Introduction from Voices from America:
Ten Healthy Community Stories from Across the Nation,

a publication of the Coalition for Healthier Cities and Communities and the Health Research and Educational Trust, 1998
By Mary Pittman, Dr.P.H. and Tyler Norris

For ten years the healthy community movement has been growing in the United States. In cities and neighborhoods across the country, citizens have linked with their local hospitals, health systems, governments, businesses, and nonprofit organizations in a dynamic partnership to improve health and quality of life. Voices from America is a snapshot of this movement, telling the stories of the finest initiatives from coast to coast.

This is a collection of case stories. A case story is a hybrid derived from two other types of writing - a feature article and a case study. Similar to a case study, we have tried to sketch some of the practical considerations of this work; and similar to a feature article we have also tried to convey the vitality for civic renewal and the desire to live healthy lives that fuel each of the initiatives. All of the stories have a section that shares the lessons that the participants have learned so far; and all but one has a separate section on outcomes. (In the Joint Venture: Silicon Valley story the outcomes are integrated into the story itself.)

With the exception of two, these stories were written by people within the local communities. In the stories you can hear distinct voices of rural South Carolina, mega-urban Los Angeles, and small-town New England. Even though the stories are told differently, all the authors share a deep dedication to their communities and a belief in the power of community partnerships. Some of the writers were professionals and others had never before published anything. In a way this is a metaphor for the healthy community movement: experts and volunteers working together in partnership to create something lasting and important.

In the case of the other two stories, each of them involved statewide initiatives. These stories were written by Chris Adams, who has also served as the general editor of the entire collection. Although these stories demonstrate a tremendous diversity of healthy community initiatives, it is nothing other than a testament to the breadth of the movement that many other types of initiatives could have been included. The selection process was difficult. The initiatives presented here, however, serve as inspiring examples of how local communities and neighborhoods have defined health and quality of life for themselves, and then designed initiatives to achieve their aspirations. Below is a preview of the stories you will find in the following pages. We hope you will take the time to give us feedback through our web site, www.healthycommunities.org.

A PREVIEW

Smoke-Free California: Democracy Meets Public Health California Smoke-Free Cities (CSFC), an initiative of the California Healthy Cities Project, is a sophisticated example of how healthy communities principles can be mobilized as a vehicle to make public policy. By offering technical assistance, training, speakers, and the publication Tobacco Control in California. Cities: A Guide for Action, CSFC helped nearly 300 city governments to write and pass tobacco control legislation. As a result, by 1994 it had become so clear to state legislators that the public desired laws to protect residents from second-hand smoke that they passed a comprehensive ban on smoking in workplaces, including bars and restaurants. Even though the ban has only been in effect a short while, the state health director has announced that smoking-related diseases are declining at faster rates in California than in other sates.

Tithing to Create Community Partnerships: Memorial Hospital, South Bend, Indiana Memorial has long been acknowledged as a leader in redefining the relationship between a health system and the community it serves. It was one of the first hospitals in the nation to voluntarily tithe a percentage of its net revenue (10%) to the community and it has scores of impressive programs to show for it. It has used this money to fund immunization programs, lead screening, child advocacy, congregational nursing, mammography screening, and expanded health care coverage. In addition, the fundamental idea behind tithing - a mechanism to bind the community together - has permeated the way that Memorial views its relationship with the community. As a result of their relatively long experience with tithing, Memorial is uniquely situated to ask some transformative questions about the meaning of partnership.

Healthy Community - Healthy Economy: A Joint Venture: Silicon Valley Network Initiative Joint Venture: Silicon Valley (JVSV) was created in the heart of the world's computing industry as a response to the dramatic "wake up" call issued by the economic hard times in the early 1990s. As a result of high cost of living, cuts in jobs, a "brain drain" to other regions, and increasing concern about quality of life, leaders from business, government, education, and the community formed an organization to make comprehensive improvements in the region. As one of JVSV's three initiatives, Healthy Community - Healthy Economy focuses on programs to help at-risk children and to improve health in the workplace. JVSV is an impressive undertaking that has garnered substantial support from the business sector.

Community Responsibility for Health: Citrus Valley Health Partners Partnership is such a strong concept for Citrus Valley Health Partners in East Los Angeles County that the word even appears in its name. This hospital system is attempting to improve health and quality of life in the communities it serves by standing the traditional model of what a hospital should be on its head. Part of its mission is a commitment "to empower the communities it serves to take control over their health." In large part it does this by convening various institutions such as schools, social service agencies, police, and fire departments to address problems that any institution alone could not solve.

Healthy Valley 2000: Making a Community Vision a Reality Healthy Valley 2000 (HV2000) is a remarkable story of collaboration across six town lines in the Lower Naugatuck Valley of Connecticut. Facing tremendous demographic change, an organization of health and human services providers was created to help build a regional vision and plan. They selected the healthy community model as "their vehicle of choice" and in so doing created an initiative that would have a far-reaching impact. HV2000 now has 28 initiatives, which include Electronic Valley, which contains over 1,000 pages of community information; Project CoNECT, a program to administer 5,000 health risk assessments; and a guide to arts and recreation in the community.


A Healthy Rural Community: PRO Hampton County Set in a small, racially diverse county in South Carolina, PRO Hampton County has organized itself to deal with issues ranging from diabetes screening to improving the school readiness of first graders. It has found creative ways to capitalize on characteristics that are unique to rural areas, such as a small population and a media with a local focus. At their Baby Fair, an effort to teach about the importance of prenatal care and other parent-related topics, 950 people participated in a county of just over 18,000. In their words, "that is a pretty big dent!"

When the Funding Runs Dry: Sustaining the Healthy Boston Coalitions Healthy Boston was one of the very first large-scale healthy communities initiatives in the nation. Created in 1991 out of the vision of the city's health commissioner, over four years Healthy Boston helped 21 neighborhood coalitions to organize themselves around a broad definition of health. This case story reports on what happened when funding provided through the city ended. The results are encouraging - twelve of the coalitions have found ways to sustain themselves and continue to serve their neighborhoods.


Trendbending in Vermont: The Champlain Initiative The Champlain Initiative in Chittenden County, Vermont (including the city of Burlington), takes a very broad view of what constitutes health. According to a vice president of a local hospital that was instrumental in the initiative, "We quickly came to the realization that 90% of what constitutes the health of a community has nothing to do with medical care." The initiative focuses on five "trendbender areas": community sustainability; lifelong learning; individual and family support; community public health promotion; and governance and participation.


Uniting the Media Against Violence: The Healthy York County Coalition As part of the Healthy York County Coalition's (HYCC) Community Health Assessment, HYCC confirmed that violence has a serious impact on the quality of life in the area. In an effort to change a culture of violence, HYCC helped to create a massive media campaign called W.A.V.E (Work Against Violence Everywhere.) This media advocacy campaign utilized the talents of students in a design school to create a logo and the donation of time and space from media outlets.


Investing in Communities to Create Health: The Colorado Trust As one of the very first conversion foundations/philanthropies created from the proceeds of the sale of nonprofit hospitals, health is at the heart of the mission of The Colorado Trust. In 1992 it sought the most effective way to use its resources to improve health by creating The Colorado Healthy Communities Initiative, a $9 million effort that has produced 28 undertakings around the state. Some of the results include pollution prevention efforts, the establishment of family centers, and the creation of a community foundation. This story serves as an excellent model for how a foundation can help create healthy communities.

LESSONS FROM THE STORIES

In addition to the inspiration these case stories provide, they are also rich sources of learning for the healthy communities movement as a whole. In each of the stories, the writer has included a section that draws out some of the key lessons for that particular initiative. While each of the initiatives is unique, there are some lessons that can be of use across the board.

1. There is a consensus that the organizing principle for a healthy communities initiative - namely health - needs to be defined locally based on the conditions in individual communities and also broadly encompassing more than the traditional medical definition of health. While health in the medical sense is certainly a key part of this definition, successful healthy community initiatives also include economic, civic, environmental, educational, and community-building efforts. In Hampton County, South Carolina, for example, one of the first projects undertaken to create health was a "singing Christmas tree" which included singers from all of the 100 churches in the county, and helped to build community among predominantly black and predominantly white congregations that had never before mixed.

2. People in these initiatives understand the need for partnerships among both individuals and institutions. No person alone is sufficient to create the type of change required to become a healthy community; nor is any single institution - even one as resource-rich as government or a hospital system - powerful enough. In order for an initiative to be successful it must engage both individuals and institutions in a dynamic partnership. A broad definition of health means that a broad coalition of partners is needed to achieve it.

3. At some point in their development, all of the initiatives have made use of paid staff, at least on a part-time basis. While volunteers are often the main drivers of these efforts, without the support and accountability that a paid staff can provide it is difficult to sustain the effort. Funding often comes from several sources (including foundations), and a paid staff member helps to provide the accountability funders usually require. A staff member is also important for continuity.

4. Technical assistance is very useful. An outside facilitator who is perceived as neutral can help with process design and management as well as coaching the initiating partners. Building local facilitation is also important for sustainability.

5. All but one of these efforts were initiated by a previously existing institution (eight of which were either hospitals or could trace their roots directly to hospitals). Having an established institution within the community as a convenor is a great help in mobilizing people to undertake healthy communities initiatives. An important caveat, however, is that while a single institution can be the catalytic convenor, it must ultimately become a partner in the healthy community initiative.

6. The people who carried out these initiatives had a high level of dedication to their communities. Put simply, none of these initiatives could have been a success if there were not a group of people who persevered to improve their communities against what must have seemed in the beginning like great odds. Very often the early outcomes from healthy communities initiatives are not measurable or even explainable to skeptics, making it necessary for those who carry them out to possess a certain faith that through their efforts -in partnership with others - they will be successful.


This last lesson deserves further comment. While this faith is laudable, with ten years of experience behind it the healthy communities movement in this country is moving into a position to offer justification for such faith. The story of The Colorado Trust is especially helpful here because of the extensive analysis it has done on the outcomes of the 28 initiatives it funded in Colorado.

HEALTH OUTCOMES TIED TO "Community capacity"

According to a survey of participants in The Colorado Trust's eight-year, $9 million initiative, the most significant outcomes of the effort were not improvements in traditional health statistics. Rather they had to do with developing leadership and the capacities of the communities to solve their own problems collaboratively and with broad participation from many stakeholders. In its assessment of the results, the Trust has concluded that one of the principal benefits of its work with healthy communities has been to build what it calls "community capacity."

Given these results, the Trust has built a strong link (based on cutting-edge social science and public health research) between community capacity and health improvement. For example, a recent study has shown a link between the level of trust, civic engagement, and helpfulness (which fit their definition of community capacity) in a community and differences in mortality by state. Another study links low birth weight to neighborhood social and economic conditions - also factors which are part of community capacity. In its analysis, the Trust has concluded that "a healthy community leads to a healthy community."

For the healthy community movement, the experience of The Colorado Trust provides evidence that outcomes that may not at first seem relevant to health improvement can indeed increase health. These findings help to demonstrate how hard it is to have healthy individuals in the absence of a healthy community. It provides grounds, for example, to count as a public health success an effort in Vermont to encourage neighbors to dine with each other at potlucks. Social support building activities such as this have been shown to promote health.

Furthermore, since eight of these stories can directly trace their founding to hospitals, the outcomes and lessons of The Colorado Trust and the other case stories also have implications for how health care providers can use their resources - from financial to in-kind - to improve the health of the communities they serve. In each of the stories in this collection, the community defines health for itself- and it is a different (though related) definition than that used traditionally by the health care field.

When The Colorado Trust first issued its request for proposals, it intended to receive applications to fund public health projects. But after having a year to plan how to improve health, the communities did not say they needed more public health projects. Rather, they determined they needed to develop their capacity as communities to deal with health threats, which they defined as poor transportation, urban sprawl, a lack of good jobs, and other issues that are not usually associated with health but are ultimately determinants of health.

The corollary lesson for hospitals is that the best way to serve their mission to improve health may have little to do with adding a new surgical suite. It may mean finding other ways to invest resources in the community. For example, much of the money that Memorial Hospital in South Bend uses to tithe is money that would likely be used for buildings and equipment if it did not invest it in support of community projects.

At ten years the healthy communities movement is yielding a tremendous amount of learning about how health - broadly defined - can be improved in this nation. We now have an idea of what works and what does not, of what types of outcomes we are likely to get and how to evaluate them, and some concrete examples of the vitality in a healthy community. Often these lessons and outcomes are different than what was expected at the outset. But for a movement that ultimately seeks to transform the way that health is achieved in this country, we must always be prepared to be surprised.

Christopher Freeman Adams served as general editor for this collection of case stories. He is president of the Healthy Outcomes Institute in Boulder, Colorado, and frequently writes and speaks about healthy communities.

The Coalition for Healthier Cities and Communities was formed in 1997 to support and increase awareness of a growing nationwide grassroots healthy communities movement. The Coalition brings together nearly 300 organizations representing health care providers, human service agencies, public health departments, community and advocacy groups, businesses, academic and religious institutions, and federal and local governments in 1,300 communities across the country. The Coalition serves as a strategic link to resources and a voice for policy and action to address the challenges facing the nation's cities and communities as they work toward improving the health and quality of life for their citizens. For more information about the Coalition, visit www.healthycommunities.org.

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