HCC is found in many regions of the world. As noted previously, this movement began in 1986 with the WHO’s Ottawa Charter. In essence, in 1986, the WHO’s Ottawa Charter became the first worldwide action plan for health promotion. At that time, the delegates to the conference declared that the following broad categories were prerequisites to health: peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice, and equity. This is a much different approach to viewing health than the individualistic approach that holds that each person is responsible for his or her own health. Although 1986 seems to be in the distant past, the areas for action that were determined by the Ottawa Charter for Health Promotion deserve attention today (WHO, 1986). They are:

As discussed in Chapter 17, health promotion is a process designed to help people increase control over, and improve, their health. Health promotion is not just the responsibility of the health sector but rather includes individuals, families, groups, and communities. Strategies and programs should be customized to meet local needs and take into account different economies, customs, resources, and priorities. The original goals of the Ottawa Conference continue to be areas of concern, and work must continue to achieve the goals. Chapter 4 also addresses, from a global health perspective, the need for a healthy community approach in selected countries around the world.

HCC began in the United States in 1988, with Healthy Cities Indiana and the California Healthy Cities project. Healthy Cities Indiana adapted the European experiences to the American context. The concept of Healthy Communities was used to include localities that were not cities but rather smaller communities such as towns or counties. In recent years, many U.S. communities have initiated the HCC process with the result that thousands of communities have taken local action to promote health. Several of these communities are featured in the chapter as examples of what a focus on health promotion at the community level would look like.

In other parts of the world, HCC has different names, including Healthy Islands, Healthy Villages, and, in Latin America, Healthy Municipalities and Communities. In addition, national networks have developed in Australia, Canada, Costa Rica, Iran, and Egypt. Other regional networks have been developed in Francophone Africa, Latin America, Southeast Asia, and the western Pacific. Particular attention will be given later in the chapter to Healthy Municipalities and Communities in the Pan American Health Organization (PAHO) region, since PAHO’s work is long standing and well developed and has demonstrated effective results.

Some claim that the concept of a healthy community or city is not new (Hancock, 1993). It is based on the belief that the health of the community is largely influenced by the environment in which people live and that health problems have multiple causes—social, economic, political, environmental, and behavioral. The HCC process has been applied to rural and metropolitan areas. The HCC process engages local residents in action and is based on the premise that when people have the opportunity to work out their own locally defined health problems, they will find sustainable solutions to those problems. This concept is integral to good public health practice, which is to engage those for whom programs are being developed in the identification of need for, planning, implementing, and evaluating the programs. The Healthy People 2020 process is consistent with the way in which healthy communities and cities have developed their priorities and plans. One of the four goals of Healthy People 2020 is to create physical and social environments that promote good health for all. This goal relies on an ecological perspective that says that health and health behaviors are determined by many influences including personal, organizational, environmental, and policy factors. Many of the goals of Healthy People 2020 will be challenging to meet in light of the poor economic conditions in the United States and many other countries. For example, it is difficult to increase the income of low-income persons in an era in which people continue to lose their jobs. See the Healthy People 2020 box for objectives that relate to healthy communities and cities.

There are many definitions of a healthy community. The Healthy People 2010 document described a healthy community as one that included those elements that enable people to maintain a high quality of life and productivity (USDHHS, 2000). To expand on this definition, consider what was stated in the document, Healthy People in Healthy Communities: A Community Planning Guide Using Healthy People 2010, that a healthy community would include access to health care services that include both treatment and prevention for all community members; the community would be safe; and there would be adequate roads, schools, playgrounds, and other services to meet the needs of the people in the community and that the environment would be healthy and safe (USDHHS, 2001).

The CDC defines a healthy place as one that is “designed and built to improve the quality of life for all people who live, work, worship, learn, and play within their borders—where every person is free to make choices amid a variety of healthy, available, accessible, and affordable options” (CDC, Healthy Places, n.d.). The CDC also points out that a healthy community is one that continuously creates and improves both the physical and social environments and expands community resources to enable people to mutually support each other in carrying out essential life functions as well as in developing to their maximum potential. A healthy community seeks to improve the quality of life of its people and does this through collaboration, partnerships, diverse and extensive citizen ownership, and partnership in the process.

Instrumental in the development of the Healthy Cities movement were the principles of primary health care (WHO and UNICEF, 1978) and the Ottawa Charter for Health Promotion (WHO, 1986). Primary health care refers to meeting the basic health needs of a community by providing readily accessible health services. Because health problems transcend international borders, international cooperation is important to ensure health. The principles of primary health care include equity, health promotion, community participation, multisectoral cooperation, appropriate technology, and international cooperation.

Equity implies providing accessible services to promote the health of populations most at risk for health problems (e.g., the poor, the young, older adults, minorities, the homeless, and immigrants and refugees). As discussed in Chapter 17, health promotion and disease prevention focus on providing community members with a positive sense of health that strengthens their physical, mental, and emotional capacities. Individuals within communities become involved in health promotion through community participation, whereby well-informed and motivated community members participate in planning, implementing, and evaluating health programs. Multisectoral cooperation is the coordinated action by all parts of a community, from local government officials to grassroots community members. Appropriate technologyrefers to affordable social, biomedical, and health services that are relevant and acceptable to individuals’ health, needs, and concerns.

There are different models of community practice, and the assumptions that professionals have about communities shape the implementation of the HCC process. The classic work of Rothman and Tropman (1987) describing these different models and some of the key assumptions continue to be relevant today, as will be seen in the examples used in this chapter. The key models for community practice include the following:

Effective models of community practice use a partnership between citizens and professionals in which there is delegated power and citizen control (Rothman and Tropman, 1987). A partnership approach, considered a bottom-up approach, incorporates the concepts of a multisectoral approach as well as community participation. A partnership approach contrasts with the top-down type in which professionals and experts tell the citizens what to do rather than involve and ask them.

A bottom-up approach uses broad-based community problem solving that includes health professionals, local officials, service providers, and other community members, including those at risk for health problems. The locality development and social action models are examples of a bottom-up approach, in which community participation is evident in all stages of community health planning and practice.

In the following paragraphs, HCC initiatives in various regions of the United States are discussed. These examples show the different models of community practice that are being implemented. Specifically, the CDC’s Healthy Communities Program emphasizes policy, systems, and environmental changes that focus on chronic diseases and that encourage people to be more physically active, eat a healthy diet, and not use tobacco. The rationale is based on the fact that about 50% of Americans are affected by chronic disease, and these diseases account for 7 of the 10 leading causes of death in the country. Also, there are many direct and indirect costs associated with being obese and overweight. Many chronic diseases are preventable. By preventing a chronic disease from occurring, people can enjoy a higher quality of life, communities have a decreased burden of illness, and both the state and federal governments are able to reduce the amount they spend on health care (CDC, 2009a). Using diabetes as an example, the CDC says that between 1994 and 2009, the number of people with diabetes doubled. The CDC predicts that if that trend continues, one third of the children born in 2000 will develop type 2 diabetes during their lifetime. The CDC said also that more than one third of all adults fail to meet recommendations for aerobic physical activity based on the 2008 Physical Activity Guidelines for Americans; that tobacco is the single most preventable cause of disease, disability, and death; and that excessive alcohol use is the third leading cause of death related to lifestyle (CDC, 2009a).

These chronic disease facts support the priority that the CDC has placed on funding projects that will interrupt chronic diseases in communities around the country. Since 2003, the CDC has funded more than 240 rural, urban, and tribal communities to support their goals. Specifically, their programs include: Strategic Alliances for Health Communities, ACHIEVE (Action Communities for Health, Innovation, and EnVironmental ChangE), REACH U.S., Pioneering Healthy Communities (in collaboration with the YMCA of the USA), and Steps Communities (CDC, 2009b).

The CDC has also developed a set of “tools for community action” that can be used in developing healthy communities. The Did You Know? box includes examples of the CDC tools for community action.

As mentioned earlier, PAHO in collaboration with the WHO has a long-standing involvement in developing healthy communities that they call the Healthy Municipalities and Communities Movement. The mission of this movement is to “strengthen the implementation of health promotion activities at the local level, making health promotion a high priority of the political agenda; fostering the involvement of government authorities and the active participation of the community, supporting dialogue, sharing knowledge and experiences and stimulating collaboration among municipalities and countries” (PAHO, Healthy Municipalities and Cities, n.d.). Other key concepts in their approach are that of multisectoral partnerships to improve social and health conditions and advocacy for developing healthy public policy, maintaining healthy environments, and promoting healthy lifestyles. PAHO believes that creating a healthy municipality involves a process that relies on strong political commitment and support that is aligned with equally strong communities who are determined to achieve their goals and who participate actively in the process of goal achievement (PAHO Healthy Municipalities and Cities, n.d.).

PAHO recommends a participatory development framework in which you gain commitment from the mayor, local government (all sectors), and representatives of community groups and organizations. PAHO has found this process to be the most effective in the Americas. The phases are:

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