IntroductionSince 1986, the World Health Organization has promoted a Healthy Communities/Healthy Cities initiative, also known as the Alliance for Healthy Cities, with hundreds of participating municipalities across the world (Hancock, 1993; World Health Organization, 2018). The purpose of the Alliance for Healthy Cities is to encourage local governments to incorporate health promotion into all areas of public practice, economic policy, and urban development (World Health Organization, 2018). Goals of the Healthy Communities/ Healthy Cities approach include reducing public health risks including obesity, and promoting healthy lifestyles, public safety, and health equity. The success of Healthy Cities programs and policies directly depends on the empowerment of nurses at all levels of practice, including community-based nurses. Because each community presents different needs, goals, and challenges, nurses in each community can collaborate with partners and stakeholders to promote and reach realistic public health goals.

Healthy Communities: Relevance to the Nursing Profession

The Healthy Communities/Healthy Cities approach is based on the ecological model of public health and nursing, which is systemic in approach. Individual health is viewed as part of a whole; the individual is influenced by socioeconomic and cultural factors as well as by issues related to quality of life in the community. Public infrastructure, clean air, and normative behaviors all have a strong impact on individual decision-making, lifestyle, and attitudes towards health, healthcare, and wellness (Bowen, Barrington & Beresford, 2015; Story, Kaphingst, Robinson-O’Brien, et al., 2008). Nurses also treat patients within the same normative environment; when nurses make lifestyle recommendations for patients, those recommendations are much more meaningful and easier to act on when the patient is supported by community infrastructure and health-seeking paradigms. Community health approaches like the Healthy Cities/Healthy Communities projects are grounded in evidence-based practice Bowen, Barrington & Beresford, 2015; Story, Kaphingst, Robinson-O’Brien, et al., 2008). While the majority of studies focus on the impact of public policy and community nursing on obesity and related health issues, a growing body of evidence also supports public health approaches and nursing policy to reducing violence and extremism too (Weine, Eisenman, Kinsler, et al., 2016). The Healthy Communities/Healthy Cities approach is flexible, taking into account the diverse needs of heterogeneous communities and has proven successful all over the world (Hu & Kuo, 2016; Rice, Franseschini, Wallerstein, et al., 2017). Because participation in the initiatives is fully voluntary, the implementation of the Healthy Communities approach to health promotion is generally achieved in a bottom-up fashion, although some municipalities find that a top-down approach to implementation works better. Ultimately, the mechanisms of action and specific methods of policy implementation can be

adaptable to suit the needs of individual communities, their residents, and business owners.

Financial Impact

The financial impact of healthy cities initiatives varies depending on how the policy is implemented at the local level. In most cases, executing a Healthy City/Healthy Community plan requires the participation of both public and private sector, creating opportunities for strategic partnerships. Healthy Cities initiatives involve public works and urban planning projects that have the dual effect of promoting health behaviors and stimulating economic growth and development in the area. Similarly, municipalities that adopt a healthy communities approach also build alliances with businesses that are committed to social responsibility. Improving public health in the community has a positive effect on economic growth by encouraging community involvement in local businesses, encouraging foot traffic through walking and bicycle paths through the community, and also, improving health outcomes. Improving health outcomes in targeted communities reduces unnecessary healthcare expenditures, liberating healthcare resources for making improvements to critical care.

Values and Ethical Principles

Ethical principles guide the nursing profession. When nurses actively participate in policy development related to the creation of Healthy Cities/Healthy Communities, they fulfill most of the core ethical objectives of the profession including patient autonomy, beneficence, equity, and social justice. Nurses are committed to care at every level of delivery: the individual, family, and community (Pope, Hough & Chase, 2016). The principle of beneficence means that nurses act in ways that benefit their patients, including their extended families, not through paternalistic actions but through patient empowerment. Patient empowerment depends on knowledge and information, but also on awareness and access of public health services. Communities that have robust healthy infrastructure are beneficent communities, and nurses have an ethical obligation to participate in urban planning that reflects the core goals of public health and health promotion. The beneficent parameters of a healthy city include features like high...

Nurses promote patient autonomy by encouraging patients to make decisions based on available information and resources. Patients are not coerced in any way to access or utilize public health resources or community services, but those services are available and the patient and family members are aware of those services. Finally, Healthy Cities/Healthy Communities promote social justice and health equity. The fundamental tenets of the nursing and public health policy include the assurance that all residents of the community have the opportunity to live as a high a quality of life as possible.
Policy Brief: Healthy Communities

Audience and Decision Makers

Uriel Jones, Mayor of Puerto Santa Lucia, is the primary audience for this policy brief. As a chief decision maker in the Puerto Santa Lucia community, Jones has the ability to make the top-down executive decisions that affect economic policy, business development, infrastructure changes, and citywide public health policies. Jones has worked with nurses and public health advocates before, and is therefore a sympathetic audience. However, Jones also needs to know that the business community in Puerto Santa Lucia supports the initiative and is able to participate in the decision-making process.

Review of Literature

To consider making changes to community policy and transforming Puerto Santa Lucia into a Healthy Community, Jones should be made aware of emerging literature and the corpus of nursing research substantiating the efficacy of the proposed changes. For one, changes made to local community infrastructure have a direct and immediate bearing on quality of life in the community as well as global health outcomes. “Land-use and transport policies contribute to worldwide epidemics of injuries and non-communicable diseases through traffic exposure, noise, air pollution, social isolation, low physical activity, and sedentary behaviors,” (Sallis, Bull, Burdett, et al., 2016, p. 2936). Institutional changes, political commitment, capacity building, innovative public planning, and other partnership-based local solutions have been shown to promote “overall sustainable urban health development,” (Hu & Kuo, 2016). Rice, Franceschini, Wallerstein, et al. (2017) also show how communities like Puerto Santa Lucia stand to benefit financially from improving the brand identity of the municipality, which would therefore improve the area’s attractiveness to investors.

Research also shows that a top-down approach might help improve public health in tangible and measurable ways, by increasing equitable access to healthy food sources, promoting healthy lifestyles, and creating a normative culture of health (Bowen, Barrington & Beresford, 2015; Story, Kaphingst, Robinson-O’Brien, et al., 2008). The proposed policy change directly addresses the ethical imperative of social justice and equity, which would help establish Puerto Santa Lucia as a leader in sustainable, equitable community development. Research shows that especially when it comes to preventable health issues like obesity, which can be addressed through nursing advocacy and interventions, community-level issues like public infrastructure and public policy, have a direct impact on health outcomes. For example, “obesogenic nutrition environments are spatially patterned such that they cooccur in areas with larger proportions of low-income and minority populations,” (Bowen, Barrington & Beresford, 2015, p. 290). The low-income neighborhoods of Puerto Santa Lucia can enjoy improved health outcomes, higher quality of life, and sustainable economic growth through a concerted effort at creating a Healthy Community.

While macro-level policies can be helpful, driving down overall costs, impacting public health announcements, media, and advertising, ultimately the immediate and daily life factors like having parks, walking paths, and cycling paths are issues over which mayors like Smith have direct control. The proposed changes imply both bottom-up and top-down approaches to public development. When cities like Puerto Santa Lucia solicit the active participation of nurses and nursing coalitions into their public planning departments, they can achieve measurable outcomes in accordance with the ethical values and goals of the Healthy Cities/Healthy Communities objectives. Improving the local application of Healthy Communities initiatives has the potential to reduce healthcare costs, improve the economy, and also enhance all quality of life factors including social justice, affordable housing, and health outcomes. Therefore, the Mayor of Puerto Santa Lucia is motivated by a strong set of data-driven, evidence-based solutions.

Challenges

Challenges to making policy changes include the need to solicit funding and other perceived financial impediments, and the time it takes to realize public health behavioral changes. Behavioral changes require normative culture changes, which…