Back to Basics: Creating and Sustaining Healthy Communities
by Tyler Norris, Gruffie Clough and Darvin Ayre
Principals, Community Initiatives, Boulder, CO

Going by many names, hundreds of community-based initiatives have formed a national movement of local partners working to improve health status and create healthier, more livable communities. But there's more to building a healthy community than just conducting a health promotion or disease prevention project.

A healthy community requires quality education, ethical behavior, jobs, a healthy environment, housing, faith, governance, transportation, and early childhood development-as well as access to medical care and traditional health services.

Building a healthy community is about making people's health status and quality of life a determining factor in every local action, policy, and resource allocation. For health care organizations, it's about breathing life into the mission statement. A real commitment is visible in the budget. And it's not just the business of institutions - every citizen has a role to play in creating health.

Trustee Leadership

Since most of what actually creates "health" exists outside of the health care delivery system, the role of leadership is not as simple as allocating staff and financial resources. True healthy community leaders need to learn how to design and implement community processes that result in cultural and behavioral change.
What does this mean? Leaders need to extend their credibility and relationships to bring other leaders, and a diverse representation of community members, to the table. A trustee's role is to harness the values, assets, and aspirations of a community and mobilize them for action toward better health. Internally, administrative, medical, nursing and support staff all have a role to play. But the real leverage point is out in the community. Health begins where people live, work, and play - not in our care facilities. Your bottom line may eventually depend on how well you understand this.

As Americans raised in the democratic tradition, we all have a highly developed sense of our rights and privileges. But the time has come for us to become equally sophisticated about our responsibilities. In many communities, this growing sense of collective accountability implies a needed change in civic culture. But how do leaders direct the creativity and resources of a community to bring about change that builds long-term health and quality of life? And how can we sustain the shared commitment and focus necessary to realize a measurable return on our community investments?

The Healthy Communities Movement

The movement began in the mid-1980s with the "Healthy Cities" initiative spearheaded by the World Health Organization. That effort was designed to bolster quality of life in 34 European cities. Since that time, the movement has spread to more than 3,000 communities in 50 countries and counting. In the United States, the initiative has a distinctive American flavor.

The U.S. Department of Health and Human Services formally embraced the healthy community concept in 1989, asking the Denver-based National Civic League to help launch the U.S. Healthy Communities Initiative. Since then, scores of health care associations and organizations, human services and public health agencies, and community-based organizations have adopted the healthy communities approach. The Coalition for Healthier Cities and Communities, formed in 1996, is now a network of more than 450 organizations serving as a link to resources and a voice for policy to the growing movement. More than 1,000 U.S. communities and many states are now active in the movement, each defining their strategies in a locally relevant way.

Although our organizations, schools, churches, and hospitals are separate institutions pursuing separate agendas, they are interrelated parts of a single community, united in the vision of providing for the well-being of all its citizens. Building healthier communities means building stronger, more positive relationships among all constituents that cross racial, geographic, interest-group, and ideological lines.

Healthy Community Principles
Communities across the nation are using a variety of models and processes to work together to achieve their vision of improved health. The following ideals are guiding the most successful efforts to build healthy communities:

  • A broad definition of "health": Health is not the absence of disease. Half of what creates health is lifestyle and behavior; 20 percent is affected by socioeconomic, cultural, and environmental determinants; 20 percent is genetic; and 10 percent is medical.
  • A broad definition of "community:" By using as broad a definition as possible of what constitutes a community, individuals and partnerships can address their shared issues in the most fruitful way possible. Communities are based on faith, perspective, and profession, as well as geography.
  • Shared vision from community values: A community's vision is the story of its desired future. To be powerful and inspiring, a community's vision should reflect the core values of its diverse members. A vision is not bullet points on the wall - it is a living expression of shared accountability for priorities.
  • Quality of life for everyone: Healthy communities strive to ensure that the basic emotional, physical, and spiritual needs of everyone in the community are addressed.
  • Diverse participation and widespread community ownership: In healthy communities, all people take active and ongoing responsibility for themselves, their families, their property, and their community. A leader's work is to find common ground among participants, so that everyone is empowered to take direct action for health.
  • Focus on "systems change:" This means changing the way people live and work together. It is about how community services are delivered, how information is shared, how local government operates, and how business is conducted. It's about resource allocation and decision-making, not just nice projects.
  • Use of local assets and resources to enhance the community: This means starting from existing community strengths and successes and then investing in the community's infrastructure. By developing an infrastructure that encourages health, fewer resources will need to be spent on "back end" services that attempt to fix the problems resulting from a weak infrastructure.
  • Measurement of progress and outcomes: Healthy communities use performance measures and community indicators to help expand the flow of information and accountability to all citizens, as well as to reveal whether residents are heading toward or away from their stated goals. Timely, accurate information is vital to sustaining long-term community improvement.

Community Change Model

A decade of healthy community work has uncovered a series of core principles and best practices in designing community change efforts.
The following model is built upon real-life experience with dozens of communities throughout the world. Two key elements of the change model are its focus on sustainability and its usefulness to communities regardless of where the communities are in their change process.

This model can be used in a linear way to design and implement new initiatives. It can also be used more flexibly, drawing on specific components as needed to enhance community change efforts. You are an architect and catalyst for community change and will need to determine the most effective approach tailored to your community.

Assessing Readiness

Learn before you leap! It's essential to size up your community's readiness and capacity to act before committing valuable energies and resources. An important conversation is not always whether to act, but how? Start from scratch? Build upon and link existing initiatives? Work to strengthen an existing effort by refining their approaches and implementation strategies? What is the impact of existing initiatives in the community, and what does that imply for the next step?

Energizing Ourselves and Our Communities

Every community improvement effort needs energized, committed leaders. No lasting, positive change ever happens without people who have the passion to take action - and are committed enough to persevere to the point of success. A core group of people with talent, relationships, resources and credibility is needed to lead the charge.

A thoughtful approach - building on visioning, asset mapping, civic capacity assessment, community profiling, and community immersions - is needed to build the type of understanding that inspires action. These activities also foster relationships by providing learning opportunities in team building, creating working agreements, using facilitation and listening skills, and practicing collaborative problem solving.

Early Wins

A community leadership team has many roles and responsibilities in supporting the success of a community-wide change effort. These include developing a clear mission, creating an effective community process design, generating a powerful set of activities to engage and communicate with community members, and establishing a resource base commensurate with the task. Further, it needs to consider how to strengthen the will of the community to move into action.

Setting Direction for Change

Community members may have a vision of their future, understand the current realities and trends, and be aware of available resources. But they must also understand the implications for how decisions are made, problems are solved, who is at the table, and how resources are allocated. In order to change individual and organizational behavior, have an impact on old systems and structures that may have outlived their purpose, and get beyond a "project mentality" of quick-fix solutions, community priorities need to be established for more than the most conspicuous issues emerging out of an assessment process. This involves identifying actions based on many types of learning i.e., data, resources, listening to community constituents, and direct experience.

Implementing Change

Community initiatives that measurably improve health and quality of life have many active dimensions. Among these is an ongoing process of building relationships of trust and commitment across lines of sector, race, and class. Another is building the skills of collaboration and the muscle of civic capacity that allows a community to do what it must. Another involves a continuous process of learning and acting, visioning and revisioning, ongoing performance tracking, and the active engagement of underutilized or misallocated community assets.

These six core themes form the backbone of effective community change partnerships. These themes are not so much steps as ingredients. Sustainability should be understood as a starting point, not something to be considered later. Three "sustainability streams" of leading, learning, and communicating add consistency and focus to the process.

  • Leading is the art of developing effective partnerships among diverse people in a community. It is a commitment to building relationships of trust and caring, and aligning shared resources with community values.
  • Learning is the power of continuous reflection, measurement and evaluation as
    a complement to planning and action. It is a commitment to mutual accountability for the results. Learning is the springboard to lasting change.
  • Communicating is the practice of meaningful community dialogue at all levels. It involves developing a culture of authentic conversations that frames issues, promotes critical thinking, and allows for the development of community cohesiveness. It is also about sending messages: sending them often, and sending them boldly.

The Community Change Model presented here is adapted from Facilitating Community Change © 2000