Healthy Cities: Facilitating the Active Participation and Empowerment of Local People

Abstract

Community participation and empowerment are key values underpinning the European WHO Healthy Cities initiative, now in its fifth phase. This paper provides a brief overview of the history, policy context, and theory relating to community participation and empowerment. Drawing on Phase IV evaluation data, it presents the findings in relation to the four quadrants of Davidson’s Wheel of Participation—information, consultation, participation in decision making, and empowerment. The large majority of European Healthy Cities have mechanisms in place to provide information for and to consult with local people. Most also demonstrate a commitment to enabling community participation in decision-making and to empowering citizens. Within this context, the evaluation highlighted a diversity of approaches and revealed varied perspectives on how participation and empowerment can be integrated within city leadership and governance processes. The paper concludes by suggesting that there is a need to strengthen future evaluative research to better understand how and why the Healthy Cities approach makes a difference.

Concepts and Contexts

Introduction

Community participation and empowerment are core principles underpinning the World Health Organization (WHO) European Healthy Cities initiative. While Phase I (1987–1992) was characterized by innovative examples of action,¹ the principle was subsequently formalized within designation criteria.^2–4 Phase II (1993–1997) required cities to establish mechanisms for public participation; Phase III asked cities to “demonstrate increased public participation in the decision-making processes… thereby contributing to the empowerment of local people”;^3(p19) and Phase IV (2003–2008) called for an emphasis on participatory and democratic governance within health development. Building on evaluations of Phases III⁵ and IV, this paper outlines the relevant policy context, provides an overview of theory and practice, and critically considers how cities in the WHO European Healthy Cities Network have integrated community participation and empowerment within their work.

Origins, Evolution and International Policy Context

Community participation and empowerment have long and complex histories, with roots in colonial and urban development programs,^6,7 consensus-based and conflict-oriented social action,^8,9 and popular education and conscientization.^8,10,11 Reflecting growing dissatisfaction with conventional approaches to health development, the 1978 Alma-Ata Declaration¹² highlighted social justice and equity^6,13,14 and focused on community participation in health planning and delivery.¹⁵

Although WHO’s approach was subject to critique for its atheoretical and depoliticized pragmatism,^6,16,17 the Health for All movement gained widespread support in “developing” and “developed” countries. The Ottawa Charter for Health Promotion¹⁸ incorporated the primary health care perspective within a broader framework for the “new public health.” It defined health promotion as “the process of enabling people to increase control over, and to improve, their health”^18(p1) and suggested that:

Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities—their ownership and control of their own endeavours and destinies.^18(p3)

Subsequent publications have reinforced this perspective (see Box 1). Alongside other landmark documents such as Agenda 21,¹⁹ these have guided and reflected the journey taken by the WHO Healthy Cities movement in embedding participation and empowerment within strategic city leadership for health and sustainable development.

Box 1:

Building on the Ottawa Charter—Community Participation and Empowerment in International Policy

1991 Sundsvall Statement on Supportive Environments for Health20

Argued that empowerment and community participation are “essential factors in a democratic health promotion approach and the driving force for self-reliance and development”20(p4)

1997 Jakarta Declaration on Leading Health Promotion into the 21st Century21

Reinforced the importance of participation, highlighting the need to increase community capacity and empower individuals, and emphasizing that actions should be “carried out by and with people, not on or to people”21(p3)

1999 Health21 22

Advocated a participatory health development process involving “reaching out to empower individuals, local communities and private and voluntary organizations in different settings for health, e.g. homes, workplaces, schools and cities”22(p68)

2005 Bangkok Charter for Health Promotion in a Globalized World23

Affirmed the centrality of policies and partnerships to empower communities, advocating that “empowered communities are highly effective in determining their own health, and are capable of making governments and the private sector accountable for the health consequences of their policies and practices”23(p5)

Defining and Exploring the Concepts

The term community is understood as “a group of people who share an interest, a neighbourhood, or a common set of circumstances… [who] may, or may not, acknowledge membership of a particular community,”^24(p79) while participation implies being involved or sharing in something. Bringing the words together, WHO has proposed the following working definition of community participation within the context of the Healthy Cities:²⁵

A process by which people are enabled to become actively and genuinely involved in defining the issues of concern to them, in making decisions about factors that affect their lives, in formulating and implementing policies, in planning, developing and delivering services and in taking action to achieve change.^{25(p. 10)}

The concept of empowerment remains contested. At its core is the notion of power, defined as “the ability to control the factors that determine one’s life”^26(p300) Laverack²⁷ suggests that empowerment is a “process by which relatively powerless people work together to increase control over events that determine their lives and health”^27(p113) and Schuftan²⁸ defines it as “a continual process that enables people to understand, upgrade and use their capacity to gain better control over and gain power over their own lives.”^{28(p. 60)} While the nature of power continues to be debated,^27–32 it is important to appreciate that public health involves both “zero-sum” and “non-zero-sum” formulations of power.¹⁴ A zero-sum approach argues that power is limited—and therefore requires practitioners to advocate and enable shifts in the balance of power within societies. In contrast, a non-zero-sum approach views power as unlimited—and seeks to facilitate the release of strengths and assets within disadvantaged communities.^8,33 Laverack¹⁴ suggests that community empowerment is a “synergistic interaction between individual empowerment, organisational empowerment and broader social and political actions”^14(p36) and various writers have suggested that “conscientization” can serve as a mediating process involving the development of critical consciousness through the social analysis of conditions and of people’s role in bringing about transformational change.^8,26,29,34

Towards Effective Community Participation and Empowerment

It is widely appreciated that effective community participation and empowerment need to be practised coherently and connect spheres of action.^24,35 With reference to Healthy Cities, it is suggested that this should involve: support for community-level action and capacity-building; strengthening of infrastructures and networks; and meaningful organisational development and change.³⁶

Community participation operates at different levels and embraces a range of practices, as conceptualized by the ladder/continuum, popularised by writers such as Arnstein³⁷ and Brager and Specht³⁸ (see Figure 1). Healthy Cities advocates high levels of participation that promote active and meaningful engagement, involvement, and empowerment. However, it also appreciates that a city’s approach depends on particular political, social, economic, and organizational contexts offering different opportunities and constraints.²⁵ Recognizing that it may be helpful to view participation in a non-hierarchical way,^39,40 Davidson’s Wheel of Participation⁴¹ offers a non-linear model that distinguishes objectives and techniques under four quadrants of information, consultation, participation, and empowerment (Figure 2).

FIGURE 1.

A ladder of community participation: Level of participation, participants’ action, and illustrative modes for achieving it. Source: adapted from Brager and Specht.³⁸

FIGURE 2.

The wheel of participation. Source: adapted from Davidson.⁴¹

Methodology

The research instruments used within the European Healthy Cities Phase IV evaluation were the Annual Reporting Template (ART) for 2006–2007 and 2007–2008 and General Evaluation Questionnaire (GEQ), versions of which were sent to 78 network cities and 29 national networks. Additionally, case studies were generated by cities and national networks, and reports were produced by thematic sub-networks.

In order to evaluate the place of community participation and empowerment within Phase IV, a basic word search was carried out on collated responses to the networks’ questionnaire and the cities’ and networks’ ARTs. However, the principal data source proved to be the cities’ GEQ, returned by 58 of the 78 network members (73%). One section addressed community participation and empowerment, asking four questions based on Davidson’s Wheel.⁴¹ Responses were analysed and coded, identifying key themes, supported by illustrative examples and quotations from cities.

Findings

An analysis of the evaluation documentation revealed that 18 (23%) cities mentioned either “community participation” or “empowerment” in their ART returns, with no national networks mentioning these terms in either their GEQ or ART returns. Of the 58 cities returning the GEQ, 57 answered the questions relating to consultation, participation and empowerment, and 56 cities answered the question about providing information.

Providing Information

All cities completing this question indicated that they prioritize the provision of information to their citizens (Figure 3), a number consciously adopting a broad-brush approach:

[We inform citizens] via flyers, brochures, publications, public discussions, press conferences, local media, web pages, various health events. They are all equally effective. (Rijeka)

Bursa… uses its web sites, bulletins and meetings to inform citizens. (Bursa)

Website, media, brochures, advertisements, meetings, conferences, consultations, letters. (Ostfold County)

FIGURE 3.

Mechanisms used for providing information to citizens.

The most commonly used mechanisms are the “traditional” mass media, with 66% stating that they used television, radio, and/or newspapers:

Informing of the townspeople occurs through mass media (TV, radio, press, banners). (Cheboksary)

We inform the local press about activities. (Bartin)

The internet is also widely used, with 64% mentioning this as an important communication channel and referring to either their own healthy city website or to other health-related web pages:

Belfast Healthy Cities redesigned and launched a new website during Phase IV – this strengthens our ability to share learning and experience. (Belfast)

The municipal website is perhaps the fastest and most effective way for citizens to access the latest developments in the municipal agreements and actions. (Leganes)

The use of specialist newsletters/bulletins was highlighted by 48% of cities, with 16% publishing their own newsletter and 36% utilizing general publications:

We have a well-established magazine called ‘Gesunde Stadt’ that informs citizens about health issues, our own projects and services and projects within the city. (Vienna)

The weekly municipal newspaper is the most effective way because citizens regularly follow it. (Kadikoy)

Other communication channels featuring in cities’ responses include specialist publications such as health profiles (20%), city health plans (7%), and other booklets/brochures (21%); seminars, conferences, and training courses (20%); campaigns (18%); meetings and events (14%); posters (13%); exhibitions (5%); creative media (5%); billboards (4%); a health shop (2%); and a city center speaker system (2%).

A number of cities emphasized the importance of developing a strategic approach to informing citizens about health (see Box 2), several discussing the value of utilizing a diversity of mechanisms and drawing on creative approaches:

We think is important to use a range of methods, specific to each population and each age. (San Fernando)

Strategies frequently use arts and culture as a methodology for providing information in a form that is specifically tailored and appropriate to the relevant target audience. (Liverpool)

During Phase IV, two health magazines were produced addressing important health issues… informed by social marketing approaches. (Brighton)

Box 2:

A Strategic Approach to Providing Information

Kuopio has adopted a comprehensive approach to information provision, using a wide range of mechanisms and demonstrating a concern to integrate passive information giving with experiential learning:

“On the strategic level, the City of Kuopio has made a decision that the Healthy Kuopio programme and the WHO Healthy Cities Network are the major brands of the region… To achieve this, we inform our citizens about health in all possible ways: via the internet, media co-operation, leaflets, posters, events, etc. Residential halls function especially as meeting points for the elderly and work in concert to promote health information… The Social and Health Care sector has had its own information officer… which has improved communication within the city administration and to citizens. A planning officer who is responsible for health promotion gives lectures and information.”

Udine demonstrates a wide-ranging approach to keeping citizens well-informed, utilizing general and targeted mechanisms:

“Citizens are kept informed about health topics, projects and statistics as well as about educational, cultural or recreational initiatives regarding health or community life in general through local newspapers, radio and TV. Moreover, specific publications are produced regarding specific themes or addressing specific population groups such as older people and children. For example, the Department of Social Services produces a publication taking stock of all the activities that the municipality implemented every year and of the services offered. Some pages are also devoted to the Healthy Cities Project activities. This publication is distributed as an attachment to the local newspaper. Another specific publication is the City Health Profile… Information is inserted on websites both by the Municipality and by the Local Health Agency allowing users to get real-time and accessible information about the performance of local services.”

Consulting Local People

All cities consult with their citizens (Figure 4), but whereas some discussed the difficulties of undertaking direct consultation across a large area or indicated that they restrict the process to the project level, others demonstrated their commitment to consulting across the breadth of their work, using a variety of methods (see Box 3).

FIGURE 4.

Mechanisms used for consulting local people.

The most commonly used consultation mechanism is the questionnaire, highlighted by 62% of cities. Internet-based, postal and face-to-face surveys are used with the general population, with specific sub-groups and about particular topics of concerns. Methodological approaches vary:

[We used] a systematic random sampling approach… allow[ing] for ±3% confidence interval and based on the number of households in the sampling frame. (Galway)

A survey team consisting of 13 university students… visits residents in their houses… and the results are immediately reported. (Eskisehir)

Interviews and focus groups were highlighted by 23% of cities as important mechanisms for exploring citizens’ views:

We consult with local citizens through interviewing. (Stavropol)

Focus groups… of local citizens took part in developing local documents and legislative acts. (Yevpatoria City)

Forty-six percent of cities use meetings and public events, some working through organizations, others directly with citizens:

There are meetings with local citizens and associations on important issues and decisions. (Torino)

Rennes has developed large public events such as the 2004 ‘City Desire’… to gather the inhabitants’ wishes concerning the City of Tomorrow. (Rennes)

[We] organize meetings with organizations of the citizens… with groups of citizens… with the community. (Athens)

Another important focus was neighborhood-based consultation, 21% mentioning district committees or panels in different geographical areas:

…the municipality was organised into five civic committees… to raise citizens’ participation in decision-making processes… [and produce] local development plans. (Helsingborg)

Recently, discussion groups of inhabitants have been put in place in different districts of the city. (Dunkerque)

Formal groups of citizens are established in the local areas… with representatives from the civil society… These local units are also consulted before decisions in the City Council. (Copenhagen)

The importance of consulting specific population groups was highlighted by 18% of cities, some linking their processes to thematic priorities:

Older persons are active members of the ‘Active Ageing’ working group. Joint discussion of the Healthy Ageing Profile… has received a big resonance in the city. (Cherepovets)

Crime prevention work has involved setting up five young people’s groups/district groups with local participation. The area committee… includes local youth representatives. (Sandnes)

In addition to serving as information vehicles, the internet and mass media were highlighted by a number of cities (12% and 7%, respectively) as a means of inviting citizens to contribute views:

…within the scope of Healthy Urban Planning, our goal is to construct an online discussion platform… [to] allow for greater… gathering of opinions. (Seixal)

Radio programmes about health and environment issues are all interactive (telephone, internet). (Pecs)

In addition, a small number of cities mentioned specific techniques such as citizens’ juries, planning for real, open space, citizens’ panels, call centers, referenda, media content analysis, and visioning. Feedback was emphasized by 16% of cities, some also demonstrating a proactive commitment to enabling the consultation process:

We have learnt the importance of local accessible venues, providing the basics (e.g. transport, childcare, interpreting), making it a good experience, giving and receiving feedback and being accountable. (Newcastle)

Feedback… is usually provided through publications, final reports and public meetings to let people understand they can affect decisions… and that their efforts have been useful for the improvement of the urban environment. (Udine)

Box 3:

Comprehensive Approaches to Consulting Local People

Lodz consults widely with a diversity of citizens, using a range of surveys to gather information that can inform health-related planning:

“The opinions of the inhabitants on important issues such as lifestyles, health-related behaviours, level of satisfaction with health care and other services, public transport, access to culture and sports facilities, were acquired in a HEPRO survey*… of 1000 adult residents of Lodz; a survey on a representative group of elderly citizens; a survey on the clients of nursing homes and day-care centres for the elderly; and a study on health behaviours of the pupils of Health Promoting Schools in Lodz… Information collected in this way allows us to adjust our action for health to the actual needs of the inhabitants.”

Dimitrovgrad uses more informal approaches to gather community perspectives and views, including questionnaires, polls, meetings, and public hearings—and also prioritizes feedback:

“The population’s opinion about public health problems… is found out through polls. Questionnaires are published in mass media and handed out in hospitals, polyclinics, social service organisations etc. Children and teenagers are asked to fill in forms at school… or they may take the questionnaires home (if the questions are for grown-ups). Sometimes polls are organized by experts… in the street, on the phone, or by visiting people at their homes… The population’s attitude to the social policy of the authorities is found out at personal meetings of the city officials with citizens [which] take place monthly in neighbourhoods of the city, according to a plan published in newspapers. The most important documents… must pass public hearings. The feedback is provided by publishing results in the local mass media. If it is children who answered the questions, the results are given to their parents at parents’ meetings at school.”

*HEPRO was an EU-funded project (2005–2007) that brought together Healthy Cities in the Baltic Sea Region with the aim of helping to put public health issues on the political agenda. Through developing tools for use in health planning, conducting a survey to describe health conditions, both regionally and locally, and developing educational programs.

Enabling Community Participation in Decision Making

Three cities indicated that they have no mechanisms to enable citizens to participate actively in decision making, while others reiterated consultation methods, such as meetings, questionnaires, and public events (Figure 5). However, many more highlighted specific mechanisms (see Box 4), with 35% emphasizing their commitment to enabling representation of non-governmental organizations (NGOs) and community organizations on steering committees:

The Healthy Cities Steering Committee [has] five community representatives from 15 members. (Dresden)

Many community representatives are members of the Steering Committee. The most important requirement is that these members represent general and not specific interests. (Arezzo)

They are an equal partner… They were chosen according the population sub-group they are representing [and] their willingness to work in this project. (Celje)

FIGURE 5.

Mechanisms used for enabling community participation in decision making.

Furthermore, 18% of cities highlighted the importance of enabling more general participation in strategic processes and program formulation and delivery:

Participation of community representatives… specifically aimed at the contribution to the design of strategical planning documents. (Montijo)

The Urban Centre was established… to enable involvement of Brno public into the decision-making process in matters concerning city development and urbanism. (Brno)

Fourteen percent mentioned their concern to ensure community representation on thematic working groups and 19% stressed the importance of community participation in area-based decision making:

The citizen representatives (associations) are members of Healthy City workshop groups… They participate and decide what are the priorities in the matter of health in the district. (Nancy)

The Community Development Plans empower the community representatives to decide and implement action at the territorial level. (Barcelona)

Focusing on specific structures, 11% mentioned the existence of a community forum or network, some integral to their healthy city initiative, others established as an all-purpose municipal venture:

The Community Forum… is also an important mechanism enabling community representatives to participate in the Healthy City decision-making and nurturing a sense of ownership of the Healthy City agenda. (Horsens)

The city has an established community network, supported by funding from the city council… tasked with co-ordinating community and voluntary sector representation and engagement in policy and the formal partnership decision-making structures. (Manchester)

Looking beyond their specific healthy-city actions, a number of cities also highlighted the importance of general municipal mechanisms for enabling citizen participation in decision making:

No application of management has been implemented without determination of the public’s views and demands. (Aydin)

Within this context, 5% of cities mentioned commissions and a wider range referred to formal councils/fora giving voice to particular sub-populations (older people, 18%; young people, 12%; disabled people, 7%; minority ethnic groups, 4%). Reflecting on how best to mobilize interest, Horsens highlighted the value of having healthy city representation on wider thematic, sub-population group and area-based bodies, while several cities referred to agreements that influence decision-making processes:

The Sunderland Compact is a code of practice that governs the relationship between the voluntary, community and statutory sectors… and covers… how voluntary and community sector organisations can be involved in commissioning. (Sunderland)

Box 4:

Enabling Meaningful Community Involvement in Decision Making

Sheffield has used a wide range of innovative mechanisms to ensure that community engagement and empowerment are constant threads in its approach to decision making:

“To ensure citizens have a local voice to influence key decisions, Sheffield established 12 Area Panels who engage with local neighbourhoods in decisions that affect their quality of life. The Health Partnership Network is a well-established Voluntary and Community Sector network of over 700 organisations… [It] feeds directly into the Healthy City Partnership through five representatives who communicate with the sector via regular newsletter bulletins and bi-annual events. The network provides a powerful mechanism by which the sector can challenge, contribute to and lead the development and delivery of both the strategy and activities to tackle health inequalities.”

Izhevsk has prioritised the participation of a wide range of NGOs in its decision-making processes:

“[We have enabled community participation in decision making by] involving the people in the participation in working groups on preparing of the Health Profiles; in working groups on preparing of the City Health Development Plans; in different kinds of activities (round tables, actions, meetings, conferences) concerning health. The vivid example was the City Forum of Health for choice of the city priorities in health… Known and authoritative public organizations (pensioners, the ecological organizations, children’s and youth’s NGOs)… were involved in this work.”

Empowering Citizens

One city indicated that it has no mechanisms in place to empower citizens and others acknowledged that, although they have begun to embed community participation into city governance, they are at an early stage in developing a culture of empowerment:

Empowerment is a typical English word and the translation in French…is not convenient. But worst, the fact [that it] is not yet part of our culture. (Liège)

…as a result of the health plan, the population’s perspective has been integrated in municipal management… [This] represents the beginning of a process which… encourages the empowerment of the population. (Sant Andreu de la Barca)

It was also apparent that cities had extremely varied perspectives on community empowerment (making it inappropriate to quantify data)—a few equating it with informing or consulting, others demonstrating a more developed strategic understanding. Many methods used for consulting and enabling participation in decision making are viewed as empowerment mechanisms, but there is also an emphasis on the proactive enabling role of funded professionals and on active participation, leadership and management by citizens themselves:

The Community Empowerment Network and Black and Ethnic Minority Forum are funded programmes of work with empowerment as a core aim. (Stoke-on-Trent)

‘District Partnership’ is a specific model for community participation and empowerment… supported by the city by funding the employment of a coordinator and district workers. (Turku)

…we believe that empowerment is about people taking control over their lives. (Ljubjana)

We produced a strategy for involvement of vulnerable groups in Participatory Budgeting, a feasible and tested methodology for local government to produce ‘maps of priorities.’ (Tirana)

The main aim of TODAM [a social solidarity network] is to help people who are disadvantaged in the community… The 18 TODAM centres… [have] changed the mentality of the people… living their lives passively in their homes and seeking help from others, by helping them become learning, sharing and producing individuals. (Cankaya)

Three cities highlighted the empowerment role of international cooperation through EU-funded programmes:

The INTERREG IIIC programme² allowed the additional learning mechanism of ‘study visits’—learning by travelling and seeing. (Brussels)

Dealing with similar problems but in a foreign context helped citizens to gain a clearer view on their neighbourhood’s situation. They visit the foreign cities’ projects, they compare, they learn; at the end they pass through a process of empowerment which make them wiser and more active. (Milan)

Shape Up³… involves the school and community… jointly with the child… A Shape Up promoting group will be convened with the support of the city council to assist children, families and schools with the development of initiatives. (Poznan)

In providing examples of empowerment initiatives, the following priorities emerged:

• A focus on training and competence-building, including: a concern to equip citizens with the skills, confidence, and capability to participate meaningfully in the city’s decision-making processes; an emphasis on participatory research; and the development of cohorts of community leaders empowered to enhance community participation

• A focus on peer support and mutual aid as methods of building self-esteem and individual empowerment within communities of interest

• The use of visioning, drama and other creative techniques as processes that are in themselves empowering, but which also empower people to imagine and shape the future

• A focus on specific disadvantaged sub-populations—including older people through the Healthy Aging Sub-Network—often linked to thematic priorities (see Box 5)

Box 5:

Empowering vulnerable and marginalized communities

A major focus was the active participation and empowerment of vulnerable and marginalized sub-populations, often linked to a particular theme:

Seixal uses arts-based methods to empower older people, promoting positive and active aging:

“(Des) Dramatizar is based on theatre, but its objectives reach far beyond… in that mutual aid is promoted, along with inter-personal skills and assertiveness training… Topics related to the ageing process, emotions and health… are discussed… Studies have demonstrated that the elderly population participating in this project is active… and possesses a better quality of living and a more favourable perception of their health than other seniors.”

Stockholm provided an example of empowerment work with young people:

“LAFA (Stockholm County Aids Prevention) provides a methodology and knowledge base for people working with issues relating to sexuality and personal relationships at schools, youth clubs and youth clinics… LAFA also works directly with target groups by means of special projects, advertising and taking part in exhibitions, festivals and other activities.”

Novocheboksarsk profiled a project concerned to empower disabled people, focusing on sport:

“The Healthy Cities project provides support to any projects aimed at the well-being of the population… In particular, participation of disabled organizations in the project ‘Vozrozhdenie’ (Sport and Tourism), as a means of rehabilitation and integration of the disabled into modern society. In total, the health of 150 disabled people of the town has been improved.”

Vitoria-Gasteiz discussed a project aimed at reducing inequalities through empowering women experiencing violence:

“One of the specific goals is to contribute to reducing gender health inequalities… [We have] strengthened the municipal programme to ‘fight against violence exercised on women’… We offer counselling and training for women victims of gender violence and empowerment workshops to promote women’s own social image analysis.”

Yevpatoria City highlighted their empowerment work with HIV positive people and sex workers:

“In collaboration with VNG international (Netherlands), Yevpatoria municipality carried out the project ‘Municipal Response to HIV/AIDS in Crimea’. Some groups of HIV-infected people were established for self support. Later a similar group was established for persons from the sex business. All the groups act within non-governmental organizations which the local government supports.”

Discussion

The Phase IV evaluation data confirm that the European WHO Healthy Cities initiative has continued to be characterized by a strong commitment to community participation and empowerment, reflecting its intention to serve as a “laboratory” for values-based public health innovation. Although different emphases were apparent, cities collectively demonstrated an inspiring wealth of activity across the four quadrants of Davidson’s Wheel⁴¹—informing citizens, consulting with local people, enabling participation in decision making, and empowering communities.

The qualitative nature of the data did not readily enable a detailed categorization in relation to “new blood”/“backbone” or East/West European cities. However, reflecting earlier observations,^5,42 it was apparent that length of experience and cultural differences both influence how cities interpret different concepts and how active they are within the four quadrants. Thus, some cities profiled “blanket coverage” mechanisms for information provision while others discussed the importance of tailoring methods to particular themes and target sub-populations. Some have a requirement for consultation enshrined within national legislation or government policy, while others struggle within less supportive political and organizational contexts. Some rely largely on consultation methods to enable citizens to influence policy, while others have formalized participation in decision making through representation of community and voluntary sectors on steering groups. Some view empowerment as taking place largely through information provision and consultation, while others prioritize a more active process by which professionals enable communities to release capacities and shift power balances. Alongside this, a small number of cities clearly demonstrated commitment to a wide-ranging strategic approach combining grassroots action with networked support and organizational change across the four quadrants.

Whilst the Phase IV evaluation has revealed the rich diversity of community participation and empowerment that exists within Network cities, it has not readily articulated the mechanisms by which Healthy Cities initiates, develops, and sustains such activity. Furthermore, although it has suggested the importance of contextual factors in influencing practice, it has not fully elucidated what works for whom in which circumstances, and why.⁴³ These observations echo those of other writers. Dooris et al.⁴⁴ have highlighted the potential contribution of critical realism in overcoming the restrictions of traditional evaluation and helping build evidence of effectiveness for settings-based health promotion. De Leeuw and Skovgaard have discussed the potential value of theory-based evaluation and utility-driven evidence in increasing understanding how Healthy Cities works.⁴⁵ Green and Tsouros,⁴⁶ reflecting on the evaluation of Phases I–III of the European initiative, have suggested that “realist” evaluation could help to address challenges of accounting for context, addressing multiple, interactive interventions, and identifying mechanisms for change.

Looking ahead, what practical changes might need to be introduced in order to design evaluative research that can secure a fuller understanding of how Healthy Cities is enabling community participation and empowerment in different contexts? Firstly, there is a need to address the challenge of communication presented by an initiative spanning 78 cities in 28 countries. The questionnaire responses suggest that while some respondents are fluent in English, others struggled to understand the subtleties of the questions and communicate detailed responses, thereby generating data of variable quality. Secondly, a full “realist” evaluation arguably demands interactive face-to-face research that can explore theories and processes of change in relation to contexts, mechanisms, and outcomes. Thirdly, in order to understand the relative influence of different contextual factors and change mechanisms, the evaluation needs to include detailed analysis across its different dimensions, thereby generating understanding of how city leadership and governance processes influence and are influenced by community participation and empowerment.

Conclusions

Recent publications^29,40,47 affirm the belief that community participation and empowerment have important benefits through increasing democracy, mobilizing resources and energy, developing holistic approaches, achieving better decisions and more effective services, and ensuring ownership and sustainability of programs.^24,35 As Wallerstein argues, “empowerment… [is] an important outcome in its own right, and also an intermediate outcome in the pathway to reducing health disparities and social exclusion,”^29(p18)—a point reiterated by Hothi, who suggests that “empowerment ‘done well’… helps individuals and communities to exert control over the circumstances that affect their lives, thereby improving local well-being.”^47(p55)

Guareschi and Jovchelovitch⁴⁸ have commented that participation for empowerment not only serves a conscientization role, but also “re-shapes the relationship between individuals, community and the political arena, empowering, developing citizenship and forging spaces for the presence of grassroots in the institutional structures of the state.” The Phase IV Healthy Cities evaluation identified numerous examples of facilitating access to information, consulting, and enabling participation in decision making by local people. Many cities also showed a commitment to empowering processes. Through encouraging visible city leadership that prioritizes innovative participatory governance, the European Healthy Cities movement has demonstrated its ability to bridge the gulf between “top-down” and “bottom-up” and make an important contribution to health, well-being, and sustainable development. During Phase V, the challenge for the European Healthy Cities initiative is to build on this evaluation. Future research needs to capture the richness of activity across Network cities in order to generate robust evidence that can be used to better understand how and why the Healthy Cities approach makes a difference.