healthy cities evaluation

7/30/2019 Healthy Cities Evaluation

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HEALTHY CITIES EVALUATION:TRACKING PROCESSES AND OUTCOMES

ACROSS THE SOCIAL SYSTEM

Iain Butterworth, PhD1

BACKGROUND.....................................................................................................................................................2

HEALTHY CITIES EVALUATION...................................................................................................................6

CALIFORNIAN HEALTHY CITIES AND COMMUNITIES PROGRAM...................................................8

VICTORIAN HEALTHY LOCALITIES PROGRAM ...................................................................................18

INDICATORS RESEARCH...............................................................................................................................22

CONCLUSION.....................................................................................................................................................24

1 Visiting Senior Fellow, Faculty of Health and Behavioural Science, Deakin University, Burwood, VIC

Australia. Email: [email protected]



Background

It is a great honour to be sharing my ideas with you today, in such esteemed company.

The year of my birth, 1963, was the same year that Prof Len Duhl published an edited

book called The Urban Condition: People And Policy In The Metropolis. For me this

book is a landmark in terms of looking at the social ecology of cities and the mental

health implications of urban design. As you may know, Prof Duhl's ideas helped give

rise to the Social Model of Health and the international Healthy Cities movement in the

1980s. It was my privilege to spend eight months recently working with Len in Berkeley

as a Fulbright Visiting Scholar, looking at Healthy Cities evaluation. Today I am going

to share my reflections from this study, and offer some ideas for Healthy Cities

evaluation that draw on my background as a community psychologist.

Community psychology involves the study of behaviour of the individuals, families, and

groups within the context of their community ecosystem. By ecosystem, I am referring

the interplay of the built, natural, economic, social, political historical and cultural

environments that impact on people’s individual and collective lives. I refer to

Bronfenbrenner’s (1979)1 concept of multiple interconnectedness within and between

levels of the microsystem (the person’s immediate setting), the mesosystem (settings in

which the person participates), exosystem (settings in which the person may never enteror have any direct experience, but which will affect their immediate environment), and

the macrosystem (the “overarching patterns of ideology and organization of the social

institutions common to a particular culture or subculture”, p. 8).

Community psychology is an applied discipline that seeks to use the skills of the

psychologist to maximize the competence of community members to solve problems and

to ensure the delivery of programs and services to aid community members within the

context of their everyday lives. Key themes within community psychology include

empowerment, participation, human rights, social justice, equity, and sense of

community, and their connection with psychological health and wellbeing. ‘Place’, both

physical and social, plays an important role in community psychology, as both the

background context for human experience, and as the subject of research itself.

Community Psychology draws very heavily on environmental psychology and

geography in order to understand people’s relationship to place and how it impacts on

individual and collective behaviour and wellbeing. Research in these fields has much of



relevance to public health, because of the ecological nature of these interrelated

concepts, and their overlap with research on the social determinants of health.2 3 4

Program evaluation forms a major part of community psychology research. The user-

focused evaluation approach of Michael Quinn Patton resonates with community

psychology. Patton (1982) defines evaluation as “the systematic collection of information

about the activities, characteristics and outcomes of programs, personnel and products

for use by specific people to reduce uncertainties, improve effectiveness and make

decisions with regard to what those programs, personnel or products are doing and

affecting”5. Patton argues that we should conduct evaluation that is ultimately usable,

but also feasible, use ethically and culturally appropriate strategies, and, finally,

accurate. To do this, we need to engage meaningfully with stakeholders – such as the

people who participate in Healthy Cities programs – as equal colleagues in the

evaluation process, and work with them to develop the evaluation strategy at the same

time that we develop the Healthy Cities initiative.

Another evaluation approach that has strong ties to community psychology – and action

anthropology - is David Fetterman’s (1994) empowerment evaluation6. He defines

empowerment evaluation as:

“… the use of evaluation concepts and techniques to foster self-determination.The focus is on helping people help themselves. This evaluation approach focuses

on improvement, is collaborative, and requires both qualitative and quantitative

methodologies... It is a multifaceted approach with many forms, including

training, facilitation, advocacy, illumination, and liberation” (p. 1).

Empowerment evaluation is based on the principle of self determination – the ability to

chart one’s own course in life, including the ability to: (i) identify and to express one’s

needs; (ii) establish goals and expectations; (iii) develop a plan of action to achieve these

goals; (iv) make rational choices from various alternative courses of action; (vi) take

appropriate steps to pursue one’s objectives (vii) evaluate short and long-term results

(including reassessing plans and expectations and taking necessary detours); and (viii)

persist in the pursuit of these goals. Empowerment evaluation can involve training,

facilitation, advocacy, adult learning and liberation.7

I have applied a community psychology orientation to my work in many settings.

Between 2000-2003 I worked for the State Government of Victoria, Australia. I was



involved in the development and dissemination of the Australian municipal public

health planning policy framework, Environments for Health8. Drawing on the social

model of health, this Framework provides an ecological approach to planning that

considers the overall impact on health and wellbeing of factors originating across any or

all of the built, social, economic and natural environments. In order to anchor the policy

framework in international research and best practice, we made sure that

Environments for Health drew very strongly on the Healthy Cities approach, and the

principles developed by both Profs Len Duhl and Trevor Hancock. A major thrust of

my work involved implementing a range of initiatives to encourage enhanced integrated

planning outcomes amongst health planners and urban planners, and developing links

between state government policy makers in the areas of public health and urban

planning. The Framework clearly demonstrates the link between urban planning and

health, and the need to integrate these planning approaches. Special attention was given

to this issue, because:

• Urban planning and health planning are key activities of Victorian state and

local government;

• These planning processes frequently occur in isolation (English-speaking

cultures are currently referring to this as the ‘silo’ model);

• Through the Healthy Cities Program, there is a concerted international effort by

WHO to highlight and build on this relationship.

Whilst at Berkeley, I investigated the role that research on community cognitions (sense

of place, sense of community, place attachment, social capital) can play in Healthy

Cities programs, municipal public health planning, community building, strategic

planning, policy, and indicator development. I focused on how Californian Healthy

Cities programs have been evaluated, and how they may have been shown to help

connect people better with their significant places, and with their local neighbourhoods

and communities. I examined the potential for Healthy Cities programs - and Victorian

Local Governments - to develop methods to track developments in the interrelated

areas of place attachment, sense of community, participation and social capital.

It has been interesting to read about the enormous efforts of WHO Europe to develop a

systematic, continental monitoring and evaluation system, and compare this with

approaches used in Australia and the USA. Len has noted that this is partly due to a

bureaucratic value system. Today I would like to share with you some of my reflections

of what I have read and experienced about Healthy Cities. I am going to describe the



recent evaluation of the Californian Healthy Cities and Communities program, and

offer strategies for strengthening evaluations by incorporating research and practice on

measures of sense of community, social capital and empowerment.

One of the surprising issues I had to deal with in the US was the way that the Healthy

Cities approach was dismissed by some academics. One person, probably a traditional

clinician, referred to Healthy Cities, as ‘just rhetoric’. After all, in her view, how do you

show that a broad community development approach to promoting health and

wellbeing is responsible for reducing levels of disease? And yet with about 10,000 cities

and communities using this approach, can it be so easily written off as ‘rhetoric’, a fad?

Clearly incommensurate paradigms are still clashing here, some twenty years after

Healthy Cities and the ‘new’ ecological approach to public health began. Healthy Cities

evaluations need to be able to show whether all that effort to create multi-sectoral

partnerships has been worth it. But worth what? Here we need to draw on the social

determinants of health and show how Healthy Cities initiatives have influenced the

policies and programs that impact on the social determinants. In a globalising world, we

need increasingly to consider the influence of social determinants operating at the local,

regional, state, national and global levels. Healthy Cities approaches need to be

understood by clinicians as a broad based approach to coordinating upstream anddownstream initiatives to promote health and wellbeing and reduce incidence of disease

and infirmity. I have been particularly interested in the importance of tracking

psychological health aspects of participation in health planning, and the importance of

identifying the role that urban planing can have on people’s sense of belonging. A lot of

psychological research has focused on the interrelationship between the built

environment, participation, social inclusion, and psychological sense of community and

empowerment. We also need to map change against the benchmarks of the Ottawa

Charter. In other words, how have HC initiatives managed to help build healthy public

policy, create supportive environments, strengthen community action, develop personal

skills, and reorient health services? I was surprised to discover how little-known is the

Ottawa Charter in the US. It has been suggested to me that the US ignores most of

WHO’s work. We need to use it to alert potential allies to its value as an educational

tool and as a framework for evaluating health initiatives.

It is true that Healthy Cities approach takes time, and it can be challenging to locate

causality to one or two initiatives. Yet as Prof Fran Baum from Australia has noted, we



all need to consider the impact of globalized, external decision making, and the

globalising of health inequalities. Globalization is challenging all public health

initiatives, be they from ‘old’ or ‘new’ paradigms. Global travel has brought us SARS

and other diseases, whilst NAFTA has impacted on opportunities for local communities

to participate in the decisions that affect their local economies. Prof Baum also

identified the need for HC programs to evaluate their role in strengthening the links

between civil society and governments. As Len Duhl frequently has written, we need to

focus on the processes by which people become engaged in civic participation as a result

of HC initiatives. What mechanisms can we create to encourage the thousands of

official and ‘unofficial’ HC programs to join the global advocacy movement to ensure

global and local equity, and be evaluated as such? For me, the ecological characteristics,

principles and components of the Healthy Cities approach provide the basis for their

evaluation. Obtaining a detailed ecological map of a city gives us clues about where and

how one could intervene, and how to evaluate our efforts.

Healthy Cities Evaluation

As stated in the Healthy Cities literature, HC programs are characterized by:

• A broad-based, intersectoral commitment to health and wellbeing in its broadest

ecological sense,

•

High levels of political endorsement and support• A commitment to innovation,

• Intersectoral action

• An embrace of democratic community participation, and

• A focus on creating healthy public policy9 10

In the early days of HC, Trevor Hancock and Len Duhl proposed the following 11

elements as key parameters for healthy cities, communities and towns11:

1. A clean, safe, high-quality environment (including housing).

2. An ecosystem that is stable now and sustainable in the long term.

3. A strong, mutually supportive and non-exploitative community.

4. A high degree of public participation in and control over the decisions affecting

life, health and wellbeing.

5. The meeting of basic needs (food, water, shelter, income, safety, work) for all

people.

6. Access to a wide variety of experiences and resources, with the possibility of

multiple contacts, interaction and communication.



7. A diverse, vital and innovative economy.

8. Encouragement of connections with the past, with the varied cultural and

biological heritage and with other groups and individuals.

9. A city form (design) that is compatible with and enhances the preceding

parameters and forms of behaviour.

10. An optimum level of appropriate public health and sick care services accessible

to all.

11. High health status (both high positive health status and low disease status).

It is my contention that the more traditional public health efforts traditionally have

focused on securing outcomes in the last two domains, and often the first, yet have

tended to overlook the remainder. I have found this list of parameters tremendously

useful in my policy development work, for it unites my interests as a community

psychologist with a WHO-endorsed set of outcomes that we were able to use to persuade

government bureaucrats both inside and outside health of the importance of integrated

planning approaches that looked at the overall wellbeing of the whole person and the

whole community.

In a related way, Prof Fran Baum from Australia (1993)12 has proposed that cities and

communities can be judged for their health – and thus human rights, social justice andequity – according to three sets of criteria:

• Physical form, including the use of land, housing type and standard,

communications infrastructure, transport provision and the quality of the built

and natural environment

• Interaction, recognizing that people come to cities for contact with others. This

contact includes politics, work, economic activity, caring, education, fellowship,

recreation and home life

• Individual experiences of the city, which include the sense of history and

tradition, life-style, culture, expressions of spirituality, creativity and art.

Again, these criteria integrate the social determinants of health into an ecological

framework that encourages innovative, systematic monitoring and evaluation.

I am drawn to HC evaluation approaches that manage to combine concern for the

principles of HC programs, the HC dimensions identified by Professors Hancock, Duhl

and Baum, and in a way that can map change against the benchmarks of the Ottawa



Charter. I have been able to learn of two such evaluation approaches. One was

conducted in my Australian state of Victoria in the early 1990s; the other was published

in California last year. I will begin with California.

Californian Healthy Cities and Communities program

The Californian Healthy Cities and Communities program began in the mid-1990s, and

in the longest running HC program in the US. Thirty-five HC/C initiatives have been

funded throughout the life of the program. A key organisation is the Center for Civic

Partnerships13, based in the State capital of Sacramento. A center of the Public Health

Institute14, the CCP is a collective of community building initiatives that emphasizes

participatory governance and a systems approach to healthier communities. The Centreadministers funding for localities participating in California Healthy Cities and

Communities (CHCC) that it secures through a wide range of grants and contracts15.

CCP provides technical support, sponsors educational programs and develops resource

materials for various audiences including local policy makers and government

administrators, community-based organizations and residents.

The Center for Civic Partnerships, recently conducted a detailed evaluation of the 20

Californian Healthy Cities and Communities initiatives established in the second roundof funding. These 20 projects were selected to fulfil particular criteria. Programs were

favoured that were:

• In geographically or socially isolated regions

• Targeted populations “at risk” for inequities in health status.

• Were attempting to engage communities in the initial stages of forming, or

reconstituting, collaborative partnerships to address issues of community health

and well-being.

• In diverse geographic regions of California

• Addressed varied socio-demographic characteristics.

The evaluation was designed to explore the process of community development

undertaken by the initiatives, and the changes resulting from these initiatives. Kegler,

Norton and Aronson’s (2003) report, Evaluation of the Five-Year Expansion Program

of California Healthy Cities and Communities (1998 – 2003)16, was powerful in that it

used a detailed social ecology framework to assess changes in community capacity

across five levels: (i) changes in individuals; (ii) changes in civic participation; (iii)



organizational development; (iv) inter-organizational activity; (v) community level

changes.

Community capacity - the characteristics of a community that enable it to mobilize,

identify and solve community problems17 – is a key outcome that relates to the Ottawa

Charter and to Baum’s (1993) ‘interaction’ criterion mentioned above. Kegler, Norton

and Aronson identified that community capacity can be assessed according to numerous

elements, depending on local context. These include:

• Civic participation

• Mechanisms for community input

• Mechanisms for the distribution of community power

• Skills and access to resources

• Sense of community and social capital/trust

• Social and inter-organizational networks

• Community values and history

• Capacity for reflection and learning18

Using a social ecology framework 19 20 21, the Evaluation team analysed the 20 initiatives

at multiple levels of analysis, including:

•Changes in individuals

• Changes in civic participation (such as leadership and community volunteer

roles)

• Organizational development

• Inter-organizational activity

• Community level changes, including development and implementation of social

policy

In order to map the impact of HC/C initiatives across the social spectrum, the

researchers designed a detailed, multiple case study with cross-case comparisons. Data

collection involved:

• Review of program documents

• Participant surveys in year 1 and year 3

• 165 in-depth interviews with:

o coordinators

o community leaders

o sponsoring organization directors and CHCC staff



o 26 focus groups in the nine communities selected as primary sites

• Analysis by ‘type of community’, based on population density, proximity to a

large metro area, and its urban/rural character.

The evaluators worked with HC/C programs to develop both process and outcome

evaluation methods to monitor progress. Common process measures included:

• Attendance records

• Sign-in sheets

• Logbooks used to track participation

• Completion certificates

• Membership lists

• Copies of media coverage

• Press releases

• Program publicity materials

• Meeting minutes

• Meeting agendas

• Memoranda of understanding

Common outcome measures included knowledge and skills in:

•Leadership

• Vocational / life skills

• Community-building

• Project specific areas

• Learning

• Civic education

• Sense of community

Psychological Sense of Community

Kegler, Norton and Aronson (2003) did investigate ‘sense of community’ as an outcome

measure, using both qualitative and quantitative approaches. The evaluators used

McMillan and Chavis’ (1986) well-known definition of sense of community: a feeling

that members have of belonging, a feeling that members matter to one another and to

the group, and a shared faith that members' needs will be met through their

commitment to be together. This definition gives SOC four elements: (i) membership;

(ii) influence, (iii) integration and fulfilment of needs and (iv) shared emotional



connection22. McMillan and Chavis argued that SOC had a ‘place’ dimension as well as

a ‘relationship’ dimension. Since McMillan and Chavis published this four-dimensional

conceptual framework, Perkins et al’s (1990) 12-item Sense of Community Index (SCI),

and variations of it, has become the most widely used measure of the construct23,

spawning a host of research.24 However, despite its widespread adoption and use, there

has been ongoing concern about the limited evidence of the validity or reliability of its

dimensions or subscales.25 Long and Perkins (2003) recently revised the SCI. Their

resulting eight-item, three-factor Brief SCI (BSCI) presented sense of community as a

cognitive-perceptual construct with dimensions of social connections, mutual concerns,

and community values. 26 Because of statistical concerns, the authors removed the place

attachment items, keeping them as a separate ‘place attachment’ index. However, these

items did contribute significantly to measures of social capital. It is worth noting in the

light of these evaluations that Doug Perkins and colleagues are attempting to develop

statistical measures to identify the shared, collective dimension to sense of community

that can exist among people from the same locale.27

Kegler, Norton and Aronson’s (2003) evaluation identified sense of community as a

community-level outcome of the HC/C initiatives. Participants from almost all

communities felt that their local initiative had aimed to increase SOC amongst area

residents, and that their programs had helped to increase the cooperation andcommunication in the community and created a new gathering place and the

opportunities it provided for diverse people to interact and form relationships. The

researchers surveyed governance team members using an adaptation of the original

Sense of Community Index28. The survey showed that compared with the first year, by

the end of the third year there was a significant increase in the belief among governance

team members feeling that residents were able to influence their communities and

generally get along with each other.

Other community-level outcomes included changes in civic activity and changes to the

physical environment. The evaluation identified that the second round of Californian

Healthy Cities and Communities programs had created over 1,100 new civic leadership

roles, with 1500 people acting in these roles over the grant period.

Many organizational changes were identified, including:

• A broadened definition of health

• Increased community input into decision-making



• Expanded and new forms of inter-organizational collaboration

• Adoption of shared HC/C vision

• Expanded or restructured programs/services aimed at increasing equity

• Administrative policy changes designed to enhance service delivery and equity

The evaluation identified that CH/C programs were able to leverage these kinds of

changes in other organizations, including private organizations, non-profit, county

government, city government, schools, and so on.

Most HC/C reported at least one public (government) policy change arising from their

efforts. Seven communities identified policy change as explicit goal area, yet only two of

the 20 communities (both rural) had made public policy change the central focus of

their activities.

Social Capital

Social Capital focuses on the social networks that people develop that lead to

cooperation, trust, social power and beneficial outcomes (Baum, 2000)29. It can be

“defined and measured at the interpersonal, community, institutional, or societal levels

in terms of networks (bridging) and norms of reciprocity and trust (bonding) withinthose networks” (Perkins, Hughey & Speer, 2002, p.1)30.

Baum (2000) offers three ways in which HC programs can add to social capital around

civic engagement (and be evaluated as such):

• HC framework presents a “space in which civil society and formal government

structures can meet, interact and form partnerships and alliances in order to

promote health (p. 11), thereby making encouraging good governance by making

government more open, integrated and responsive.

• HC programs reinstate the view and role of community members as

democratically-participating citizens rather than customers or consumers

• “Healthy Cities players can be powerful advocates for a view of cities which sees

them as far more than places to promote economic growth. The ideology of HC

stresses the importance of history, culture and social interaction” to overall

health and wellbeing (p. 11).



The evaluators used Putnam’s definition of social capital: “the features of social life—

networks, norms, and trust—that enable participants to act together more effectively to

pursue shared objectives” (Kegler et al, 2003, p. 4). The evaluation survey indicated

that trust was strengthened among people who were directly involved in the local

initiatives. However, the evaluators noted that there was little confidence that the HC/C

initiatives has helped build trust across the community. No significant changes were

observed in social capital as it had been defined and measured in the survey. However,

through the use of qualitative data, the evaluators showed firm evidence of increased

perceptions of trust and community engagement.

Using Perkins and Long’s (2002)31 definition of social capital, we can see evidence of

change in social capital through the HC/C programs. Out of concern at the ambiguity of

the social capital construct, Perkins and Long presented empirical evidence to suggest

that sense of community, empowerment, citizen participation and neighbouring, are all

part of social capital. They developed a definition of social capital that has four distinct

components:

• Trust in one’s neighbours – relates to sense of community

• Efficacy of organized collective action – relates to empowerment theory

• Informal neighbouring behaviour

•Formal participation in community organizations

Analysis of power is central to social capital – an over emphasis on social cohesion

ignores the key role of conflict and the need for empowered communities to know how

to engage in it assertively and meaningfully. In essence, Perkins, Hughey and Speer

(2002) and Perkins and Long (2002) have called for a notion of social capital that

includes multi-level analyses of empowerment and participation, as well as individual

conceptions of sense of community and place attachment. From this ecological

perspective, I sense that the Californian HC/C initiatives had helped create social

capital, especially when measured through the evidence of civic participation.

Empowerment

Kegler et al’s (2003) ecological, community capacity-building framework has strong

parallels to the significant body of community psychology research on empowerment.

For me, HC programs are inherently about power and control. They attempt to

enhance the power of communities to determine - and drive - their own health agenda.



The social determinants of health identify the importance of participation and inclusion

to health outcomes. I believe empowerment theory can complement Kegler et al’s

approach, by making central the acquisition and utilization of community power, and

its long-term, radiating impact of empowering cognitions and behaviours at and across

individual, organizational and community levels of analysis32 33 34 35.

Empowerment has been defined as the process by which people gain efficacy and

control over their own lives while learning to participate democratically in the life of

their community (Zimmerman & Rappaport, 1988). Kieffer (1984) viewed

empowerment as a developmental process, “of becoming, as an ordered and progressive

development of participatory skills and political understandings” (p. 17). The

attainment of these insights and abilities defined as ‘participatory competence’ (p. 18).

Participatory competence incorporates three elements: (i) the development of more

positive sense of self-competence; (ii) the construction of a more analytical

understanding of the socio-political environment and (iii) the development of individual

and collective resources for social and political action. Collaboration with others was

seen as the key to attaining participatory competence. Rappaport (1987) argued that

empowerment not only conveys a psychological sense of control but is also concerned

with actual social influence, political power and the rights of all individuals, groups and

communities in certain situations.

Participation and empowerment are key principles of health promotion. Health

promotion recognizes that people should be able to make healthful choices with greater

ease; this requires an enabling political environment. Health promotion has attempted

to address socio-political aspects of health by focusing on issues of power, social

structure and social processes. It requires a critical analysis, and acknowledgement, of

the imbalance of power, ownership and control, and the fact that vested interests

maintain this imbalance (Bunton, 199236; Farrant, 199137; Tannahill, 198538).

Delineation between processes and outcomes is essential to a clear definition of

empowerment theory. Empowerment processes focus on the efforts by individuals,

groups and communities to enhance their critical understanding of the socio-political

environment and gain access to, and control over resources (Zimmerman, 199539).

“Empowering processes for individuals might include participation in community

organizations. At the organizational level, empowering processes might include

collective decision-making and shared leadership. Empowering processes at the



community level might include collective action to access government and other

community resources...” (Perkins & Zimmerman, 1995, p.570).

Empowered outcomes refer to the consequences of empowering processes. “Actions,

activities or structures may be empowering, and that the outcome of such processes

result in a level of being empowered” (Perkins & Zimmerman, 1995, p.570). For

individuals, empowered outcomes could include the perception of having gained control

over certain situations and domains of their lives, and the attainment of participatory

competence. Empowered outcomes for organizations could include enhancement of

organizational effectiveness through network development and lobbying power. At the

community level, empowerment outcomes might refer to the development of coalitions

between organizations, the development of more and better community resources, and

planning decisions that enhance urban amenity and foster participation, activity and

exercise, and sense of community.

Psychological empowerment – the individual's expression of empowerment – explores

the ways individuals develop and express their competence and efficacy through

participating in social and political change. It has been described as "the connection

between a sense of personal competence, a desire for, and a willingness to take action in

the public domain" (Zimmerman & Rappaport, 1988, p. 725). Psychologicalempowerment is not a passive, inert, intrapsychic construct: it is "rooted firmly in a

social action framework that includes community change, capacity building, and

collectivity" (Zimmerman, 1995, p. 582). I feel that elements of this political perspective

on psychological empowerment were perhaps slightly muted in the Californian

evaluation analysis.

Empowerment theory distinguishes three components of psychological empowerment,

which Healthy Cities evaluations could attempt to document. The components are

intrapersonal, interactional, and behavioural. The intrapersonal component relates to

"how people think about themselves and includes domain-specific perceived control and

self-efficacy, motivation to control, perceived competence, and mastery" (Zimmerman,

1995, p. 588). The interactional component of psychological empowerment refers to the

development of critical awareness about one's socio-political environment, and how to

act strategically to obtain desired resources, and develop the necessary resource

management skills, such as decision-making, problem solving, and self-advocacy. The



behavioural component refers to actions that people take in order to have a direct

impact on the outcomes of events.

Kegler et al noted that at the individual level of analysis, the Healthy Cities and

Communities process “has the potential to change people in significant ways – by

expanding their views of health and enhancing skills they can apply to community

improvement… helping community residents and leaders see health through a broader

lens increases the likelihood of more systemic and effective community health

improvement efforts that target meaningful community change” (p. 43). Some

community members noted that “a broad view of health conflicted with how a few key

organizations and government agencies, usually those with a more traditional, service-

delivery focus, viewed health” (p. 43). An empowerment framework would necessarily

position individual understandings of ‘health’ and skills in achieving holistic,

empowered ‘health’ outcomes, in a framework that was by necessity socially critical and

geared towards social change.

The Role of Place

Kegler, Norton and Aronson’s (2003) evaluation noted the power of place: a factor thatinfluenced projects was “the value of a central, community location that took on the

identity of the Healthy Cities and Communities initiative, as well as the value of rotating

locations to highlight the contributions of each area and encourage participation from

geographic pockets” (p. 29). In addition, whilst most Healthy Cities and Communities

initiatives had not set out to make changes to the physical environment, “changes in

physical conditions in communities seemed to be an almost natural by product of these

efforts” (p. 84). Almost all Healthy Cities and Communities initiatives reported at least

one change directly related to their efforts, with an average of three changes per

community. The most common types of changes were neighbourhood and community

beautification, followed by facilities construction, expansion and renovation; public

utilities and public safety; and construction and renovation of parks and recreation

facilities. Again, community and environmental psychology has something to offer this

finding.

Place and power are deeply interrelated. In a detailed recent theoretical overview on

place attachment, environmental psychologist Lynne Manzo Manzo noted that ‘place



attachment’ is an interaction between what a person brings to a place (in terms of their

own psychosocial development, socio-political consciousness, memories, history…) and

the power relations and other semiotic clues that are embedded in that place (history of

ownership/ inclusion/exclusion, territoriality, class/gender/racial signifiers,

barriers/openings, surveillance, cost of entry, aesthetics, symbols of dominant class /

occupiers). Manzo noted that our relationship to place is inextricably linked to the

“sociocultural context in which we find ourselves… who we are can have a real impact

on where we find ourselves and where we feel we belong” (Manzo, 2003, p. 5440). People

derive their sense of self and community through their interaction with places. The

places give people messages about who they are, what activities are intended for that

place, who the place belongs to or is reserved for, and what right those people have to be

there. Manzo argued that “we need a greater link between concepts such as ‘sense of

place’, the politics of place, and ideology” (p. 54).

Lynne Manzo’s paper is useful to ‘Healthy Cities’ thinking in that it reminds me that

HC programs – and the Ottawa Charter – are inherently about the political life of cities

and communities. The localities, places or neighbourhoods that HC programs identify

and select for renovation are the result of a political, historical and cultural process.

Place serves as a context for HC programs, irrespective of whether the HC programs

specifically identify ‘place’ as a goal area. Place and locale form the backdrop to manyof the more pressing issues that communities must address, for example, who lives

there, the resources in that community, and the presenting health issues. Decisions

about developing or demolishing places, amenities, infrastructure or buildings, or

changing graffiti laws, surveillance of public places or evoking planning regulations are

all formed through expressions of power and control. Conflict is an essential component

to empowerment: it occurs in and over places. Therefore, HC programs designed to

address the physical environment and place must address power dynamics,

sociocultural context, history, power relations, and the politics of inclusion and

exclusion. Healthy Cities participants may be working on a certain place to build on a

positively-held affect – but they could also be working to change places due to negative

feelings and associations. People may be acting consciously as well as unconsciously with

respect to these places – we need to try to encourage people to articulate these

associations and feelings. This is an inherent component of ‘place making’, but needing

to be made transparent.



It is worth noting too how little many people know about the places in which they live,

work, and play. They are also living in silos, and see other places outside their domain

as dark and unsafe. People from differing cultural, racial and economic backgrounds

are increasingly separated by geography, provision of amenities such as public

transportation, and - in the case of gated communities – security guards and fences. In

societies in which much community life is lived in private, Healthy Cities approaches

can help develop mediating structures to encourage participation. Social support is a

key element to sustainable communities: “community life is sustained when social

networks are strong, when there are people with common interests and who feel a sense

of common fate” (Berkowitz, 1996, p. 452)41. Berkowitz stated that we need to create

opportunities to encourage residents to physically see each other, in order to begin to

get to know each other through socializing and talking. Safe, attractive public spaces

and venues need to be built to encourage community mingling and socializing. The path

to community participation begins with seeing, and knowing, liking, trusting, and

finally, acting. In order to be fully sustainable, communities also have deeper needs

which must be met, in addition to practical infrastructure needs, such as sense of

community.

Overall findings of the Californian Evaluation

Kegler et al concluded:

“Overall, the evaluation findings point to a central outcome: participation in the

California Healthy Cities and Communities Program fostered development of

increased community capacity. Specific aspects of capacity that appeared to

flourish in the participating communities included leadership, mechanisms for

civic participation, inter-organizational and social networks, skill-building in

participants, and the ability to leverage resources. At the same time, local context

partially governed the unique set of achievements and results for each and every

participating community. This finding suggests that there is not a single path to

community health. Programs, like California Healthy Cities and Communities,

clearly provide tools that facilitate the unique journey of capacity-building and

health improvement that each community takes” (Kegler et al, 2003, p. xiii).

Victorian Healthy Localities Program

It has been interesting to compare the Californian Healthy Cities evaluation with that of

the Victorian Healthy Localities programs conducted in Australia in the early 1990s,



with the support of the local government sector, NGOs and state government. The

Victorian Healthy Localities Program implemented the Healthy Cities framework at the

local community level, on the assumption that the local community would act as a

mediator between level of city and level of individual. The Healthy Localities Project

aimed to promote:

• The social model of health, and dealt with social inequalities of health

• A range of health promotion strategies, drawing fully on the Ottawa Charter,

and placing particular emphasis on community participation

• Collaborative planning between local government and their communities

• Systematic monitoring and evaluation of the effectiveness of these strategies to

create supportive environments and change behaviours

• Innovation

• Adoption of this systemic health promotion approach by councils and

communities across Victoria.

One of these projects, in Benalla, aimed to ‘halt negative effects of rural decline, [and]

deteriorating sense of community.’42 The strategy included:

• Local level community development

• Task groups developed to deal with specific issues

•A Health Policy Committee – a broad-based coalition of decision-makers

• Major campaigns to deal with

o Drugs and alcohol

o Public transport

o Youth

o Occupational health and safety on farms

Garrard, Hawe and Graham’s evaluation (1995)43 offered an early analysis of work

linking the social determinants of health with sense of community and community

attachment. Project impact assessment was designed to uncover changes at the level of

individuals, organizations, communities, and Councils (it was then a novel approach to

involve local government). Impact assessment was completed in two ways:

• Qualitatively – document analysis, interviews with project officers and key

informants was conducted to “identity the range of effects, unintended impacts

and reported outcomes such as changes in practices, policies or events”

• Quantitatively: pre and post surveys to measure changes in attitudes knowledge

or behaviour.



Not only did the evaluators use a social ecology framework to measure the impact of the

program across multiple levels of analysis, but they also made a detailed study of the

impact of the Benalla program on people’s sense of community.

The Benalla evaluation was designed to measure the project’s impact on community

attitudes around community capacity and community empowerment. A pre-post survey

was carried out over an 18-month period between 1991/92 and 1993. Factors measured

included:

• Sense of community

• Community attachment

• Community participation in problem solving

• Locus of ‘blame’ for community problems, and

• Awareness of the Benalla Healthy Localities Project

Unlike Kegler, Norton and Aronson’s (2003) evaluation, Garrard, Hawe and Graham

tracked sense of community amongst individual people within the population, using an

early sense of community scale by Davidson & Cotter. They also used Goudy’s

community attachment measure to document what would appear to be place

attachment. Slight but statistically significant increases were measured on both scales.Other population measures gathered included

• Community participation in problem solving activities,

• Situation blame vs person blame for problems experiences in the community

• Community confidence in problem solving,

• Quality of life, and

• Self-reported health status

People most closely involved in the project (indeed, all projects) identified the most

personal change in terms of understanding, confidence and skills. The pre-post random

population survey of approximately 11% of Benalla’s residents identified that in

general, Benalla residents had become more involved in community affairs. In addition,

there had been small but significant increases in:

• Sense of community (defined as how highly a person regards their local area)

• Community attachment (a measure of the degree to which people feel they

belong in a community)

• Community participation



The authors noted caution on these findings because of the absence of serial data from

other localities for comparative purposes. However, these findings do corroborate with

the qualitative findings obtained from interviews and with the evidence of structural

changes in organizations and resource availability. Community-level changes in Benalla

included:

• A town bus route changed, affecting use, satisfaction and social isolation

• A national TV serial drama showcased the integrated community approach to

dealing with youth and alcohol

• Nine local hotels adopted responsible alcohol policies

• Changes observed in how young people use alcohol

• Changes in how the community began to think about itself

• Broad changes in social health – ‘improved mental attitude and the way people

relate to each other’ (1995b, p. 84)

• Decline in public drunkenness and offensive behaviour at major events

• Many organizations began working together to achieve common goals

• The Healthy Localities Project assisted local groups to obtain funding to conduct

local initiatives

• Significantly, Benalla participants also worked together to apply successfully for

$270,000 to continue project-related activities.

However, attempts to establish a Benalla Health Policy Committee lapsed. This was at

least partly because overarching policy coordination had not been identified as an initial

goal, which meant that stakeholder groups had not done the work needed to identify a

shared vision and ways of working together. This raised the issue in general of the goals

that the Healthy Localities Project set out to achieve. Despite the principles of social

model of health and Ottawa Charter, most Healthy Localities projects had impacts at

the individual and immediate network level, rather than at the broader community and

macro-levels of change to policies, structures and environments. These system-level

changes were hoped for, rather than planned, and possibly also lie outside the three-

year funding cycle. However, again, an empowerment framework perhaps could have

tracked and identified systemic empowering efforts and outcomes across the life of the

project.



Indicators Research

In tandem with my research on issues of measuring dimensions of place and

community, has been my effort to understand better the indicator movement that has

gathered so much worldwide momentum in recent years. It has been fascinating to

compare the Healthy Cities scene in the US with that in Europe, in which WHO has

developed a huge (and often unwieldy) bureaucracy, including numerous monographs

on planning and evaluation44, and a special office on indicators. Len has noted that

whilst the Europeans made it a program, the Americans have seen it as a pseudo-

anarchic process, more like the development of Linux.

An indicator is ‘a variable with characteristics of quality, quantity and time used to

measure, directly or indirectly, changes in a health and health-related situation and to

appreciate the progress made in addressing it. It also provides a basis for developing

adequate plans for improvement’ (WHO, 200245).

Much on indicators has been published in the urban design field, including the methods

that urban planners can use to obtain unobtrusive physical measures of community’s

functioning. Aicher (1998) listed hundreds of determinants of urban health that urban

developers must consider, and guidelines for addressing them, including dimensions

such as sense of place and environmental satisfaction.46 Interestingly, the aesthetics of

place and community have not featured in WHO Europe’s official indicator set 47.

WHO's original set of 53 indicators did initially have some interesting, broad indices of

community functioning. However many of these were removed along with some 18

others due to the many logistical problems of collecting comparable (even usable) data

from 47 countries.

The most useful discussion I have read in indicators is by UC Professor Judith Innes,

from Berkeley’s Institute of Urban and Regional Development. Firstly, Innes andBooher (1999)48 noted that indicator projects often focus on developing the numbers

instead of considering how they will be used. Producing the indicator report is often

made a priority, as opposed to considering how the report may be used, or how the

community can learn from the process of developing indicators in the first place.

Indicators thus need to be

• Interesting

• Relevant

• Easily understood



• Accessible

• Useful

• Cost effective

• Fully supported by key stakeholders

• Directly applicable to Policy

Innes and Booher argued that it is the joint learning that can occur among stakeholders,

and the changes in practices that can occur, that is considered more important than the

indicators themselves. However what is learned and how practices may change depends

on the way information is developed and who is involved. If it is collaborative and

iterative, then the indicators can become part of the players’ meaning systems. “They

act on the indicators because the ideas the indicators represent have become second

nature to them and art of what they take for granted” (p. 7).

The second major point of Innes and Booher’s paper is that many indicator projects

also operate on a linear, ‘steady state’ assumption about cities, with cities seen as “an

object of formal policy making” (p. 7), when in fact they are open-ended, ‘out-of-

control’ ecological systems, involving a multitude of inputs in a state of constant flux49.

Therefore, we need to embrace complexity theory. This seems particularly germane to

the issues confronting Healthy Cities practitioners, and an important point for thetraditional critics of HC programs to consider.

Innes and Booher noted that the lack of sustainability in many cities – sprawl decaying

infrastructure, overcrowding, comes from participants making unilateral decisions with

no sense of the ‘big picture’ or even of the immediate impacts of their own decisions and

actions on their own wellbeing. They recommended three types of indicators for use in a

complex, adaptive urban system, comprising:

• System performance indicators – need to have a few carefully designed, high-

profile indicators that give feedback on the overall health and wellbeing of a

community or region, to help frame public discussion;

• Policy and program measures to provide policy makers with feedback about the

operation of specific programs and policies;

• Rapid feedback indicators for individuals, agencies and businesses to help all

people who are part of the city system – individual residents, commuters and

businesses – make better decisions about their own actions, based on accurate

and timely information.



Innes and Booher describe this three-level system as contributing to “distributed

intelligence” – multiple levels of indicators to distribute coherent, integrated

information to a broad cross section of the populace in such a way that people could all

make decisions based on information that all pointed people in a creative, coordinated

way towards sustainability. “Many individual participants, following simple rules for

adjusting their actions without seeing or understanding the dynamics of the larger

system, can deal with complex reality” (p. 12).

Conclusion

I would like to make the following observations:

• The evaluation reports documented above all present opportunities for

evaluators of HC programs to consider the systemic impacts of their work in

helping to encourage individual, organizational and community empowerment,

build sense of community and foster sense of place.

•

Including consideration for sense of community, psychological conceptions of place and social capital can help to anchor Healthy Cities in this broader social

ecological model that includes consideration for place, belonging, participation,

social networks and power. An empowerment framework can make manifest the

process of power transference to community members to gain some control over

the issues that determine their health and wellbeing.

• Evaluation approaches that use a range of quantitative and qualitative methods

are more likely to document the range of actions initiated by a Healthy Cities

program, and their ripple effects across the social spectrum over time.

• Ecological approaches to HC evaluations offer innovative opportunities to

explore links between social policy and the social determinants of health. This is

a key goal of Healthy Cities principles and the Ottawa Charter, and needs to be

encouraged in order to highlight the political dimension to civic democracy and

wellbeing.



• Healthy Cities initiatives are well served by a central evaluation team, such as a

university partnership, that can provide ongoing consultancy throughout the

project, using an action research approach or ‘empowerment evaluation’

approach50 , assist project stakeholders to keep track of process and outcome

milestones, and apply some theoretical rigor and organizational support to the

questions posed and information collected.

• Indicators are best developed through praxis as part of a collaborative,

participatory approach involving the community in a meaningful way.

I hope that the ideas I have shared today have been useful, and look forward to

discussing them with you at this conference and into the future.

Thank you.



1 Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA:

Harvard University Press.2 See A. T. Fisher, C. C. Sonn, & B. J. Bishop (Eds.), Psychological sense of community: Research, applications, andimplications (pp. 291-318). New York: Kluwer Academic/Plenum Publishers.3 Sarason, S. B. (1974). The Psychological Sense of Community: Prospects for a Community Psychology. San Francisco:

Jossey Bass.4 Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology.

American Journal of Community Psychology, 15, 121-148.5 Patton, M. Q. (1982). Practical evaluation. London: Sage.6 Fetterman, D. M. (1994). Empowerment evaluation. Evaluation Practice, 15 (1), 1-15.7 See www.stanford.edu/~davidf/empowermentevaluation.html 8 See www.health.vic.gov.au/localgov 9 (WHO, 1995). Twenty Steps for Developing a Healthy Cities Project (2nd Ed.). Copenhagen, Denmark: World Health

Organization Regional Office for Europe. Available on-line: http://www.who.dk/healthy-

cities/Documentation/20010918_14. Accessed 3 March 200410 WHO (1997). City planning for health and sustainable development. Copenhagen: WHO Regional Office for Europe.

Available: http://www.who.dk/document/wa38097ci.pdf . Accessed 1 March 2004.11 See Duhl, L. J., & Sanchez, A. K. (1999). Healthy Cities and the city planning process: A background document on links

between health and urban planning. Copenhagen: WHO Regional Office for Europe. Available on-line:

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31-40.13

Website: www.civicpartnerships.org. Email: [email protected] http://www.phi.org/ 15 See http://www.civicpartnerships.org/files/Profiles.pdf 16 see http://www.civicpartnerships.org/files/TCEFinalReport9-2003.pdf 17 Goodman et al, cited on p. 93 of Kegler, M. C., Norton, B. L., & Aronson, A. E. (2003). Evaluation of the five-year

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March 2004.18 Norton, cited in Kegler, Norton & Aronson (2003), p. 93.19 Butterworth, I. M. (1999). Adult environmental education: A community psychology perspective. Unpublished doctoraldissertation. Melbourne, Australia: Victoria University.20 Garrard, J., Hawe, P., & Graham, C. (1995). Acting locally to promote health: An evaluation of the Victorian Healthy

Localities Project. Volume 1: Evaluation Overview. Melbourne, Australia: Municipal Association of Victoria.21 Kegler, Norton, & Aronson (2003)22 McMillan, D. W., & Chavis, D. M. (1986). Sense of community: A definition and theory. Journal of Community

Psychology, 14(1), 6-23.23 Perkins, D. D., Florin, P., Rich, R. C., Wandersman, A., & Chavis, D. M. (1990). Participation and the social and physical

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115.24 See A. T. Fisher, C. C. Sonn, & B. J. Bishop (Eds.), Psychological sense of community: Research, applications, andimplications (pp. 291-318). New York: Kluwer Academic/Plenum Publishers.25 Long, D. A., & Perkins, D. D. (2003). Confirmatory factor analysis of the Sense of Community Index and development of

a Brief SCI. Journal of Community Psychology, 31(3), 279-296.26 Long & Perkins (2003).27 Perkins & Long (2002).28

Perkins, D. D., Florin, P., Rich, R. C., Wandersman, A., & Chavis, D. M. (1990). Participation and the social and physicalenvironment of residential blocks: Crime and community context. American Journal of Community Psychology, 18(1), 83-

115.29 Baum, F. E. (2000). Healthy Cities: History, progress and prospects. Keynote address at the Australian Pacific Healthy

Cities Conference, Canberra 26th-28th June 2000.30 Perkins, D. D., Hughey, J., & Speer, P. W. (2002). Community psychology perspectives on social capital theory and

community development practice. Journal of the Community Development Society 33 (1), 1-22.31 Perkins, D. D., & Long, D. A. (2002). Neighborhood sense of community and social capital: A multi-level analysis. In A.

T. Fisher, C. C. Sonn, & B. J. Bishop (Eds.), Psychological sense of community: Research, applications, and implications

(pp. 291-318). New York: Kluwer Academic/Plenum Publishers.

http://www.stanford.edu/~davidf/empowermentevaluation.html


http://www.health.vic.gov.au/localgov

http://www.who.dk/healthy-cities/Documentation/20010918_14


http://www.who.dk/document/wa38097ci.pdf




http://www.civicpartnerships.org/



mailto:[email protected]

http://www.phi.org/

http://www.phi.org/

http://www.civicpartnerships.org/files/Profiles.pdf

http://www.civicpartnerships.org/files/TCEFinalReport9-2003.pdf




http://www.health.vic.gov.au/localgov






mailto:[email protected]

http://www.phi.org/

http://www.civicpartnerships.org/files/Profiles.pdf





32 Zimmerman, M. A., & Rappaport, J. (1988). Citizen participation, perceived control and psychological empowerment.

American Journal of Community Psychology, 16, 725-750.33 Perk ins, D. D., & Zimmerman, M. A. (1995). Empowerment theory, research and application. American Journal of

Community Psychology, 23, 569-579.34 Kieffer, C. H. (1984). Citizen empowerment: A developmental perspective. In J. Rappaport & R. Hess (Eds.), Studies in

Empowerment (pp. 9-36). New York: Haworth Press.35 Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology.

American Journal of Community Psychology, 15, 121-148.36 Bunton, R. (1992). More than a woolly jumper: Health promotion as social regulation. Critical Public Health, 3 (2), 4-11.37 Farrant, W. (1991). Addressing the contradictions: Health promotion and community health action in the United

Kingdom. International Journal of Health Services, 21, 423 439.38 Tannahill, A. (1985). What is health promotion? Health Education Journal, 44 (4), 167 168.39 Zimmerman, M. A. (1995). Psychological empowerment: Issues and illustrations. American Journal of Community

Psychology, 23, 581-600.40 Manzo, L. C. (2003). Beyond house and haven: toward a revisioning of emotional relationships with places. Journal of

Environmental Psychology, 23, 47-61.41 Berkowitz, B. (1996). Personal and community sustainability. American Journal of Community Psychology 24, 441-459.42 Garrard, J., Hawe, P., & Graham, C. (1995a). Acting locally to promote health: An evaluation of the Victorian Healthy

Localities Project. Executive Summary. Melbourne, Australia: Municipal Association of Victoria. Quote taken from p. 5.43 Garrard, J., Hawe, P., & Graham, C. (1995b). Acting locally to promote health: An evaluation of the Victorian Healthy

Localities Project. Volume 1: Evaluation Overview. Melbourne, Australia: Municipal Association of Victoria.44 See http://www.euro.who.int/healthy-cities/Documentation/20010914_2 45 World Health Organization (2002). Practical Methodologies for the Evaluation of Healthy Cities Projects. Manila: WHO

Western Pacific Region.46 Aicher, J. (1998). Designing healthy cities: Prescriptions, principles and practice. Malabar, FL: Krieger.47 See http://www.euro.who.int/document/hcp/ehcpquest.pdf 48 Innes J., & Booher, D. E. (1999). Indicators for sustainable communities : A strategy building on complexity theory and

distributed intelligence. Berkeley, CA: Institute of Urban and Regional Development, University of California at Berkeley.49 This point was made in 1963 by Leonard Duhl in the seminal The urban condition: People and policy in the metropolis.

NY: Basic Books.50 http://www.stanford.edu/~davidf/empowermentevaluation.html

http://www.euro.who.int/healthy-cities/Documentation/20010914_2


http://www.euro.who.int/document/hcp/ehcpquest.pdf






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