Dr Iain Butterworth Visiting Senior Fellow Faculty of Health and Behavioural Sciences

1. Healthy Cities Evaluation: Tracking Empowering Efforts and Outcomes Across the Social System Dr Iain Butterworth Visiting Senior Fellow Faculty of Health and Behavioural Sciences School of Health and Social Development Deakin University

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

3. Uses for Evaluation • Rendering judgments – did this program attain its goals? • Facilitating improvements – what are the program's strengths and weaknesses? • Generating knowledge – enlightening program staff and the wider public. (Patton, 1997; http://www.si.umich.edu/Community/connections/archives/evaluationprep.html)

4. Evaluation must be • Practical • Cost-effective • Ethical • Accurate (Patton, 2002, www.wmich.edu/evalctr/checklists/ufechecklist.htm)

5. Characteristics ofHealthy Cities Projects • Commitment to health • Political decision-making • Intersectoral action • Community participation • Innovation • Healthy public policy (Duhl & Sanchez, 1999)

6. 11 Key Parameters for Healthy Cities, Communities and Towns • A clean, safe, high-quality environment • A stable, sustainable ecosystem • A strong, supportive community. • A high degree of public participation in and control over the decisions affecting life, health and wellbeing. (Hancock & Duhl, 1988)

7. 11 key parameters… • The meeting of basic needs (food, water, shelter, income, safety, work) • Access to a wide variety of experiences and resources • A diverse, vital and innovative economy. • Encouragement of connections with cultural and biological heritage

8. 11 key parameters… • A city form (design) that enhances parameters 1-8 • An optimum level of appropriate public health and sick care services accessible to all. • High health status (both high positive health status and low disease status).

9. Change across the social system

10. Indicators • Variables 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(WHO, 2002) • Act as a tool for health promotion by raising public awareness of what is going well and what is threatening a community’s well-being(Conner et al, 2003)

11. Revised 32 Baseline Healthy Cities Indicators (Doyle et al, 1999; WHO, 1998) A Health indicators A1 Mortality: all causes A2 Cause of death A3 Low Birth weight B Health service indicators B1 Existence of a city health education programme B2 Percentage of children fully immunized B3 Number of inhabitants per practicing primary health care practitioner B4 Number of inhabitants per nurse B5 Percentage of population covered by health insurance B6 Availability of primary health care services in foreign languages B7 Number of health related questions examined by the city council every year

12. Revised Baseline Indicators… C Environmental indicators C1 Atmospheric pollution C2 Water quality C3 Percentage of water pollutants removed from total sewage produced C4 Household waste collection quality index C5 Household waste treatment quality index C6 Relative surface area of green spaces in the city C7 Public access to green space C8 Derelict industrial sites C9 Sport and leisure C10 Pedestrian streets C11 Cycling in city C12 Public transport C13 Public transport network cover C14 Living space

13. Revised Baseline Indicators… D Socio economic indicators D1 Percentage of population living in substandard accommodation D2 Estimated number of homeless people D3 Unemployment rate D4 Percentage of people earning less than the mean per capita income D5 Percentage of child care places for pre-school children D6 Percentage of all live births to mothers > 20; 20-34; 35+ D7 Abortion rate in relation to total number of live births D8 Percentage of disabled persons employed

14. Indicators must be: • Interesting • Relevant • Easily understood • Accessible • Fully supported by key stakeholders • Directly applicable to Policy • Developed using collaborative, iterative process • Cost effective • Useful (Innes & Booher, 1999)

15. Website: www.civicpartnerships.org

16. Social ecology framework to assess changes in community capacity • Changes in individuals • Changes in civic participation • Organizational development • Inter-organizational activity • Community level changes (Kegler, Norton & Aronson (2003)

17. Dimensions of community capacity • Civic participation • Mechanisms for community input • Mechanisms for 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 learning

18. 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 Psychological Sense of Community (McMillan and Chavis, 1986)

19. Social Capital • Focus on networks between people that lead to cooperation, trust, social power and beneficial outcomes (Baum, 2000) • Interpersonal, community, institutional, or societal levels (Perkins, Hughey & Speer, 2002)

20. Evaluation design • Multiple case study with cross-case comparisons • Data collection involved: • Review of program documents • Participant surveys in year 1 and year 3 • In-depth interviews • Analysis by ‘type of community’

21. Individual-level changes • More than 1,100 new civic leadership roles • 1,500 people acted in these roles • Urban participants reported gaining skills in advocating for policy change

22. Organizational Changes • A broadened definition of health • Increased community input into decision-making • Expanded and new forms of collaboration • Adoption of shared vision • Expanded or restructured programs/services aimed at increasing equity • Administrative policy changes designed to enhance service delivery and equity

23. Community level changes • HC/C programs leveraged changes in other organizations • Most programs reported at least one public (government) policy change arising from their efforts • Seven of the 20 communities identified policy change as explicit goal area

24. Sense of Community: • Increased number of diverse participants the program • Increased cooperation and communication in the community • New gathering place and the opportunities the program provided for diverse people to interact and form relationships

25. Key categories of change to physical environment • Neighbourhood and community beautification • Facilities construction, expansion and renovation • Public utilities and public safety • Parks and recreation facilities – construction and renovation

26. Psychological Predictors of Social Capital: • Place attachment • Community satisfaction • Communitarianism • Community confidence • Demographics • Collective efficacy • Participation in a neighbourhood association • Neighbouring behaviour (Perkins & Long, 2002)

27. Empowerment The acquisition of critical social insight, skills, and sense of competence needed to participate meaningfully in society (Kieffer, 1984) • concerned with actual social influence and political power (Rappaport, 1987) • long term process, many actions • psychological, organizational, community

28. (Balcazar et al., 1994; Kieffer, 1984; Perkins & Zimmerman, 1995; Rich et al., 1995; Zimmerman, 1995)

29. Some personal reflections… • HC programs are conducted in a geopolitical space or locale • HC programs are inherently about power and control: • Power of communities to determine and drive their own health agenda • Political decision-making • Empowerment framework can integrate place, community and social capital

30. Personal reflections… • Document community capacity building efforts and outcomes • Use mixed methods • Qualitative and quantitative • Scales, indicators, interviews, focus groups • Collect population measures: • Garrard, J., Hawe, P., & Graham, C. (1995). Acting locally to promote health: An evaluation of the Victorian Healthy Localities Project. Melbourne, Australia: Municipal Association of Victoria.

31. Personal reflections… • Indicators need to be developed as part of participatory evaluation framework • Use indicators to stimulate community thinking and action and to document process, as much as outcomes • University collaborations invaluable