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Coordination and collaboration among public, private, and nonprofit groups is the cornerstone of the Healthy Cities and Communities philosophy. The road to collaboration is fraught with challenges. Turf issues, crossed communications, and conceptual misunderstandings all have the potential to derail rewarding, synergistic efforts. Nonetheless, collaboration has been a key ingredient in much of the Program’s success.

To promote the collaboration, the Project decided to locate its office in the state capital. In Sacramento the Project was well positioned to form significant partnerships with DHS programs and with local government associations, policy groups, health care organizations (and their associations), a food security organization, the state recreation society, and the education and faith sectors. Because each sector reaches a different constituency, these relationships allow for cross-pollination that would not otherwise be possible.

One of the most important—and certainly the longest running—collaborations has been with DHS. Beyond funding, this collaboration has included the Program’s roots in what was then the Department’s Health Promotion Section. Being physically housed within a DHS facility for the first 10 years provided for an exchange of ideas and resources and heightened visibility. Later, when the Program moved to an off-site location in 1998, Program and DHS staff continued to serve on each other’s advisory committees and grant review panels, and alert each other to opportunities and resources for communities with which they work.

Working with so-called “good government groups” has enhanced communication with both elected and appointed local government officials. At the state level, Program staff and groups such as the League of California Cities, the Institute for Local Self-Government, and the Local Government Commission have presented at each others’ conferences and shared expertise on ad hoc committees and review panels. At the national level, information has been shared with groups such as the National Civic League and the National League of Cities through journal articles, newsletters, and conference presentations.

Local health departments have been critical partners for local initiatives and the Program. Key officials in local health departments attend Program orientations and receive the names and contact information of representatives from cities and communities in their service areas. Local health department staff are routinely invited to Program events and are frequently asked to make presentations, serve on award and grant review panels, and co-sponsor programs in their area. All local Healthy Cities and Communities initiatives are encouraged to involve health department representatives in their work, and health officers are notified about any initiatives in their jurisdictions. The Program also regularly sends publications and announcements to health departments.

Finally, mutual support is an important, albeit intangible, aspect of all of these relationships. The Healthy Cities and Communities movement is about people. Emotional and spiritual support and encouragement to continue this work might be the most valuable outcome of collaboration.

Systems reform. One of the Program’s goals has always been to influence policy making and resource allocations on the part of public and private organizations at the local and state level. In California, systems reform at the municipal level—which generally has no statutory responsibility for public health—has involved instituting policies and practices that make explicit the city’s role and contribution in community health promotion and protection. At the local level, policy initiatives have transformed vacant land, increased access to healthful foods, expanded community gardening, reduced exposure to environmental tobacco smoke, restricted alcohol availability, and improved transportation safety.

At the state level, systems reform may take place within and across state-level organizations. For example, it is systems reform when a state public health department partners with organizations or develops constituencies outside the traditional public health infrastructure. Like¬wise, it is systems reform when non-health organizations incorporate Healthy Cities and Communities principles into their missions and operations and when they collabo¬rate across sectors to improve the public’s health.

Several California Healthy Cities have made food security a priority. Seed grants have stimulated and supported demonstration programs, which are resulting in cross-sectoral action and policy. Community garden cooperatives and related micro-enterprises have been established. Food policy councils, with representation from multiple sectors, are working to improve summer lunch programs and to promote community gardening through reducing city water fees, organizing a healthy canned food drive, and supporting teachers as they integrate gardening and physical activity into daily classroom routines. The Adopt-a-Lot Program in the City of Escon-dido takes advantage of an exemplary land use policy to allow residents, neighborhood groups, and organizations to qualify for a special, no-fee permit when they “adopt” public or private vacant land on a temporary basis for recreational use or other community purposes.

New resources have been made available by schools and city governments. In the city of Chula Vista one teacher now works full-time to institute a garden-based school curriculum. The city of Berkeley developed public use standards for community gardens on city property, providing free water use, fences, and help with installation.

The private sector has been active in the food security arena as well. In the city of West Hollywood, a small, densely populated urban area in greater Los Angeles, positive experiences with school-based community gardens prompted the manager of an apartment complex where one student lives to establish an on-site garden for its residents. The Escondido Downtown Business Association provides same-day reimbursement for farmers who accept food vouchers at their open-air market.

Systems reform benefits tremendously from a comprehensive framework. The city of Pasadena developed a ground-breaking Quality of Life Index to improve planning, policy making, and resource allocation with extensive input from residents, technical panels, and neighborhood groups. The Index identified more than 50 indicators affecting community life—for example, safety, education, substance abuse, recreation, economy, and housing—which are now being monitored. The Index has guided policy development with regard to alcohol availability, infant health, and tobacco control, has assisted city and community agencies in priority-setting and resource development, and was used as the basis for the city’s performance-based budget system.

Increasingly, DHS programs have taken a more environmental perspective. Several DHS programs, especially those in the area of chronic disease and injury prevention, now recognize municipalities and Healthy Communities coalitions as major players in advancing prevention objectives and specifically focus on them for local assistance contracts.
For several years, beginning in 1990, the Project worked in a formal partnership with the League of California Cities and Americans for Nonsmokers’ Rights to educate and support municipal officials statewide about tobacco control. Before January 1990, only one California city had an ordinance that completely banned smoking in restaurants. Four years later, more than 100 cities had banned smoking in restaurants and almost 90 cities had eliminated smoking in the workplace. This local action provided the foundation for state legislation, which went into effect in 1995, that required smoke-free workplaces and allowed local governments to enact stronger policies.

Senate Bill 697, California’s hospital community benefits law, provided a strategic window to integrate the Healthy Communities philosophy into the mission statements and assessment and planning processes of the state’s 250 nonprofit hospitals. The Program has partnered with the Office of Statewide Health Planning and Development (OSHPD), which has oversight for this leg islated mandate, to coordinate work wherever possible. OSHPD, a freestanding office within DHS, has endorsed the Healthy Communities framework, as have many health care industry and association leaders.

The Association of California Healthcare Districts (ACHD), a membership organization of hospital trustees, physicians, and key staff, is partnering with the Program to involve its members in Healthy Communities work. ACHD’s 1997-1998 annual report includes strong recommendations to its membership to get actively involved in Healthy Communities efforts. As a result of this partnership, four health care districts are participants in Healthy Cities and Communities initiatives.

Evaluation. Methods for evaluating progress have changed over time as the Healthy Communities movement has grown. The intensity of early Project activities and limited budgets during the first decade combined with the nascent state-of-the-science of community-based evaluation meant that efforts were directed primarily at site-specific evaluations. Later, the Program devel¬oped more sophisticated evaluation methods.

Program participants have always been required to submit work plans with, at minimum, quantifiable process measures and, whenever possible, outcome measures. Revisions to the reporting form over the years have been responsive to feedback from program participants. Reports are due at six-month and year intervals. New resources acquired or leveraged are reported, including in-kind contributions and increases in budget or staff allocations. Participants are also asked to describe the challenges experienced, unanticipated spin-offs, anecdotes, presentations to other communities or groups, and a financial accounting of grant expenditures.

For several years, participants annually self-administered a leadership questionnaire that provided an opportunity to reflect on vision/mission, community participation, city Ъиу-in,” the representativeness of the steering committee/coalition and its progress, and continuous quality improvement measures. The questionnaire included a checklist of municipal activities, designed by staff in one of the participating cities, to assess (and encourage) the presence of health-promoting policies and programs in areas such as health, the environment, planning and development, public safety, recreation, the city workplace, and city-sponsored events.

In 1997, after critically reviewing the reporting system and its uses for evaluation, the Program hired a consultant who specializes in community-based health promotion programs to review and revise the evaluation system.

Any change to the reporting system needed to take into account the challenges of conducting evaluations at the local level and across sites. These challenges include limited staff time and budget resources, diversity of efforts across communities, and inherent difficulties in using the “community” as the unit of analysis due to confounding factors. (For example, births, deaths, in- and out-migration mean that the “community” changes over time.) The consultant revised the system with substantial input not only from Program staff members but also from staff representatives from the participating cities.

Based on this input, the consultant identified the concepts and sub-concepts that were most important to measure, devised possible measures or surrogate measures for them, linked these measures to elements of the existing data collection and reporting system, and added elements for sub-concepts or concepts for which measures were missing. Now the evaluation includes measures of organizational-level change (for example, adoption of new policies and practices, institutionalization of health-enhancing programs), inter-organizational change (for example, new partnerships, new linkages outside the community), and civic participation (for example, emergence of new leadership, involvement of informal community leadership).

These concepts and sub-concepts fall under three major categories:
• Skill-level increases: ability of the city/community and its partners to facilitate community action;
• Institutionalization/systems reform: the extent to which institutional changes, within and beyond the organizational unit in which the initiative was originally established, have occurred to foster a safer and healthier city; and
• Increases in community competency and capacity: the extent to which exposure to and implementation of the Healthy Cities/Communities model have made a community stronger and more self-sufficient and have encouraged and expanded community participation in identifying concerns and facilitating problem-solving and decision-making.

Evaluation methodologies for the 20 communities receiving planning and implementation grants involve:
• Stratification of communities by location, size, and other community characteristics to enhance data analysis;
• In-depth study of approximately 10 communities, beyond what is available from standard evaluation reports; and
• Use of triangulation for the in-depth studies, using various strategies, including direct observation of events such as coalition meetings, a survey of coalition members, followed by focus groups or interviews in communities to be studied in depth, and a review of documents generated by the community, such as coalition meeting agendas, minutes, and attendance records.

Celebration. Community building and collaboration require hard work and perseverance; it may take years before there is discernible progress. Celebration and recognition are important elements in promoting and sustaining community efforts.

Through its publications and when providing technical assistance, the Program encourages participating cities and communities to regularly celebrate their accomplishments. Participants have devised many ways to celebrate. The city of Tulare, for example, has a “Take Stock in Tulare” program that issues shares of “stock” to resident volunteers for a broad array of non-paid community service activities such as mentoring and house painting. The awards are presented to individuals and groups on a regular basis during city council meetings. The city council in West Hollywood formally acknowledges, with official certificates presented at Council meetings, community members who contribute to Healthy Cities accomplishments.
The Program also offers a recognition program for participating Healthy Cities and Communities. Program staff members make formal presentations of awards, often at city council meetings. To acknowledge specific accomplishments, Awards of Distinction are offered in several categories such as community participation, resource development, and program impact. For cities and communities not officially participating in the Program, there is a Special Achievement Awards Program. Communities are eligible for these awards based on successful programs and policies consistent with the Healthy Cities and Communities model. Initiated in 1992, these awards recognize innovative local programs, policies, and plans that take a broad view of health. Applicants are encouraged to convey how planning and implementation has addressed the many factors that improve the health of residents—including employment, culture and recreation, housing, education, environmental preservation, and violence prevention. Applications are judged on several criteria, including innovation, community-based leadership, equity, collaboration, and impact. In the last seven years, 35 communities have been recognized through these awards. To generate maximum local publicity, awards are presented locally and community celebrations are strongly encouraged.

THE FUTURE: DEVELOPING A STATEWIDE NETWORK

The experience of the Program over the past 12 years leads to three important observations about launching and sustaining a Healthy Communities movement: the need to be inclusive of, and responsive to, communities’ interests; the need to clarify the scope and breadth of what constitutes Healthy Communities work; and recognition of the long-term nature of this work. Program participants report that the Healthy Cities and Communities movement provides encouragement, peer and Program staff support, energy to persevere, hope, credibility, and status.

The Program has a goal of growing into a statewide movement encompassing all California collaboratives that are engaged, or interested, in this work. Unfortunately, limited resources and funding restrictions have limited participation in the Program to two major categories: cities prepared to implement local initiatives and collaboratives just coalescing to do Healthy Communities work. As a result, existing collaboratives as well as cities interested in this work, that don’t apply for funding have no way to officially affiliate with the Program. Statewide, however, there is widespread interest in the movement, as evidenced by the receipt of more than 40 applications on average for the Program’s annual Special Achievement Awards.

During the last two years, research has revealed a consensus around the value of a statewide network. The most valued benefits include linkages to like-minded colleagues, the potential to locate/leverage resources, use of the network as a source of information, shared learning around best practices, and the opportunity to demonstrate a commitment to Healthy Cities and Communities principles.

Establishing a California network is high on the Program’s agenda for the coming year. Under consideration are: defining levels of participation that match the “readiness” of cities and communities; expanding mechanisms of service delivery, including linkages between “veterans” and newer collaboratives; and expanding computer-based technology.
Healthy Cities and Communities work is by nature long-term, both at the state and local level. It takes years to build the relationships and corresponding trust that allow community efforts to take root and be fruitful. Too often, there is a failure to appreciate how “upstream” this work is, especially when its benefits will not be realized for years or during the terms of political office holders. It is a privilege to have been given this opportunity in California, and we look forward to the expansion of the Healthy Cities and Communities movement in the next millennium.