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It is a great honour to be sharing my ideas with you today, in such esteemed company.
The year of my birth, 1963, was the same year that Prof Len Duhl published an edited
book called The Urban Condition: People And Policy In The Metropolis. For me this
book is a landmark in terms of looking at the social ecology of cities and the mental
health implications of urban design. As you may know, Prof Duhl's ideas helped give
rise to the Social Model of Health and the international Healthy Cities movement in the
1980s. It was my privilege to spend eight months recently working with Len in Berkeley
as a Fulbright Visiting Scholar, looking at Healthy Cities evaluation. Today I am going
to share my reflections from this study, and offer some ideas for Healthy Cities
evaluation that draw on my background as a community psychologist.
Community psychology involves the study of behaviour of the individuals, families, and
groups within the context of their community ecosystem. By ecosystem, I am referring
the interplay of the built, natural, economic, social, political historical and cultural
environments that impact on people’s individual and collective lives. I refer to
Bronfenbrenner’s (1979)1 concept of multiple interconnectedness within and between
levels of the microsystem (the person’s immediate setting), the mesosystem (settings in
which the person participates), exosystem (settings in which the person may never enteror have any direct experience, but which will affect their immediate environment), and
the macrosystem (the “overarching patterns of ideology and organization of the social
institutions common to a particular culture or subculture”, p. 8).
Community psychology is an applied discipline that seeks to use the skills of the
psychologist to maximize the competence of community members to solve problems and
to ensure the delivery of programs and services to aid community members within the
context of their everyday lives. Key themes within community psychology include
empowerment, participation, human rights, social justice, equity, and sense of
community, and their connection with psychological health and wellbeing. ‘Place’, both
physical and social, plays an important role in community psychology, as both the
background context for human experience, and as the subject of research itself.
Community Psychology draws very heavily on environmental psychology and
geography in order to understand people’s relationship to place and how it impacts on
individual and collective behaviour and wellbeing. Research in these fields has much of
relevance to public health, because of the ecological nature of these interrelated
concepts, and their overlap with research on the social determinants of health.2 3 4
Program evaluation forms a major part of community psychology research. The user-
focused evaluation approach of Michael Quinn Patton resonates with community
psychology. Patton (1982) defines evaluation as “the systematic collection of information
about the activities, characteristics and outcomes of programs, personnel and products
for use by specific people to reduce uncertainties, improve effectiveness and make
decisions with regard to what those programs, personnel or products are doing and
affecting”5. Patton argues that we should conduct evaluation that is ultimately usable,
but also feasible, use ethically and culturally appropriate strategies, and, finally,
accurate. To do this, we need to engage meaningfully with stakeholders – such as the
people who participate in Healthy Cities programs – as equal colleagues in the
evaluation process, and work with them to develop the evaluation strategy at the same
time that we develop the Healthy Cities initiative.
Another evaluation approach that has strong ties to community psychology – and action
anthropology - is David Fetterman’s (1994) empowerment evaluation6. He defines
empowerment evaluation as:
“… the use of evaluation concepts and techniques to foster self-determination.The focus is on helping people help themselves. This evaluation approach focuses
on improvement, is collaborative, and requires both qualitative and quantitative
methodologies... It is a multifaceted approach with many forms, including
training, facilitation, advocacy, illumination, and liberation” (p. 1).
Empowerment evaluation is based on the principle of self determination – the ability to
chart one’s own course in life, including the ability to: (i) identify and to express one’s
needs; (ii) establish goals and expectations; (iii) develop a plan of action to achieve these
goals; (iv) make rational choices from various alternative courses of action; (vi) take
appropriate steps to pursue one’s objectives (vii) evaluate short and long-term results
(including reassessing plans and expectations and taking necessary detours); and (viii)
persist in the pursuit of these goals. Empowerment evaluation can involve training,
facilitation, advocacy, adult learning and liberation.7
I have applied a community psychology orientation to my work in many settings.
Between 2000-2003 I worked for the State Government of Victoria, Australia. I was
recent evaluation of the Californian Healthy Cities and Communities program, and
offer strategies for strengthening evaluations by incorporating research and practice on
measures of sense of community, social capital and empowerment.
One of the surprising issues I had to deal with in the US was the way that the Healthy
Cities approach was dismissed by some academics. One person, probably a traditional
clinician, referred to Healthy Cities, as ‘just rhetoric’. After all, in her view, how do you
show that a broad community development approach to promoting health and
wellbeing is responsible for reducing levels of disease? And yet with about 10,000 cities
and communities using this approach, can it be so easily written off as ‘rhetoric’, a fad?
Clearly incommensurate paradigms are still clashing here, some twenty years after
Healthy Cities and the ‘new’ ecological approach to public health began. Healthy Cities
evaluations need to be able to show whether all that effort to create multi-sectoral
partnerships has been worth it. But worth what? Here we need to draw on the social
determinants of health and show how Healthy Cities initiatives have influenced the
policies and programs that impact on the social determinants. In a globalising world, we
need increasingly to consider the influence of social determinants operating at the local,
regional, state, national and global levels. Healthy Cities approaches need to be
understood by clinicians as a broad based approach to coordinating upstream anddownstream initiatives to promote health and wellbeing and reduce incidence of disease
and infirmity. I have been particularly interested in the importance of tracking
psychological health aspects of participation in health planning, and the importance of
identifying the role that urban planing can have on people’s sense of belonging. A lot of
psychological research has focused on the interrelationship between the built
environment, participation, social inclusion, and psychological sense of community and
empowerment. We also need to map change against the benchmarks of the Ottawa
Charter. In other words, how have HC initiatives managed to help build healthy public
policy, create supportive environments, strengthen community action, develop personal
skills, and reorient health services? I was surprised to discover how little-known is the
Ottawa Charter in the US. It has been suggested to me that the US ignores most of
WHO’s work. We need to use it to alert potential allies to its value as an educational
tool and as a framework for evaluating health initiatives.
It is true that Healthy Cities approach takes time, and it can be challenging to locate
causality to one or two initiatives. Yet as Prof Fran Baum from Australia has noted, we
Charter. I have been able to learn of two such evaluation approaches. One was
conducted in my Australian state of Victoria in the early 1990s; the other was published
in California last year. I will begin with California.
Californian Healthy Cities and Communities program
The Californian Healthy Cities and Communities program began in the mid-1990s, and
in the longest running HC program in the US. Thirty-five HC/C initiatives have been
funded throughout the life of the program. A key organisation is the Center for Civic
Partnerships13, based in the State capital of Sacramento. A center of the Public Health
Institute14, the CCP is a collective of community building initiatives that emphasizes
participatory governance and a systems approach to healthier communities. The Centreadministers funding for localities participating in California Healthy Cities and
Communities (CHCC) that it secures through a wide range of grants and contracts15.
CCP provides technical support, sponsors educational programs and develops resource
materials for various audiences including local policy makers and government
administrators, community-based organizations and residents.
The Center for Civic Partnerships, recently conducted a detailed evaluation of the 20
Californian Healthy Cities and Communities initiatives established in the second roundof funding. These 20 projects were selected to fulfil particular criteria. Programs were
favoured that were:
• In geographically or socially isolated regions
• Targeted populations “at risk” for inequities in health status.
• Were attempting to engage communities in the initial stages of forming, or
reconstituting, collaborative partnerships to address issues of community health
community level might include collective action to access government and other
community resources...” (Perkins & Zimmerman, 1995, p.570).
Empowered outcomes refer to the consequences of empowering processes. “Actions,
activities or structures may be empowering, and that the outcome of such processes
result in a level of being empowered” (Perkins & Zimmerman, 1995, p.570). For
individuals, empowered outcomes could include the perception of having gained control
over certain situations and domains of their lives, and the attainment of participatory
competence. Empowered outcomes for organizations could include enhancement of
organizational effectiveness through network development and lobbying power. At the
community level, empowerment outcomes might refer to the development of coalitions
between organizations, the development of more and better community resources, and
planning decisions that enhance urban amenity and foster participation, activity and
exercise, and sense of community.
Psychological empowerment – the individual's expression of empowerment – explores
the ways individuals develop and express their competence and efficacy through
participating in social and political change. It has been described as "the connection
between a sense of personal competence, a desire for, and a willingness to take action in
the public domain" (Zimmerman & Rappaport, 1988, p. 725). Psychologicalempowerment is not a passive, inert, intrapsychic construct: it is "rooted firmly in a
social action framework that includes community change, capacity building, and
collectivity" (Zimmerman, 1995, p. 582). I feel that elements of this political perspective
on psychological empowerment were perhaps slightly muted in the Californian
evaluation analysis.
Empowerment theory distinguishes three components of psychological empowerment,
which Healthy Cities evaluations could attempt to document. The components are
intrapersonal, interactional, and behavioural. The intrapersonal component relates to
"how people think about themselves and includes domain-specific perceived control and
self-efficacy, motivation to control, perceived competence, and mastery" (Zimmerman,
1995, p. 588). The interactional component of psychological empowerment refers to the
development of critical awareness about one's socio-political environment, and how to
act strategically to obtain desired resources, and develop the necessary resource
management skills, such as decision-making, problem solving, and self-advocacy. The
behavioural component refers to actions that people take in order to have a direct
impact on the outcomes of events.
Kegler et al noted that at the individual level of analysis, the Healthy Cities and
Communities process “has the potential to change people in significant ways – by
expanding their views of health and enhancing skills they can apply to community
improvement… helping community residents and leaders see health through a broader
lens increases the likelihood of more systemic and effective community health
improvement efforts that target meaningful community change” (p. 43). Some
community members noted that “a broad view of health conflicted with how a few key
organizations and government agencies, usually those with a more traditional, service-
delivery focus, viewed health” (p. 43). An empowerment framework would necessarily
position individual understandings of ‘health’ and skills in achieving holistic,
empowered ‘health’ outcomes, in a framework that was by necessity socially critical and
geared towards social change.
The Role of Place
Kegler, Norton and Aronson’s (2003) evaluation noted the power of place: a factor thatinfluenced projects was “the value of a central, community location that took on the
identity of the Healthy Cities and Communities initiative, as well as the value of rotating
locations to highlight the contributions of each area and encourage participation from
geographic pockets” (p. 29). In addition, whilst most Healthy Cities and Communities
initiatives had not set out to make changes to the physical environment, “changes in
physical conditions in communities seemed to be an almost natural by product of these
efforts” (p. 84). Almost all Healthy Cities and Communities initiatives reported at least
one change directly related to their efforts, with an average of three changes per
community. The most common types of changes were neighbourhood and community
beautification, followed by facilities construction, expansion and renovation; public
utilities and public safety; and construction and renovation of parks and recreation
facilities. Again, community and environmental psychology has something to offer this
finding.
Place and power are deeply interrelated. In a detailed recent theoretical overview on
place attachment, environmental psychologist Lynne Manzo Manzo noted that ‘place
barriers/openings, surveillance, cost of entry, aesthetics, symbols of dominant class /
occupiers). Manzo noted that our relationship to place is inextricably linked to the
“sociocultural context in which we find ourselves… who we are can have a real impact
on where we find ourselves and where we feel we belong” (Manzo, 2003, p. 5440). People
derive their sense of self and community through their interaction with places. The
places give people messages about who they are, what activities are intended for that
place, who the place belongs to or is reserved for, and what right those people have to be
there. Manzo argued that “we need a greater link between concepts such as ‘sense of
place’, the politics of place, and ideology” (p. 54).
Lynne Manzo’s paper is useful to ‘Healthy Cities’ thinking in that it reminds me that
HC programs – and the Ottawa Charter – are inherently about the political life of cities
and communities. The localities, places or neighbourhoods that HC programs identify
and select for renovation are the result of a political, historical and cultural process.
Place serves as a context for HC programs, irrespective of whether the HC programs
specifically identify ‘place’ as a goal area. Place and locale form the backdrop to manyof the more pressing issues that communities must address, for example, who lives
there, the resources in that community, and the presenting health issues. Decisions
about developing or demolishing places, amenities, infrastructure or buildings, or
changing graffiti laws, surveillance of public places or evoking planning regulations are
all formed through expressions of power and control. Conflict is an essential component
to empowerment: it occurs in and over places. Therefore, HC programs designed to
address the physical environment and place must address power dynamics,
sociocultural context, history, power relations, and the politics of inclusion and
exclusion. Healthy Cities participants may be working on a certain place to build on a
positively-held affect – but they could also be working to change places due to negative
feelings and associations. People may be acting consciously as well as unconsciously with
respect to these places – we need to try to encourage people to articulate these
associations and feelings. This is an inherent component of ‘place making’, but needing
In tandem with my research on issues of measuring dimensions of place and
community, has been my effort to understand better the indicator movement that has
gathered so much worldwide momentum in recent years. It has been fascinating to
compare the Healthy Cities scene in the US with that in Europe, in which WHO has
developed a huge (and often unwieldy) bureaucracy, including numerous monographs
on planning and evaluation44, and a special office on indicators. Len has noted that
whilst the Europeans made it a program, the Americans have seen it as a pseudo-
anarchic process, more like the development of Linux.
An indicator is ‘a variable 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. It also provides a basis for developing
adequate plans for improvement’ (WHO, 200245).
Much on indicators has been published in the urban design field, including the methods
that urban planners can use to obtain unobtrusive physical measures of community’s
functioning. Aicher (1998) listed hundreds of determinants of urban health that urban
developers must consider, and guidelines for addressing them, including dimensions
such as sense of place and environmental satisfaction.46 Interestingly, the aesthetics of
place and community have not featured in WHO Europe’s official indicator set 47.
WHO's original set of 53 indicators did initially have some interesting, broad indices of
community functioning. However many of these were removed along with some 18
others due to the many logistical problems of collecting comparable (even usable) data
from 47 countries.
The most useful discussion I have read in indicators is by UC Professor Judith Innes,
from Berkeley’s Institute of Urban and Regional Development. Firstly, Innes andBooher (1999)48 noted that indicator projects often focus on developing the numbers
instead of considering how they will be used. Producing the indicator report is often
made a priority, as opposed to considering how the report may be used, or how the
community can learn from the process of developing indicators in the first place.
Innes and Booher describe this three-level system as contributing to “distributed
intelligence” – multiple levels of indicators to distribute coherent, integrated
information to a broad cross section of the populace in such a way that people could all
make decisions based on information that all pointed people in a creative, coordinated
way towards sustainability. “Many individual participants, following simple rules for
adjusting their actions without seeing or understanding the dynamics of the larger
system, can deal with complex reality” (p. 12).
Conclusion
I would like to make the following observations:
• The evaluation reports documented above all present opportunities for
evaluators of HC programs to consider the systemic impacts of their work in
helping to encourage individual, organizational and community empowerment,
build sense of community and foster sense of place.
•
Including consideration for sense of community, psychological conceptions of place and social capital can help to anchor Healthy Cities in this broader social
ecological model that includes consideration for place, belonging, participation,
social networks and power. An empowerment framework can make manifest the
process of power transference to community members to gain some control over
the issues that determine their health and wellbeing.
• Evaluation approaches that use a range of quantitative and qualitative methods
are more likely to document the range of actions initiated by a Healthy Cities
program, and their ripple effects across the social spectrum over time.
• Ecological approaches to HC evaluations offer innovative opportunities to
explore links between social policy and the social determinants of health. This is
a key goal of Healthy Cities principles and the Ottawa Charter, and needs to be
encouraged in order to highlight the political dimension to civic democracy and
1 Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA:
Harvard University Press.2 See A. T. Fisher, C. C. Sonn, & B. J. Bishop (Eds.), Psychological sense of community: Research, applications, andimplications (pp. 291-318). New York: Kluwer Academic/Plenum Publishers.3 Sarason, S. B. (1974). The Psychological Sense of Community: Prospects for a Community Psychology. San Francisco:
Jossey Bass.4 Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology.
American Journal of Community Psychology, 15, 121-148.5 Patton, M. Q. (1982). Practical evaluation. London: Sage.6 Fetterman, D. M. (1994). Empowerment evaluation. Evaluation Practice, 15 (1), 1-15.7 See www.stanford.edu/~davidf/empowermentevaluation.html 8 See www.health.vic.gov.au/localgov 9 (WHO, 1995). Twenty Steps for Developing a Healthy Cities Project (2nd Ed.). Copenhagen, Denmark: World Health
Organization Regional Office for Europe. Available on-line: http://www.who.dk/healthy-
cities/Documentation/20010918_14. Accessed 3 March 200410 WHO (1997). City planning for health and sustainable development. Copenhagen: WHO Regional Office for Europe.
Available: http://www.who.dk/document/wa38097ci.pdf . Accessed 1 March 2004.11 See Duhl, L. J., & Sanchez, A. K. (1999). Healthy Cities and the city planning process: A background document on links
between health and urban planning. Copenhagen: WHO Regional Office for Europe. Available on-line:
http://www.who.dk/healthy-cities/Documentation/20020514_1 Accessed 3 March 2004.12 Baum, F. E., (1993). Healthy Cities and change: Social movement or bureaucratic tool? Health Promotion International, 8,
31-40.13
Website: www.civicpartnerships.org. Email: [email protected] http://www.phi.org/ 15 See http://www.civicpartnerships.org/files/Profiles.pdf 16 see http://www.civicpartnerships.org/files/TCEFinalReport9-2003.pdf 17 Goodman et al, cited on p. 93 of Kegler, M. C., Norton, B. L., & Aronson, A. E. (2003). Evaluation of the five-year
expansion program of Californian Healthy Cities and Communities (1998-2003): Final report. Sacramento CA: Centre for
Civic Partnerships. Available on-line: http://www.civicpartnerships.org/files/TCEFinalReport9-2003.pdf . Accessed 3
March 2004.18 Norton, cited in Kegler, Norton & Aronson (2003), p. 93.19 Butterworth, I. M. (1999). Adult environmental education: A community psychology perspective. Unpublished doctoraldissertation. Melbourne, Australia: Victoria University.20 Garrard, J., Hawe, P., & Graham, C. (1995). Acting locally to promote health: An evaluation of the Victorian Healthy
Localities Project. Volume 1: Evaluation Overview. Melbourne, Australia: Municipal Association of Victoria.21 Kegler, Norton, & Aronson (2003)22 McMillan, D. W., & Chavis, D. M. (1986). Sense of community: A definition and theory. Journal of Community
Psychology, 14(1), 6-23.23 Perkins, D. D., Florin, P., Rich, R. C., Wandersman, A., & Chavis, D. M. (1990). Participation and the social and physical
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a Brief SCI. Journal of Community Psychology, 31(3), 279-296.26 Long & Perkins (2003).27 Perkins & Long (2002).28
Perkins, D. D., Florin, P., Rich, R. C., Wandersman, A., & Chavis, D. M. (1990). Participation and the social and physicalenvironment of residential blocks: Crime and community context. American Journal of Community Psychology, 18(1), 83-
115.29 Baum, F. E. (2000). Healthy Cities: History, progress and prospects. Keynote address at the Australian Pacific Healthy
Cities Conference, Canberra 26th-28th June 2000.30 Perkins, D. D., Hughey, J., & Speer, P. W. (2002). Community psychology perspectives on social capital theory and
community development practice. Journal of the Community Development Society 33 (1), 1-22.31 Perkins, D. D., & Long, D. A. (2002). Neighborhood sense of community and social capital: A multi-level analysis. In A.
T. Fisher, C. C. Sonn, & B. J. Bishop (Eds.), Psychological sense of community: Research, applications, and implications
(pp. 291-318). New York: Kluwer Academic/Plenum Publishers.
32 Zimmerman, M. A., & Rappaport, J. (1988). Citizen participation, perceived control and psychological empowerment.
American Journal of Community Psychology, 16, 725-750.33 Perk ins, D. D., & Zimmerman, M. A. (1995). Empowerment theory, research and application. American Journal of
Community Psychology, 23, 569-579.34 Kieffer, C. H. (1984). Citizen empowerment: A developmental perspective. In J. Rappaport & R. Hess (Eds.), Studies in
Empowerment (pp. 9-36). New York: Haworth Press.35 Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology.
American Journal of Community Psychology, 15, 121-148.36 Bunton, R. (1992). More than a woolly jumper: Health promotion as social regulation. Critical Public Health, 3 (2), 4-11.37 Farrant, W. (1991). Addressing the contradictions: Health promotion and community health action in the United
Kingdom. International Journal of Health Services, 21, 423 439.38 Tannahill, A. (1985). What is health promotion? Health Education Journal, 44 (4), 167 168.39 Zimmerman, M. A. (1995). Psychological empowerment: Issues and illustrations. American Journal of Community
Psychology, 23, 581-600.40 Manzo, L. C. (2003). Beyond house and haven: toward a revisioning of emotional relationships with places. Journal of
Environmental Psychology, 23, 47-61.41 Berkowitz, B. (1996). Personal and community sustainability. American Journal of Community Psychology 24, 441-459.42 Garrard, J., Hawe, P., & Graham, C. (1995a). Acting locally to promote health: An evaluation of the Victorian Healthy
Localities Project. Executive Summary. Melbourne, Australia: Municipal Association of Victoria. Quote taken from p. 5.43 Garrard, J., Hawe, P., & Graham, C. (1995b). Acting locally to promote health: An evaluation of the Victorian Healthy
Localities Project. Volume 1: Evaluation Overview. Melbourne, Australia: Municipal Association of Victoria.44 See http://www.euro.who.int/healthy-cities/Documentation/20010914_2 45 World Health Organization (2002). Practical Methodologies for the Evaluation of Healthy Cities Projects. Manila: WHO
Western Pacific Region.46 Aicher, J. (1998). Designing healthy cities: Prescriptions, principles and practice. Malabar, FL: Krieger.47 See http://www.euro.who.int/document/hcp/ehcpquest.pdf 48 Innes J., & Booher, D. E. (1999). Indicators for sustainable communities : A strategy building on complexity theory and
distributed intelligence. Berkeley, CA: Institute of Urban and Regional Development, University of California at Berkeley.49 This point was made in 1963 by Leonard Duhl in the seminal The urban condition: People and policy in the metropolis.