Healthy cities and municipal administrations in Türkiye: the case of Denizli Metropolitan Municipality

Urbanization has intensified health challenges including malnutrition, infectious and chronic diseases, mental health problems, environmental pollution, unsafe working conditions, poverty, and inadequate local services. While cities can promote health, mismanagement can exacerbate health deficits. In response, the World Health Organization (WHO) launched the Healthy Cities Movement in 1986, which expanded globally by the 1990s and advocates cross-sectoral approaches to place health on urban agendas. In Türkiye, Healthy City initiatives began in 1993 and are coordinated nationally by the Healthy Cities Association of Türkiye and internationally through the WHO Healthy Cities Network. The first objective of this study is to examine the conceptual framework, targets, action fields, and contributions of the Healthy City concept, emphasizing its importance for municipalities. The second objective is to analyze Healthy City practices in Denizli, a city recognized for its activities, plans, and projects aligned with the Healthy City concept. The research question asks whether citizens' knowledge of the Healthy City concept affects (a) their awareness of Healthy City practices in Denizli MM and other Turkish municipalities; (b) their views on success factors for metropolitan municipalities' Healthy City efforts; (c) which Denizli MM service areas should be prioritized; and (d) which institutions should be effective in managing Denizli Healthy City. Sub-questions test relationships with demographics, awareness of Denizli's awards and rankings, and views on information provision, participation, and prioritization of services and responsible institutions.

WHO defines a Healthy City as one that enables residents to support each other to improve health and preserves natural and social environments, with robust environmental and health services and safe, clean living conditions. Contributions include supportive built environments, opportunities for healthy lifestyles across all ages and social groups, and strengthened welfare and cultural identity. Fundamental action areas include improved urban governance, equity and prioritization of vulnerable groups, creation of health-promoting social and physical environments, empowerment and community development, reduction of health inequalities, enhanced local public health capacities, Health-in-All-Policies, improved access and quality of social and health services, and preparedness for public health emergencies. International examples include Copenhagen, Vancouver, and Vienna. WHO criteria for healthy cities emphasize community organization, intersectoral collaboration, information systems, environmental health (water, sanitation, food safety, air), emergency preparedness, education and literacy, capacity building and microcredit. Healthy Cities is a multilevel movement centering community participation and partnerships among municipal authorities, civil society, and stakeholders, with active leadership by mayors and local political actors. The approach supports municipalities in enhancing environmental health services, building participatory capacity, and shifting urban health from reactive treatment to community-based prevention. In Türkiye, Metropolitan Municipality Law No. 5216 delineates municipal responsibilities for health, social services, and facilities, positioning metropolitan municipalities as key actors for Healthy Cities.

Design: Quantitative survey with categorical items analyzed using non-parametric statistics. Statistical analysis: SPSS was used to conduct Pearson's chi-square tests and cross-tabulations to test associations between categorical variables. Reliability: Cronbach's alpha > 0.70 indicated acceptable internal consistency. Normality checks (skewness, kurtosis, outliers, histograms) indicated non-normal distributions; hence non-parametric chi-square tests were applied. Sampling: A multiphase approach combined simple random sampling (to randomly select neighborhoods within Denizli MM's jurisdiction) and purposive sampling (to recruit individuals knowledgeable about Denizli MM's local services). Inclusion required verbal consent and prior awareness of Denizli MM services. Given limited public awareness of Healthy City initiatives and difficulty accessing informed respondents, purposive sampling was used. Sample size: 100 volunteer participants from Denizli neighborhoods. Demographics: 58% male, 42% female; ages 31–40 (40%) and 41–50 (39%) most represented; education: 79% university graduates, 10% with master's degrees; 50% had resided in Denizli for ≥30 years. Instrument: A 56-item questionnaire in seven parts. Part 1 gathered demographics. Parts 2–4 assessed awareness of the Healthy City concept and municipal Healthy City practices in Türkiye and Denizli (including THCA membership, city health profile, awards, environmental and climate actions, animal protection, sports, etc.). Part 5 assessed views on factors influencing success of metropolitan municipalities' Healthy City practices (e.g., THCA membership, informing citizens, inter-institutional cooperation, citizen consultation and participation, inclusion of public/private/NGOs, effectiveness of municipal directorates). Part 6 asked respondents to prioritize Denizli MM service areas relevant to Healthy City (demography, education, socioeconomics, health services, environment, transportation, culture and arts, economy, disabled and vulnerable groups, sports, infrastructure, social responsibility, other) with multiple selections allowed. Part 7 identified which institutions should be effective in managing Denizli Healthy City (local government, central government, provincial public institutions, NGOs, private sector), with multiple selections allowed. Hypotheses: H0 posited no impact of Healthy City knowledge on awareness, perceived success factors, prioritization, or responsible institutions; H1–H8 tested specific relationships regarding duration of residence, awareness of Denizli’s awards and rankings, awareness of Denizli MM’s services, importance of informing citizens and participation, prioritization of infrastructure, and the role of local governments.

Awareness of the concept: 37% of participants reported knowledge of the Healthy City concept; 67.6% of these obtained information via the Internet. H1 supported: Knowledge of the Healthy City concept was significantly associated with longer residence in Denizli (Pearson’s chi-square p=0.04); 63.9% of those knowledgeable had lived in Denizli ≥30 years. Awareness of municipal initiatives: Across items on awareness of Healthy City initiatives (in Türkiye and Denizli MM), chi-square tests showed significant associations with knowledge of the concept (all p<0.05). Specific awareness levels included 40% knowing Denizli received Türkiye’s cleanest, most environmentally friendly, and healthiest city title in 2012, and 34% knowing Denizli MM placed second globally in the 2019 International One World Cities Competition for water management and climate change projects. H2 supported (p=0.001): knowledge associated with awareness of Denizli’s 2012 title. H3 supported (p=0.001): knowledge associated with awareness of Denizli MM’s international ranking. Awareness of Denizli MM practice areas (Table 4): Most recognized areas were modern wastewater treatment (64% Yes) and animal protection (63% Yes). Significant associations with concept knowledge were found for sports (p=0.000), environment and climate change (p=0.038), social responsibility (p=0.018), public education (p=0.015), and disability services (p=0.039); other areas showed no significant association. H4 supported: awareness of the concept related to awareness of Denizli MM services in the above areas. Success factors for metropolitan municipalities (Table 5): The highest-rated factors overall were THCA membership and ensuring participation of public, private, and NGOs in decision-making. Significant associations with concept knowledge were found for informing citizens about Healthy City services/projects (p=0.006) and ensuring participation of public, private, and NGOs in decision-making (p=0.023). H5 and H6 supported: knowledgeable respondents more often endorsed these as critical success factors; respondents without knowledge tended to indicate these factors did not impact success. Prioritization of service areas (Table 6): Infrastructure (67% Yes) was the top area to prioritize; among those aware of the concept, 30.6% endorsed infrastructure as priority. H7 supported: knowledge positively related to prioritizing infrastructure. Responsible institutions (Table 7): Overall, local government received the highest share (25.1%) as the institution that should be effective in managing Denizli Healthy City; among those aware of the concept, 10.1% endorsed local governments. H8 supported: knowledge positively related to the view that local governments should be effective. Overall, H0 was rejected: knowledge of the Healthy City concept significantly influenced citizens’ awareness of initiatives, perceived success factors, prioritized service areas, and preferred responsible institutions.

The findings demonstrate that citizen knowledge of the Healthy City concept is a key determinant of awareness and evaluation of municipal Healthy City initiatives. Knowledgeable respondents were more aware of Denizli’s recognitions and Denizli MM’s specific activities, and they more strongly endorsed practices central to Healthy City implementation—namely, proactive information provision to residents and inclusive decision-making involving public, private, and NGO stakeholders. Knowledge also shaped priorities, with informed citizens emphasizing infrastructure—core to environmental health and service delivery—and identifying local governments as the primary actors for Healthy City governance. These results address the research questions by showing that conceptual awareness connects to both recognition of ongoing initiatives and to preferences for governance mechanisms and service prioritization. The study underscores the importance of public information and engagement strategies by metropolitan municipalities to build citizen understanding and support for Healthy City policies, aligning with WHO’s emphasis on community participation, intersectoral collaboration, and Health-in-All-Policies. In cities like Denizli, where substantial progress has been made (city health profile, climate action planning, water conservation, education programs), strengthening citizen awareness can enhance legitimacy, co-production, and the effectiveness of Healthy City interventions.

Denizli Metropolitan Municipality has developed notable Healthy City practices, plans, and award-winning projects. Using SPSS-based Pearson’s chi-square tests and cross-tab analyses of a 56-item survey, the study shows that citizen knowledge of the Healthy City concept is significantly associated with: (a) awareness of Denizli’s awards and Denizli MM’s initiatives; (b) endorsement of critical success factors, especially informing citizens and engaging public, private, and NGOs in decision-making; (c) prioritization of infrastructure within Healthy City services; and (d) the view that local governments should be effective in managing Denizli Healthy City. The majority of participants lacked knowledge of the concept, and those without such knowledge were less likely to recognize key factors and initiatives. Practical implications include the need for metropolitan municipalities to actively inform citizens about Healthy City services, projects, collaborations, memberships, and achievements, and to institutionalize participatory mechanisms (workshops, seminars, round tables, city councils) that involve diverse stakeholders. Aligning with WHO criteria, municipalities can develop city health profiles, health community strategies, and city health development plans, and allocate resources for health promotion and emergency preparedness, with special attention to disadvantaged groups. Promoting participation, social inclusion, and empowerment can improve the effectiveness and sustainability of Healthy City initiatives at local and national scales.

The study employed purposive sampling restricted to Denizli residents who were aware of Denizli MM services, resulting in a sample of 100 participants, which limits statistical power and generalizability beyond Denizli or Türkiye. The cross-sectional, self-reported survey design may introduce awareness and reporting biases. The small, non-probabilistic sample and focus on a single city preclude broad generalization to the Turkish population. The underlying dataset is not publicly available due to privacy concerns.