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The Beginning of Healthy Cities
The Healthy Cities movement internationally was initiated by Trevor Hancock and Len Duhl when they met to discuss a healthy community model in 1984. Hancock was a Physician and Duhl a Psychiatrist

The movement may have had some of its origins in the middle of the 19th century where the spread of disease from typhoid and cholera was causing a high rate of deaths in the population of cities around the world. These diseases were being spread by the open sewer drains and polluted drinking water and this situation motivated governments act to build new underground piped sewerage and water systems to and from houses.

The Egyptians and Romans were also health conscious as they were one of the first to provide rudimentary sewerage and water to the elite in their society . Duhl stated that community health was the main issue as “medicine only deals with the ill” and “…. health really involves schools, employment, environment and everything else” in society. An International Healthy Cities Unit was formed at Berkeley University in 1984 which sought to give prominence to health issues as being an important factor of community development. From this unit the World Health Organisation (WHO) developed a regional European office to foster the Healthy Cities programme in 1986 which comprised of 1500 cities throughout Europe. Worldwide coverage of the Healthy Cities movement has now been achieved with up to 8000 communities participating in the programme. The Healthy Cities programme is delivered by governments, councils and in some areas through private enterprise.

The University of Queensland developed a Positive Parenting programme to encourage the self-esteem of parents with their newborn children. This programme was adopted by Glasgow Council for use by 1,000 families who had just given birth and were provided with home visits by specialist allied health services.

The WHO defines social determinants of health as “conditions in which people are born, grow, live, work and age” .These determinants can be influenced by other factors beyond their control which involve “distribution of money” or wealth, “power and resources at global, national and local levels.

In Australia a recently published report by the National Centre for Social and Economic Modelling for Anglicare found that the poorest people in our nation grew by thirteen percent over the past ten years and there is an expected further growth of ten percent in ten years. The report also comments on the disposable income/living standards of the bottom twenty percent of households and found that it had only risen by fifteen percent,  whereas the top twenty households increased by twenty eight percent over the past ten years. Another comparison was used to show that there was a widening gap between the rich and poor. The poor were on welfare payments like Newstart and Youth Allowance and it was found that their living standards had only grown by four percent but pensions and non-welfare payments had increased by twenty percent. The report concluded that the current policies by government are impacting on the most vulnerable and the divide between the rich and poor is become greater.

In countries where the policies of government reflect neo liberal ideas, social determinants can be seen as a form of socialist policies to the distribution of wealth and power and the creation of a fairer society. An example of the outrage that has occurred over health reform policy in America recently is when President Obama legislated a health reform package 2010 Healthcare. “The Patient Protection and Affordable Care Act, is the largest overhaul of the US healthcare system since the 1960’s”. The health reforms were to cover approximately 15% of the US population who lacked any form of health cover, mainly the poor or elderly. The principle was to require all Americans to have an affordable/subsidised health insurance and generally it would be paid for by encouraging the healthier younger people to take out private health insurance.

The WHO and "Healthy Cities"
The Health Cities Programme was developed by multinational agency The World Health Organisation (WHO) and came to being in 1987. It’s aim was to develop a long-term project that would influence the way cities approached health issues, particularly at a local level. The initial project was designed to aid the development and implementation of public health plans with consideration for the structural and financial changes required. Originally the programme focussed specifically on industrialised cities within Europe. However, the programme soon became an international “movement,” leading to the establishment of Healthy Cities projects across the globe as well as the improved focus on health inequity at the national and international levels.

Early Development
From its inception in 1948, WHO has consistently described health as not simply to absence of disease, but a state of physical, social and mental well-being. Prior to the Healthy Cities programme, city governments had been largely focussed on discouraging migration and promoting rural living. Despite their efforts the attraction to city living was prevalent, with increasing urban dwellers leading to both improved GDP per capita and human development indices on a national scale. During the 1970s, outmigration from rural areas had put the spotlight on regional health inequity and the growing health problems associated with urbanisation was going largely unnoticed. This was largely in part to the assumption made by governments and international organisations that urban population were in a position of privilege with their proximity to healthcare and basic services. In 1977, the WHO announced the “Health for All” movement, which aimed to support health policy and address issues of health inequity in its members, aiming to enable every person to lead socially and economically productive lives by the year 2000. The Health for All movement eventually became a key feature of the Healthy Cities Programme. The Healthy Cities project first became a definite concept in 1984 when the city of Toronto, a region well known for adequate health systems, began to notice significant areas of poverty and ill-health throughout . The acknowledgement that even cities with good records of health could experience the negative impacts of urbanisation helped kick the Healthy Cities programme into gear. In 1986, the Ottawa Charter for Health Promotion saw the increasing development of health promotion policies and strategies sectors other than health, acknowledging an ecological approach to health and establishing parameters for defining healthy environments. In the same year Trevor Hancock and Leonard Duhl published Healthy Cities: Promoting Health in the Urban Context which outlined the 11 parameters of health that begun the first steps in the Healthy Cities programme.

Approach
A key feature of the Healthy Cities Programme, and the resulting movements, has been the WHO’s approach to defining the urban environment and its processes for implementation at the local, national and international levels. According to the WHO “a city is a living, breathing, growing, changing complex organism that has too often been considered as only an economic entity”. They define a Healthy City not simply by a resultant outcome or health status level, but by its own health awareness and commitment and plan for improvement. The Healthy Cities concept is attractive to the masses as it promotes the non-economic benefits of urban development, such as social well-being, quality of life and community pride, which is inherently important to all communities. It argues that health should be viewed as an investment that generates return for the community, rather than an expense. Top-down solutions, wherein experts or persons in authority impose change on communities, have always dominated potential implementations for addressing social problems. These solutions have often been fruitless and have resulted in an increased number of grassroots methods that emerge from the communities facing the problems. Whilst this decentralisation of power has often been seen as a threat to governing bodies, the WHO calls for those at the “top” to provide local government with the opportunity to make real change in the areas of health. The Healthy Cities programme focusses on changing public policy, creating intersectional strategies for dealing with health in all areas of government and encouraging community participation. The Healthy Cities Programme adopts a “best practice” approach to urban management, encouraging the development and international sharing of research findings and successful approaches to health. There is a strong focus for the WHO to encourage communities to control and take responsibility for their own health whilst ensuring that external groups do not resort to victim blaming. This process of increasing equity is continued through the programmes methods of advocating, on behalf of, and mediating between different interest groups with varying degrees of power. The WHO Healthy Cities programme also advocates resource redistribution, wherein joint action will result in increased funding for those cities with the greatest problems and fewest resources. This focus on resource and power distribution has led to more recently developed projects that focus on the social determinants role in improving equity on a global scale.

The 11 Parameters of Health
In the 1986 WHO publication titled Healthy Cities: Promoting Health in the Urban Context, Leonard Duhl and Trevor Hancock named 11 criterion for defining a healthy city, thus providing a framework for the Healthy Cities model and goal for member cities to aim to achieve.

1. High quality physical environment
The provision of quality housing, an environment free from pollution and urban design that creates a clean and safe quality environment

2. Ecosystem Sustainability
The creation and maintenance of a viable ecosystem that is currently stable and will be sustainable in the long term.

3. Community Strength
The development of a community that is strong, mutually-supportive, non-exploitative and founded on mutuality.

4. Participation and Control
The facilitating of a high degree of public participation that enables citizens to exercise control over the decision making processes that affect ones life and health.

5. Basic Human Needs
The universal provision of clean water and sanitation, which has been a key goal for the United Nations for a long time, are considered to be the two of the most important factors in creating healthy urban environments. The provision of food, shelter, income, safety and the ability to work are also considered basic needs that must be provided to all.

6. Access to Variety
The ability for all residents to access to a wide variety of experiences and resources. Residents must also have the right exercise their ability to interact and communication with multiple contacts.

7. A diverse City Economy
The development of a vital economy that provides a variety of enterprises of different kinds and sizes and that facilitates innovation and improvement to the level and distribution of wealth throughout.

8. Sense of Connectedness
The encouragement of connectedness with the past, with the cultural and biological heritage and with other groups and individuals.

9. City Form
The creation and development of urban form that is both compatible with, and enhances, with above parameters and behaviours. It must be both stable and adaptable to sudden and incremental change.

10. Optimum Public Health and Healthcare Services
The provision of appropriate and accessible healthcare and “sick care” services that are available to all regardless of their ability to pay as well as the development of preventative healthcare measures.

11. High Health Status
High positive health status with increased life expectancy and low disease status with decreased risk behaviour, stress, morbidity, mortality and disability.

Reception and Impact
As of 1992, the Healthy Cities project had spread to a coverage of 18 million people across 18 European countries, eventually encompassing 400 cities throughout Europe, North America and Australia and creating 17 national networks and 3 international networks. Of these member states, half had successful implemented new strategies for addressing health. The WHO Healthy Cities Program now has 1400 member cities and towns internationally with several global Healthy Cities networks including the European Healthy Cities Network and the Alliance for Healthy Cities. Whilst the globalisation of the Healthy Cities programme has been a positive result, the aim of the program was to encourage change at a local level. Many cities have adopted the Healthy Cities model in order to educate their citizens about health. For example, the city of Tehran adopted a primary education program in which children were encouraged exercise good hygiene and cleanliness and a magazine called Healthy Message was established to encourage health innovation. Similarly, the city of Kuching ran a “Healthy City Week” in 1995 in order to conduct community consultation that was later reviewed at a conference and led to a five year action plan addressing the primary concerns of the public. This led to it being named the cleanest and most beautiful city in Malaysia. The WHO states that the success of the Healthy Cities Programme is due to both the enticing nature of the project, as well as the enthusiasm of all of the communities who have embraced it. Whilst the programme was designed primarily for the industrialised cities in Europe, smaller communities have adopted the Healthy Cities approach in other parts of the world. The Healthy Communities project was established within Canada with the aim of incorporating all municipalities of any size, from country’s largest cities Toronto and Montreal, to towns with populations as small as 3000 people. The project too special care to include areas inhabited by native communities that often suffered the lowest quality of health. The Villes et Villeges en sant project in the Canadian province of Quebec took on the international approach advocated by the WHO and established an international French speaking Healthy Cities network with France and Belgium (Tsouros 1992, 37). The Villes et Villeges en sant programme now operates in French, English and Spanish and participates in over 800 global health programs organised by the WHO. As the Healthy Cities programme, and the international community’s response to urban health, has developed, there has been increased effort to encourage uptake in the Global South. The Healthy Cities programme launchd in Chittagong in 1993, for example, led to the representation of informal settlement inhabitants with the Slum Dwellers Forum that represents around a million people. Similarly, the Healthy Municipios project in Latin America has enabled health to become a priority in increasingly urbanised regions. It’s international standing has allowed for some political decentralisation in order for local governments and communities to make health part of the agenda in various sectors of government. The Healthy Cities Movement has also had an impact in non-member cities. Kampala, for instance, established a programme of community engagement with a focus on primary health in urban slums by adopting the Healthy Cities concepts in its approach to repairing drainage systems.

Closing the Gap in a Generation
The Healthy Cities initiative aimed to make individual cities more conscious and aware of urban health within communities and their policy making. Whilst the project did aim to incorporate cities of the Global South within its programme, the WHO acknowledge that there are cities within states of all levels of wealth that do not have the resources or tools to implement the programme. The 2005 Closing the Gap in a Generation project was borne out of a need for social justice in order to tackle the problem of health inequity within and between all states of all levels of income. The project aims to help all communities improve health conditions, challenge the inequity of power and wealth and continue to process of researching and assessing the state of health. The WHO state that whilst removing inequity within a generation is an aspiration rather than a prediction, the global community must act now for any change to occur.

The Social Gradient
The foundation for the Closing the Gap project has been the understanding of the social gradient. Whilst it is widely accepted that cities in the Global North experience lower levels of poverty and ill-health than there Global South counterparts, the WHO states that no matter how wealthy a country is, the socioeconomic position of the citizen will impact their health. Economic growth, whilst an important element for health promotion, can not increase equity without appropriate guidance.

The Social Determinants of Health
In order to achieve health equity, the WHO has outlined three overarching Social Determinants of Health that are required to implement the Closing the Gap program. At the heart of these determinants is a need to reduce the unequal distribution of power, income and resources on a national and global scale. The determinants are listed below.

1. Improve Daily Living Conditions

 * The improvement of daily living conditions harks back to the 11 parameters for Healthy Cities. Like the parameter for addressing basic human needs and a high quality physical environment, the WHO calls for the creation of healthy places that allow for access to quality housing, clean water, sanitation and nutritious food through good land use management and provision of services and infrastructure regardless of resident income. The determinant also builds on the need for work, calling for employment that is both mentally and physically safe, as well as fairly paid through the provision of core labour standards and worker protection legislation.
 * Whilst the 11 parameters call for preventative and primary healthcare services, the social determinants also state that universal healthcare should be provided as a service by the public sector and not be treated as a market commodity, encouraging the implementation of taxation-paid healthcare systems with universal coverage and investment in the health workforce.
 * The social determinants also focus on the need to maintain health equity throughout the life course. Beginning with the improvement of Early Child Development (ECD), the project aims to ensure appropriate nutrition and development for children from prenatal to 8 years of life. The WHO argues that 200 million children are not all to reach their development potential which, in turn, limits their educational and occupational opportunities throughout their lives. The project also wishes to aid the implementation of social protection for people of all ages in the case of “shocks” such as loss of income or disability and aid the reduction of poverty transmission from parent to child.

2. Tackle the Inequitable Distribution of Power, Money and Resources

 * One of the major successes of the Healthy Cities programme was to alter the way the public sector approached health and health related issues. The notion of public sector responsibility is expanded in the second Social Determinants of Health.
 * Like the Healthy Cities programme, Closing the Gap calls for whole government action, wherein all sectors at all levels adopt policies that incorporate the social determinants framework and must assess all policy decision in terms of their impact on health.
 * The public sector must also finance and support socioeconomic development through progressive attitudes to taxation and through the provision of global aid, as well as regulate the market to ensure that commercialisation does not further inequity and that basic service provision is maintained.
 * The parameters of community strength and participation and control are also addressed by the social determinants of health. The enabling of political empowerment and the ability for disadvantaged groups to participate economically, socially and politically is supported through strengthening the legal systems and decision making transparency. Gender equity is also promoting as a necessary step toward health equity, with the WHO stating that if the lives of women are not improved, then half of the world will suffer from inequity.

3. Measure and Understand the Problem and Assess the Impact of Action

 * The Healthy Cities program aimed to encourage the sharing of knowledge and research throughout its networks. The Closing the Gap program, however, names research and assessment as a necessary step in the provision of health equity. Evidence has shown that many countries do not have basic systems to record births and deaths and, as such, countries that do not have access to data that explains causes for illness and mortality suffer from lack of direction in terms of creating and implementing health policy. As such, the WHO advocates the implementation of such systems in all countries.
 * As in the case of the Healthy Cities programme, the WHO advocates community awareness, stakeholder consultation and training to gather and share new evidence that may assist in improving the social determinants of health at all points in the future.

WHO health settings
The Ottawa Charter (1986) developed a settings approach to health promotion and produced a statement from the meeting, “Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love”. This healthy promotion includes principles such as community participation, partnership, empowerment and equity resulting in a Healthy Cities programme. It is a “multi-disciplinary” method and combines working through the risks involved, and its end result is to prevent disease through a group approach which covers a range and scope of resources. The type of facilities that the Healthy Cities settings include are cities, villages, municipalities and communities, schools, workplaces, markets, homes, islands, hospitals, prisons, universities and aged care centres. The setting can be in any urban area where people meet to discuss and initiate issues relating to their personal or the community’s health welfare. Lawrence in Building Healthy Cities discusses the issues facing society today and suggests that consideration should be given to the way we construct cities, its environment, politics and social interaction for the health of the area and neighbourhood. The eleven principles of the WHO Healthy Cities is a guideline of what needs to be included and achieved in providing a Healthy City for the basic needs of human beings. Hancock and Duhl suggest that a Healthy City is one that is changing and modifying the urban environment so that people can provide a supportive network for each other to enable them to reach a quality of lifestyle in their environment.

Wilkinson and Marmot, 2003 discuss the issue of life expectancy and emphasise its relationship with health, relating it to a person’s position on the social ladder and their occupation. The graph to the right illustrates the difference in life expectancy between white collar workers and un-skilled workers in England and Wales. The gap between professional men and un-skilled men is approximately ten years in life expectancy.

They also report that if you are born in the lower economic social order that your health issues can remain with you throughout your life.

Hong Kong has produced a Heathy Cities Guideline (Building Healthy Cities, Guidelines for implementing a Healthy Cities project in Hong Kong) based on a WHO publication (Twenty Steps for Developing a Healthy Cities Project, Copenhagen)  checklist of twenty critical steps to develop a Healthy City.

Getting started

 * Building a support group
 * Understanding Healthy Cities concepts and principles
 * Getting to know your city
 * Finding project funds
 * Deciding organisational location
 * Preparing project proposal
 * Obtaining project approval

Getting organised

 * Appointing the steering committee
 * Analysing the project environment
 * Defining project work
 * Setting up the project office
 * Planning project strategy
 * Building project capacity
 * Establishing accountability mechanism

Taking action

 * Increasing health awareness
 * Advocating strategy planning
 * Mobilising intersectional action
 * Encouraging community participation
 * Promoting innovation
 * Securing healthy public policy

Early Healthy Cities projects
The WHO, LIFE (Local Initiative Facility for Urban Development), UNDP (United Nations Development Programme) and the Dutch bilateral aid agency co-ordinated with five country/cities to establish a Healthy Cities Programme. These were developing countries ranging from Bangladesh, Tanzania, Egypt, Nicaragua to Egypt with the purpose of implementing some of the objectives of a HCP. One of the cities Dar es Salaam in Tanzania used settings based ideas to implement healthy markets, healthy schools and unplanned settlements.

Melbourne City Council
The City of Melbourne (CoM) adopted the WHO Healthy Cities model and it forms part of the Council plan/Municipal Public Health and Wellbeing Plan 2013-2017. The model proposed is based on five principles of capital- human, economic, social and cultural, natural and built. These principles have a broad relationship to the eleven principles of the WHO Health Cities Project (Goldstein, 2000). The image below explains how the CoM, by involving its community in healthy behaviours and quality of life issues, provides a supportive programme in health and wellbeing.

The CoM involves and consults various groups, community, business, professional stakeholders and other levels of government to enable it to plan activities and initiatives that form part of their public health and wellbeing four year plan. The plan when developed encourages and prioritises a number of activities to improve the health of the community and includes the following: One of these initiatives has been the reduction in outdoor smoking when it introduced a smoking ban in a number of outdoor areas. This was enacted under the CoM Tobacco Act 1987 and another by the Victorian Government Act of April 2015. Illness and death are seen as one of the major by-products of smoking and include cancer, cardiovascular disease and other related heath diseases. Exposure to tobacco smoke puts your health at risk in any environment according to the WHO. Generally the new Victorian law of April 2015 bans smoking in the following areas enclosed workplaces, restaurants/cafes, licensed premises, shopping centres as well as the entrances to all public buildings. The CoM law encompasses a number of smoke free areas in public space like The Causeway, Block Place, Howey Place and Equitable Place as well as all Child Centres run by the CoM. The diagram below illustrates some of the results from the 2009-2013 Council Plans which included thirty eight public health and wellbeing issues that were evaluated. Indicators of community health activities were used to quantify the positive changes and areas for improvement that had occurred over the past four year period of the plan.
 * sufficient physical activity.
 * healthy eating and access to nutritious foods.
 * social inclusion and opportunities to participate and connect with others.
 * community safety, including family violence and the use of alcohol and drugs.
 * improved environmental health including tobacco control and climate change management.
 * access to community services, transport, education, affordable housing and open space.

Healthy Cities Illawarra
The Healthy Cities programme in Illawarra (Healthy Cities Illawarra) is a non-government, not for profit community based organisation. A large portion of its funding is from a NSW government agency, Illawarra Shoalhaven Local Health District. The Healthy Cities Illawarra (HCI) was formed in 1987 and is active in the Local Government areas of Wollongong, Kiama, and Shoalhaven. The managing committee comprises local representatives from government, health, environment, education and community sectors. The HCI covers a differing range of health issues which include social and environmental, children’s health, community health and safety, community cultural development, healthy ageing, transport, healthy urban design, HIV/AIDS prevention and tobacco control. The HCI endeavours to be a leader and innovator in the promotion of healthy practices and lifestyle for the community

How urban planning and design can influence health
Since the mid 20th century technological advances such as motorised transportation, labour-saving devices and digital communications have altered the way buildings and neighbourhoods are constructed. In turn these changes have transformed the ‘way populations are mobilized and fed, the nature of work, and the methods of communication’. The layout of suburbs, the configuration of supporting transportation networks, the allocation of recreational space and community infrastructure has influenced how urban populations interact with the built environment, obtain physical exercise, source food and maintain social connections. While research shows that since the mid 20th century developed nations around the globe have experienced a decline in the prevalence of infectious diseases and an increase in living standards in urban areas, a new and challenging population health threat is emerging that is shown to be directly influenced by risk factors associated with contemporary urban living.

Chronic disease represents the leading cause of death and disability in affluent nations and describes to a range of illnesses and disorders that cause a high disease burden. A number of chronic diseases such as diabetes, heart disease, obesity, depression, anxiety, asthma and some cancers are shown to be linked to the

sedentary lifestyles unhealthy food choices, predominant motor vehicle usage, social isolation, excessive alcohol, drug and tobacco use and air pollution that are the ‘characteristics of daily urban life’. Arguably, the spatial planning processes and urban design treatments that have shaped our urban environments have contributed to the rise of health burdens associated with chronic disease. Indeed, there is there is a large body of evidence that demonstrates causal links between chronic disease risk factors and the built environment. Conversely, studies have shown that urban planning and design interventions that target these risk factors, and the societal inequities that can influence poor health, can produce meaningful health benefits for urban populations.

Principles of healthy planning
Factors such as physical activity, diet, social cohesion, equity and sustainability have been recognised as important contributors to health and wellbeing status. These factors and their impacts and benefits in supporting population health are also represented in the theoretical and practical frameworks of the Healthy Cities and Communities programme, such as the social determinants of health and the 11 parameters of a health city.

Physical activity
The spatial geography of built environments such as land-use mix, density of development, legibility of street networks and the accessibility of supporting transportation networks, and perceived safety in public spaces can influence how urban populations interact with their surrounding environment. At a neighbourhood level, the distance, connectivity and available modes of transportation that link local focal points such as homes, shops, schools and work places can either limit or promote opportunities for physical activity. Ensuring opportunities for active, passive and recreational physical activity within cities and neighbourhoods, that supports walking, cycling and public transportation options have been shown to increase opportunities for physical exercise and contributes to health benefits. Providing opportunities for incidental movement within neighbourhoods, public and semi-public spaces is also essential for increasing physical activity, although studies show that technological innovations and time-saving devices employed in homes and work places reduce opportunities for exercise. Urban design interventions to promote incidental exercise include ensuring visible and safe access to stairways, public open space connectivity, foot path connectivity.

Diet
Research shows that access to fresh and affordable food is a key determinant of health and when accompanied by regular exercise promotes positive health benefits. Convenient access to food outlets and the variety and affordability of food options is influenced by spatial land-use policies that regulate retail and commercial activity within residential areas. In some cases, planning policies create barriers to purchasing healthy food, by limiting the diversity, style (eg supermarket, neighbourhood grocer, and convenience store) and proximity to food outlets within residential areas. Conversely, studies have demonstrated a correlation between the distribution and density of alcohol outlets in residential areas and the prevalence of ‘domestic violence, assault and harmful consumption of alcohol’. Accessibility to locally grown food increases the health benefits associated with eating a diversity of fresh, seasonal produce. Spatial planning policies that encourage a mix of land-uses within residential areas, which incorporate community gardens and opportunities for urban food production, can increase levels of physical activity, promote social interaction and increase community capacity in preparation of healthy food. Spatial planning policies that identify and protect valuable agricultural land on the fringe of urban environments can contribute to long-term local food security.

Social cohesion
Butterworth maintains that ‘a sense of belonging to the places where we live, work and travel is an influential determinant’ of mental health and wellbeing. Urban design considerations such as lighting, street furniture, signage, sightlines and clear pathways within neighbourhoods and public spaces can impact accessibility and aesthetics and affect perceptions of personal safety and belonging. Ensuring opportunities for ‘informal and spontaneous social interaction’ is shown to have positive mental health and wellbeing benefits. Urban design considerations to support social interaction include the provision of accessible and conveniently located multi-purpose community spaces, providing park benches and maintaining public infrastructure. These measures can encourage informal interaction and build social cohesion within ‘third spaces’, a term coined by Williams and Pocock to describe places such as playgrounds, community gardens and semi-public spaces such as shopping centres and cafés.

Equity
According to Ritsatakis achieving equity in health ‘requires interventions to tackle differences’, wherein factors associated with the social determinants of health can cause avoidable, unjust and unfair outcomes that detrimentally affect health status. To achieve health equity it is widely understood that ‘everyone should have a fair opportunity to attain their full health potential’, yet in Australia, those that are socially and economic disadvantaged are more likely to experience health inequality.

From a spatial and social planning perspective this means that urban design considerations and planning policies should provide for universal access to social, educational and health care services, ensure access to equal opportunities for physical activity, healthy food choices and provide for social interaction. Barton & Tsourou suggests that equity within the urban environment can be promoted by providing affordable housing, supported by active transportation that links local employment, educational, community and recreation facilities and opportunities.

Sustainability
The WHO has expanded on Brundtland’s (https://en.wikipedia.org/wiki/Brundtland_Commission) definition of sustainability by describing sustainable urban development as an urban form that seeks ‘to deliver basic environmental, social and economic services to all residents and the community without threatening the viability of the natural, built and social systems upon which the delivery of these services depend’. Factors that can impact on achieving sustainable development and negatively influence the health and wellbeing status of urban populations include: poor water quality, air pollution, toxic chemical exposure, climate change, depletion of agricultural land.

By reducing car dependency and increasing opportunities for active transportation at both a neighbourhood and city-wide level, a number of health ‘co-benefits’ can be achieved, including a reduction of air pollution, increased opportunity for physical activity and social interaction. Further sustainable development measures may include the adaptive re-use of heritage buildings and the incorporation of energy-conservation technologies in old and new buildings, the provision of new green spaces for urban forestry and horticulture, the promotion of urban water-harvesting and recycling of green waste.

Participating in governance processes
The Healthy Cities programme relies on a participatory Governance structure and a futures methods approach to inform its strategic planning processes, wherein individuals and communities collaborate to set priorities and shape agendas for creating healthy cities.

According to Barton & Tstourou, participatory governance involves ‘informed, motivated and actively participating communities’ working collaboratively with municipal administrators, urban designers and public health professional to realise a shared vision for sustainable health. The Healthy Cities movement advocates for inter-sectorial collaboration and encourages community participation in planning for health. It is recognised that what constitutes ‘community’ has ‘both spatial dimensions (geographic, the city, town or neighbourhood) and non-spatial dimensions (affinity, shared interests based on class, gender, race or specific concerns)’ and that representatives from various groups identified as stakeholders or actors should be sought.

Alternative futures
Future-oriented methodology or ‘futures methods’ is a strategic framework utilised by a number of disciplines, including public health and economics to develop and test alternative futures and devise long-term strategies to tackle complex challenges Futures methods relies input from a number of stakeholders or actors, drawn from the existing governance structure of an organisation or representatives drawn from key stakeholder groups in the context of community development and heath promotion initiatives. According to Edgar, Grant and Lin, there are five steps involved in developing future projections to inform strategic planning, these including:


 * 1) Gather together actors / stakeholders / participants;
 * 2) Generate alternative stories / pathways about the future based on possible, probable, plausible and preferable scenarios;
 * 3) Identify, distinguish and discuss the multitude of drivers and variables in the local and broader environment relevant to each scenario;
 * 4) Identify the key drivers and critical uncertainties that underpin each scenario;
 * 5) Consider the current capacity / state of preparedness of the organisation in dealing the risks and challenges posed by each scenario.

The Healthy Cities programme utilises a scenario planning or ‘alternative futures’ framework that focuses on generating alternative pathways or stories based on the challenges and risks that may impact urban environments and in turn, impact the health and wellbeing status of urban populations According to Handcock and Bezhold, the future health of a city is shaped by variable local and external factors that may include: climate change and loss of biodiversity, population growth, urbanisation and the growth of slums. Positive transformations can also shape the health of a city and in turn impact on population health and these may include: a reduction in wage disparities, the wide-spread adoption of sustainable renewal energy and an increase in the provision of active transport infrastructure. Viewed through a healthy cities lens, these positive and negative variables can be understood as an extension of the social determinants of health framework, wherein forces such as ‘the distribution of money, power, and resources at global, national, and local levels’ can profoundly shape urban environments.

Future methods and participatory governance
While the goal of scenario planning is to increase organisational preparedness by developing strategies that take into account complex long-term external forces, the process is also considered to be an effective technique for fostering collaboration, building capacity and empowering participants Scenario planning can be a transformative experience for those involved and according to Wiseman and Rickards, alternative futures planning forces participants ‘to confront the uncomfortable reality that in preparing for the future [one] must prepare for multiple outcomes’ and that these future scenarios may unsettle the foundations of an assumed future. Hancock and Bezhold maintain, however that this approach ultimately a positive one as it fosters collaboration and creativity, whereby participants work together to create a shared vision for a preferred healthy future.

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