Citizen participation, also named community engagement in the literature, is increasingly supported in government policies to promote health. Two recent articles18,19 have highlighted different benefits (such as enhanced social capital or improved self-efficacy) for citizens participating in participatory action research projects. Citizen participation may be very useful in order to achieve population health improvements outside scientific processes. Other authors have developed different frameworks and models to establish and generate effective community participation and community empowerment beyond research. Yet, it is essential to test and adapt these models to integrate intervention activities into community networks.

Enhancing citizen participation can create a sense of public ownership of research and political processes, contributing to the democratization of this new neighborhoods and health agenda.8 However, the engagement of citizens in research and political processes is extremely challenging. While different ways of articulating this collaboration exist (e.g. intersectorial health councils), it should be noted that sometimes ongoing participation processes are not connected to each other. Further, duplicities can occur between different sectors, generating dysfunctional processes (e.g. within different departments at the local level). As such, there is a need to offer new ways of ensuring citizen participation, and to mobilize residents within community processes.

Back in 1978, the conference of Alma-Ata (during the International Conference on Primary Health Care, organized by the World Health Organization) already established citizen participation as a right and duty in planning and implementing health care. In Spain, the Spanish Constitution (1978) also acknowledges citizens’ participation as a fundamental right. However, as stated by Rowbotham et al.8, it is key to engage citizens of different backgrounds and socioeconomic positions, to ensure that the potential benefits of their participation (and their suggested interventions) «do not disproportionately benefit those who are already better off». Thereby, we argue that including those residents with the greatest need to make their voices heard, will reduce health inequalities.

In this context, we argue that citizens’ participation will narrow the gap between researchers, policy makers, health professionals and citizens, and increase the support for public health interventions and policies. Thereby, citizen participation will have positive effects on neighbourhoods and health by contributing to include new knowledge and ideas for different processes of intervening in any given neighbourhood provided by participating citizens. As an example, the Health Observatory in Asturias, part of the public health administration in this Autonomous Community in Spain, launched an action guide on community health in 2016 (publicly available at https://goo.gl/hyqGyW) building on previous regional and national experiences. At the Spanish National level, a Community Health Alliance has been founded to coordinate and visualize local and regional efforts in this area.

As Oliver20 stated back in 2006, «science can identify solutions to pressing public health problems, but only politics can turn most of those solutions into reality». He argued that there are many reasons why population health is a political issue. First, individual and institutional actions often produce effects that can be harmful. Compensating these effects requires taking political decisions about when and how to impose restraints. Second, governments are supposed to identify and satisfy a variety of physical and social society needs. Third, protecting public health involves values and moral judgments, which are less a matter of scientific facts, yet a matter of political organization.21 These values can promote the inclusion of some public health policies in the political agenda. Fourth, a healthy population and workforce is vital to economic growth and social order.

Humphreys and Piot22 also argued that scientific evidence alone is not sufficient basis for health policy because science also has limits in health policy decision making. Therefore, it is also important to take into account government and societal values. In this context, social inequalities in health, as also the different actions implemented to reduce them, can be more or less prioritized (depending on these government and societal values). Moreover, the root causes of health inequalities are hardly known by city policymakers,23 and health policy documents of cities sometimes do not address these causes, because there are mainly focused in targeted interventions.24

One of the strategies to tackle health inequalities is to implement neighborhood-level policies, addressing more resources to those neighborhoods in greater need. It is worth mentioning that neighborhood health inequalities are due to the persistence of structural inequalities due to political decision making, available neighborhood equipment, economic development within the neighborhood, as well as residents’ demographic characteristics.25 Governments that have social justice as a priority will include more easily health inequalities in the political agenda, assigning a specific budget to tackle them.

As an example, we should note that the movement of ‘indignados’ that occurred in Spain after May 2011, criticizing the current economic model26 was important to situate inequalities as a relevant and current problem in our societies and therefore very visible in our cities. As an example, the political parties ‘Barcelona en Comú’ and ‘Ahora Madrid’, that won the elections in 2015 in the cities of Barcelona and Madrid, respectively, are political parties directly emerging from the ‘indignados’ movement of May 2011. ‘Barcelona en Comú’ and ‘Ahora Madrid’ have included social and health inequalities in the focus of their political agenda. As such, several measures have been implemented to reduce social inequalities and consequently health inequalities. It is important to acknowledge that local policies may be influenced by regional, national and supranational, e.g. European-level policies.

High quality urban health research studies can help developing a neighborhoods and health agenda aimed to significantly reduce health inequalities and improve population health in our cities. Sound research projects need to receive sufficient funds form independent science agencies. This is a crucial starting point for conducting good and impactful research. Participatory urban health research may add innovative processes and will definitely help giving voice to relevant knowledge stemming from citizens.

In Spain, there is a current need for securing sufficient and independent research in order to advance neighborhoods and health research,7,27 which will have implications for the next generations of citizens in a country where 79.8% of the population lived in urban settings in 2016 (according to World Bank population estimates). Researchers may not only produce new and relevant knowledge, but we are also continuously training the next generations of researchers who will produce the necessary knowledge to improve population health in the following decades.

As such, interdisciplinary approaches in neighborhoods and health research are warranted since the relation between cities and health is an extremely complex issue. Experts from different fields of social sciences and public health need to work together in a sustained and integrated fashion. Further, this agenda will benefit from collaborating with media/communication specialists (e.g. journalists, photographers or documentarists). Interdisciplinary and inter-sectorial work is a difficult task given the way that public administrations and academic and research centers are usually organized.

As examples of relevant neighborhoods and health interdisciplinary work that has been conducted in Madrid and Barcelona, respectively, are one on examining alcohol normalization,28 and one evaluating the effects of the Neighborhoods Law on health and health inequalities in Barcelona.29 Interdisciplinary work necessarily leads to the application of different and complementary methodological approaches to study complex problems occurring in neighborhoods in relation to health. These mixed-methods approaches can be successfully applied in public health in order to understand residents’ perspectives on their urban environments determinants.

In order to produce policy relevant urban health research30 it is mandatory to disseminate all the scientific results and evidence obtained.31 Evidence should be shared and presented to policy makers, local technicians and practitioners through reports, policy briefs and presentations.32 Research results and evidence also needs to be communicated to citizens and local residents through national and local media as well as specific and relevant social media. In Table 1 we describe several methodologies used by the authors and other public health workers in this area.

Improving population health and addressing health promotion from a local environment perspective (e.g. neighborhood, district, municipality) requires establishing collaborative relationships between community groups, researchers, health professionals and local representatives. These relationships will facilitate effective responses to health priorities.

Given that each urban context has its own characteristics, these relationships will be very context-specific; however, several investigations have identified several factors that influence whether these collaborative relationships are finally effective. Estacio et al.33 pointed out four basic elements for an effective communication strategy between different stakeholders: patience, perseverance, continuous open communication and learning. These relationships need to be based on respect and trust, allowing each person to contribute with their own skills and knowledge. These different stakeholders —health professionals, researchers, community leaders, lay citizens and local policy makers— contribute to the process using their own and differentiated skills and knowledge. Yet, these skills will not emerge without a respectful and trustful communication environment. Including all these stakeholders will necessarily lead to processes of both confrontation and co-creation. In the same way, Eriksson et al.34 concluded that, in order to close the gap between academia and community, it will be required to: share knowledge about effective methods and instruments, time and specific training, leadership and administrative support, a shared language for concepts and tools, an order and commitment to action.

Within the world of primary health care organization and research, a community orientation is absolutely key when stablishing collaborations within a given territory as those needed in a neighborhoods and health agenda.

Regardless of the local context, it is always necessary to clearly identify both the objective of the process, as well as the roles of each of the participants. It is important to consider that all of these processes will be mediated both by the participants’ roles, and by what Peel and Parker35 coined as the ethos and emotional intelligence of each person. Therefore, it is important to set who leads the “relationship”; the one that should promote a culture of solidarity work for all participants, avoiding imposing the procedures and processes.

Developing a policy relevant neighborhoods and health agenda will help effectively improving population health and reducing health inequalities in our cities. Establishing collaborative and sustained relationships between citizens, policy makers, health professionals and researchers is a challenging but necessary step toward this public health need.

M. Franco conceived the idea. All the authors contributed substantially in writing and critically revising this article. All authors approved the final version.

J. Diez, P. Gullón and M. Franco were funded by the European Research Council under the European Union's Seventh Framework Programme (FP7/2007-2013/ERC Starting Grant Heart Healthy Hoods Agreement no. 336893).

None.