Healthy Cities Evaluation:
Tracking Empowering Efforts
and Outcomes Across the
Social System
Dr Iain Butterworth
Visiting Senior Fellow
Faculty of Health and Behavioural Sciences
School of Health and Social Development
Deakin University
Uses for Evaluation
Rendering judgments – did this program
attain its goals?
Facilitating improvements – what are the
program's strengths and weaknesses?
Generating knowledge – enlightening
program staff and the wider public.
(Patton, 1997;
Evaluation must be
(Patton, 2002,
Characteristics of
Healthy Cities Projects
Commitment to health
Political decision-making
Intersectoral action
Community participation
Healthy public policy
(Duhl & Sanchez, 1999)
11 Key Parameters for Healthy
Cities, Communities and Towns
A clean, safe, high-quality environment
A stable, sustainable ecosystem
A strong, supportive community.
A high degree of public participation in
and control over the decisions affecting
life, health and wellbeing.
(Hancock & Duhl, 1988)
11 key parameters…
5. The meeting of basic needs (food, water,
shelter, income, safety, work)
6. Access to a wide variety of experiences
and resources
7. A diverse, vital and innovative economy.
8. Encouragement of connections with
cultural and biological heritage
11 key parameters…
9. A city form (design) that enhances
parameters 1-8
10. An optimum level of appropriate public
health and sick care services accessible
to all.
11. High health status (both high positive
health status and low disease status).
Change across the social system
• Variables 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 (WHO, 2002)
• Act as a tool for health promotion by raising
public awareness of what is going well and what
is threatening a community’s well-being (Conner et al,
Revised 32 Baseline Healthy Cities
Indicators (Doyle et al, 1999; WHO, 1998)
A Health indicators
A1 Mortality: all causes
A2 Cause of death
A3 Low Birth weight
B Health service indicators
B1 Existence of a city health education programme
B2 Percentage of children fully immunized
B3 Number of inhabitants per practicing primary health care
B4 Number of inhabitants per nurse
B5 Percentage of population covered by health insurance
B6 Availability of primary health care services in foreign
B7 Number of health related questions examined by the city
council every year
Revised Baseline Indicators…
C Environmental indicators
C1 Atmospheric pollution
C2 Water quality
C3 Percentage of water pollutants removed from total sewage
C4 Household waste collection quality index
C5 Household waste treatment quality index
C6 Relative surface area of green spaces in the city
C7 Public access to green space
C8 Derelict industrial sites
C9 Sport and leisure
C10 Pedestrian streets
C11 Cycling in city
C12 Public transport
C13 Public transport network cover
C14 Living space
Revised Baseline Indicators…
D Socio economic indicators
D1 Percentage of population living in substandard accommodation
D2 Estimated number of homeless people
D3 Unemployment rate
D4 Percentage of people earning less than the mean per capita
D5 Percentage of child care places for pre-school children
D6 Percentage of all live births to mothers > 20; 20-34; 35+
D7 Abortion rate in relation to total number of live births
D8 Percentage of disabled persons employed
Indicators must be:
Easily understood
Fully supported by key stakeholders
Directly applicable to Policy
Developed using collaborative, iterative process
Cost effective
(Innes & Booher, 1999)
Social ecology framework to assess
changes in community capacity
Changes in individuals
Changes in civic participation
Organizational development
Inter-organizational activity
Community level changes
(Kegler, Norton & Aronson (2003)
Dimensions of
community capacity
Civic participation
Mechanisms for community input
Mechanisms for distribution of community power
Skills and access to resources
Sense of community and social capital/trust
Social and inter-organizational networks
Community values and history
Capacity for reflection and learning
Psychological Sense of Community
A feeling that members have of belonging, a
feeling that members matter to one another
and to the group, and a shared faith that
members’ needs will be met through their
commitment to be together
(McMillan and Chavis, 1986)
Social Capital
• Focus on networks between people that
lead to cooperation, trust, social power
and beneficial outcomes (Baum, 2000)
• Interpersonal, community, institutional, or
societal levels (Perkins, Hughey & Speer, 2002)
Evaluation design
• Multiple case study with cross-case
• Data collection involved:
– Review of program documents
– Participant surveys in year 1 and year 3
– In-depth interviews
– Analysis by ‘type of community’
Individual-level changes
• More than 1,100 new civic leadership roles
• 1,500 people acted in these roles
• Urban participants reported gaining skills
in advocating for policy change
Organizational Changes
A broadened definition of health
Increased community input into decision-making
Expanded and new forms of collaboration
Adoption of shared vision
Expanded or restructured programs/services
aimed at increasing equity
• Administrative policy changes designed to
enhance service delivery and equity
Community level changes
• HC/C programs leveraged changes in
other organizations
• Most programs reported at least one
public (government) policy change arising
from their efforts
• Seven of the 20 communities identified
policy change as explicit goal area
Sense of Community:
• Increased number of diverse participants
the program
• Increased cooperation and communication
in the community
• New gathering place and the opportunities
the program provided for diverse people to
interact and form relationships
Key categories of change to
physical environment
1. Neighbourhood and community
2. Facilities construction, expansion and
3. Public utilities and public safety
4. Parks and recreation facilities –
construction and renovation
Psychological Predictors of
Social Capital:
Place attachment
Community satisfaction
Community confidence
Collective efficacy
Participation in a neighbourhood association
Neighbouring behaviour
(Perkins & Long, 2002)
The acquisition of critical social insight, skills,
and sense of competence needed to
participate meaningfully in society (Kieffer, 1984)
• concerned with actual social influence and
political power
(Rappaport, 1987)
• long term process, many actions
• psychological, organizational, community
Le vel of
A naly sis
Em po w erin g P roc es ses
(foc us on efforts)
E m pow ered O utc om es
(res ults of e fforts )
Ind ividu al
• P articipation in em pow erin g
c om m unity orga nizations
• E nga ging in s oc ial c ritiq ue
• R eflec ting on life ex perie nc es
• Le arnin g h ow soc ial sys tem w o rk s in
pa rtic ular c ontext
• Le arnin g h ow to obtain res ourc es
• D eve loping sk ills to m an age
r esou rc es
• Intr apers ona l em p ow er m ent: perc eption
of h avin g g ained c ontrol o ve r c ertain
• Ins trum ental em pow erm e nt: g aining
s ociopo litic al aw are ness
• R e definition of self and pers ona l his tory
• T ak ing action to influenc e e vents:
gainin g p articipatory c om petenc e
G roup/
orga nization
C ollabor atio n w ith m entors
P rod uctive gr oup m eetings
C ollective dec is ion-m ak ing
S har ed leaders hip
P eer s uppo rt
C ollective ac tio n
P articipation in form al dec isionm ak ing proc es s es
• A ction res earc h appr oac h
C om m un ity
• D eve lopm ent of c oalitions
• S takeh olders invo lved from ac ros s
le vels of soc ial s ys tem
• Institution al s uppo rt
• D e velo pm ent of m ore and better
c om m unity r esou rc es
• P olicy c om mitm ents; le gislation
• Im p ro ved collec tive lives
• S ubstanti ve em p ow e rm ent: ec ologic ally
s ustainable outc om es
N etw o rk de velo pm ent
Lob bying po w er
S ecur ed res ourc es
E nhanc ed org aniz ation al vision,
ideolo gy, values , an d c ulture
• Im p ro ved org anizationa l s truc ture
• E nhanc ed org aniz ation al effec ti venes s
• Ins trum ental em pow erm e nt
(Balcazar et al., 1994; Kieffer, 1984; Perkins & Zimmerman, 1995; Rich et al., 1995; Zimmerman, 1995)
Some personal reflections…
• HC programs are conducted in a
geopolitical space or locale
• HC programs are inherently about power
and control:
– Power of communities to determine and drive
their own health agenda
– Political decision-making
• Empowerment framework can integrate
place, community and social capital
Personal reflections…
• Document community capacity building efforts and
• Use mixed methods
– Qualitative and quantitative
– Scales, indicators, interviews, focus groups
• Collect population measures:
– Garrard, J., Hawe, P., & Graham, C. (1995). Acting locally to
promote health: An evaluation of the Victorian Healthy
Localities Project. Melbourne, Australia: Municipal
Association of Victoria.
Personal reflections…
• Indicators need to be developed as part of
participatory evaluation framework
• Use indicators to stimulate community thinking
and action and to document process, as much
as outcomes
• University collaborations invaluable

Healthy Cities, Municipal Public Health Planning, Sense of