Evaluating the Healthy Cities initiative: A scoping review of process evaluations

The Healthy Cities initiative, initially a grassroots movement and later adopted by the World Health Organization (WHO), is a health promotion approach that was developed primarily to increase municipal governments' capacities to address citizen health. The Healthy Cities initiative aims to incorporate health within urban policymaking through local intersectoral, community-driven collaboration. Given that the Healthy Cities movement has been underway for several decades, understanding how the Healthy Cities initiative itself has been evaluated is important. This is particularly timely given recent major shifts in global health governance, including funding cuts at the WHO that may have repercussions for efficiency and results. In this study, we investigate how Healthy Cities projects have been evaluated over the years. We conducted a scoping review reported in accordance with the PRISMA guidelines for Scoping Reviews (PRISMA-ScR). We searched for both peer-reviewed and grey literature in Ovid MEDLINE, Ovid Embase, Web of Science Core Collection, SCOPUS, and the WHO Institutional Repository for Information Sharing (IRIS) from database inception to the date the search was conducted. Our scoping review identified 2206 non-duplicate results for screening, which yielded a total of 95 texts evaluating the Healthy Cities initiative conducted across 57 unique settings that met the inclusion criteria. We present our findings according to regional distribution, evaluation methods, and focus of evaluations. The distribution of evaluations across regions varied significantly, with certain locations serving as focal points for research activity, such as the WHO European Healthy Cities Network. The widespread use of surveys and interviews underscores the emphasis on capturing both quantitative and qualitative dimensions in assessing the Healthy Cities initiative. Although the strong representation of themes such as implementation approach, community participation, and policy development reflects a clear focus on implementation, engagement, and policy outcomes, the underrepresentation of themes such as intersectoral collaboration and capacity building points to areas requiring greater attention.