1. Introduction
Since the mid-1970s, discussions on health promotion have diffused globally. At the “Healthy Toronto 2000” workshop, held in Canada in 1984, the “Healthy Community” model was established, pioneering the Healthy Cities movement. Consequentially, the respective movement began in Europe in 1986. The goal of Healthy Cities is to create a healthier urban environment for the members of the community by going beyond health approaches. The World Health Organization defines a Healthy City as a place where all members of the community mutually cooperate and continuously endeavor to improve the citizens’ health and quality of life by improving the physical and social environment. Currently, the Healthy City program is being promoted globally by the formation of a Healthy Cities network [
1].
The Healthy City program is a local health movement based on the premise that living conditions, including physical, social, and economic conditions, may influence the health status of citizens. It intends to change the living environment into a health-friendly one by eliminating health risk factors. Since health and wellbeing are closely related to community activities, local government policies, citizens’ participation in government, and collaboration between the local government and the community enables citizens’ health promotion and a sustainable Healthy City program [
2,
3]. The local government is trying to enforce effective health policies by identifying various health determinants, in order to improve citizens’ health condition. A comprehensive health promotion program implemented from these viewpoints is the Healthy City program [
4].
As health has been identified as an important factor to assess the quality of life, the quality of life related to health is being utilized as a notion to measure the degree of happiness in society. Citizens’ health promotion is closely related to the urban environment, which is directly connected to the improvement of the quality of life. Because an interaction between individual and community factors occurs in health-related life quality, in order to improve the life quality of the citizens, the will to improve is necessary at the community level as well as at the personal level [
5]. To improve citizens’ health levels, local governments are providing governance to create Healthy Cities. As the action plan toward a Healthy City, the “plan to expand the living infrastructure to improve the quality of life” has been proposed, leading to the improvement of people’s health and living standards through the creation of living infrastructures, such as parks and green areas. As such, the importance of Healthy Cities, which aim to improve the quality of life of citizens through health promotion activities in daily life, is increasing [
6].
The definition of happiness is very diverse, owing to its subjective and objective aspects. When considering happiness as a subjective feeling about one’s personal life, it may vary according to values, expected level of quality of life, and environment. In terms of objective standards, we may investigate national income, education level, and average life span, amongst others [
7]. Positive changes in individuals’ health behaviors improve satisfaction of life and enable them to live happily [
8]. Improving lifestyle through increased life expectancy and elimination of health risk factors enhances health and increases the happiness of citizens. Accordingly, since citizens’ health status is related to their happiness, the policies of the local government tend to concentrate on personal health promotion. Therefore, they are creating a better urban environment through the Healthy City program for health and happiness [
9,
10].
Recently, the proportion people who had “a feeling of happiness” in the local welfare level has been increasing, which leads to an improved quality of life. In addition, the measurement of life quality is used as an indicator for feelings of happiness, health, and so on, in the subjective dimension [
11]. Therefore, quality of life and happiness are affected by health, and the Healthy City program seems to increase citizens’ feeling of happiness. In this study, we investigated the effect of the Healthy City program on citizens’ happiness and analyzed the structural relationship between the Healthy City program and happiness by using quality of life as a parameter. Moreover, we prepared basic data for improving the happiness index of local residents of Seoul, a city actively implementing the Healthy City program, by measuring health, quality of life, and happiness index.
4. Discussion
This study attempted to verify the structural influencing relationship of the Healthy City program on the citizens’ happiness index and the mediating effect of the quality of life on the relationships between them. First, we compared the effects of the Healthy City program according to demographic characteristics. The results showed significant differences in educational background and income. The lower the education background and the higher the income, the higher the effect of the Healthy City program appeared. These results differ from those of existing precedent studies, which found that the lower the socioeconomic status (education, income, occupational status, etc.), the higher the mortality and the prevalence rate of various illnesses including the chronic disease. A high education background is related to economic advantages; resulting in a higher health level because of better access to medical services due to better working conditions, income, and so forth. In addition, personal education level influences the ability to choose health behaviors and to solve problems, affecting participation in health promotion activities [
28,
29,
30]. Since the resources for health promotion and health risk factors are not evenly distributed, they expect all citizens to be affected by the physical and social environments with the same conditions and to maintain a high healthy level, by institutional support through the Healthy City program [
31]. However, the results of this study showed that the effects of the Healthy City program differed according to education background and income, which seems to suggest that health equity has not been achieved through the Healthy City program. The goal of the Healthy City program is to reduce the gap in the health level of citizens, and the fact that the effect of the Healthy City program differed according to educational background and income seems to show that the Healthy City program is not being implemented in a way that improves the health level of all citizens.
Next, structural equations were used to analyze the structural influencing relationships of the Healthy City program, quality of life, and happiness index, and the key focuses of the research results were as follows. First, the Healthy City program has been shown to increase citizens’ happiness index. This corresponds to the result of an existing study that found health promotion programs, such as sports activities, smoking-cessation classes, and so forth, may improve the health of residents and enhance subjective happiness [
32]. Another study result found that the quality of social services provided by communities, such as parks, accessibility to public transportation, and health care services, may improve citizens’ health, and that health is closely related to happiness [
33]. In other words, the Healthy City program seems to increase the happiness index through the health improvement of local residents. Therefore, through the Healthy City program, the accessibility of public transportation facilities, provision of various leisure facilities, expansion of bicycle and pedestrian paths, abundant green areas or parks, and so forth, may support individual physical activities and improve citizens’ health. Furthermore, the implementation of the Healthy City program will increase the number of facilities that citizens can use to exercise regularly, and it will stimulate citizens’ health promotion activities by providing health check-up services and health promotion programs provided by local governments.
Second, the Healthy City program had a statistically significant effect on the quality of life of citizens. This corresponds to a precedent study result that found when individuals are physically healthy and the welfare level provided by the community is high, their anxiety may decrease; thus, their quality of life appears higher [
34]. The goal of the Healthy City program is to improve the quality of life and health of citizens by strengthening social, economic, and environmental health. This seems to imply that citizens’ health is determined not only by the accessibility of healthcare services, but also by the quality of life and the physical and socioeconomic environments. Therefore, the Healthy City program is improving the quality of life by addressing health-related problems by each health setting (school, workplace, residence, traditional market, etc.) and building a healthy environment.
Third, as a result of examining the mediating effect of the quality of life with respect to the causal relationship between the Healthy City program and happiness index, the Healthy City program did not affect happiness by mediating the quality of life. The reason for this result is due to frequent leadership changes and that the Healthy City program in Korea is limited to the single task of health promotion projects. The improvement of the quality of life for citizens through the Healthy City program may appear when resources are effectively used in an integrated way and is made sustainable. In addition, improved quality of life, coming from the sustainable development in the community, will increase the happiness index. Urban levels, including cleanliness, transportation accessibility, eco-friendly spaces, health, and crime rates in residential areas, affect the quality of life and happiness index, which want to achieve environmental improvement through the Healthy City program [
35]. The European Healthy City program is improving the city environment by linking health with sustainable urban development and emphasizing the importance of locally centered activities and the role of local governments. On the other hand, because the Healthy City program in Korea is being promoted in a single project type, such as the improvement of individual health behaviors like health diet and smoking cessation or the creation of health village environment, it seems that there is a limitation in conducting sustainable policies for the Healthy City [
36].
5. Conclusions
It is determined that the following efforts will be required for the Healthy City program to have positive effects.
First, health equity should be achieved through Healthy City programs based on socioeconomic characteristics. In order to be a Healthy City, it is not enough to simply create a pleasurable environment or a nature-friendly environment. After considering the various factors constituting citizens’ lives, an environment that could be actually helpful must be created. An individual’s health is determined by various factors, such as socioeconomic factors, cultural factors, environmental factors, educational background, community network, lifestyle, medical services, and genetic factors. As the gap in the health system appears to correlate with socioeconomic factors, health equity issues stem in the aftermath. Therefore, municipalities should implement the Healthy City program by linking health with policies in various sectors in order to improve health equity. Furthermore, a health profile should be systemized for cities to establish effective health policies. The health profile may provide information on the citizens’ health levels and health determinants by eliciting various health-oriented data from the region. Based on such evidence, they must understand the health determinants in the community and implement the Healthy City program effectively. It seems that Healthy City programs aimed at improving the health level of vulnerable groups are likely to improve health equity by directly addressing inequality. These Healthy City programs include improvements for the living conditions of the urban poor and health promotion education to reduce health inequality [
37,
38].
Second, the quality of life of citizens must be improved by expanding the Healthy City program based on living ground. Because quality of life is a subjective evaluation that citizens feel in a living environment, it is closely related to the level in daily life. Health is regained by citizens wherever they are residing, learning, and working. Hence, the living space centered Healthy City program, which changes the environments where citizens are living their daily lives (cities, villages, homes, schools, restaurants, hospitals, etc.) into a health-friendly place will improve citizens’ health and quality of life [
39]. The living ground is a place where citizens can participate in the Healthy City program and where the community resources are invested. For large cities, living ground-based Healthy City programs are centered on schools and apartments; in the case of rural areas, they are centered on villages and senior citizen centers. Moreover, the living ground-based Healthy City program is being implemented through health promotion in schools, workplaces, and hospitals. However, living ground-based Healthy City programs are not operationalized effectively due to a lack of policies, systems, and strategies in the local community, and a lack of understanding about the living ground. In order to ensure the success of the Healthy City program, it is imperative that citizens are determined toward promoting health. Hence, in order to expand the living ground-based Healthy City program, citizen-centered participation in the community should be activated, and partnerships between the health sector and local governments should be created.
Third, the citizens’ happiness must be improved through a sustainable Healthy City program. The increased sustainability of a healthy environment may enhance the levels of happiness among the members of the community. Healthy City is a comprehensive health promotion program that improves the health of cities by eliminating health risk factors. However, it is not appropriate to include all health promotion programs within the framework of the Healthy City program. The scope of health promotion programs varies according to countries and cities. In the case of Korea, the Healthy City program exists within the health promotion program. On the other hand, European countries include their health promotion programs in the Healthy City program. Thus, in the process of approaching the physical and social environment of the community, the related health promotion program must be meticulously implemented through integration within the Healthy City program. Similarly, the health-related program should be linked with the Healthy City program, redundant projects should be integrated, and the sustainability of the Healthy City program must be secured by consistently promoting related projects. Additionally, for the Healthy City program to be sustainable, support from the local government is necessary to strengthen the program’s capabilities. It seems that an organic cooperation system is also needed between divisions. Since the factors affecting health are complicated, cooperation with other sectors is essential in order to implement the Healthy City program. Accordingly, a sustainable Healthy City program can only be implemented once intersectional cooperation is expanded and community participation is established through Healthy City governance.
Because the survey area was limited, it was not possible to analyze the influencing relationship of the Healthy City program according to region. Thus, in future studies, it is necessary to separate subjects into the influence of the Healthy City program according to the region, and the types of participation in the Healthy City program, before analyzing them. Currently, the Health City project is spreading globally, and the regions in which it is the most active are Europe and Asia. Therefore, studies in the future also need to compare the results with those in European countries, such as Denmark and the UK, and Asian countries, such as Australia and Japan. The scope and expansion of the Health City project can be determined for Korea by comparing its performance with that in other countries.