Essential State Level Capacities for Support
of Local Healthy Communities Efforts

by Peter R. Lee, MPH; Tom Wolff, Ph.D.; Joan Twiss, MPH; Robin Wilcox; Christine Lyman, ACSW; Cathy O'Connor, MPH

Abstract:

The Healthy Cities/Communities movement is in its second decade. Internationally it sprung to life rapidly through the leadership of the World Health Organization. In the United States, California Healthy Cities and Healthy Boston initiated the movement early. At the national level, the National Civic League, the AHA Health Research and Education Trust, and the Health Forum have all been involved in advancing this movement. Public health/CDC, academic institutions, national and community foundations, the United Way, and other governmental agencies have also been active, to some extent. At the local community level, the movement has been fostered by local hospitals and hospital related foundations as part of "community benefits." Health departments and/or individuals interested in community improvement have also been instigators. State level support, including the public health agency, United Way, Chambers of Commerce, hospital association, municipal association, voluntary not-for-profit organizations, has been much less consistent or organized. Herein lies an important challenge for communities which depend on the state level leadership, resources and support. Movement leaders from four states (California, Massachusetts, Pennsylvania and South Carolina) have contributed their experiences in building state support to the development of: "The Key Components of State Support for Local Healthy Communities Efforts." This paper addresses these Key Components, examines how widespread these supports are, assess these supports to successful local efforts and makes recommendations based on this analysis that could be used to strengthen the state-level support which can go a long way to assuring success where it is the MOST important, the community.

Introduction

As the Healthy Communities movement continues to grow and evolve in the United States, it is becoming apparent to many in the field that statewide support mechanisms are critical to the sustainability of the movement at the community level. These mechanisms are currently put together in a piecemeal fashion, varying widely from state to state.

State-level organizational involvement in Healthy Communities efforts can be found throughout the nation. Many states have loose confederations or networks of partners formed during the last five to ten years. Leadership has come either solely from the state public health agency or hospital association or from alliances between these two entities. Some statewide alliances also include a municipal association, the United Way, and/or other organizations or foundations. In some states, major leadership has come from Area Health Education Centers (AHEC), citizen coalitions, or conversion foundations. Each state is different and has a different and unique model.

In the U.S., each state is an important entity to any local effort, and growing and sustaining the Healthy Communities movement is no different. Laws, resources, policies and modeling are just some of the more obvious reasons that state-level organizations and agencies can and should be involved. With the "devolution" of government from the federal level, state-level functions have gained a more important role. Entities at the state level have major leadership responsibilities which "devolution" of government has enhanced. Additionally, the Healthy Communities movement emphasizes that no one sector alone can or should put forward this movement. What happens at the state level to operationalize this and to enhance or support collaborative leadership becomes even more important.

Leaders of Healthy Communities efforts in four state networks have contributed to the development of the following list of components necessary to sustain a "healthy" statewide Healthy Communities effort.

I. Community Vision/Community Mobilization: Explicit opportunities for individual communities, especially neighborhoods, to come together in forums where they can build a sense of core community values and envision the future must be encouraged, enabled, and supported. This is key to community mobilization.

Each and every successful Healthy Communities effort begins with "where the people [in the communities] are," to paraphrase a Chinese maxim. In communities with successful Healthy Communities efforts, citizen-driven community engagement is key to assuring broad-based citizen participation. "Top-down" efforts do not work; "bottom-up" is where the movement begins.

Opportunities must be provided for people in communities to come together to envision their future, outline community improvements, set priorities and create the political will to drive the movement forward. Government, organizations and other entities often become disenchanted with community participation because the process is difficult, slow and "messy." The reason does not lie in lack of interest, but in how communities are engaged. It is important to start with listening to the community; forums allow for the stories--good and bad--to come forward. For bureaucracies, listening is the first step to rebuilding trust.

Experience tells us that where community visioning occurs, people are not only ready, but more than willing to roll up their sleeves and get to work. In Easley, South Carolina; Pasadena, California; and Easthampton, Massachusetts, communities galvanized around such opportunities. In Ft. Worth, Texas, the city health department redesigned itself. It now provides no personal health services. Instead, public health teams at the neighborhood level are assigned to community policing, shopping centers, and community centers. They focus on the dreams and desires of the people for community improvement, and have developed a whole new relationship with the neighborhoods in Ft. Worth.

Recommendation: Community building must be intentional and should be built as a part of all community programming in its earliest stages. It is not a self-initiating, self-sustaining activity in the absence of some sort of crisis, problem or natural disaster.

II. Training: Comprehensive training linked to other relevant training programs, easily and quickly accessible to people desiring the training, must be available at both state and local levels. At a minimum, this training should provide skills building in the principles, process and practice of Healthy Communities/community building (including best practices); collaborative leadership; working with the media to ensure good community-media relationships; and benchmarking for success.

The Healthy Communities process expects people in agencies, organizations and communities to work, act and relate in new ways. It is unrealistic to expect that these people already possess the skills to do this. Opportunities to build the necessary skills must be made available.

In the article "Where the Rubber Meets the Road," Dr. Trevor Hancock strongly stresses that community health improvement happens at the local level, but expecting people at the local level to work in new ways without adequate skills is folly. Particular attention must be given to the new skills that are "expected" of citizen volunteers. Efforts must be developed to sustain local leaders, "grow" new leaders, build capacity to work effectively with the media to spread the word, identify measurable benchmarks relevant to community interest and priorities, and to build capacity to organize and mobilize the grass roots.

Many successful Healthy Communities efforts have been jump-started by well-constructed state training programs that cover the basics of the Healthy Communities process. The California Healthy Cities Project was based on city and town training efforts. Additionally, the National Civic League's Healthy Communities Action Project was a vital initiator of many local efforts. Massachusetts, South Carolina, Colorado, and hundreds of communities across the country have begun significant efforts because of these training opportunities. Only a few states have actually instituted this type of training, such as Massachusetts, Louisiana, and South Carolina. New Mexico, Maine, Missouri and Pennsylvania have developed similar types of training.

Recommendation: If people are expected to behave in new and different ways, training opportunities must be made readily available to build these new skills.

III. Technical assistance: Each of the different sectors involved in community health improvement must provide competent technical assistance in community building at the local level. Community efforts have fertile ground to grow. However, as with training, communities need access to experts who can help them with their processes. The different state-level organizations involved in Healthy Communities, such as public health, municipal associations, United Ways, hospital associations, and Chambers of Commerce, all need to assist their local counterparts, enabling them to work more closely with communities.

Technical assistance can be provided to help a community identify or develop a data reporting system that allows the use of one common data collection system so that various efforts in the community are not in competition to "get the stats." In other areas, assistance can keep competing "needs assessments" from being conducted. In one community, the hospital spent $150,000-$200,000 to do a needs assessment that virtually duplicated one that the United Way had done a year earlier in the same community.

Recommendation: As with training, technical assistance should almost be an "on demand" service available to communities. Efforts at the community level are constantly looking for advice, information and technical assistance on the "hows" of addressing issues they choose to address. While communities know themselves well and have their own ways of doing things, they are inconstant need of support which comes by way of technical assistance.

IV. Funding: Sufficient state and local funding must be made available to carry out and sustain Healthy Communities activities. As identified in articles in the March/April & May/June, 2000 issue of the Public Health Reports, the Healthy Communities movement has been an interesting "foster child." Everyone likes the concept, thinks it is important, but the resources to truly support the movement have not been put forward. Various funding requirements within each sector have been the major culprit in this regard. Because Healthy Communities is "owned" by everyone, no one really owns it.

Basic to the Healthy Communities process is a broad definition of health which recognizes that people are healthy not because of access to medical services alone, but also because of neighborhood vitality, employment, safety, adequate recreational opportunities, and many other factors. When a Healthy Communities effort attempts to address these broad concerns, it often finds funding for its activities lacking. Community building, or a neighborhood development issue such as voting or building a community center, is not "fundable" by health-related foundations and public health agencies because they require a focus on specific health issues such as heart disease, drug abuse, or teen pregnancy prevention, to name just a few. Hospital funds may be available for programs designed to address specific health issues, but then civic entities are unable to contribute to those efforts because of their own funding requirements, which focus on community development.

In many instances, Healthy Communities efforts have been funded by hospital outreach or community benefits funds. In a couple of states, federal Prevention Block Grant funds have been used, but examples of this are very limited. Foundations, such as Kellogg, have assisted from time to time, but sustainable funding has been a difficult problem for Healthy Communities efforts.

The Healthy Boston projects initiated in the early '90s lost their core funding from the City of Boston and now spend much of their time submitting applications for various grants for HIV/AIDS prevention, community policing, safe streets, and so on, in order to keep functioning. Their roots in a broad-based community coalition places them in an advantageous position for these funds, but they continue to be affected by the "disease of the month" funding with which they have to patch their efforts together.

The national Healthy Communities movement is the epitome of coalition building among different sectors. Yet, the national Coalition for Healthier Cities and Communities, itself, has been caught up in the funding conundrum: difficulty finding long-term funding commitment to sustain its efforts at the scale truly needed to support the ever-growing nationwide network of state and local efforts. The Coalition has partnered with several different entities, with limited funding on projects that do not always embrace the overall Healthy Communities strategy. States are in the same position. Funding issues must be addressed to assure core support for sustaining the movement at both state and local levels.

Recommendation: Core funding to support and sustain on an ongoing basis is key and essential for any community effort to be sustained. This funding can come from a variety of places such as the tobacco settlement funds, several agencies and organizations at the state level coming together and setting aside core funds or organizations at the local level such as municipal government, public health, hospitals, community development and social service setting aside funds of $45,000 to $70,000 which would assure minimum core staff can devote their energies to building the movement at the local level and not be forced to "grant surf" for fund to sustain their employment.

V. Systems Change: Systems change at and between state and local levels must occur. One of the most challenging issues faced by organizations at the state level is a re-examination of state policies and procedures that can get in the way of community building. This has to be done in both the public and private sectors. Efforts must be implemented to build new relationships between and among citizens, government and the private sector in building and supporting communities

States are important, if not vital, to local efforts. It is a long way to the national efforts for people at the local level, and they seek support for their efforts from the state. Policies and procedures, funding mechanisms, and other support at the state level should assist communities rather than discourage them. For example, work hours and training programs are generally scheduled to accommodate agency workers rather than citizens/residents. Personnel policies should allow government workers to work on the "community's time," (weekends and evenings) rather than "government time" (8:30-5:00).

Recommendation: As is the case which is put forth here, organizational ways of doing things may have to change in order to assist and enable communities in doing what they can do best. It is recommended that mechanisms be developed which inform state level organizations of ways that things can be changed that accomplishes this mission.

VI. Coordination/Collaboration at the State Level: There is a need for increased coordination and collaboration among the entities, at all levels, involved in Healthy Communities efforts. Collaboration does not happen automatically. Systemic efforts to ensure real coordination and collaboration at the state level must be implemented. The single most important area of complexity, which has implications for almost all community efforts, is the funding of state programs. State funding streams need to be modified so as to encourage, support and reinforce collaboration. Simply mandating collaboration at the local level is not enough. Systemic efforts at the local level which ensure real coordination and collaboration often happen naturally; it is time for entities at the state level to do the same.

Early in the development of South Carolina's Healthy Communities Initiative, a Healthy Communities Partnership Advisory Board was established. This body meets periodically and identifies areas in which collaboration and cooperation will improve matters at the community level. Representatives serve on various planning committees of the individual partners to help assure coordination. In Massachusetts, members of a similar advisory board for the Training Institute serve as the selection committee for scholarships to communities and for Investing in Healthy Communities Grants. This type of group decision-making strengthens the connections and helps to assure that all relevant information is considered in the decisions which can help communities.

The Turning Point initiatives funded by Kellogg and Robert Wood Johnson, have been effective in bringing about closer collaboration among partners in several states, and have been closely aligned to the Healthy Communities efforts in Maine, South Carolina and Louisiana.

Recommendation: State level organizations must implement cross organizational collaborations, seek ways for funding grants from different organizations, select representatives from different agencies and organizations to work together to develop programs, train together, enter into legally binding relationships, produce data reports and provide training together for people at the community level. State level organizations must simply practice what they preach.

VII. Motivation/Celebration: Recognize, celebrate, honor, and reward exemplary local and regional efforts. The state level can be a major re-enforcer of local efforts through the holding of conferences that celebrate progress in various communities. These conferences can recognize and honor individuals and activities in such a way as to bring honest reward and revitalization to the people and communities involved. These conferences can be vehicles for networking among communities and disseminating best practices. When communities share information, one can see the positive energy that this simple activity imparts to people who have no idea that what they are doing is truly exemplary.

The state can also institute an awards program (The Governor's Award for becoming a Healthy Community, for instance) for individuals, communities and programs. These honors go a long way to encourage and sustain local efforts. Awards, recognition, sharing, networking--all have very positive effects on local efforts.

Awards of Distinction in categories such as community participation, resource development, and program impact are highly sought after by official participants of California Healthy Cities and Communities. For cities and communities not officially participating, Special Achievement Awards recognize innovative local programs that take a broad view of health. Formal presentations of the these awards are made in the communities, often during city council meetings. The Pennsylvania Institute for Healthy Communities uses its bi-monthly newsletter to provide recognition and shared learning among local partnerships. For several years, The Healthcare Forum was a real promoter of Healthy Communities efforts through its national and international Healthier Communities Awards. In Texas, as in some other states, a healthy schools award has done a great deal to wed community and schools together to reward efforts that truly support children being healthy.

Recommendation: Healthy communities must be fun communities as well. Lifting up an honoring what is good and what is done well will help to spread the word, reward accomplishments and create an exciting movement which everyone wants to be involved in.

VIII. Championship: Keep and spread the vision! At every governmental level and in every community sector, there needs to be an individual or organization (preferably many of both) which serves as a "champion" of the effort, selling the concept and mobilizing citizens and organizations. This does not happen without intentional work identifying key people who can fulfill the role of champion. It might be a legislator or other elected official, an organization head, a leader in the medical community, a sports leader, a foundation head, or a civic group.

The Pennsylvania Institute for Healthy Communities is a champion for healthy communities, and specifically targets hospitals and health systems to encourage them to actively support and engage in community health improvement partnerships. The Institute has developed a "Community Health Policy" which explains why community health is an important strategic direction for health care providers, describes community health improvement methodologies, and sets forth roles and responsibilities of health care provider organizations. In conjunction with this, they have also developed a "Health Care Organization Self-Assessment Tool for Commitment to Communities' Health Improvement."

Other state organizations provide articles and reports for journals, business and professional associations' magazines and local newspapers. These articles constantly lift up and give visibility to the unique mobilization for health improvement happening in scores of communities in their state.

Recommendation: Identify and support leaders from different sectors who can clearly outline the vision, make the connections between graffiti eradication and diabetes (safer streets yield better opportunities for people to be physically active and encourages senior who fear going outside to visit their medical care provider) and other community and civic renewal efforts and health. Encourage these people to speak up often.

XI. Evaluation/Documentation: This is an area that usually "breaks the back" of local community groups. How and where do they identify the resources to collect data on their efforts? A vicious cycle begins: no data for proof, or even for program improvement, then various funders are not interested. Healthy Communities efforts need assistance with conducting evaluations. State-level organizations, especially state government and academic institutions, have resources that can help with this effort.

Healthy Communities Massachusetts has conducted two simple, but much needed, evaluations with the assistance of experts at the University of Massachusetts. Other states have conducted evaluations as well.

Recommendation: Make resources availoable to communities to do evaluations, do not simply require it, do it.

X. Data: Connected to the evaluation issue, access to data, as well as skill in interpreting data, is an area that needs support from experts in the field. Planning, targeting, tracking and documentation are elements of community health improvement efforts with which local communities need assistance. Few in local communities have the sophisticated skills required for accesing, interpreting, and using data. Internet technology has made easier access a distinct possibility, but training in interpreting and using the data is vital.

Most states have made significant efforts to assure that communities have access to appropriate data. Massachusetts Department of Public Health has developed MassCHIP, an Internet access data system designed to make access to community data as easy as possible. Many states involved in Turning Point Initiatives are improving their data systems to make access to data easier for communities. This includes community-based training, such as efforts underway in South Carolina.

Recommendation: Develop ways to make data more readily available at the local levels in timely and user friendly ways. Make training in data use and understanding available at the community level often.

XI. Research: Academic study of Healthy Communities beyond evaluation--especially research on the optimal roles of government, urban planning, community and economic development, the faith community, social and human services, education and architecture--will enhance the movement's credibility, provide information needed to ensure success, and, perhaps, improve local communities' efforts to obtain funding.

The Interfaith Health Program of the Carter Center/Emory University is a particularly useful research effort regarding the role of faith communities in Healthy Communities efforts. Several states have schools of public health involved in research, and Steven Fawcett (University of Kansas), Patricia Sharpe (University of South Carolina), Nina Wallerstein (University of New Mexico), are among a handful of professors interested in and committed to research and study around Healthy Communities efforts. Urban research prevention centers, funded by CDC, function in Detroit and Seattle. This growing effort will contribute to the movement.

Recommendation: Provide funding for community-based research in academic institutions and seek ways to encourage the use of community work by academicians to count towards their tenure process. Improve the relationships between community and academia to one of mutual respect and collaboration. Assure that communities are not used.

XII. Learning Communities: There is a lot to learn, or relearn, about community building. Inter-community networks can begin to form a "learning community" among communities through intentional connections and by ensuring a sense of being part of the greater whole. Evaluation data, research data, and community stories all help to build a community learning process. Regional meetings of local Healthy Communities efforts are supported and encouraged in many states as a way for communities to share experiences and lessons learned.

Recommendation: Seek ways for ongoing learning through the use of the internet and other opportunities.

Conclusion

This list of key components of a statewide Healthy Communities effort can serve as a checklist for states to use in assessing their support of the Healthy Communities movement. State-level scanning of Healthy Communities activities, using this listing, can help a state identify its strengths and weaknesses, and target areas for improvement. Such a scan can help build the case for multisectoral involvement and define appropriate roles for the different sectors to assure that no one sector dominates.

It is very clear to those who contributed to the development of this list (though none is so fortunate as to already have all the components fully in place) that no one sector can or should be responsible for the entire Healthy Communities effort in a state. Citizens, government, and public health in particular, are key leaders, but none should dominate. Each sector is important. All are necessary. It will not work if any sector is missing.

Special thanks to Cathy O'Connor, Michael Coughlin, Ralph Fuccillo, and Michael Hatcher for their input and assistance in the development of the key components.

Peter Lee, MPH, is Director of Healthy Communities Massachusetts and can be reached at 617-451-0049 or peterlee@netway.com