Assessing the construction of a Healthy City in China: a conceptual framework and evaluation index system

Abstract

Objectives

COVID-19 has brought challenges to the health of all mankind. It is particularly important to promote the construction of a ‘Healthy China’ and build a ‘healthy community’. The aims of this study were to construct a reasonable conceptual framework for the Healthy City concept and to assess Healthy City construction in China.

Study design

This study combined qualitative and quantitative research.

Methods

This study proposes the concept model of ‘nature–human body–Healthy City’ and accordingly constructs an evaluation index system for the construction of a Healthy City that integrates five dimensions, namely, the medical level, economic basis, cultural development, social services, and ecological environment to explore the spatial and temporal heterogeneity of Healthy City construction in China. Finally, the influencing factors of Healthy City construction patterns are explored using GeoDetector.

Results

(1) The pace of Healthy City construction is generally on the rise; (2) the construction of Healthy Cities exhibits significant global spatial autocorrelation and gradually increasing agglomeration. The spatial distribution of cold hotspot areas was relatively stable; (3) medical and health progress is an important factor; the level of economic development is the leading support; the endowment of resources and environment is the basic condition; public service support provides important support; and scientific and technological innovation capabilities provide technical support for the construction of a Healthy City.

Conclusions

The spatial heterogeneity of Healthy City construction in China is evident, and the state of spatial distribution is relatively stable. The spatial pattern of Healthy City construction is shaped by a combination of factors. Our research will provide a scientific basis for promoting the construction of Healthy Cities and helping to implement the Health China Strategy.

Introduction

Although global urbanization brings convenience and opportunities, it also poses great threats and challenges. Living standards and production practices have increased along with various health risks due to environmental pollution, the global spread of infectious diseases, and aging populations. In particular, the outbreak of COVID-19 at the end of 2019 put the safety of the people and the country's stability at risk.¹ Building Healthy Cities to manage social and environmental factors is the best way to address urban health challenges. The ‘Healthy City’ was first introduced in 1984 in Toronto, Canada. In 1988, Dual and Hancock proposed that a healthy city is a city that enables the creation and improvement of the natural and social environment and the expansion of social resources to enable people to support each other, perform all the functions of life, and achieve the most desirable state of health. A Healthy City was defined by the World Health Organization (WHO) in 1995 as “a place that provides services to people and the planet; where the natural, ecological, and social environments develop steadily; where people's well-being increases; and where a dynamic cycle of health is achieved.”² The Healthy City movement is gaining popularity worldwide, with many cities in Asia, Europe, and the United States building distinctive Healthy City models.3, 4, 5 A Healthy City, as currently identified by the WHO, puts health, social well-being, equity, and sustainable development at the center of local policies, strategies, and programs based on the core values of the right to health and well-being, peace, social justice, gender equality, solidarity, social inclusion, and sustainable development. The guiding principles of Healthy Cities are health for all, universal health coverage, intersectoral governance for health, health-in-all-policies, community participation, social cohesion, and innovation. A healthy city, as currently identified by the WHO, is one that puts health, social well-being, equity and sustainable development at the center of local policies, strategies, and programs based on core values of the right to health and well-being, peace, social justice, gender equality, solidarity, social inclusion and sustainable development and guided by the principles of health for all, universal health coverage, intersectoral governance for health, health-in-all-policies, community participation, social cohesion, and innovation.⁶ The WHO also approaches Healthy Cities as a process that enables the possibility of health in people instead of an end state.⁷ Monitoring and evaluation are important safeguards for the sustainability of Healthy City.⁸ In 1996, the WHO arranged for experts and scholars to identify a total of 32 indicators in four dimensions, population, services, environment, and economy, to constitute a system of indicators for evaluating the health of a city.⁹ Later, politics,¹⁰ transportation planning,¹¹ information,¹² and other categories were also added to the evaluation indicator system, emphasizing the role of public,¹³ government,¹⁴ non-profit organizations,¹⁵ and private sector.¹⁶ The basis for the development of indicators was the 11 objectives of a healthy city according to the WHO.¹⁷ Strengthening the governance of different urban sectors is key to healthier cities,¹⁸ emphasizing that health cuts across all policies through inter sectoral synergies.¹⁹ Most scholars have focused on the transformation of cities into healthier ones by improving health systems and urban infrastructure and promoting the equalization of public services.20, 21, 22 Building a healthy city is the key to improving urban livability,^{23 , 24} improving the habitats by strengthening environmental pollution control,^{25 , 26} improving the human environment,^{27 , 28} and enhancing the vitality and metabolism of a city is also the focus and direction of Healthy City construction.²⁹ Urban planning is a tool for healthy urban development,^{30 , 31} and urban planners have long emphasized the need for urban planning to be ‘people centered,’ with health promotion as a goal. Urban planning also includes the need for better public education, dissemination, and mental health support in the context of public mental health emergencies³² in an effort to improve the health literacy of residents. The introduction of policies such as new urbanisation³³, high-quality development³⁴, smart cities³⁵, and shared cities³⁶ also provides a good opportunity to Healthy City. Since its launch, the Healthy City campaign has provided models for other regions through strict management systems, policies, financial investments, and pilot projects.³⁷

Academic enquiry into the ‘Healthy City’ has moved from qualitative theoretical research to quantitative research. Research themes have been updated over time, whereas research directions have intersected with more disciplines. Therefore, the indicators of Healthy City need to be updated according to the research objectives. In addition, there is a lack of investigation into the spatial and temporal evolution and influencing factors Healthy City construction. This study explores the spatial and temporal patterns of Healthy City construction in 341 Chinese cities. It also analyzes the factors affecting spatial and temporal patterns of Healthy City construction in China, discusses the regulation paths and key construction directions for Healthy City construction, and provides theoretical guidance.

Methods

Research framework

Healthy City construction research is a comprehensive system composed of connotation generalization, spatial–temporal pattern evolution, construction paths, and other systems. The exploration and deepening the connotation of Healthy City form the basis of research on Healthy City construction. A five-dimensional model for measuring the construction of Healthy City was developed, starting from five subsystems (medical level, economic foundation, cultural development, social services, and ecological environment) and analyzing the comprehensive construction level of Healthy City among cities, provinces, and districts. The spatial evolution of the construction of Healthy City is discussed from the perspective of spatial analysis, and the formation mechanism and regulation strategies affecting the construction of Healthy City are discussed from five aspects: medical and health progress, resource and environmental endowment, public service support, economic development level, and scientific and technological innovation capacity (Fig. 1 ).

Fig. 2.

Healthy City composition based on human–land system synergy.

Fig. 1.

Theoretical framework of Healthy City construction in China.

Connotation and developmental changes of Healthy City

Healthy City is a global movement proposed by the WHO in 1980. It has been widely applied as an academic concept in many fields of research. This research summarizes Healthy City as follows: under the guidance of the harmonious symbiotic relationship between man and the land system, a healthy city adheres to a people-oriented concept and rationalizes the mechanism of action among various elements by solving the relationship of ‘population-society-economy-space-ecology’. A virtuous cycle system of all elements is thereby constructed, with a sound ecological environment as the basis, medical and health care as the key, economic development as the support, public services as the guarantor, and scientific and technological innovation as guidance. Finally, a new city construction pattern is formed, including healthy and coordinated development of ‘man-land’, and characterized by fair medical services, economic and efficient development, cultural quality improvement, social harmony and progress, and a supportive ecology and environment.

Yi's philosophical theory states that all things are interconnected and interact with each other. All things in the world are in a kind of correlation, whether celestial phenomena, objective substances, or earthly, human, or imaginary phenomena. Nature is a large system composed of five basic substances: gold, wood, water, fire, and earth, each of which is mutually exclusive to achieve the harmony and unity in nature. In traditional Chinese medical theory, it is customary to draw on the theory of generation and restriction among five elements to analyze the phase of the heart, liver, spleen, lung, and kidney in the human body and to establish a one-to-one correspondence between the five elements and the five organs from the perspective of the human–earth relationship. What a healthy city pursues is not only the health of people but also the overall health with the external environment. ‘Wood’ and ‘Liver’ correspond to the medical level, and both have the function of detoxification and elimination of diseases, which is the key to the construction of Healthy City. ‘Fire’ and ‘Heart’ correspond to the cultural development, and these three represent the spiritual civilization in their respective systems, which is the innovation and direction of Healthy City construction. ‘Spleen’ and ‘Earth’ correspond to the social services, and they are functionally the guarantors of the functioning of the system and the cornerstone of the development of a healthy city. ‘Gold’ and ‘Lung’ correspond to the economic foundation and are both functionally supportive and important pillars of the construction of Healthy City. ‘Water’ and ‘kidney’ correspond to the ecological environment, and all three of them have the function of purification and elimination in their respective systems; ecological health is the environmental foundation for the construction of Healthy City. The five dimensions of Healthy City construction complement each other in promoting the development of the city toward wellness.

Research methods

After standardizing the original data, the principal component analysis method³⁸ was used to determine the index weight using the orthogonal transformation of N-dimensional factors. Then, the comprehensive measure model of Healthy City construction was used to calculate the Healthy City construction level in each period in the study area. ArcGIS and global spatial autocorrelation tools were used to determine the distribution status of Healthy City construction.³⁹ After this, the spatial agglomeration patterns were analyzed using Getis-Ord Gi∗ through local spatial autocorrelation analysis,⁴⁰ and the spatial and temporal distribution patterns of Healthy City construction were quantitatively analyzed. Finally, a factor detector of GeoDetector⁴¹ was used to analyze the spatial differentiation mechanism of Healthy City construction (the parameter descriptions of the specific research methods are presented in Table 1 ).

Table 1.

Description of research methods.

Research methods	Equation		Method description
Comprehensive measurement model incorporating the 'five dimensions' system	$I_k=\frac{\sum Y_{ij}{W}_j}{\sum W_j}$	(2.1)	IK represents the composite score of each subsystem, where k is the ordinal number of primary indicators, MK (medical level health index), ECK (economic foundation health index), CK (cultural development health index), SK (social services health index), EVK(ecological environment health index). (Notes: i: municipalities; j: measure indicators; Yij: standardized data; Wj: weight of each measure indicator).
	$HC=M_K{W}_j+E{C}_K{W}_j+C_K{W}_j+S_K{W}_j+E{V}_K{W}_j$	(2.2)
Analysis of spatial–temporal differences	$I=\frac{\sum _{k=1}^n\sum _{j=1}^n\left(X_k-\overline{X}\right)\left(X_j-\overline{X}\right)}{S^2\sum _{k=1}^n\sum _{j=1}^n{W}_{kj}}$	(2.3)	Moran’s I lies between [−1,1]; when the value tends to 1/−1, it indicates the presence of spatial positive/negative correlation and spatially clustered/dispersed distribution; equal to 0 indicates no spatial autocorrelation and spatially random distribution. When there are clustering or dispersion characteristics, if Z (Gi × [d]) is positive and significant, it indicates that location I and its adjacent spaces is a high-value spatial clustering, that is, a hotspot area; conversely, it is a cold spot area, so as to analyze the spatial and temporal distribution pattern of Healthy City construction. (Notes: Xk and Xj denote the attribute values of cell k, j, $\overline{X}$ represents series mean, Wkj denotes the weighting matrix, S2 denotes the variance of sample, E(I) represents expected value, var(I) is the coefficient of variation, $E\left(G_i^{\ast }\left(d\right)\right)\mathrm{a}\mathrm{n}\mathrm{d}Var\left(G_i^{\ast }\left(d\right)\right)$ denote the mathematical expectations and variance of $G_i^{\ast }\left(d\right)$).
	$Z\left(I\right)=\frac{1-E\left(I\right)}{\sqrt{\mathrm{v}\mathrm{a}\mathrm{r}\left(I\right)}}$	(2.4)
	$G_i\ast \left(d\right)=\frac{\sum _{k=1}^n\sum _{j=1}^n{W}_{kj}\left(d\right)X_j}{\sum _{j=1}^n{X}_j}$	(2.5)
	$Z\left(G_i\ast \left(d\right)\right)=\frac{G_i\ast \left(d\right)-E\left(G_i\ast \left(d\right)\right)}{\sqrt{\mathrm{v}\mathrm{a}\mathrm{r}\left(G_i\ast \left(d\right)\right)}}$	(2.6)
Analysis of the mechanism of spatial differentiation	$\mathrm{q}=1-\frac{{\mathrm{\Sigma }}_{h=1}^{L}Nh{\sigma }_h^2}{N{\sigma }^2}=1-\frac{SSW}{SST}$	(2.7)	q-value between [0,1], with larger q-value, indicating more pronounced spatial heterogeneity; the larger value of q indicates a stronger explanatory power of the independent variable X on Healthy City construction and vice versa. (Notes: h = 1, …, L represent the stratification of Y or X, that is partitioning; Nh, N are the number of cells in stratum h and the whole region; ${\sigma }_h^2$, ${\sigma }^2$ are the variance of variable Y in stratum h and the whole region; SSW and SST denote the sum of variance within stratum and the total variance of the whole region).

SSW, within sum of squares; SST, total sum of squares.

Index system and data sources

Evaluation of Healthy City construction

The current evaluation of a healthy city refers to the evaluation index system provided by WHO. This study combined the current strategic outline of Healthy China with the evaluation indicators of Healthy City in China (2018) to develop Healthy City construction evaluation index system (Table 2 ), consisting of 25 specific indicators from five aspects: medical level, economic foundation, cultural development, social services, and the ecological environment. A total of 341 cities in China were used as research subjects. Primary data were obtained from the Statistical Yearbook (2011 and 2021), the National Economic and Social Development Statistical Bulletin, and the official Web sites of local governments. The national intangible cultural heritage list was obtained from the China Intangible Cultural Heritage Web site. Energy data were obtained from energy consumption bulletin for each province and city. Missing data were supplemented by extrapolating from the trends in adjacent years. The administrative map of China is a standard map with review number GS (2019)1822, downloaded from the standard map service Web site of the Ministry of Natural Resources of China.

Table 2.

Evaluation index system of Healthy City construction.

Target layer	Index layer	Unit	Weight
Medical level	Life expectancy	Years of age	0.0485
	Natural population growth rate	%	0.0372
	Ten thousand people have the number of doctors	Person/ten thousand person	0.0481
	Coverage rate of basic medical insurance for urban and rural residents	%	0.0562
	The proportion of healthcare expenditure in general public finance expenditure	%	0.0419
Economic foundation	Proportion of output of secondary and tertiary industries in GDP	%	0.0563
	Average salary of employees in employment	yuan	0.0366
	Percentage of employees in the tertiary industry	%	0.0164
	Per capita general budgetary income of local finance	yuan	0.0412
	Reduction rate of energy consumption per unit GDP	%	0.0443
Cultural development	Number of university students per 10,000 people	Person/ten thousand person	0.0429
	10,000 people have the number of books in public libraries	Volume/ten thousand person	0.0408
	Patent ownership per 10,000 people	Piece/ten thousand person	0.0360
	R&D spending as a percentage of GDP	%	0.0319
	Number of national intangible cultural heritage protection catalogs	Piece	0.0357
Social services	Urbanization rate	%	0.0400
	Unemployment insurance participation rate	%	0.0254
	Internet penetration rate	%	0.0444
	Number of buses per 10,000 people	Unit/ten thousand person	0.0434
	Per capita sports field area	Square meters per person	0.0347
Ecological environment	Days of air quality (API) at or above level	Number of days	0.0251
	Centralized treatment rate of urban domestic sewage	%	0.0351
	Green coverage rate of built-up area	%	0.0508
	Harmless disposal rate of domestic garbage	%	0.0461
	Comprehensive utilization rate of industrial solid waste	%	0.0408

GDP, gross domestic product.

Selection of influencing factors

Combined with the specific situation of Healthy City construction in China, 10 driving factors were selected from five dimensions, medical and health progress, resource and environment endowment, public service support, economic development level, and scientific and technological innovation capacity to explore the degree of impact of different factors and mechanism on Healthy Cities.

Results

Overall differentiation pattern of Healthy City construction

The Jenks natural breaks method was used to classify the construction levels of a healthy city in 341 prefecture-level cities in China in 2010 and 2020 into five levels: low level, comparatively low level, medium level, comparatively high level, and high level (Fig. 3 ), and the construction of Healthy Cities in China showed noticeable regional differences in both years, with a long-term structural layout of ‘coastal high and inland low levels, eastern high and western low levels’.

Fig. 3.

Comprehensive assessment results of Healthy City construction in 2010 and 2020.

From these two periods, the average comprehensive health index of Chinese cities increased from 0.367 in 2010 to 0.438 in 2020. The number of cities at a high level in 2010 was 12, and it reached 33 by 2020, mainly in developed cities in the eastern region of China, such as Beijing and Shanghai, as well as individual provincial capitals in the inland region, showing a sporadic distribution pattern, also in the Yangtze River Delta region, there is already an evident agglomeration feature, and the spatial agglomeration increased by 2020. In 2010, there were 41 comparatively high-level cities, and by 2020, there were 92, mainly in the Yangtze River Delta city cluster, Shandong Peninsula city cluster, and the Pearl River Delta city cluster, showing a cluster-like agglomeration distribution around the higher level cities and a trend of extending to the inland areas, with the number of comparatively high-level cities in the central and northeastern regions increasing significantly. In 2010, there were 74 medium-level cities, and by 2020, there were 139, mainly in the central cities of China, showing concentrated and contiguous growth. By 2020, most medium-level cities were concentrated in northern, central, and southern China, as well as in the western regions of Xinjiang and Gansu Province, with more significant clustering characteristics. Notably, 119 cities at comparatively low level in 2010 shrank to 58 by 2020, with concentrated distribution in the western and northeastern border areas of China, especially in the southwest, northwest, and northeast regions where a large number of cities will be upgraded from low level to comparatively low level, with greater changes in spatial distribution patterns. Ninety-five cities at low level in 2010 shrank to 19 by 2020, mainly in the Qinghai-Tibet Plateau region and the western part of the Yunnan-Guizhou Plateau, and the distribution range was greatly reduced.

Spatial distribution correlation analysis

As presented in Table 3 , Moran's I index was greater than 0 in 2010 and 2020, with Z-statistic values greater than 2.58 and p-statistics values of 0. This indicates that Healthy City construction of the 341 prefecture-level city units in China is not homogeneous in its spatial distribution and that there is a significant spatial correlation. The spatial agglomeration of Healthy City construction between prefecture-level administrative units has increased significantly, and the differences in the spatial distribution of Healthy City construction between regions have gradually increased.

Table 3.

Estimation of Global Moran's I for Healthy City construction in 2010 and 2020.

Year	Moran's I	Z (I)	P-values
2010	0.278	19.27	0
2020	0.295	21.12	0

The Getis' G index was calculated for Healthy City construction in 2010 and 2020 after classifying them into five types: hot spots, sub-hot spots, transitions, sub-cold spots, and cold spots areas (Fig. 4 ). From 2010 to 2020, the geospatial distribution of each district type was relatively stable, and cold and hot spot cities showed dynamic changes within a specific range. In 2010, there were 27 cities in the hot spot area, with a relatively scattered spatial distribution, mainly in the Beijing-Tianjin-Hebei region, Shandong Peninsula region, Yangtze River Delta region, and the Pearl River Delta region, forming local hot spot areas in cities, such as Beijing, Tianjin, Yantai, Weifang, Shanghai, Hangzhou, Guangzhou, and Shenzhen. By 2020, the number of cities in hot spot areas reached 40 in the Shandong Peninsula city cluster and the Yangtze River Delta. The hot spot areas in the urban agglomerations have a tendency to spread to the periphery, expanding the radiation range and showing cluster characteristics. The sub-hot spot areas mainly show a tendency to spread from the hot spot areas at the core, showing a certain hierarchy, and expanded significantly by 2020, especially the Shandong Peninsula urban agglomeration, the West Coast urban agglomeration, the Pearl River Delta urban agglomeration, and the Beijing-Tianjin-Hebei urban agglomeration. The cold spots are mainly located in the Tibet Autonomous Region, Qinghai Province, Xinjiang Uygur Autonomous Region, and the northern part of Heilongjiang Province in the western interior of China. In addition, because of the national policy of revitalizing the old industrial bases in the northeast, the extent of the cold spot areas in the northeast has also been further reduced. From 2010 to 2020, the transition areas and sub-cold spot areas are the most widely distributed in the country, indicating that the overall level of Healthy City construction in China is not high and still needs to be further developed. Further strengthening of construction efforts is therefore needed.

Fig. 4.

Hot spot analysis of Healthy City construction in 2010 and 2020.

Analysis of influencing factors of spatial–temporal pattern of Healthy City construction

The magnitude of the influence of each factor on the level of Healthy City construction in China was using GeoDecter (Table 4 ). The results show that all 10 driving factors from 2010 to 2020 were significant at the 0.01 level, with q-values ranging from 0.174 to 0.578, indicating that all indicators help to explain the characteristics of the current spatial–temporal pattern of Healthy City construction (Fig. 5 ).

Table 4.

Detection results of influencing factors of Healthy City construction.

Target layer	Index layer	q-value (2010)	q-value (2020)
Medical and health progress	X1 Number of tertiary and above hospitals	0.444	0.466
	X2 Index of aging	0.326	0.348
Resource and environment endowment	X3 Forest coverage rate	0.507	0.516
	X4 Comprehensive index of air quality	0.551	0.578
Public service support	X5 Ratio of per capita disposable income between urban and rural	0.174	0.207
	X6 Proportion of expenditure on basic public services in general public budget expenditure	0.195	0.231
Economic development level	X7 Per capita disposable income	0.395	0.457
	X8 Per capital GDP	0.406	0.431
Scientific and technological innovation capacity	X9 Proportion of expenditure on science education in total fiscal expenditure	0.252	0.315
	X10 Contribution of scientific and technological progress	0.237	0.260

Fig. 5.

Driving mechanism of Healthy City construction.

Discussion

Previous studies on Healthy City construction have focused mainly on different perspectives such as sociology, sports, and national policies. In addition, much research has been conducted on the evaluation of Healthy Cities from the perspectives of society, population, and environment, thereby providing suitable reference and guidance. However, the research lacks a targeted evaluation of any specific city, and there is little research on the improvement measures and implementation suggestions for the construction of Healthy Cities. In the present research, we calculated the Healthy City construction level and analyzed the spatial and temporal distribution patterns and factors influencing of Healthy City construction. The spatial heterogeneity of Healthy City construction in China is evident. With per capita disposable income and a per capita GDP q-value greater than 0.395, strengthening the economy will lead to the flourishing of modern technologies in many enterprises, forming a sustainable development model and a healthy economic structure. Therefore, ‘health promotion and health first’ should be integrated into economic construction to promote a sustainable development model and a healthy economic structure. A balance between the environmental and human systems is the premise of Healthy City construction. The results show a steady increase in the influence of the combined air quality index and forest cover, especially the q-value of the combined air quality index is more significant among the driving factors reaching 0.578, indicating the increasing maintenance and response to the ecological environment in the construction of a healthy city. We should insist on following the concept of green development, strictly protecting the ecological environment, and striving to improve the greening of national space to lay a firm foundation for the survival and health of human beings. The influence of the healthcare progress factor rose significantly from 2010 to 2020, and the influence of the indicator of the number of tertiary hospitals on the level of Healthy City construction in 2020 reached a q-value of 0.466, emphasizing the key role of health care in the construction of Healthy City. Taking the COVID-19 as an example, as the diversity of medical services increases, the public's awareness of health will be enhanced in several ways, good living habits will be developed, and life expectancy per capita will increase. How to coordinate the better use of existing medical resources so that people can enjoy life while giving full play to their potential is a question worthy of in-depth consideration. From 2010 to 2020, the q-value of “scientific and technological innovation capacity” is smaller compared to other influencing factors, indicating that the role of “scientific and technological innovation capacity” in promoting the construction of a healthy city is weak but increasing. Building Healthy City and realizing the national strategy of building a ‘Healthy China’ must be supported by technology. It is important to promote the integration of cultural and technological innovation with the health industry and the modernization of health governance. The supporting capacity of public services plays an important role in guaranteeing the construction of a healthy city, and with the implementation of the new urbanization strategy, the state has gradually developed policy and increased financial support for urban and rural development and increased expenditure on health care, education, sports, and social security. This shows that public services provide important support for Healthy City, and it is necessary to strengthen the status and management role of the government in the construction of a healthy city. We must explore innovation and strive to provide quality and efficient health services.

Administrative divisions and the hierarchy of cities exacerbate the unevenness of urban health development. To promote Healthy City construction, it is necessary to adhere to local conditions. Each region and city should be selected based on their levels of economic and social development and work foundations. They should explore distinctive experience models and gradually develop effective patterns of integrated development.

Healthy City construction in China adheres to government leadership. The global COVID-19 pandemic suggests that the construction of Healthy City should involve all aspects of production and life and that there is an urgent need to consider how to deepen the development of Healthy City and the specific implementation paths to promote them. It is necessary to continue to deepen the coordinated development of various complex systems such as ‘population-society-economy-space-ecology’. Socio-economic development and practical experience should be promoted to increase the number of Healthy City, taking into account the characteristics of the time and region.

Conclusion

The construction rate of Healthy City in China is on increasing, and the spatial distribution pattern shows a clear positive global spatial correlation and a gradual increase in spatial agglomeration. The local spatial autocorrelation results show that the cold and hot spot areas of Healthy City construction in China from 2010 to 2020 showed dynamic changes within a certain range, and the spatial distribution was relatively stable. Healthy City construction is a complex system formed by the combined effects of several factors. The level of economic development, resource and environmental endowment, medical and healthcare progress, scientific and technological innovation capacity, and public service support are the driving factors affecting the spatial pattern of the construction of Healthy City. Health care, economic development levels, environmental resources, the support of public services, and the orientation of scientific and technological capabilities play a role in advancing Healthy City construction. This research put forward the concept model of ‘nature—human body—Healthy City’ and accordingly constructs an evaluation index system for the construction of a Healthy City that integrates five dimensions of ‘medical level, economic foundation, cultural development, social services, and ecological environment’, which provides a theoretical reference and guidance for other countries or regions to assess the construction of Healthy Cities and countries.

Author statements

Ethical approval

This research was ethically approved by Ludong University.

Funding

This research was supported by the grant from the National Social Science Foundation of China (Grant Number:19CGL070) and Shandong Higher Education ‘Youth Innovation Science and Technology Support Program’(Grant Number:2021RW042) and Yantai School-Land Integration Development Project (Grant Number: 2021XDRHXMQT31).

Competing interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Author contributions

M.Z. contributed to conceptualization, data curation, formal analysis, visualization, and writing the original article. W.Q. contributed to data curation, review and editing the article, formal analysis, visualization, resources, supervision, methodology, and funding acquisition. S.Z. contributed to conceptualization, data curation, and visualization. F.Q. contributed to data curation and writing, reviewing, and editing the article. X.L. contributed to visualization and review and editing the article. X.L. contributed to data curation and review and editing the article.