart Growth, Child Friendly Cities, Safe Routes to Schools, Safe Communities, Active Living Communities, Livable Communities, Social Cities, Age-Friendly Cities, and Dementia Friendly Cities) on positive health outcomes. Empirical studies were identified through a search of the academic and grey literature for the period 2000–2014. Of the 231 articles retrieved, 26 met the inclusion criteria with four receiving moderate quality ratings and 22 poor ratings using the Effective Public Health Practice Project Quality Assessment Tool. The majority of studies evaluated Safe Routes to School Programs and reported positive associations with students’ active commute patterns. Fewer studies assessed benefits of Smart Growth, Safe Communities, Active Living Communities and Age-Friendly Cities. The remaining approaches were relatively unexplored in terms of their health benefits however focused on conceptual frameworks and collaborative processes. More robust studies with longer follow-up duration are needed. Priority should be given to evaluation of healthy community projects to show their effectiveness within the population health context.


Introduction
Health is shaped by the daily conditions in which we are born, live, work, play and age [1].These social determinants of health engender differential exposures and vulnerability to health damaging conditions and influence an individual's opportunities to live a healthy life.This is the fundamental basis for socioecological models that frame health as the confluence of multiple factors that operate in a nested genetic, biological, behavioral, social and environmental context [2].Consequently, interventions that seek to improve health outcomes must target multiple levels and engage multisectoral partners to create the supportive conditions that foster healthy choices across settings and throughout the lifecycle.Healthy community interventions offer a local societal response to address common threats to population health.The term "healthy communities", originally coined in Canada in the 1980s, refer to communities that employed health promotion and community development strategies to address multiple determinants of health [3].
The built and social environment sometimes limit the resources available to individuals and communities and make it difficult to adopt and maintain healthy behaviors [4].Community efforts to promote health often target one or both of these domains.The general discourse on this subject is broad and without any specific model that cuts across all approaches.A community's vision for health is unique and can be pursued through multiple strategies according to their needs, assets and resources.In this article, the term healthy community approach was operationalized as deliberate efforts to improve health at the local/community level.The scope of the review was focused on health promoting strategies and interventions that target the social and physical environment, reflecting the importance of non-medical determinants in health.
The Healthy Communities Unit of the Public Health Agency of Canada commissioned this review and set out to inform their work priorities by understanding which approaches were effective in promoting the health of communities.As a result of their considerable experience with some approaches such as Age Friendly Cities, there was particular interest in approaches that target the social environment, while all the same recognizing the emerging emphasis in the literature on changing the built environment.Ten most common approaches including Healthy Cities/Healthy Communities, Smart Growth Planning, Child Friendly Cities, Safe Routes to Schools, Safe Communities, Active Living Communities, Livable Communities, Social Cities, Age-Friendly Cities, and Dementia Friendly Cities were selected for further examination.These were selected to be representative of healthy community approaches and reflect a balanced focus on the social and built environment in concert with the current understanding of determinants of health.The majority of these initiatives have global momentum that supports national efforts, are grounded in the mandate of a coordinating entity and employ multiple strategies (e.g., policies, services and structures) in various settings to achieve the objectives.There is considerable overlap in the goals and objectives with some initiatives nested within the priority areas of broader approaches.Table 1 describes the key elements of each approach.In this review each initiative has been presented independently although at the local level, these initiatives may be implemented synergistically, or as part of integrated efforts to improve health and wellbeing of communities.
There has been growing interest in the implementation of healthy community approaches with concomitant investment of public and private resources.One example is provided by the federal funding commitment of $612 million US dollars to support Safe Routes to School (SRTS) Programs in the United States [15,16].The Robert Wood Johnson Foundation has also provided several grants in the sum of US$200,000 to support Active Living by Design (ALbD) projects [17].With limited resources to support project implementation, it is important to determine which approaches have demonstrated benefits for whom and under what circumstances.Despite active research in some areas, evidence of effectiveness is still relatively scarce.Few reviews have explored selected approaches including SRTS and Safe Communities; however, note the absence of evidence of program impact on health outcomes [18,19].The Cochrane systematic review of the effectiveness of WHO Safe Communities model excluded the few identified studies from the US because no injury outcomes were assessed [19].To the best of our knowledge, this group of approaches have not previously been examined collectively nor with a specific geographical focus.
The purpose of this review was to evaluate the evidence for the effectiveness of the ten most common healthy community approaches on positive health outcomes in Canada and the United States.This bridges a gap in the literature about what is effective and informs future priorities for research to strengthen the evidence base.The heterogeneity of interventions, study designs and outcomes as well as the small number of studies identified precluded meta-analysis.A qualitative approach with narrative synthesis of the available evidence is presented.

Safe Communities Whole populations
A global initiative supported by WHO that engages communities to promote safety and injury prevention.Multiple global networks have been established and provide accreditation to committed communities who satisfy the designated criteria [9].The concept was introduced as a policy initiative in Sweden in 1989.

Active Living Communities Whole populations in selected communities
A movement that is dedicated to increasing opportunities for population physical activity.Some projects may include other components such as Safe Routes to School or Smart Growth [10].Active Living by Design (ALbD) was at the forefront of the movement and was launched in 2002.

Livable Communities Whole populations
Livable communities embody multiple factors that contribute to good quality of life such as recreational and educational opportunities, attractive built and natural environment, social stability and economic prosperity [11].Programs have been implemented by various partners for more than 25 years.

Social Cities Whole Populations
A social city fosters social connectedness of its residents and improves the social architecture to strengthen these relationships [12].The concept has been growing in popularity since 2009.

Age-Friendly Cities Elderly population
Global Initiative that promotes active aging of older residents and increases opportunities for their social participation and security.The movement builds on the 2002 Policy Framework for Active Aging and considers key domains of the social and physical environment that need to be optimized to enhance the quality of life of older persons.These include the outdoor spaces and buildings, transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support and health [13].

Persons living with dementia and their care givers
This initiative is supported by the Alzheimer's Society and seeks to improve inclusion and quality of life of people living with dementia [14].It has been gaining momentum especially in the United Kingdom since 2012.

Data Sources and Search Strategy
The studies included in this review were identified through a systematic search of the academic and grey literature.Peer reviewed publications were searched in selected electronic databases including PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus and the Cochrane Library.The reference lists of all included papers were examined for additional articles not discovered through the primary search.
Google Scholar was used to search the web based literature to identify additional articles of relevance such as dissertations, reports, conference presentations and abstracts.A search of the grey literature focused on initiative specific websites (e.g., Child Friendly Cities, Safe Communities Canada, Active and Safe Routes to School) and websites of agencies coordinating the respective approaches (e.g., UNICEF, World Health Organization Three domains of search terms were identified: effectiveness, 'healthy community approaches' and country/geographical region.Specific terms used for the search were derived from the subject headings in MeSH list, free text and review studies related to the selected approaches.Search strategies were tailored for each approach and adapted for different databases.An example of the search strategy used for Safe Routes to School approach is shown in Appendix.Searches were limited to papers published in the English language during the period January 2000 to December 2014.A diverse range of studies with both experimental and observational study designs were included.This allowed for consideration of evidence from interventions that could not be randomized for practical or ethical reasons.Systematic reviews were excluded as empirical research was thought to offer the best available quality of evidence.

Selection and Review Process
Studies were screened initially using titles and abstracts.All articles that were potentially relevant were subjected to a detailed assessment.Studies selected were required to meet the following inclusion criteria: (1) explicitly reference an intervention based on one of the ten healthy community approaches; (2) measure at least one health outcome (morbidity, mortality or intermediary outcomes); and (3) conducted in North America (limited to Canada and United States).The following exclusion criteria were applied to the search results: (1) the article was an opinion, editorial, audit or review; (2) it included only a description of an approach but no assessment of its impact on health outcomes; and (3) employed only qualitative methods.Any disagreements about inclusion of studies were resolved through consensus of the authors.Relevant data was extracted from the articles including descriptive information; indicators of quality and measures of effectiveness.The quality of the evidence was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for quantitative studies.The tool and accompanying dictionary are available at http://www.ephpp.ca[20].The EPHPP examines six methodological dimensions: selection bias, study design, confounders, blinding, data collection methods, withdrawals and dropouts.A rating of strong, moderate or weak was assigned for each of the study components and then a global rating was calculated.

Results and Discussion
The search identified 1415 potential articles among the various sources.From these papers, 231 were assessed for eligibility based on full text review.Twenty six articles were selected and subsequently underwent quality assessment.There were no studies that received a methodologically strong rating, four were of moderate quality and 22 were assessed as weak.The main reasons for weak ratings included selection bias, failure to control for confounding and high attrition.A flow diagram of the search results is illustrated in Figure 1. 5 231 were assessed for eligibility based on full text review.Twenty six articles were selected and subsequently underwent quality assessment.There were no studies that received a methodologically strong rating, four were of moderate quality and 22 were assessed as weak.The main reasons for weak ratings included selection bias, failure to control for confounding and high attrition.A flow diagram of the search results is illustrated in Figure 1.

Safe Routes to School
The majority of studies identified were related to evaluation of Safe Routes to School Programs (SRTS) in the United States (Table 2).In terms of study quality assessed using the EPHPP tool, most studies were assessed as weak based on methodological limitations.Two studies that examined the impact of Walking School Bus (WSB) interventions received moderate ratings.The earlier of the two studies assessed the short and long term effects on student travel in a low income minority population [21].Another pilot study by Mendoza and colleagues employed a cluster randomized controlled trial to investigate the impact of a five week WSB intervention on rates of active commuting and physical activity levels [22].Most studies employed multifaceted interventions that included education, traffic enforcement and engineering improvements however a few studies utilized only one strategy (commonly walking school bus) to influence active modes of school transportation [21][22][23][24][25][26][27][28][29][30][31][32][33][34].Consistent with the goal of increasing rates of children's active transportation to and from school, most studies focused on reporting intermediary outcomes such as travel behavior and attitudes.Only two studies also incorporated objective measures of physical activity to corroborate the results [21,34].

Safe Routes to School
The majority of studies identified were related to evaluation of Safe Routes to School Programs (SRTS) in the United States (Table 2).In terms of study quality assessed using the EPHPP tool, most studies were assessed as weak based on methodological limitations.Two studies that examined the impact of Walking School Bus (WSB) interventions received moderate ratings.The earlier of the two studies assessed the short and long term effects on student travel in a low income minority population [21].Another pilot study by Mendoza and colleagues employed a cluster randomized controlled trial to investigate the impact of a five week WSB intervention on rates of active commuting and physical activity levels [22].Most studies employed multifaceted interventions that included education, traffic enforcement and engineering improvements however a few studies utilized only one strategy (commonly walking school bus) to influence active modes of school transportation [21][22][23][24][25][26][27][28][29][30][31][32][33][34].Consistent with the goal of increasing rates of children's active transportation to and from school, most studies focused on reporting intermediary outcomes such as travel behavior and attitudes.Only two studies also incorporated objective measures of physical activity to corroborate the results [21,34].
While the overwhelming emphasis of study outcomes focused on rates of active travel, five articles attempted to estimate the safety benefits that accrue from SRTS programs [35][36][37][38][39]. Di Maggio and Li found that annual rates of pedestrian injuries in children aged 5-19 years decreased in census tracts with SRTS improvements when compared to those census tracts without projects [35].Two other studies reported a change in the number of collisions involving school aged children over baseline for intervention and control/comparison sites [36,37].However, neither study could conclusively confirm the safety effects of Safe Routes to School Programs because of limitations inherent in the study design and lack of data on other correlates of collisions that may offer alternative explanations for the results.Another recent study by Ragland et al. also found a significant reduction in collisions involving pedestrians of all ages within 250 feet of countermeasure buffer zones [38].Although a decrease in collisions also occurred among pedestrians aged 5 to 18 years, it was not statistically significant.Mendoza and colleagues also assessed the impact of a brief WSB intervention on pedestrian safety behaviors [39].They found that children at intervention schools were more likely to cross at the corner or crosswalk at intersections (OR = 5.01, 95% CI 2.79-8.99)although fewer children stopped at the curb compared to children in control schools (OR = 0.21, 95% CI 0.15-0.31).Although a randomized control trial, the brief duration of the intervention limits conclusions about sustainability of behavior change.Additionally, observations were made of all children at intersections whether or not they were study participants.This would tend to underestimate any effects.Future studies that gather longitudinal data on WSB study participants would be more useful to confirm these results.
In Canada, School Travel Planning (STP) is the vehicle to promote Active Safe Routes to Schools Programs (ASRTS) by engaging stakeholders to develop and implement action plans that are sustainable at the local level.There were two studies that explored the effect of STP interventions on student active school travel [25,26].Buliung and colleagues conducted the first pilot study of twelve schools across four Canadian provinces [25].Over a two year period, the proportion of children (grades K-8) who used active modes of transportation for their daily school commute was monitored.There was a slight increase in the percentage of children who use active modes of travel from 43.8% at baseline to 45.9% at follow up.Parental attitudes were also more supportive of active modes of transportation in pilot schools.
A larger study consisting of 106 public elementary schools was implemented in 2010 across nine Canadian provinces [26].Data was only available for 53 schools.There was no significant increase in active school travel after a year.In multivariable models, only season of data collection predicted a decrease in active travel in the morning.More research is needed to confirm the efficacy of STP interventions.Variation in mode change was noted between schools which suggests that other contextual factors may be important for success.Furthermore, a year may not have been adequate to demonstrate benefits of the intervention given the varied needs and heterogeneity of interventions.
There is a growing body of literature about the impact of Safe Routes to School (SRTS) programs fueled by the need to evaluate SRTS projects that received US federal funding through the Safe Accountable Flexible Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), often for infrastructural projects.The available evidence to support an effect of Safe Routes to School Programs on rates of active commute shows a consistent positive association although the strength of impact is generally weak.There is less evidence to support safety benefits of programs although studies suggest a reduction in morbidity from injuries.Only a few studies employ robust designs that address common threats to internal validity such as selection bias, include objective measures of health outcomes and adjust for potential confounding factors in multivariable analyses.Longer duration of follow up is also needed to demonstrate the sustainability of efforts.Future studies must address these limitations in order to strengthen the evidence base related to effectiveness of these interventions.
Among other healthy community approaches included in this review, there was a paucity of evidence to support a positive impact on health outcomes.There were relatively few studies identified with three studies related to Active Living Communities [40][41][42]; one each for Safe communities [43] and Smart growth [44] and two related to Age Friendly Cities [45,46].While various study designs were employed, none were randomized controlled trials.The assessment of methodological quality also revealed low ratings as a result of selection bias, less rigorous study designs and analytic methods.The characteristics of various studies are reported in narrative format in Table 3 where information is provided about study design, interventions and outcomes.Small increases occurred in rates of active transportation from 43.5% (baseline) to 45.9% (follow up).Higher rates (43.5%) of active travel occurred at afternoons compared to mornings (37.3%).Among household respondents, 13.3% indicated that the intervention "resulted in less driving".There was an increase in the rates of walking to school in the morning (p < 0.0001) during the intervention period however no significant change was observed for the afternoon commute.Parental perception about school support for active modes of transport and the health benefits (0.01 < p < 0.001) and enjoyment associated with active modes of transportation (p < 0.0001) also improved.There was a statistically significant increase in rates of active transport for all modes of transport in all states except for biking in Florida.
Rates of walking increased more than cycling.Changes in rates of active transport were not correlated with any project, school or neighborhood characteristics.The study examined the effect of a walking school bus intervention on physical activity in three elementary schools in Missouri.
There was no difference between the groups in physical activity levels (p = 0.17).The percentage of time spent in moderate to vigorous physical activity (MVPA) during the study was 38 (20.9 ˘6.9) for WSB participants and 39 (23.4 ˘8) in comparison group.In multivariable models, age was negatively associated with percentage of time spent in moderate to vigorous physical activity (r = ´0.79,p < 0.001).The study assessed the long term impact of SRTS funded infrastructural improvements on safety and walking and bicycling to school.
In pedestrians ages 8 to 18 years there was a 50% reduction in collisions in the treatment area (within 250 feet of the countermeasure buffer zones).Although effect not statistically significant.Among pedestrians of all ages, there was a statistically significant 75% reduction of collisions in the treated areas compared to control areas.
In the mobility analysis, living within 250 feet of the SRTS project improvement was associated with an increased probability of walking to school.Children in smart growth communities engaged in a greater proportion of physical activity bouts a few blocks from home (p < 0.001) and travelled more by walking (p < 0.011) than children in control communities.Over time, social context of physical activity did not change for either group however children in smart growth communities were more likely to report decreased physical activity indoors and an increase in outdoor locations with no traffic (p = 0.036).
There was a greater increase in six month daily moderate to vigorous physical activity among children in intervention communities however it was not statistically significant (p = 0.10).In adjusted multivariable analyses, significant predictors of better self-rated health included access to health care (p < 0.01), social support (p < 0.01) and community engagement (p < 0.01) while neighborhood problems were associated with poorer self-rated health (p < 0.01).Addition of age-friendly environment characteristics weakened the association between self-rated health and three health measures (two functional limitations and chronic conditions) although still significant p < 0.001).Education and income variables were no longer significant when age-friendly characteristics were included in the model.Higher Age-Friendly ratings were associated with greater life satisfaction (p < 0.0001) and self-perceived health (<0.01).

Menec and Nowicki
In multivariable analyses among seniors, the Age-Friendly Index as well as five of the seven domains was associated with life satisfaction.Community support and health services were not associated with any health outcomes.
Self-perceived health was associated with fewer age-friendly domains including physical environment, housing, social environment and transportation options.These results differed for younger respondents as age friendliness was not associated with self-perceived health and life satisfaction was only associated with health services/community support and opportunities for participation (p < 0.05).

Active Living Communities
Active Living Communities increase the opportunities for physical activity through the creation of supportive policies and infrastructure that foster active modes of commuting [47].References to "active living" are common in the literature however a formal, universal definition is difficult to find.The most organized efforts to create a shared vision and operationalize the active community living concept have come from the Robert Wood Johnson Foundation in the United States.In 2003, the Robert Wood Johnson Foundation approved 25 grants to US communities to implement Active Living by Design (ALbD) Projects.These five year grants supported projects to promote physical activity by employing a Community Action Model with five components namely preparation, promotion, programs, policy influences and physical projects.Using this approach, communities assess their needs and devise unique solutions to transform local environments to foster opportunities for increased physical activity [17].The ALbD Project evaluations in Massachusetts [40], Michigan [41] and Missouri [42] reported an increase in the number of persons using active modes of transportation over the study period; however, methodological limitations in these studies limit causal attribution of any effects solely to the project's influence.Project reports emphasize the changing community dynamics, rich partnerships and community empowerment that occur with project implementation as key achievements over health outcomes.More research is needed that focuses on measuring the effect of interventions on health outcomes in order to justify future investments in Active Living Initiatives.

Age-Friendly Cities
The review identified several narrative accounts of process evaluations of Age-Friendly Initiatives [48][49][50][51].Despite this finding, there is a gap in knowledge about the holistic impact of Age-Friendly Initiatives on outcomes in the lives of older persons.The disparate results of the two studies suggest that further empirical evidence is needed that employs standardized definitions of age-friendly environments across diverse settings and health outcomes [45,46].
Cognizant of the need to update the monitoring and evaluation framework for the Age-Friendly Initiative to capture process as well as outcomes, the World Health Organization began work in 2012 to develop core indicators that would meet these expectations [52].The proposed core indicators will retain the emphasis on tracking the progress towards the achievement of age-friendly environments however will include a few distal long term outcomes that reflect improved health and quality of life of older persons.This will pave the way for future project impact evaluations that report health outcomes.

Safe Communities
Safe Communities is an approach to injury prevention and safety promotion that embraces interventions at the community level [53].The initiative advocates for multisectoral cooperation to devise local solutions to community safety concerns.Communities that satisfy established benchmark criteria receive the safe community designation.Evaluation frameworks emphasize the achievement of milestones in the planning process such as establishment of coordination structures, community assessment, plan development and mobilization of funding [54].While discrete health outcomes may be measured (e.g., road traffic accidents, child mortality from unintentional injuries) in specific projects, the commitment is often to the process and creation of supportive environments that foster change in determinants There are few studies of outcome evaluations of interventions in Western developed settings.The review identified only one study in Texas that examined the effect of a community based intervention on the use of child restraints in motorized transport [43].The authors found that the intervention positively influenced safety behaviors such as the use of child restraints, drivers using seat belts and children riding in the back seat.Johnson has argued that while the study outcomes are likely the direct result of the intervention's efforts, any links to the 'safe community' designation are at best tenuous.He recommends that future studies should explore the interaction between safe community designation and injury prevention programs and define success not only by outcomes but also process dynamics such as reach, sustainability of efforts and pathways of change [55].

Smart Growth Planning
Smart Growth (or Smart Growth Planning) is a philosophy that strategically directs urban development activities in order to promote environmental sustainability, economic revitalization and sense of community.While there is a burgeoning body of research that links urban form, physical activity and obesity the evidence linking Smart Growth and improved health outcomes is still emerging [56,57].Only one article was identified that sought to explicitly connect Smart Growth Planning with physical activity [44].The authors did not find a statistically significant increase in moderate to vigorous physical activity among children in smart growth communities compared to control communities.These results may be explained by a number of study limitations including small sample size, measurement of physical activity on the weekend only and subjective reporting of physical context.
There are too few studies that explore the effect of Smart Growth Planning on health outcomes.Future studies are needed that employ more robust designs with larger sample sizes, fuller complement of health outcome measures, and adequate periods of follow up to assess whether there is a critical time period for impacting health outcomes.There is also the need for a public health component of Smart Growth Planning that would facilitate mapping of principles to established community health goals as part of project evaluations.

Other Healthy Community Approaches
There is a dearth of studies that met the inclusion criteria related to Healthy Cities, Child Friendly Cities, Livable Cities, Social Cities and Dementia Friendly Cities.A closer examination of the literature provided a number of plausible explanations for the gaps in knowledge about whether these approaches result in measureable improvements in the health of populations.Some approaches are relatively new and or emerging hence more work is needed to bring conceptual clarity in order to define criteria for designation and facilitate evaluation of projects.This is the case for Dementia Friendly Cities where work has begun to define the features of the home and built environment that facilitate ease of navigation by persons with dementia who often have sensory and cognitive deficits [58][59][60].The literature related to Social Cities is also very scant and further work to promote coherence and definition of the concept needs to be undertaken so that it becomes a discrete and measurable entity.Once consensus is achieved on established criteria and experience with implementation grows, evidence can more easily be generated on any associated benefits and outcomes on quality of life and wellbeing.
The concept of livability has received growing attention over time.While there is general consensus that it refers to desirable characteristics of the social, physical and economic infrastructures of cities and towns, a common definition has been elusive [61].Consequently, "livable" communities reflect a confluence of healthy community approaches that find unique expression in individual cities.Although all members of the society are intended beneficiaries of efforts to create livable communities, the concept has often been viewed from the perspective of older persons who comprise a growing segment of the population and for whom independent living and aging in place are contingent on a supportive environment.
A search of the literature revealed several tools and checklists for assessing characteristics of communities.There were several narrative reports that described conceptual frameworks or achievements of initiatives such as the Partnership for Sustainable Communities Initiative (US) [62], and Livable Centers Initiative [63]; however, efforts to locate studies and evaluation reports that included quantifiable health outcomes were unsuccessful.This is surprising given that improvement in the quality of life is often an explicit objective of programs that address livability [64].Studies are needed that explore the health benefits for communities willing to employ those strategies.
The complex nature of the approach also poses challenges for the assessment of impact on health outcomes.Both approaches that support the development of Healthy Cities and Child Friendly Cities are broad in scope and seek to impact health through distal upstream efforts.Additionally, both approaches emphasize the process of implementation and focus on the creation of supportive environments through the development of enabling multisectoral structures and community assets [65,66].The emphasis on development of an inclusive collaborative process may also result in a relative neglect of measurement of health outcomes as milestones of success.These challenges may be addressed with the use of alternative evaluation approaches such as social return on investment [67], realist evaluation [68] and outcome mapping [69].While they are distinctly different methodologies, they allow for broader conceptualization of the value of a program from the perspective of stakeholders and may better accommodate complexity while providing even more comprehensive answers about how programs work and in what settings.A common set of outcomes including self-rated health and percentage time spent in moderate to vigorous physical activity may be useful program impact indicators.
The gap in the literature with respect to evidence of the effectiveness of Healthy Cities has been recognized.There is still considerable international debate about evaluation needs and methods [70,71].The current research emphasis remains on questions related to the process of implementation (what works and what does not, and why, in the implementation process of a complex intervention such as this) with the expectation, of course, that changes in the social determinants cascade will impact health and well-being of communities.Without a clear mandate and consensus on how the value of healthy communities should be judged, this is likely to hamper work in this area.
There are several limitations of the study that should be considered in the context of its results.The scope of the review is limited to studies pertaining to selected healthy community approaches.As a result of the focused examination, extrapolation of the results to other approaches is limited.Initiatives were not equally represented in US and Canadian jurisdictions with the latter contributing fewer studies.Despite efforts to search the grey literature, many of the programs were implemented by institutions or community organizations at the local level and may not have been published in the public domain.There were few studies that were identified and employed a rigorous design that would allow for strong causal inference.This meant that available studies were not well suited to explore research questions related to the program impact.While this does not imply that the studies do not contain valuable information, it highlights the need for more research that examines what works and under what circumstances.

Conclusions
The body of research to support the effectiveness of selected healthy community approaches on health outcomes is limited, mainly in terms of both the depth of the evidence base and the rigor of the studies.Despite the fact that it seems reasonable, based on underlying explanatory frameworks, to suggest that healthy community approaches should be effective, there is relatively little confirmation provided by the literature.In many instances, communities and institutions lack the enabling resources (expertise, time and finances) to conduct an evaluation or do not prioritize evaluation alongside program implementation.Without adequate provisions to collect baseline data, this compromises future efforts to determine program effectiveness.Consequently, the majority of studies employed a quasi-experimental or observational design with the attendant limitations that result from lack of random allocation or absence of a concurrent or well-delineated comparison group.There is also a notable absence of theory that guides studies related to most healthy community approaches that were examined.Other frequent flaws encountered included failure to control for potential confounding factors; reliance on subjective assessment of the outcomes to the exclusion of more objective measures that can be verified and duration of follow up that was inadequate to determine if any observed changes were sustained.In the case of Safe Routes to School programs and ALbD projects where the necessary support and priority is accorded to evaluation, more studies have been conducted.
A related issue that affects the availability of evidence of effectiveness is the differential emphasis on evaluation of the process of implementation over outcomes.Healthy community approaches depend on the establishment of multisectoral partnerships to achieve their goals.In many instances, benchmark criteria require demonstration of these collaborative processes for legitimacy.There is a need to promote more comprehensive approaches to evaluation that address structure, process and outcome components and better satisfy the information needs of all stakeholders.
Although there are inherent difficulties with attribution of observed outcomes to interventions with observational designs, there is weak evidence to support an association between selected healthy community approaches and achievement of positive health outcomes.The majority of included studies pertained to Safe Routes to School Programs and reported consistent positive association between students' active commute and program implementation.Safety benefits and changes in physical activity levels need to be confirmed with further studies.There is a paucity of studies about Active Living Communities, Age-Friendly Cities, Safe Communities and Smart Growth Planning.The evidence base needs to be strengthened by additional studies that are conceptualized to assess the effect of multifaceted interventions that may exert an influence synergistically or on specific health outcomes.
Several approaches including Healthy Cities/Communities, Child Friendly Cities, Dementia Friendly Cities and Social Cities have been relatively less studied in terms of health outcomes.The process of implementation has traditionally been emphasized in Healthy Cities and Child Friendly Cities given their focus on influencing policy to address broad social determinants.Research on these approaches is likely to be driven by practical considerations, relevance and utility in the specific city/community context.The latter two approaches (Dementia Friendly and Social Cities) require consensus and definition of uniform criteria to support design of interventions that can be evaluated.

Figure 1 .
Figure 1.Summary of search and selection process for identification of relevant studies.

Figure 1 .
Figure 1.Summary of search and selection process for identification of relevant studies.

Table 1 .
Description of healthy community approaches.
The US national program that uses multiple modalities including education, engineering improvements, enforcement and encouragement to increase student active travel[8].Although activities occurred as early as 1997 in the US, the National Program Safe Routes to School Program was established by federal legislation in 2005.
).Other relevant resources consulted included the Best Practices Portal, Centers for Disease Control (CDC) Community Interventions Evidence Database, the National Transportation Library (NTL), the McMaster University's General Database of Public Health Interventions and the Effective Public Health Practice Policy Portal.

Table 2 .
Summary of Quality Assessment of Studies using Effective Public Health Practice Project Tool (EPHPP).

Table 3 .
Summary of evidence for effectiveness of interventions.