CITIES AND COMMUNITIES. SYSTEMS REFORMOne of the Program’s goals has always been to influence policy making and resource allocations on the part of public and private organizations at the local and state level. In California, systems reform at the municipal level—which generally has no statutory responsibility for public health—has involved instituting policies and practices that make explicit the city’s role and contribution in community health promotion and protection. At the local level, policy initiatives 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. At the state level, systems reform may take place within and across state-level organizations. For example, it is systems reform when a state public health department partners with organizations or develops constituencies outside the traditional public health infrastructure. Likewise, it is systems reform when non-health organizations incorporate Healthy Cities and Communities principles into their missions and operations and when they collaborate across sectors to improve the public’s health. Several California Healthy Cities have made food security a priority. Seed grants have stimulated and supported demonstration programs, which are resulting in cross-sectoral action and policy. Community garden cooperatives and related micro-enterprises have been established. Food policy councils, with representation from multiple sectors, are working to improve summer lunch programs and to promote community gardening through reducing city water fees, organizing a healthy canned food drive, and supporting teachers as they integrate gardening and physical activity into daily classroom routines. The Adopt-a-Lot Program in the City of Escon-dido takes advantage of an exemplary land use policy to allow residents, neighborhood groups, and organizations to qualify for a special, no-fee permit when they “adopt” public or private vacant land on a temporary basis for recreational use or other community purposes. New resources have been made available by schools and city governments.

In the city of Chula Vista one teacher now works full-time to institute a garden-based school curriculum. The city of Berkeley developed public use standards for community gardens on city property, providing free water use, fences, and help with installation. The private sector has been active in the food security arena as well. In the city of West Hollywood, a small, densely populated urban area in greater Los Angeles, positive experiences with school-based community gardens prompted the manager of an apartment complex where one student lives to establish an on-site garden for its residents. The Escondido Downtown Business Association provides same-day reimbursement for farmers who accept food vouchers at their open-air market. Systems reform benefits tremendously from a comprehensive framework. The city of Pasadena developed a ground-breaking Quality of Life Index to improve planning, policy making, and resource allocation with extensive input from residents, technical panels, and neighborhood groups. The Index identified more than 50 indicators affecting community life—for example, safety, education, substance abuse, recreation, economy, and housing—which are now being monitored. The Index has guided policy development with regard to alcohol availability, infant health, and tobacco control, has assisted city and community agencies in priority-setting and resource development, and was used as the basis for the city’s performance-based budget system. Increasingly, DHS programs have taken a more environmental perspective. Several DHS programs, especially those in the area of chronic disease and injury prevention, now recognize municipalities and Healthy Communities coalitions as major players in advancing prevention objectives and specifically focus on them for local assistance contracts.

For several years, beginning in 1990, the Project worked in a formal partnership with the League of California Cities and Americans for Nonsmokers’ Rights to educate and support municipal officials statewide about tobacco control. Before January 1990, only one California city had an ordinance that completely banned smoking in restaurants. Four years later, more than 100 cities had banned smoking in restaurants and almost 90 cities had eliminated smoking in the workplace. This local action provided the foundation for state legislation, which went into effect in 1995, that required smoke-free workplaces and allowed local governments to enact stronger policies. Senate Bill 697, California’s hospital community benefits law, provided a strategic window to integrate the Healthy Communities philosophy into the mission statements and assessment and planning processes of the state’s 250 nonprofit hospitals. The Program has partnered with the Office of Statewide Health Planning and Development (OSHPD), which has oversight for this leg¬islated mandate, to coordinate work wherever possible. OSHPD, a freestanding office within DHS, has endorsed the Healthy Communities framework, as have many health care industry and association leaders.

The Association of California Healthcare Districts (ACHD), a membership organization of hospital trustees, physicians, and key staff, is partnering with the Program to involve its members in Healthy Communities work. ACHD’s 1997-1998 annual report includes strong recommendations to its membership to get actively involved in Healthy Communities efforts. As a result of this partnership, four health care districts are participants in Healthy Cities and Communities initiatives. Evaluation. Methods for evaluating progress have changed over time as the Healthy Communities movement has grown. The intensity of early Project activities and limited budgets during the first decade combined with the nascent state-of-the-science of community-based evaluation meant that efforts were directed primarily at site-specific evaluations. Later, the Program developed more sophisticated evaluation methods.

Program participants have always been required to submit work plans with, at minimum, quantifiable process measures and, whenever possible, outcome measures. Revisions to the reporting form over the years have been responsive to feedback from program participants. Reports are due at six-month and year intervals. New resources acquired or leveraged are reported, including in-kind contributions and increases in budget or staff allocations. Participants are also asked to describe the challenges experienced, unanticipated spin-offs, anecdotes, presentations to other communities or groups, and a financial accounting of grant expenditures. For several years, participants annually self-administered a leadership questionnaire that provided an opportunity to reflect on vision/mission, community participation, city Ъиу-in,” the representativeness of the steering committee/coalition and its progress, and continuous quality improvement measures.

The questionnaire included a checklist of municipal activities, designed by staff in one of the participating cities, to assess (and encourage) the presence of health-promoting policies and programs in areas such as health, the environment, planning and development, public safety, recreation, the city workplace, and city-sponsored events. In 1997, after critically reviewing the reporting system and its uses for evaluation, the Program hired a consultant who specializes in community-based health promotion programs to review and revise the evaluation system.

Any change to the reporting system needed to take into account the challenges of conducting evaluations at the local level and across sites. These challenges include limited staff time and budget resources, diversity of efforts across communities, and inherent difficulties in using the “community” as the unit of analysis due to confounding factors. (For example, births, deaths, in- and out-migration mean that the “community” changes over time.) The consultant revised the system with substantial input not only from Program staff members but also from staff representatives from the participating cities.

Based on this input, the consultant identified the concepts and sub-concepts that were most important to measure, devised possible measures or surrogate measures for them, linked these measures to elements of the existing data collection and reporting system, and added elements for sub-concepts or concepts for which measures were missing. Now the evaluation includes measures of organizational-level change (for example, adoption of new policies and practices, institutionalization of health-enhancing programs), inter-organizational change (for example, new partnerships, new linkages outside the community), and civic participation (for example, emergence of new leader¬ship, involvement of informal community leadership).

These concepts and sub-concepts fall under three major categories:
• Skill-level increases: ability of the city/community and its partners to facilitate community action;
• Institutionalization/systems reform: the extent to which institutional changes, within and beyond the organizational unit in which the initiative was originally established, have occurred to foster a safer and healthier city; and
• Increases in community competency and capacity: the extent to which exposure to and implementation of the Healthy Cities/Communities model have made a community stronger and more self-sufficient and have encouraged and expanded community participation in identifying concerns and facilitating problem-solving and decision-making.

Evaluation methodologies for the 20 communities receiving planning and implementation grants involve:
• Stratification of communities by location, size, and other community characteristics to enhance data analysis;
• In-depth study of approximately 10 communities, beyond what is available from standard evaluation reports; and
• Use of triangulation for the in-depth studies, using various strategies, including direct observation of events such as coalition meetings, a survey of coalition members, followed by focus groups or interviews in communities to be studied in depth, and a review of documents generated by the community, such as coalition meeting agendas, minutes, and attendance records.