Healthy City Fall River – A Community Partnership

Michael Coughlin, MS

Community Health Planner

Massachusetts Department of Public Health

Adjunct Instructor of Human Services and Psychology

Bristol Community College

David Weed, PsyD.

Psychologist

Corrigan Mental Health Center, MA Department of Mental Health

Adjunct Faculty

University of Massachusetts, Dartmouth

This article was published in Colloquia: Conversations on Teaching & Learning, Fall River, MA: Bristol Community College, Vol. 11, 2004, pp. 135-136.

Healthy City Fall River (HCFR) is a broad-based community partnership to improve the quality of life for those who live and work in Fall River. HCFR is based on the healthy communities approach to community capacity building, which takes a broad view of health and employs a cross-section of activities and community resources to achieve improved health status and community quality of life. HCFR offers multiple opportunities for involvement and partnership between Bristol Community College and other sectors of the Fall River community.

Healthy City Fall River is a cooperative venture between Partners for a Healthier Community, Inc. (Partners) and the Mayor's Office of the City of Fall River. Begun in the winter of 2003, it is modeled on similar efforts that have been developed world-wide and endorsed in 1998 by the U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion. Bristol Community College (BCC) President, Dr. John Sbrega and other representatives of BCC have participated in many of the sessions held thus far.

Partners for a Healthier Community Inc. is one of the 27 Community Health Network Areas organized by the Department of Public Health (DPH) across the state. The mission of Partners is to establish a working partnership among area residents and organizations to improve health status in the City of Fall River and the towns of Somerset, Swansea and Westport.

Fall River Mayor Edward Lambert has committed staff of the Department of Public Health and Human Resources over the life of the project. This will ensure that the various functions of this Department, including elder services, public health and youth services, will be integrated into the Initiative. This level of commitment from a city executive is rare within the Commonwealth.

BCC Involvement in the HCFR

The HCFR reflects one priority of the BCC strategic plan: “Nurture and enhance community partnerships and outreach”. It provides the BCC community with multiple opportunities for student participation and professional development through community service, increased experience in peer partnership and professional collaborative activities that serve the wider community.

On March 25, 2004 Bristol Community College hosted the First Annual Healthy Fall River Summit, which built upon input from a community-wide visioning process to create a Five-Year Strategic Plan. Participants in the Summit included representatives of every key sector of the community, including residents, neighborhood organizations, churches, clubs, civic organizations, schools, businesses, and the media.

The keynote speaker at the Summit was former federal Director of Health and Human Services for Region I, Judith Kurland. Kurland, as Commissioner of Health and Hospitals for the City of Boston in the 1980s was the founder of Healthy Boston and is pioneer in the international Healthy Cities movement.

BCC was a co-sponsor of the Summit. President John Sbrega greeted the participants at the opening plenary session and expressed the commitment of the College for the ongoing success of this “important initiative”.

As the only institution of higher learning in Fall River, BCC has other opportunities to contribute to the HCFR. Seifer (2000) identifies multiple opportunities for colleges to contribute to healthy city efforts including: use of facilities, inclusion of healthy cities in college curricula, equipment and technology, policy and advocacy, and cultural activities. Co-author of this article, Michael Coughlin, M.S., has incorporated a simulated vision exercise and discussion and of the Healthy Communities approach into the syllabus of his Introduction to Social Welfare course in the Human Services Program. The Design Team of the HCFR plans to build on the existing relationships with faculty and administrators at BCC to increase the involvement of the college community in the HCFR.

Healthy Communities Approach

The healthy communities approach to community capacity building takes a broad view of health and employs a cross-section of activities and community resources to achieve improved health status and quality of community life. It is based on the premise that health is more than the absence of disease and that social and environmental conditions play an important role in determining a population's health. Efforts to improve health are best addressed through intentional efforts involving community residents working in partnership with government and other stakeholders.

This approach differs from a more traditional focus on increasing individual responsibility for health behavior and focuses instead on the empowerment of groups that have more acute and chronic health problems and who are disadvantaged by "systems of inequality" (Stoller and Gibson, 1994). Lawrence Wallack (1993) argues that "contemporary public health is as much about facilitating a process whereby communities use their voice to define and make their health concerns known as it is about providing prevention and treatment." The primary objective of this approach is to increase empowerment, which can be defined as "a social-action process that promotes participation of people, organizations and communities toward the goals of increased individual and community control, political efficacy, improved quality of community life and social justice" (Wallerstein, 1992). The method employed by this approach is community organization, "the process by which community groups are helped to identify common problems or goals, mobilize resources, and in other ways develop and implement strategies for reaching the goals they collectively have set" (Minkler and Wallerstein, 1997).

Healthy City Fall River is aligned with the international Healthy Communities movement. The movement has grown rapidly since it was launched in 1986 in conjunction with the Ottawa Charter for Health Promotion of the World Health Organization (WHO). The Charter defined health promotion as "a process of enabling people to increase control over and to improve their health." There are currently 18 national networks and thousands of towns and cities actively involved in the United States and Canada, Europe, and, increasingly the developing world (Hancock, 1993) all of which reflect this approach in varying degrees.

Principles

The HCFR is intentionally constructed to reflect the Principles of Healthy Communities that guide successful efforts to create healthy communities (Ayre, et.al. 2001). These principles further define the concept of Healthy Communities first identified in the Ottawa Charter:

• Health is defined broadly to include factors that contribute to overall health of a community.
• A shared vision is created from community values.
• Healthy Communities seek to improve quality of life for everyone by addressing the emotional, physical, and spiritual needs of everyone in the community.
• Citizen participation is diverse and widespread.
• Focus on “systems change” including the way people live and work together, services are delivered, information is shared, government operates, and business is conducted.
• Builds capacity using local assets and resources
• Measures progress and outcomes to ensure accountability to all citizens and to reveal whether an initiative is heading toward the community’s vision.

A review of the literature which documents the efficacy of these principles in contributing to improved health and quality of life in a community follows.

The Determinants of Health Broadly Defined

Many factors, including social, environmental, and biological conditions shape community health (IOM 2003). Among the specific factors are quality education, adequate housing, gainful employment, job skills training, efficient public transportation, recreational opportunities, healthy and clean physical environments, and health education and preventive services (Ayre, Clough, Norris 2002). The healthy communities approach defines health broadly by identifying the key determinants of the community’s health and identifies strategies to address them.

Physical determinants of health include environmental factors that contribute to health problems, such as toxins and other pollutants; as well as the presence of environmental factors that contribute to good health such as the built environment enabling or blocking access to healthy foods or physical activity. People who live in aging buildings in urban areas and in crowded unsanitary conditions may also experience increased levels of lead in their blood, or increased rates of asthma and allergies (CDC 2001).

Social determinants of health include consideration of socio-economic status and racial and ethnic disparities. Many minority groups in the United States are likely to be poorer and more disadvantaged than the majority white population. These same groups have corresponding disparities in health outcomes including a higher incidence of specific health indicators such as infant mortality, cancer and chronic disease, and decreased access to health care (IOM). Wilcox and Knapp (2000) suggest, “The key to health improvement is to create a social context in which healthy choices are the norm.”

The state of California, as an example of this approach, has administered a statewide Healthy Cities initiative for the past fifteen years (Twiss et.al. 2000). Healthy City initiatives in the Golden State reflect health broadly defined: they have transformed vacant land, increased access to healthful foods, expanded community gardening, reduced exposure to environmental tobacco smoke, restricted alcohol availability, and improved transportation safety.

Communities Develop Shared Vision

“A community’s vision is the story of its desired future, reflecting the core values of its diverse members. It is a living expression of shared accountability to priorities” (Norris & Pittman, 2000).

Developing a vision has been a major focus of the HCFR to date. Between June and September 2003, thirty visioning sessions were conducted throughout the City. A web site (www.gfrpartners.com) listing hundreds of recommendations from local citizens was posted for all to share. In September 2003, a "voting booth" was created by a local volunteer woodworker to display ballots with 43 categories of "Action Priorities" listed. Citizens were then invited to select their three highest priorities, in order of importance, from this list. Over 600 people cast their vote for the most important recommendations. Throughout this process, Partners and the Mayor's office demonstrated a high degree of cooperation and skill in a truly representative vision of a healthier community. Their efforts reached all sectors, communities, and corners of the Fall River community.

Improved Quality of Life

The results of the HCFR visioning process were organized into five “Action Priority Areas” and presented at the Healthy Fall River Summit in March 2004: Safety and Substance Abuse; Environment; Health Education; Adult Education, Job Training, and Employment; and Community Planning and Housing. Participants in the summit developed goal statements in each of the areas and task forces were formed to develop action plans. This broad agenda transcends health issues to address a wide spectrum of community concerns that impact the quality of life of everyone who lives and works in the Fall River area.

Two communities in Pennsylvania further illustrate this principle (Wilcox and Knapp). Pottsdown mobilized several sectors of the community including the transit authority, health care agencies, YMCA, and area businesses to improve access to work opportunities for the low income families in that community. The innovations included improved late night transportation and child care services, enabling more workers to apply for good paying jobs on the night shift at local factories. Efforts in Doylestown, PA focused on community-wide efforts to nurture local teens. An intergenerational planning team organized an ongoing series of youth activities, discussion and support groups, and other youth supports in an effort to transform Doylestown into a community that views teens as an important local asset.

Diverse Citizen Participation

A key feature of healthy community efforts is active and diverse citizen participation in all aspects of the initiative from vision setting through planning, implementation, and evaluation. In this way health communities harness the “social capital” of the community. Robert Putnam is perhaps the most frequently referenced scholar studying social capital. In his highly regarded study of the decline of social capital in the United States, Bowling Alone (2000) Putnam defines social capital as “connections among individuals – social networks and the norms of reciprocity and trustworthiness that arise from them.” Social capital in a healthy community is generated when people and organizations within a community work collaboratively in an atmosphere of trust toward the accomplishment of mutual social benefit.

While Bowling Alone documents the decline of citizen participation and involvement in American life – its title is inspired by the documented decline of participation in organized bowling leagues over the last several decades – Putnam and a co-author recently released a follow up study that documents a series of case studies across the U.S. that illustrate forces working against this trend (Putnam and Feldstein, 2003). For example, they study the city of Portland, Oregon in the 1970’s and 1980s. This period in Portland’s history saw a marked increase in civic activism driven by a network of neighborhood associations that engaged themselves and others sectors of the community in a series of successful community improvement efforts that transformed the city into a more livable and vibrant place to live and work.

The HCFR is attempting to harness the social capital of the City of Fall River. The 1,000 participants in the visioning process during the summer of 2003 spanned the full range of socio-economic, cultural, faith, groups; as well as targeted sectors such as education, business, government, and civic organizations. Action priorities identify the goals in which local citizens are willing to invest their own time and effort. The eventual outcomes of the HCFR will be evaluated by those who will enjoy the benefits of each aspect of the initiative.

Systems Change

“The healthy communities movement contemplates a different vision for the way people live and work together, how community services are delivered, how information is shared, how local government operates, and how business is conducted. It demands that resource allocation and decision making be spread throughout the community.” (Norris, 2000). Systems change in a community results in approaches to problem solving that involve all of those with a stake in the outcome – providing people with a say in decisions that affect their lives. It speaks to horizontal problem solving rather than the traditional top down approach (Ayre et.al.).

System changes address community problems at their root cause. A community with high rates of chronic disease and whose residents report high incidence of smoking and sedentary lifestyles might traditionally have responded by seeking additional medical and health care services from the state or other outside sources. The healthy community approach suggests that such a community would address their health problems by attacking the root cause and attempt to create an environment in their community which promotes physical activity – by improving parks and adding bike and running/walking trails; and by promoting new policies or ordinances which restrict smoking in public places. For example, ninety six of the three hundred fifty one cities and towns in Massachusetts have passed ordinances banning smoking in public places (Gedan, 2003). As the HCFR develops its agenda, it too, will identify opportunities to change some of fundamental ways the community conducts its affairs in order to promote a healthier community environment – making the healthier behavior the easier behavior.

Some additional opportunities for systems change are zoning for community gardens, food service at schools and intergenerational programs between schools and senior citizens and other initiatives which cut across traditional lines and boundaries for economic development, planning, education, human service delivery and so on.

Developing Local Assets and Resources

Healthy communities identify and build on a community’s existing strengths and successes. McNight and Kretzman (1993) suggest that when communities focus on their problems and deficits they may actually contribute to a cycle of dependence. An asset-based approach, on the other hand, helps communities mobilize themselves and build on what they already do well.

McNight and Kretzman have developed a process whereby communities “map” the collective assets, skills, and capacities of residents, civic organizations, and local institutions.

“Each community boasts a unique combination of assets upon which to build its future. A thorough map of those assets would begin with an inventory of the gifts, skills, and capacities of the community’s residents.” (McNight & Kretzman). They argue that historic evidence indicates that significant community development takes place only when local community people are committed to investing themselves and their own resources in the effort. Secondly, communities with multiple needs and low economic indicators have little expectation that large scale industrial or service corporations, the government, or another “white knight” will descend on them bearing high paying jobs and other gifts. Their future is dependent on their own efforts – utilizing their own assets to improve their quality of life, thereby also making their community more attractive for outside investment.

Healthy community literature is rich with examples of communities that successfully utilized their own assets to create positive changes. In low income San Francisco neighborhood, the Tenderloin Senior Outreach Project organized residents into a network of tenant organizations which successfully fought rent increases, improved eviction policies, won structural housing improvements, and formed support groups to address the emotional and spiritual needs of the large elderly population in the neighborhood (Minkler, 1997).

Putnam and Feldstein (2003) write about the success of the Valley Interfaith Project and other faith-based community alliances organized in Texas and other states by the Industrial Areas Foundation (IAF). The Chicago-based IAF was founded by legendary community organizer Saul Alinsky, who pioneered direct action community organizing to improve the quality of life for disempowered citizens and residents. In Texas these groups have successfully mobilized residents and Churches to improve under-performing schools, create job opportunities, improve housing, and direct government dollars to improve infrastructure in neglected areas.

During the visioning sessions of the summer of 2003, Fall River residents identified a rich array of local assets. Among those were an abundant municipal water supply and a large area of reserved open space within the city’s borders; a dedicated local workforce; a rich array of committed civic and neighborhood associations; an ethnically and racially diverse community of many cultures; an abundance of Churches and other places of worship; and a progressive local government who have embraced the concept of a Healthier Community. The challenge for the HCFR in the coming years will be to identify successful strategies to utilize these and other assets for positive change.

Measuring Progress

Healthy communities use community indicators and other performance measures to measure progress toward achieving their goals. “Indicators are small data sets that reflect the status of a larger system that is too large to see directly or in its entirety. A car’s gas gauge and speedometer are examples of indicators people use routinely to make informed decisions.” (Ayre et.al. 2002). Indicators show changes and trends over time and are a means of evaluating the success of community initiatives in achieving goals and changing systems.

The city of Jacksonville FL was one of the first communities to develop quality of life indicators. Since 1985, the Jacksonville Community Council has prepared an annual Quality of Life Report that informs the community on 72 community indicators in nine key areas, including education, economy, public safety, environment, health, social environment, government and politics, culture, recreation, and mobility. (Ayre et.al. 2002).

The Design Team of the HCFR, led by the City Grant Writer, compiled “An Overview of Current Data: City of Fall River” which profiled the city according to a database that included demographics, Healthy People 2010 indicators, and statistics on poverty, the local economy, education performance, and other health-related indicators (Bershevsky, 2003). This database will serve as the basis by which to measure progress for the HCFR in the coming years.

In conclusion, the HCFR provides an excellent example of how the Healthy Community model can be applied in a real setting to achieve an improved quality of health in a diverse, low-income community. It also illustrates the role that a community college can play in supporting this kind of broad-based effort.

For more information about the Healthy City Fall River and Partners for a Healthier Community visit www.gfrpartners.com

References

Ayre, D., Clough, G., Norris, T. (2002). Trendbenders: Building Healthy and Vital Communities. Chicago: Health Research and Educational Trust.

Bershevsky, Susan, (2003). Overview of Current Data: City of Fall River. Fall River, MA: HCFR Design Team and Author.

Centers for Disease Control and Prevention (CDC) (2001). CDC Fact Book 2000/2001: Profile of the Nation’s Health. Atlanta, GA: CDC

Gedan, Benjamin, (2003, 20 Dec.) Some Pubs Rebel at Somerville Smoke Ban. Boston Globe. p B1.

Hancock, Trevor (1993). Healthy Cities/Healthy Communities. Journal of Public Health Policy. Spring 1993.

Institute of Medicine (2003). The Future of the Public’s Health in the 21^st Century. The National Academies Press. Washington, D.C.

McNight, J. & Kretzmann, J., (1993). Building Community from the Inside Out. Chicago: ACTA Publications.

Minkler, Meredith, (1997). Community Organizing Among the Elderly Poor in San Francisco’s Tenderloin District. From Minkler, Meredith (ed.), Community Organizing and Community Building for Health. New Brunswick, NJ: Rutgers University Press. p 244-260.

Minkler, M. and Wallerstein, N. (1997) Improving health through community organization and community building: A health education perspective in Minkler, M. (Ed.) Community organizing and community building for health. New Brunswick, NJ: Rutgers University Press.

Norris, T. & Pittman, M. (2000). The Healthy Communities Movement and the Coalition for Healthier Cities and Communities. Public Health Reports, May/June 200, v. 115. p. 188-124.

Putnam, Robert D. (2000). Bowling Alone: The Collapse and Revival of American Community. New York, NY: Simon and Shuster.

Putnam, R. & Feldstein, L. (2003). Better Together: Restoring the American Community. New York, NY: Simon and Shuster.

Seifer, Sarena, (2000). Engaging Colleges and Universities as Partners in Healthy Community Initiatives. Public Health Reports, May/June 2000, v. 115. p. 234-237.

Stoller, E.P., and Gibson, R. (1994) Worlds of difference: inequalities in the aging experience. Thousand Oaks, CA: Pine Forge Press.

Twiss, J., et.al. (2000). Twelve Years and Counting: California’s Experience with A Statewide Healthy Cities and Communities Program. Public Health Reports, May/June 200, v. 115. p. 125-133

Wallack, L., Dorfman,L., Jernigan, D. and Themba, M. (1993) Media advocacy and public health: Power for prevention. Newbury Park, CA: Sage.

Wallerstein, N. (1992) Powerlessness, empowerment and health: Implications for health promotion programs. American Journal of Health Promotion 6:197-205

Wilcox, R. & Knapp A., (2000). Building Communities that Create Health. Public Health Reports, May/June 200, v. 115 p. 139-143.

World Health Organization Europe. The Ottawa Charter for Health Promotion. Copenhagen. 1986.

Authors:

Michael Coughlin, MS is a Community Health Planner and Contract Manager in the Office of Healthy Communities at the Massachusetts Department of Public Health, where he oversees a statewide system of Regional Centers for Healthy Communities. He is the Team Leader for MDPH with Partners for a Healthy Community, the Community Health Network (CHNA) serving Greater Fall River. Mr. Coughlin is an adjunct faculty member at Bristol Community College in Fall River, MA, where he is an Instructor of Human Services and Psychology. Michael has over 20 years of experience as a community organizer and planner and is a regular facilitator and presenter at public health conferences in Massachusetts and New England.

David S. Weed, Psy.D. is a licensed clinical psychologist with over 30 years of experience in community mental health setting in Massachusetts. He has been active in  numerous community health promotion projects in the Fall River and New Bedford Area including programs to reduce the incidence of substance abuse, suicide, violence, teenage pregnancy, HIV/AIDS, and homelessness. He is currently serving a volunteer coordinator of the Health Fall River Initiative for Partners for a Healthier Community, Inc. and the City of Fall River.

The authors wish to think Peter Lee, M.PH. for his assistance in reviewing this article.