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Healthy communities in British Columbia : a case study of the Tri-City Health Promotion Project Hill, Patricia M. 1993

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Healthy Communities in British ColumbiaA Case Study ofthe Tri-City Health Promotion ProjectByPatricia Mary HillB.A. The University of Victoria, 1986A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIES(School of Community and Regional Planning)We accept this thesis as conformingto the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril 1993© Patricia Mary Hill, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.Department of  CE71-vx v-v1 v 'AA The University of British ColumbiaVancouver, CanadaDate °) 3 DE-6 (2/88)ABSTRACTIn recent years, the term "Healthy Communities" has become a catch phraseamong planners, health promotion workers, social workers and governmentagencies, and increasing numbers of professionals have taken a role in thedevelopment of healthy communities projects. The literature on the healthycommunities concept has increased in size and scope. Yet the concept itself is byno means clearly defined. Nor is there a standard method for developing a suc-cessful healthy communities project, or a regional collaboration of healthycommunities projects. The question remains, when a planner undertakes a role inthe development of a healthy communities project, what are the most importantfactors to consider?This thesis examines the influence of various project inputs on the ability of aregional healthy communities project to achieve its objectives. The thesis uses acase study of the Tri-City Health Promotion Project, a collaborative healthycommunities project undertaken in the cities of Castlegar, Trail and Nelson in theWest Kootenay region of British Columbia.In this study, documentary analysis and interviews with Tri-City project staffilluminate the importance of several influences on a regional healthy communitiesproject. Some of these are: the approach used by the participants (task- orprocess-orientation), the resources and constraints specific to each community,the context from which the project grew, the personalities of those involved, theability of the collaborating communities to work together, and the relationshipbetween the community and regional bodies in the project structure.Conclusions:While every healthy communities project will be affected differently by variousinputs, in the case of the Tri-City Health Promotion Project, the relationshipi ibetween the regional and community bodies in the project structure had thegreatest influence on the ability of the community Steering Committees toachieve their goals.Planners working on a regional healthy communities project must carefullyexamine the design of the project, in order to develop a structure which enhancesthe working relationship between regional and community bodies. This is par-ticularly crucial in the healthy communities context, where decision-makingpower often resides at the community level, rather than being centralized in theregional body.TABLE OF CONTENTSABSTRACT^ iiTABLE OF CONTENTS^ ivLIST OF FIGURES v i iACKNOWLEDGEMENTS^ viiiCHAPTER 1 - INTRODUCTION 11.1 Thesis Organization 1(a) Purpose^ 1(b) Problem Statement^ 1(c) Method 2(d) Organization of the Thesis^ 41.2 Definition of Critical Terms 5CHAPTER 2- HEALTHY COMMUNITIES IN CANADA^72.1 Healthy Communities Literature^ 7(a) Introduction: Two Types of Literature 7(b) The Literature: Theory and Practice^ 72.2 Health in Canada^ 8(a) Shifts in Canadian Health Policy 8(b) A New Perspective^ 9(c) Emergence of the New Public Health^ 10(d) Health Defined^ 112.3 From Ideas to Practice 12(a) The Canadian Healthy Communities Project^ 12(b) Healthy Communities vs. Healthy Cities 13(c) Conclusion^ 13CHAPTER 3 - HEALTHY COMMUNITIES: WHAT ARE THEY AND HOWDO WE ANALYZE THEM?^ 143.1 Defining Healthy Community 14(a) What is a Healthy Community?^ 14iv(b) Have We Gone Too Far?^ 16(c) Analysis of Healthy Communities^ 17(d) Healthy Community Output Indicators 203.2 Conclusion^ 21CHAPTER 4 - INTRODUCTION TO THE CASE STUDY^234.1 Introduction 234.2 Context^ 23(a) Background for the Case Study^ 23(b) Health in the Kootenays 23(c) Individual Community Profiles 25(d) Similarities Within the Region^ 26(e) Regional Social Profile: 284.3 Early History: Tri-City Health Promotion Project^294.4 Conclusion^ 30CHAPTER 5 - CASE STUDY OF THE TRI-CITY HEALTH PROMOTIONPROJECT 325.1. Introduction^ 325.2 Document Analysis 32(a) Tri-City Project Structure^ 32(b) Roles and Responsibilities 32(c) Co-ordinating Committee^ 355.3 Tri-City Health Promotion Project Chronology^ 365.4 Tri-City Project History 395.5 Preliminary Conclusions - Documentary Analysis^46(a) Project Vision^ 46(b) Project Structure 475.6 Conclusion^ 50CHAPTER 6 - PERCEPTIONS OF PROJECT STAFF^516.1 The Interviews^ 516.2 Interview Results 52(a) Issue of Project Vision^ 52(b) Vision: Effect on Committees and Staff^ 52(c) Comments About Project Philosophy and Structure^53(d) Other Suggestions About Structure 55(e) Advantages and Disadvantages of the Regional Collaboration.^56(f) Unexpected Advantages and Obstacles Encountered^56(g) Additional Comments^ 576.3 Conclusion^ 58CHAPTER 7 - CONCLUSIONS^ 597.1 Introduction 59(a) Assumptions^ 59(b) New Perceptions 61(c) Implications for Planners^ 63(d) Implications for Further Research^ 647.2 Conclusion^ 65APPENDIX A: INTERVIEW GUIDE 67BIBLIOGRAPHY 69TABLE OF CONTENTSviLIST OF FIGURES1. Map of Study Area^ p. 242. Structure of Tri-City Health Promotion Project^p. 34viiACKNOWLEDGEMENTSI would like to thank the participants of the Tri-City Health Promotion Project,both committee members and staff, for allowing me to comb through theirproject files and to ask them innumerable questions. Their open and insightfulcomments about the Tri-City project were of great value to me in conducting thisresearch.I would also like to acknowledge the clear-sighted suggestions and criticalcomments of my thesis committee, and especially the efforts of Peter Boothroyd,my thesis advisor, who provided much helpful guidance over the long distancetelephone lines.I would like to thank my mother, Mary Hill, for her interesting and thoughtfulsuggestions (also long distance), my son Nikolai, for being patient with his fre-quently distracted mother, and most importantly, my husband, Ric Gerzey, whoprovided encouragement, support and many hours on the computer, helping meto bring this thesis to completion.viiiCHAPTER 1 - INTRODUCTION1.1 Thesis Organization(a) PurposeWhen a Healthy Communities project is undertaken, the participants involved aresystematically setting out to make their community "healthy", according to theirown definition of the term Healthy Community. Several factors will influencethe success or failure of the project achieving its goals. Some of these are: theapproach used by the participants, the project design, the resources and con-straints peculiar to the community, and the context from which the project grew.When small communities decide to collaborate on a regional healthy communi-ties project, additional factors become important, such as: the ability of theparticipating communities to work co-operatively, and the relationship betweencommunity and regional bodies within the project structure.The purpose of this thesis is to identify the features which most influencewhether a regional healthy communities project will achieve its objectives, and toexamine the implications of these factors for professionals who are involved inplanning for healthy communities.(b) Problem StatementIn recent years, "Healthy Communities" has become a catch phrase among plan-ners, health promotion workers, social workers, funding agencies and variousgovernment ministries. A great deal of energy has been spent by these and otherprofessionals outlining what they think healthy communities are and how they1should be developed. Projects have received funding using the Healthy Commu-nities model, and provincial and national networks have sprung up to support theefforts of local groups undertaking these projects. The literature on HealthyCommunities has expanded greatly in the last four years. Yet, the concept is byno means clearly defined. In fact, Healthy Communities may have almost asmany definitions as there are groups who use the idea. What does HealthyCommunity mean? Does it really refer to community development? To sustain-able development? To disease prevention? To regional coordination? Toeconomic self-sufficiency? To a new way of thinking about service delivery?About health? The literature is not clear on this point.In addition, because the Healthy Communities movement is still relatively new interms of existing projects, we do not yet clearly understand what "success"means in the context of healthy communities. Our lack of knowledge aboutregional healthy communities raises several questions: is it possible to develop ahealthy community within a regional framework? How do we assess a regionalhealthy comunities projects; whose criteria do we use to measure success? Whatkinds of project designs contribute most to the success of the project? Can theparticipating communities in the regional framework use different approaches(i.e. task- or process-orientation) to reach their goals, or must they all use thesame approach? Do any of these features make any difference at all?What are the implications of these and other project inputs on the job of planningfor healthy communities, or healthy regions? What should a planner know aboutdeveloping a successful project before a new one is launched?(c) MethodThe thesis will address these questions by examining the influence of differentinputs on the ability of a B.C. regional healthy communities project to achieve its2objectives. The project is the Tri-City Health Promotion Project in the WestKootenay Region of British Columbia.The Tri-City Health Promotion Project, established in 1991, is a collaborativeprocess undertaken in three communities in the West Kootenay - Nelson,Castlegar and Trail. The goals of the Tri-City project are to foster partnerships inthese communities in order to increase their capacity for community action andhealth promotion. Funded by the B.C. Health Research Foundation, this demon-stration project aims to develop a well documented health promotion model andmaterials to be used by other communities, and to provide testable propositionsabout successful health promotion processes in small communities (Tri-CitySummary Report to City Councils, January 13, 1993).The Tri-City case study was developed using documents generated by the projectover the year 1991-92, and information gathered through interviews with keyproject staff.Documentary studyDocumentary sources include meeting minutes, facilitators' reports and projecthistory documents from the Tri-Cities Project. These sources provide informationfor the development of a history, or chronology of the project. In addition to thechronology, review of the documents provides a number of preliminary conclu-sions about the different processes used by the three communities in this project.Documentary material illuminates periods of high and low momentum, obstaclesencountered, personal styles, achievements, conflicts, review and growth in theproject structures. This material also identifies issues to be raised in interviewswith project staff.Key Informant InterviewsIn addition to the documentary evidence, a round of key informant interviews3was conducted with project staff. These interviews allowed the key informants tocomment on, correct and expand on the preliminary conclusions generated fromthe documentary analysis. The interviews were qualitative in nature, using aninterview guide to facilitate discussion on a number of issues, and ending with anopen question asking for further information, suggestions, overall perceptions,etc. Interviews were carried out with the project Co-ordinator, and with each ofthe three community Facilitators.This thesis is not a project evaluation. It does not address questions aboutwhether the projects studied were effective or not, or whether funding moneywas well spent. It will not provide a "how-to" booklet for other communities whoare about to embark on a healthy communities project. Its task is to examine anexisting regional healthy communities project from a planning perspective, todetermine the influence of different factors on the ability of a project to reach itsown objectives.(d) Organization of the ThesisThe thesis is made up of seven chapters. The first chapter introduces the thesisand provides a context and organizational framework. Chapter two reviews theliterature on Healthy Communities and Health in Canada, examining both theo-retical and practice material to describe the context from which the conceptgrew. Chapter three addresses what a Healthy Community actually is, and looksat alternative evaluation methods. After having explored the concept of HealthyCommunities, the thesis then moves on to an introduction to the Tri-City casestudy in chapter four. This chapter presents a background for the study throughsocial and demographic profiles of the participating communities. Chapter fouralso gives a brief outline of the inception of the Tri-City project. In Chapters fiveand six, the history of the Tri-City project is examined in greater detail, usingdata from the documentary research and the key informant interviews. This ana-4lytical history identifies the project features which had the greatest impact on theability of the Tri-City participants to achieve their objectives. Chapter seven goeson to draw conclusions from the study, and to explore the implications of theresearch results.1.2 Definition of Critical TermsThe Thesis adopts the following definitions:Health - the extent to which an individual or group is able, on one hand, to real-ize aspirations and satisfy needs, and on the other hand, to change or cope withthe environment (WHO 1986). A state of complete physical, mental and socialwell being (Ottawa Charter on Health Promotion 1986). See Chapter 2 for addi-tional definitions (Eg. Epp 1986, Berlin 1989).Healthy Community - one in which people combine effort and effective pro-cesses to develop skills, resources and collective structures, through which theycan identify and manage their own health issues. This work may be concentratedat the local level, but is undertaken in a context of mutual respect and support forother communities. See Chapter 3 for additional definitions (Boothroyd andEberle 1990, Hancock and Duhl 1986, Berlin 1989).Community Development - a social process by which human beings can becomemore competent to live with and gain some control over local aspects of a frus-trating and changing world (Biddle and Biddle 1965 p.78).A process by which a community identifies its needs or objectives, orders (orranks) them, develops the confidence and will to work at them, finds theresources (internal and/or external) to deal with them, takes action in respect tothem, and in so doing extends and develops cooperative and collaborative atti-5tudes and practices in the community (Ross, Murray G. CommunityOrganization, Theory and Principles in Warren 1977, p. 243).Health Promotion - the combination of educational and environmental supportsfor actions and conditions of living conducive to health (Green and Kreuter 1991p.321).Health Promotion is not only concerned with enabling the development of lifeskills, self-concept and social skills but is also concerned with environmentalintervention through a broad range of political, legislative, fiscal and administra-tive means ( Stachtchenko 1990 p. 54).Participatory Planning - Bottom-up planning processes in which individuals andcommunities have control over and participate in issue-identification, approachesand strategies; as opposed to centralist or technocratic planning.Social Learning - a social change tradition described by Friedmann as "a com-plex, time-dependent process that involves, in addition to the action itself (whichbreaks into the stream of ongoing events to change reality), political strategy andtactics (which tell us how to overcome resistance) and the values that inspire anddirect the action" (Friedmann, 1987 pp.181-2).6CHAPTER 2- HEALTHY COMMUNITIES IN CANADA2.1 Healthy Communities Literature(a) Introduction: Two Types of LiteratureThere are two types of Healthy Communities literature: those dealing with theoryand those about practice. Although these two forms necessarily touch on similarquestions, there are few examples of Healthy Communities literature which dealwith both theory and practice in the same work. One objective of this thesis is tocombine theory and practice material to provide a clearer picture of what HealthyCommunities really are. This literature review will begin that process by exam-ining existing theoretical and practice works to trace the evolution of the HealthyCommunities movement, and to gain a better understanding of the concept.(b) The Literature: Theory and PracticeTheoretical literature on Healthy Communities grapples with the development ofthe concept itself; what is this idea all about; how did it evolve; what are its lim-its; where is it going. This material in turn ranges from early background workswhich formed a basis for the concept (Lalonde 1974, WHO 1981) to more recentliterature from both the planning profession (Boothroyd and Eberle 1990, Hen-dler 1989, Mathur 1989) and from other related areas such as health promotionand social work (Hancock 1989, Manson Wilms and Gilbert 1990, Stachtchenko1990, Bracht 1990, Green and Kreuter 1991).The practice literature focuses on projects that have developed in recent years.They address questions such as: what healthy communities projects exist today?How did they form? What issues and strategies are they looking at? What kinds7of communities undertake these kinds of projects? How does a community goabout initiating a healthy communities project? These sources are generally veryrecent, and are not as concerned about the theory as to what is really going on(Healthy Communities: the Process 1989, Healthy Toronto 2000 1988, Olds andMartin 1990).Both of these types of literature give us an idea of how the Healthy communitiesidea developed, and where it is today.2.2 Health in Canada(a) Shifts in Canadian Health PolicyIn the 20th century, Canadian health policy has undergone a number of paradigmshifts, and today it faces another. With strong roots in a hospital-based, bio-medical model, Canadian health policy has until recently emphasized healthservice delivery to the sick (Hancock 1985, Mathur 1989, Ashton and Seymour1988). By the mid-twentieth century, public health campaigns focusing on envi-ronmental factors such as sanitation, housing and nutrition had virtuallyeradicated the devastating infectious diseases of previous decades. During the1950's and '60's, Canada's health care system turned to the promise of techno-logical advances in acute care to enhance the health of Canadians (Ashton andSeymour 1988, Epp 1986, Berlin 1989). In this paradigm, the definition ofhealth is limited to the absence of illness or injury as determined by scientificmethods. Such faith in the biomedical model in turn necessitated the use ofintensively-trained professionals and large hospital budgets to improve interven-tions and increase access to health care. During this period, the responsibility for,and knowledge about, health was placed firmly in the hands of thescientifically-trained professional, and it remains there today (Green and Raeburn1990). An enduring legacy of these "access/intervention" years is evident in the8Canadian health insurance system, established in the 1960's, and in the numberof acute care facilities erected during a major hospital-building programme in the1950's and '60's (Spasoff and Hancock, 1990).(b) A New PerspectiveThe first sign of change in Canadian health policy came with the 1974 Lalondereport, A New Perspective on the Health of Canadians, issued by the federalgovernment. Lalonde's new perspective was detailed in a concept called theHealth Field. The Health Field concept identified four determinants of health:Human Biology, Environment, Lifestyle and Health Care Organization (Lalonde1974). While Human Biology and Health Care Organization fit comfortablywithin the existing jurisdiction of the health care system, Environment and Lif-estyle were new additions to the equation. This was the first evidence thatpolicymakers were recognizing that their narrow approach to health care mightlimit its effectiveness. Lalonde's Health Field Concept resurrected the largerperspective of early public health strategies and united it with modern techno-logical advances.The Health Field concept altered the common perception that health is basedprimarily on access and quality of medical intervention.However, the concept did have problems. First, it did not depart significantlyfrom the status quo. Health was still seen as external to the patient, something tobe endowed or protected by the health care professional (Boothroyd and Eberle1990). The foundation of the health care system would still be a client-basedmodel, where professionals holding specialized information about disease andinjury ministered to ill (and ill-informed) patients. The locus of control overhealth did not change.9Second, although the report broke new ground by identifying two determinantsof health that were outside the traditional sphere of the health care system, policythat developed during this time targeted only one of these factors: individualbehaviour or lifestyle (Boothroyd and Eberle 1990). This emphasis on the reduc-tion of risk-factors placed responsibility for health, or ill health, squarely with theindividual. Participaction ads promoted walking and jogging, anti-smoking leg-islation discouraged smoking, the Counterattack programme reducedimpaired-driving arrests. But the campaign did not address some of the influ-ences on health over which the individual has less control, eg. employment,personal safety, poverty, isolation, housing, environmental quality and so on(Working Towards a Healthier Burnaby 1990, Green and Raeburn 1990). Theseelements, and many more, combine to produce a physical and social environ-ment, which influences, and is influenced by, human action. Lalonde's report didlittle to change policy about these less controllable determinants of health.(c) Emergence of the New Public HealthPhrases such as the New Public Health, Healthy Communities and a "multisec-toral approach" to health policy emerged in the 1980's from a variety of sources.In 1981, the World Health Organization published Achieving Health for All bythe Year 2000, which opened the door for broader visions of health; it advocateda movement away from a focus on "sick care", and encouraged greater emphasison areas outside the health care sector. Further grounding of these ideas came attwo conferences held in Canada in the mid 1980's. At the Beyond Health Careconference in 1984 Trevor Hancock presented the "Healthy Public Policy" con-cept (Hancock 1985), and Leonard Duhl introduced "The Healthy City". TheWHO-sponsored First International Conference on Health Promotion in 1986produced the Ottawa Charter on Health Promotion and Global Strategies forHealth for All. In 1986 the Canadian government issued Achieving Health ForAll: a Framework for Health Promotion. These initiatives in turn contributed to10the establishment of the WHO-Europe Healthy Cities Project (1988), and theCanadian Healthy Communities Project (1988).(d) Health DefinedThe greatest contribution made in the literature during this time was the refineddefinition of health, and the broadened perception of determinants of health. In1986, the World Health Organization defined health as:the extent to which an individual or groupis able, on one hand, to realize aspirationsand satisfy needs; and on the other hand,to change or cope with the environment.Health is, therefore, seen as a resourcefor everyday life, a dimension of our'quality of life,' and not the object ofliving; it is a positive concept emphasizingsocial and personal resources, as well asphysical capabilities.- World Health Organization 1986Similar definitions of health include those found in the Ottawa Charter for HealthPromotion (1986) and Achieving Health for All (Epp 1986). The Ottawa Charterreiterates the idea that health is a resource for everyday living, and "a state ofcomplete physical, mental and social well-being." (Ottawa Charter., p.1). JakeEpp's Achieving Health for All adds the concept that health is "a resource whichgives people the ability to manage and even to change their surroundings... andimplies the opportunity to make choices and gain satisfaction from living." (Epp1986 p.3). Achieving Health for All also states that "health is influenced by ourcircumstances, our beliefs, our culture and our social, economic and physicalenvironments." (Epp 1986, p.3).Susan Berlin, the first Co-ordinator of the Canadian Healthy CommunitiesProject, illustrates the link between health and the economy, education and the11ecosystem when she writes:If the wealthiest people in Canada can expectto live between six and seven years longer thanthe poorest Canadians, what is the boundarybetween health and economic policy? If lack ofliteracy skills reduces lifetime income anddramatically increases the chances of a person'sspending time in a penitentiary, where is theboundary between health and education, or healthand justice? And what does it do to one's healthto live with the casual knowledge that the worldmay be blown apart, or ecologically destroyed,rather sooner than later?Berlin 1989 p.12.3 From Ideas to Practice(a) The Canadian Healthy Communities ProjectThese expanded visions of health have significant policy implications in manyareas beyond the health care sector. To address this new direction in healthpolicy, the Canadian Healthy Communities Project was initiated in 1988, withfunding from Health and Welfare Canada and sponsorship from the CanadianInstitute of Planners, the Canadian Public Health Association and the Federationof Canadian Municipalities. The involvement of planners and politicians in thisnetwork reforges a link between the health sector and municipal government notevident since the public health campaigns of the early twentieth century. TheCanadian Healthy Communities project was set up to provide motivation, sup-port and information resources to the myriad projects emerging all over thecountry. Smaller networks also formed, such as the B.C. Healthy CommunitiesNetwork, which was sponsered by a number of organizations, such as: thePlanning Institute of B.C., the B.0 Public Health Association, Health and Wel-12fare Canada , and the B.C. Office of Health Promotion, among others.(b) Healthy Communities vs. Healthy CitiesThe term Healthy "Communities" as distinct from WHO's Healthy "Cities"ensures that the Canadian movement includes projects initiated in towns andrural communities as well as in cities. Healthy Communities as opposed to Citiesalso allows a broader connotation of "community" than simply a referral to ageographical space. As Boothroyd and Eberle suggest, community can meansomething other than "local"; members may define their community on the basisof social networks and cooperative mutual aid rather than by physical bound-aries. The "Community" in Healthy Communities may also refer to collective ordemocratic action on health policy, as opposed to technocratic, centralist plan-ning (Boothroyd and Eberle 1990).(c) ConclusionSince the Canadian Healthy Communities Project opened its doors in Ottawa in1988, videos have been produced, newsletters published, databases established,surveys and workshops conducted on Healthy Communities. Products of HealthyCommunity projects include recycling depots, street paving, parks development,food programs, outreach to the poor, parenting programs, transit studies andaffordable housing projects. Projects using the healthy communities concept as abasis receive funding from provincial and municipal sources every year. Yettoday the concept still begs definition and the process for becoming a HealthyCommunity is still fuzzy. Chapter three addresses the question: What are wetalking about when we say "Healthy Community."13CHAPTER 3 - HEALTHY COMMUNITIES: WHAT ARE THEY AND HOWDO WE ANALYZE THEM?3.1 Defining Healthy Community(a) What is a Healthy Community?Like definitions of health, there are numerous definitions of a Healthy Commu-nity. Some suggest that a healthy community is one made up of "healthy" people,from the standpoints of mental, social and physical well-being.Others have a vision more in line with the Jericho process described in the BCRoyal Commission on Health Care and Costs, Closer to Home: that of breakingdown administrative barriers to create an integrated health system (Closer to Home p.6). The Jericho process advocates the establishment of linkages betweenmunicipal departments, health service agencies, non-governmental organizations,volunteer associations and the private sector to deal with issues which do not fitcomfortably within the mandate of any one of these actors.Still others focus on a different aspect of the process of health promotion: com-munity development or "empowering" processes, where community control overpolicy related to health is fostered. In this instance, the eradication of illness maybe less important than the process of empowering communities to manage orcope with their own health issues.A positive element, common to these definitions, is the increased awareness andresponsibility for health among community members. Sue Hendler points out thatthis concentration at the community level brings with it the risk of losing sight ofthe big picture, and forgetting about people in other communities. These myopic14underpinnings may in turn lead communities toward eliminating their "unhealthy"features (polluting industries, exploitive or dangerous occupations, landfill waste,penal institutions) by exporting them to other places, making those communitiesless healthy (Hendler 1989). For example, today it may be more healthy to live inthe West End of Vancouver than it was before prostitutes and drug dealers werepushed out of the area by a highly mobilized community effort, but what effectdoes that have on the health of residents in Strathcona, who have experiencedincreased drug-related pressures in recent years?From a regional perspective, a healthy community means one which is able towork on its own health issues within a larger context, strengtheningresource/support networks between communities, and avoiding an "us versusthem" mentality which includes the exportation of unhealthy components. Aneven broader vision of the regional model is one on a global scale, with commu-nities fostering supportive linkages with each other in an ecologically sustainableframework.In reality, healthy community projects use components of some or all of thesedefinitions, and various participants within one project often have differentassumptions about what "healthy community" really means.In the Planning literature, the definition of a Healthy Community leans toward aprocess which combines community development with the breaking-down ofadministrative walls. Boothroyd and Eberle use the definition:a community in which all organizations from informalgroups to governments are working effectivelytogether to improve the quality of all people's lives.Boothroyd and Eberle 1990 p.715Hancock and Duhl define a Healthy City as:one continually creating and improvingthose physical and social environmentsand expanding those community resourceswhich enable people to support each otherin performing all the functions of lifeand in developing themselves to theirmaximum potential.Hancock and Duhl in Lane, B.J. 1989 p.6Susan Berlin reiterates this process-orientation:Healthy communities is really more of aprocess than a product. A community cannever "become" healthy; it can onlydevelop and practice a healthy approachto working on the elements that make upa community.Berlin 1989 p.2For the purpose of this thesis, a Healthy Community is defined as one in whichpeople combine effort and effective processes to develop skills, resources andcollective structures, through which they can identify and manage their ownhealth issues. This work may be concentrated at the local level, but is under-taken in a context of mutual respect and support for other communities.(b) Have We Gone Too Far?There is a clear recognition in these definitions that health and health policy needto be more inclusive than they were in the past. Health must refer to a larger partof our lives, and health strategies need to involve sectors that normally wouldn'tconsider themselves health-oriented. However, one problem with making health16and health policy more inclusive is that we risk making "healthy community"mean almost nothing In a discussion of healthy community indicators, MansonWillms and Gilbert warn about resorting to "healthism", where "everything isdefined as health or health related, so that the concept becomes diluted at bestand a black hole at worst" (Manson Willms and Gilbert 1990 p.5). They voicethe concern that using too large a range of healthy community indicators maymake an adequate assessment of health impossible (Manson Willms and Gilbert1990).This issue of healthism, or making the term healthy community equivalent to"good things happening in our town" raises another question about the HealthyCommunities Concept: how do we analyze Healthy Communities projects?(c) Analysis of Healthy CommunitiesAnalysis of Healthy Communities projects must reflect the community's defini-tion of what a Healthy Community is. If the definition consists of a geographicalarea where individuals are all physically, socially and mentally healthy, then wemay be able to construct Healthy Communities indicators using traditional healthstatus indicators (natality, morbidity and mortality rates, levels of disease, hospi-tal admission records) combined with other social indicators (life satisfaction,social networks, job satisfaction) to measure change in the health of individualsin the community. These output indicators may provide even more valid infor-mation about community members if testimonial data are included aboutperceived values, needs, systems of support and service gaps (Konkin 1991). Inorder to avoid the inclusion of an overwhelming number of single variables in ahealthy community assessment, several specific health issues should beaddressed in some detail, according to the particular needs and resources identi-fied in the community.17However, if our definition focuses on how much community development andinter-community co-ordination exists in the region, then indicators which mea-sure individual health levels will not fit comfortably into the analysis. Instead,inventories of community resources and inter-community linkages (e.g. regionalplanning initiatives, inter-community co-ordination of service provision) wouldprovide a clearer picture of regional health.A more refined evaluative goal, as stated by Boothroyd and Eberle, is not tomeasure how many community development structures or resources exist, but tomeasure the effort that has been put into the process of attaining these goals. If acommunity works hard to identify health issues and to develop creative solutionsto problems, then the community is healthy, even if its citizens are not individu-ally robust (Boothroyd and Eberle 1990). This "process" goal is valuable becausea community or group of communities which are familiar with the process ofworking co-operatively to identify needs, resolve conflicts and test creativesolutions will retain that skill over time, whatever challenges they may facetogether in the future. Those which, alternatively, have as their primary goal thecomplete eradication of ill health for all their individual members will not neces-sarily develop these co-operative decision-making structures, and consequentlywill have to call in a consultant to advise them the next time a health challenge(inevitably) crops up.Effort, though, is not the only measure of a healthy community or region, if theeffort expended is not effective in producing desired results. Some groups areable to combine effort with effective results because of cultural or communityattributes, such as the consensus-building processes intrinsic to many traditionalIndian bands, or because they had good resources, or they were lucky. Othergroups expend a lot of effort on endeavors which achieve less because they lacksome essential component, such as leadership, enthusiasm, adequate planningbefore action, or consensus about objectives; or they face some formidable18obstacle(s), such as insufficient financial backing. Other impediments to suc-cessful effort are: time lags and barriers common in bureaucratic procedures;lack of confidence; too much talk and no action and resistance to relinquishingprofessional "turf'. In addition, unanticipated consequences of action mayreplace old challenges with new ones, such as: the loss of jobs by the closure ofan outdated pulp mill, or relocation stress placed on residents of a new seniorshousing project. In communities which face obstacles of this kind, the amount ofeffort may be high, while community health levels remain virtually unchanged.Because of the need for a mixture of effort and effectiveness, it is appropriatethat communities undertaking an analysis of their healthy communities projectlook at both "effort" indicators (attendance at community meetings, numberand/or depth of projects initiated by the team, number of inter-community meet-ings held, self-perception of effort by participants) as well as indicators whichmeasure the success of the processes used in the effort. "Success" indicators mayinclude those which measure change in health status across the community, ormay note change in the number of resource structures which help communities toco-operatively manage their own health issues. Examples of health status indica-tors are: number of persons depending on food banks as their primary source offood; incidence of tuberculosis among native families on reserves; self-perceivedisolation of single parents and numbers of high school students dropping outbefore graduation. Community resource indicators include: the establishment of acommunity health advisory council or regional health planning project; a job-support programme for disabled persons; outreach groups for persons living inpoverty or street youth.The challenge in analyzing healthy communities projects is to customize "effort"and "success" indicators so that they reflect the context of the community, thespecific objectives of the project, the effort expended, the processes used, theobstacles encountered and the resources drawn upon.19(d) Healthy Community Output IndicatorsThe following are examples of output indicators which correspond to four dif-ferent definitions of Healthy Community.If the Healthy Community definition is:Place where individuals all enjoy high levels of physical, social and mentalhealth.Examples of indicators are:Babies born under 2500 grams; work satisfaction; violent crimes reported; youthat risk for suicide; perceptions among seniors about access to support servicesand health care; rate of alcoholism.If the Healthy Community definition is:Community development structures and processes in place.Examples of indicators are:Numbers and types of community service organizations in community; pre-natalprograms offered each year by various organizations; transportation links withother communities; inter-organizational meetings on health held per year.If the Healthy Community definition is:Community which puts in effort into developing community development struc-tures.Examples of indicators are:20Number of persons attending public meetings about health issues; number andsize of health projects initiated in the community per year; telephone enquiriesreceived about the project; information sessions held concerning healthy com-munities and intra-agency barriers to community input.If the Healthy Community definition is:Combination of effort and effective process used to develop communityresources and structures.Examples of indicators are:Evidence of a participatory, community-based health advisory council or similarbody; number of workshops, conferences, public meetings held and attendance atthose meetings; persons with tuberculosis; self-perceived accessibility to shops,recreation facilities, friends; outreach groups for poor families, disabled persons,street youth; rate of HIV positive tests.3.2 ConclusionChapters two and three have reviewed the literature to explore the HealthyCommunities Concept: where it came from, how it developed and what it means.Analysis of regional healthy communities projects was also explored. As wasstated above, in order for these projects to be appropriately analysed, plannersmust customize healthy community indicators to fit the local context, with atten-tion to: the project goals, the effort expended, the processes used, the obstaclesencountered and the resources drawn upon.If attention to local context is so essential in the proper analysis of a healthy21communities project, is it equally as important in the initial development of theproject? Are there other factors that a planner should consider during the earlystages of project design which would enhance success of a regional healthycommunities project? What role do such inputs as personalities of participants,availability of funding, or relationship between community and regional bodies inthe structure, have on the development of the project? The literature does notanswer these questions.The following case study will examine the impact of various contributing factorson the development of a regional healthy communities project. Because the casestudy is not an evaluation per se, but an analysis of the influence of variousinputs on a regional project, the following chapters will focus on processes used,obstacles encountered and resources drawn upon by the three communities in theTri-City Health Promotion Project.22CHAPTER 4 - INTRODUCTION TO THE CASE STUDY4.1 IntroductionAs an introduction to the case study on the Tri-City project, this chapter has twoobjectives: 1) to provide social and demographic information about each com-munity involved in the project and about the region, and 2) to describe theestablishment of the Tri-City Project.4.2 Context(a) Background for the Case StudyIn order to understand the evolution of the Tri-Cities Health Promotion process,it is important to take a closer look at the three participating cities, to see thecontext from which the project grew. The purpose of this section is to providesocial and demographic information from a variety of sources about the WestKootenay region, and about Nelson, Castlegar and Trail in particular, to supply abackground for the case study research. This material will address six questions:what are the primary health concerns in the area; how are Nelson, Castlegarand Trail different, or similar; what kind of work do people do in each commu-nity; what is the physical environment like; what is the social make-up like; whatare the characteristics of the region.(b) Health in the KootenaysIn a recent study called the Together for Health Community Profile, undertakenby the Central Kootenay Health Unit, the Union Board of Health and the medicalcommunity, health concerns were identified by 2300 respondents in each of23Tri-City Health Promotion ProjectStudy AreaBritish ColumbiaFig. 1 Map of Tri-City Health Promotion Study Area24seven health areas within the Health Unit boundaries. Central Kootenay HealthReport Cards were then issued in each area to report the results of the research.Throughout the region, the physical environment was the leading health concernidentified by respondents. This was also true of the Health Report Cards forNelson, Castlegar and Trail, where respondents identified air and water pollutionas important issues. These concerns were identified by a greater proportion ofrespondents in Castlegar and Trail than in Nelson. In Trail, miscellaneous pollu-tion was also considered important. In all three communities, this attention to theenvironment outstrips concern for other health issues such as: heart disease,cancer, lack of resources, personal lifestyle, smoking or communicable diseases.(c) Individual Community ProfilesNelsonThe city of Nelson became incorporated in 1897, during a mining boom whichdied out in the early 20th century. The city grew substantially in its early years,with a population in 1904 almost as large as it has today (Nelson Heritage Plan1981). Mining and logging are the two main resource extraction activities in theNelson area, although both of these industries have declined in recent years incomparison with employment in government, service and trade sectors. Nelsonacts as a service and transportation hub in its area (BC Regional Index 1989),and tourism activity is also on the rise. The Together for Health study reportedthat in addition to the concern about pollution, Nelson area residents identifieddrugs and alcohol, lack of resources, AIDS and personal lifestyle as importanthealth issues.CastlegarCastlegar's economy is currently dominated by activity in the forest industry,with an emphasis on pulp and lumber production. In addition, Castlegar has tra-ditionally served as a residential centre for persons working at the Trail smelter25complex, and on major power projects in the area (B.C. Regional Index 1989).There is a strong Doukhobor component in the Castlegar population, whoseethnic customs pertaining to family and social structures contribute an importantelement to Castlegar's social fabric. The city features a major airport, which alsoserves Trail and Nelson. In the Together for Health study, Castlegar residentsidentified lack of resources, personal lifestyle and cancer as health issues, aftertheir concern about pollution.TrailThe City of Trail has developed around the large-scale Cominco Smelting com-plex, which is one of the largest non-ferrous smelters in the world. The complexcombines smelting and refining of lead, zinc, silver and gold, with production offertilizers and their components. The company employs plant operation person-nel, administrative and engineering staff, and has stimulated the growth of agoods/services sector supplying the plants (B.C. Regional Index 1989). Italian isthe second largest ethnic group in Trail, with over 5% of the population identify-ing Italian as their mother tongue. In addition to their active concern for theenvironment, Trail residents identified drugs and alcohol, AIDS, and communi-cable diseases as important health issues in the Together for Health study.(d) Similarities Within the RegionNelson, Castlegar and Trail are the three largest communities in western half ofthe Kootenay region. They are relatively close to each other geographically;Nelson and Trail are ninety kilometres apart, with Castlegar situated halfwaybetween the others. The cities' populations, ranging between 6,000 and 9,000,have age structures similar to those of British Columbia as a whole, with anincreasing percentage of elderly persons comprising total population (Togetherfor Health 1990). This is in contrast to communities in the Eastern half of theKootenays, whose populations are primarily skewed towards younger age groups26(Kootenay Regional Health Plan 1989). The populations of the three cities alsofall within the range of community size associated with lower life- and health-expectancy in Canada (Central Kootenay Health Unit, 1990).City Populations:1986 1991 GrowthNelson 8130 8760 + 7.7%Castlegar 6385 6579 + 3.0%Trail 7978 7919 - 0.7%Source: Statistics Canada, 1992.The Kootenay region suffered severe effects of the economic recession of theearly 1980's, and experienced net out-migration during this period. In 1984,between 1400-1500 jobs were lost in the Nelson area alone, due primarily to theclosure of the David Thompson University Centre and Westar Timber Plywoodand Sawmill Unemployment rates soared during these years, reaching as high as20.4% in 1985 (McCandlish, J., Personal Communication). Major industrialshifts took place during this period, with a decline in resource-based activity,while some growth in tourism and service sectors resulted in lower-wageemployment relative to industrial trade rates (Together for Health 1990). Popu-lation growth now appears to be on the rise, with a 4% population increasebetween 1986 and 1991 in the Regional District of the Central Kootenay, a 2.8%increase in the Regional District of Kootenay Boundary, and higher growth ratesexpected throughout the area by 1995 (Statistics Canada 1992).Nelson, Castlegar and Trail fall within the jurisdiction of a number of govern-ment bodies other than their local governments. Some of the geographicalboundaries of these bodies overlap, but not all are corresponding. All threecommunities are served by the Central Kootenay Health Unit. In B.C., HealthUnits are responsible for assessing public health status, and for public health27promotion and disease prevention programs. The Central Kootenay Health Unitis further divided into seven local health areas stretching west to Kettle Valleyand east to Kootenay Lake. The three cities are within different local healthareas. The subdivision of Health Units into local health areas enables healthpromotion activities to be reasonably area-specific and adaptive to local needs.Regional Districts have different physical boundaries: Trail is under the jurisdic-tion of the Kootenay Boundary Regional District, while Nelson and Castlegar areboth in the Regional District of the Central Kootenay. In the Kootenays,Regional Districts are responsible for land-use administration in rural areas,including subdivision regulation, zoning, building permits, rural parks and recre-ation facilities, and referral to other approving authorities. The Regional DistrictHospital Boards are fiscal agencies for financing capital debt for hospital needswithin the regional districts. Regional Hospital District boundaries correspondwith those of the Regional Districts.(e) Regional Social Profile:The western half of the Kootenay region is predominantly populated by personsspeaking English as their mother tongue. This is less so in the Castlegar andGrand Forks areas, where Russian speakers make up over 15% of the popula-tion. In Trail, a significant number (5.4%) of persons come from Italianbackgrounds (Together for Health 1990).Education levels in each of the three cities are similar to B.C. levels, but with amarginally greater proportion of the population taking trade or non-universitycourses, and a lower percentage of persons obtaining a university degree. Nel-son, Castlegar and Trail each have higher percentages than the province ofpeople with less than grade nine education, and the overall area has thesecond-highest illiteracy rate in B.C. (Together for Health 1990).284.3 Early History: Tri-City Health Promotion ProjectThe Tri-Cities Health Promotion Project has evolved as one of a number ofhealth promotion initiatives undertaken in the Kootenays in recent years. TheKootenay Regional Health Plan (1st Report 1989), the Together for HealthCommunity Profile (1990), and Community Report Cards (1990) are researchoriented projects, designed to identify concerns and gaps in health care. Theseimportant initial studies indicate possible action areas in health policy, and showthat respondents are interested in non-traditional health issues, such as the envi-ronment and lack of resources.In the spring of 1990, a proposal group was formed with representatives from theUnion Board of Health, the Central Kootenay Health Unit, the Mental HealthCentre and the Kootenay Lake District Hospital to submit a Letter of Intent for aspecial competition of the B.C. Health Research Foundation. The competitionwas for a "Special Research Demonstration Project, Health Promotion Grant";health promotion with a "healthy communities" theme. BCHRF was interested inprojects which would "evaluate the effectiveness and/or efficiency of healthpromotion interventions and activities.... with preference given to proposalswhich target health determinants in at-risk or disadvantaged groups" (BCHRFCall for Proposals 1989). There was no mention in the call for proposals about aregional framework, but the members of the proposal group, who had recentlycompleted work on the Together for Health Community Profiles., felt that healthpromotion with a regional focus was a natural next step from research (Togetherfor Health) to action (Tri-City). In other words, the proposal group members feltit was important to maintain the regional framework they had used in theTogether for Health study in their proposals to BCHRF for Tri-City funding(Judy Toews, Personal Communication).The Foundation approved the initial Letter of Intent and invited the group to29submit a full project proposal. A Vancouver consultant, who subsequentlybecame the project evaluator, was hired to develop the proposal which wassubmitted on September 1, 1990, after a consultation process with health careproviders, service agency representatives and government officials in eachcommunity. Funding was granted for a two-year project which started on May 1,1991.Community launch groups were formed in the early months of the project, todevelop permanent Steering Committees, hire staff and set up offices. SteeringCommittees were formed in each community by August 1991, and took overproject management responsibilities from the launch groups. Workshops wereheld by the evaluation consultant in July and October, to introduce the HealthyCommunities Framework, clarify the project objectives and set up an evaluationTask Force. Community facilitators for each city and one project co-ordinatorwere hired, and offices set up for staff. After some early turnover in staff andSteering Committee membership, the project got underway in the fall of 1991.4.4 ConclusionThis chapter introduced the case study section of the thesis by examining thecontext from which the Tri-Cities Health Promotion Project evolved, and thephysical, demographic and social features of the three communities involved inthe project. This information shows that some features are common to all of theparticipating communities in the project (eg. geographical setting, environmentalconcerns) but that there are also important differences in the social fabric andemployment profiles of each community. This is one reason why a collaborationbetween these three cities on a healthy communities project is itself a significantachievement; each participates in the Tri-City project within a context of com-monality and difference.30Chapter five presents the results of the documentary research on the Tri-CityHealth Promotion Project, in the form of a chronology of the project and a narra-tive analysis.31CHAPTER 5 - CASE STUDY OF THE TRI-CITY HEALTH PROMOTIONPROJECT5.1. IntroductionThis chapter presents an analysis of the documents produced by the Tri-CityHealth Promotion Project between May 1991 and December 1992. The chapterbegins with a description of the project structure. This is followed by a chronol-ogy of the project during this period; a bare bones representation of activitiesover the first year and a half Analysis of the project material to identify emerg-ing themes and milestones then expands on the chronology. This study focuseson project-wide issues, and does not include detailed examination of the indi-vidual projects undertaken by community Steering Committees.5.2 Document Analysis(a) Tri-City Project StructureThe Tri-City Health Promotion Project is made up of three community SteeringCommittees (for Castlegar, Nelson and Trail) and a regional Co-ordinatingCommittee. The Co-ordinating Committee is composed of representatives fromeach community Steering Committee. All of the committee members have vol-unteered their time for this project; most participants are employed as serviceproviders in their communities. Each Steering Committee has one half-time staffFacilitator, and the Co-ordinating Committee has a full-time staff Co-ordinator.(b) Roles and ResponsibilitiesCommunity Steering Committees32The community committees are responsible for undertaking activities in theirown communities which will promote health and increase local capacity forchange. They are expected to identify specific health needs in their community,and in partnership with local groups, develop projects which will address theseneeds. Members also participate in Co-ordinating Committee activities related toproject-wide activities, such as evaluation, policy and procedure development,documentation and project events (eg. Community Health Week). Specificcommunity initiatives include:Castlegar- Survey of residents and high school students which indicated information gapsabout and between service agencies, and resulted in recommendations to theHospital Board.- Development of a user-friendly and accessible database with comprehensiveinformation on community services in the Central Kootenay Region.- Collaboration with other communities on Community Health Week.Trail- Needs Assessment survey conducted among general public, service providersand employers.- Development of a "Wellness Centre", including access to a data base on com-munity programs and services, health promotion material and networking centre.- "Kitchen table" discussions held from July onwards to solicit grassroots infor33Structure of the Tri-City Health Promotion ProjectAdapted from: December 17, 1991 Special Meeting Minutes34mation from community members on health issues.- Collaboration with other communities on Community Health Week.Nelson- Youth and Poverty identified as target areas, from previous community researchand committee input.- Youth Speakouts held in March and May.- Collaboration with other communities on Community Health Week.- Initial activities to sponser an anti-poverty conference in collaboration with theNelson Anti-Poverty Action Group put on hold, but discussion is underwayabout other possible activities.(c) Co-ordinating CommitteeFor the first six months of the project the functions of the Co-ordinating Com-mittee were vague, but a reassessment at a Special Meeting of all communities inDecember 1991 clarified the roles and responsibilities of this committee. At thismeeting, members stated that the Co-ordinating Committee's role is to supportthe local action of the community committees, by assisting with communication,resource diffusion and co-ordination of project-wide initiatives. The initial ideaof the Co-ordinating Committee being, as one interview respondent described it,a dynamic centre for inspiration, information sharing, and maintaining projectvision, has not evolved. Instead, the Co-ordinating Committee acts primarily as35an administrative body for the project, where financial and personnel proceduresare formulated and conducted, evaluation activities undertaken, and, through theCo-ordinator, project reports to the funders developed and submitted.5.3 Tri-City Health Promotion Project ChronologyMay 1991 to December 1992May - October 1991- May 1: start date for Tri-City Health Promotion Project.- May 15: Orientation Workshop, conducted by Allan Best, of Wilson Banwelland Assts. (evaluator) and Judy Toews, Central Kootenay Health Unit (projectinitiator).- Steering Committees are formed.- Project Co-ordinator and three Community Facilitators hired, offices set up.- Trail and Nelson Facilitators resign and are replaced.- Oct.30: Evaluation Task Force Workshop, conducted by Allan Best.- Oct.30: Committee Workshop. "What's Going Well and What's Not GoingWell".November 1991 - April 1992- Nov.5: BC Health Research Foundation approves two month project timetableextension.36- November: Project Co-ordinator gives verbal resignation, which is later with-drawn.- Dec. 3, 17: Two special meetings facilitated by Kim Howe (MSSH) addressissues of Tri-City project direction, objectives and commitment.- Dec.17: Personnel Policy adopted.- Dec.17: Co-ordinating Committee dissolved and re-formed with group supportand renewed mandate.- January: Finance Subcommittee established, and financial procedures put inplace.- Feb.7: Nelson Steering Committee writes to BCHRF to outline concerns aboutoriginal intent of the project and their role in it.- Feb.19: Special Meeting of Nelson Steering Committee to address concernsabout their goals/objectives in relation to those of the project, to renew com-mitment.- Feb.26: Sarah Sherk, 2nd Nelson Facilitator, resigns, effective March 27.- Mar.9: Two day visit by Allan Best, evaluator, includes a workshop "Redis-covering a Future" with reps from all communities; development of a SharedVision statement for the project and draft Evaluation Plan.- Mar.25, 26: Site visit by B.C. Health Research Foundation representativesCindy Robertson and Bill Lawrence, who meet with all community Steering37Commitees, as well as with Co-ordinating Committee members, and the Co-ordinator.May 1992 - December 1992- Draft versions of the Evaluation Plan and Shared Vision statement are circu-lated to all committees. Revisions are made and final drafts approved.- May: Sheila O'Shea is hired as 3rd Nelson facilitator.- May 12-19: Community Health Week, organized by all three communities.Events in Castlegar and Trail:- Wellness fair- Public Meeting- Televised Panel on Healthy Communities- Health Promotion Workshop- Intra-project Communication Survey conducted: How Well Do We Communi-cate?- June 25: Evaluation Task Force Workshop facilitated by Allan Best. Tasks areassigned for the development of the Evaluation Tool Kit.- June: Strategy Survey carried out to identify perceived challenges and goals forthe project.- July: Co-ordinator and evaluator meet to start work on project history.- August: Tri-City and Community "Goals and Objectives" Draft circulated.38- October 6th: "Getting Communities Involved", Workshop conducted in Trail byMarilyn Gauthier (Castlegar Facilitator) to respond to the public participationcomponent of BC Royal Commission Report on Health Care and Costs, Closerto Home.- Nov. 10: Sheila O'Shea, 3rd Nelson Facilitator resigns- Project History workgroup asks for Steering Committee input on revisions forthe first draft of the history. Trail and Castlegar submit revisions.- Evaluation task force goals, objectives and indicators review circulated amongsteering committees for revisions. Nov.23: Workshop by Allan Best to finalizeevaluation objectives.Sources: Jean Jones. "Tri-City Project Milestones", Steering Committee Minutes,Project History.5.4 Tri-City Project HistoryMay to October 1991 - InitiationAs was stated at the end of chapter four, the Tri-Cities Health Promotion Projectwas established on May 1, 1991. The project history calls the summer and fall ofthat year an "Initial Mobilization" period. This time was used to: form Steeringand Co-ordinating committees; explore objectives; hire staff and set up offices.This phase included some early staff and committee member turnover, as par-ticipants became better informed about the project goals and framework, andjoined or departed as was appropriate. The Trail and Nelson facilitators resignedsoon after they were hired, but were both replaced by early October. During thistime, a Vancouver consultant who had been contracted to develop the initial39grant proposal and who subsequently became the external evaluator for theproject held workshops periodically during this time to familiarize participantswith Healthy Communities and Health Promotion concepts, to explore projectobjectives, and to facilitate the establishment of a Project Evaluation Task Force.Steering Committees in each community clarified their own roles and responsi-bilities, developed process guidelines, and talked about what their specificprojects should be.October 1991 to April 1992 - ReassessmentAccording to the project history, some tensions emerged between and within thedifferent committees as autumn progressed. These led to a major project-widereassessment between October and December 1991. Concerns were primarilystructural; they centred on the roles, volunteer commitment, and management ofthe committees, and the relationship between the community and the Tri-citylevels. These structural questions signaled a greater underlying friction: differentcommittees and participants within them had varying ideas about what theproject was meant to do, how it should be done, and what their place was in thisprocess.While all the community steering committees had initially struggled with theissue of whether Tri-City was meant to be project- or process-oriented, partici-pants state that the Castlegar Steering Committee, followed soon after by theTrail Steering Committee, resolved this issue and adopted a focus on "process"by October 1991. The Nelson Steering Committee, whose activities had beenstalled somewhat by their lack of a Facilitator until early October, found itselfwith a very different idea about the project purpose than the other two commu-nities. It was during this time that a split emerged over the issue of project vision:Castlegar, Trail and the Tri-City level on one side and Nelson on the other.40The documents generated during this time indicate that the Nelson SteeringCommittee wanted to concentrate on practical and visible community projects,"identifying an unmet health need and doing something about it" (Goals andObjectives Sheet). The minutes show that Nelson also wanted more indepen-dence from the Tri-City level, in such areas as deciding on objectives, managingtheir own project finances, participating (or not) in Tri-City level activities, eg.the Evaluation Task Force.The Trail and Castlegar Steering Committees and the Tri-City Co-ordinatingCommittee had more process-oriented goals; they wanted to focus as much on"how they got there" as on "what they did", and the actual output goals wereconsidered to be only as important as was the process of achieving them. Ofcourse, there were individuals on all the different committees who did not havethe same views as the rest of the group, eg. project-oriented persons in the TrailSteering Committee, process-oriented ones on the Nelson Committee.The two sides in this debate over project vision had valid reasons for standingbehind their viewpoint. A number of the Nelson committee members had beenpart of the original grant proposal group, which had successfully gained thefunding for the project. They felt that they knew what the project was all about,because they had written the initial documents. In addition, the committee waslargely made up of experienced agency representatives who had worked togetheron other projects which had achieved practical results in their community. Theirskills were especially suited to identifying and quickly meeting unmet needs inhealth service delivery. As it is put in the project history, "many volunteers wereused to a clear issue and action focus, limited funding and a short timeline"; thisdescription fits the general style of the Nelson Steering Committee.Alternatively, both the Trail and Castlegar Steering Committees and the projectCo-ordinating Committee had adopted the process-oriented approach which was41evident in the funding agency material and in the grant proposal itself. They alsohad a greater commitment to the "experimental" or research aspect of the project,and spent considerable energy documenting the development of the project pro-cess through the various activities of the Evaluation Task Force. The NelsonSteering Committee, on the other hand, was unwilling to commit volunteer andstaff time to participate in Tri-City meetings (Evaluation Task Force, StaffMeetings, Co-ordinating Committee) in Castlegar, when so much work wasneeded on the projects at home. Referring to the fledgling Evaluation Plan, oneNelson Committee member stated in January, "why are we worrying aboutevaluations when so far we've done nothing to evaluate?"One result of this tension over priorities and participation was that the ProjectCo-ordinator stated her intention to resign in November. Her decision to staywith the project and subsequent reappointment were prompted by her perceptionthat steps were being taken at all levels to address the emergent conflicts.December 1991 to May 1992 - Review and RenewalA review and renewal phase took place during the winter of 1991 and spring of1992. Two special meetings in December were facilitated by an outside facilita-tor, Kim Howe (MSSH) to deal with conflicts, examine levels of commitmentand clarify a vision for the project. This was a crucial time in the project history;the future of the project and/or of Nelson's participation in it was in question.Some issues that were addressed in these meetings were resolved (eg. the role ofthe Co-ordinating Committee), and others continued to affect the development ofthe project as it progressed into its second year (eg. lack of single project vision).Minutes from the December Special Meetings show that representatives from allthree Steering Committees expressed a strong commitment to the project, and adesire to address the issues which were causing trouble, in particular the Co-42ordinating Committee functions and the diversity of project visions. The secondDecember meeting reviewed and clarified the role of the Co-ordinating Commit-tee in relation to the community Steering Committees, and in particular, workedout a new mandate and membership for the Co-ordinating Committee. The con-clusion reached at this meeting was that "Action" happens at the SteeringCommittee level, and the Co-ordinating Committee and subcommittees are toprovide support for these activities (see Structure chart above).However, despite the renewed unification of all parties in the project, it becameclear in the early months of 1992 that the tension over project vision had notdisappeared. The chair of the Nelson Steering Committee contacted the B.C.Health Research Foundation by letter on February 7 1992, to express concernover the gap between Nelson's original expectations and the way Tri-City wasactually developing. She referred to a proliferation of committees, meetings andresponsibilities at the Tri-City level, which were using up volunteer and (part-time) staff time, and diverting resources from local activities. She restated theNelson Steering Committee's earlier position, that local activity is what is impor-tant and what will be evaluated. "It also seems incongruous to our group thatthere is a large amount of money allocated to evaluation but not enough appar-ently to cover postage stamps to mail our meeting minutes". The letter asks forclarification of purpose and objectives, and states that members are questioningwhether they have time to continue. While there is no BCHRF response to thisletter on file, representatives from BCHRF conducted a two-day site visit inMarch. The representatives were generally supportive of the work being done inthe communities. Their comments emphasized that because Tri-City is a demon-stration project, there is no right or wrong way to proceed.The second Nelson Facilitator left the project in late March 1992. Her letter ofresignation outlines as her reasons for departure a perceived lack of support orcommittment from the Nelson Steering Committee for her work with community43groups in Nelson, and a concern that her integrity with those groups was at risk.A third Facilitator for Nelson was hired to replace her in May 1992.May 1992 - December 1992 - Project DevelopmentDuring the week of May 12-19, the three communities jointly presented a"Community Health Week", in Castlegar and Trail which featured a WellnessFair, a televised panel, a workshop and a public meeting. Speakers from outsidethe region, such as Valerie Grano from the B.C. Office of Health Promotion, andCarol Pickup from the Healthy Saanich project, were brought in to participate,and turnout was good for most Health Week events. Participants state that bythis time there was a marked perception throughout the project that key issuesand conflicts had been resolved, and with the new Co-ordinating Committee anda new Facilitator in Nelson, that action would proceed as planned.In Trail, the Committee decided to refocus their agency-oriented initiatives tomore grassroots participation, and began conducting small group "kitchen tablediscussions" with support groups and organizations in the community. Somegroups who participated in kitchen table discussions were: single parent's supportgroups, the Catholic Women's League, secondary students from the localschools, youth on probation, volunteers from the Mental Health Association andHospice/Palliative Care, youth groups and seniors groups. The Castlegar groupcontinued the development of their comprehensive community resource database,and built communication networks within the community and outside the region.Nelson had held two successful Youth Speakouts during the spring, and contin-ued to hold discussions with a local anti-poverty advocacy group about apossible anti-poverty conference.In the summer, the Co-ordinating Committee conducted a "strategy survey"throughout the project to identify perceived challenges and to solicit input on the44future goals of the project. The survey asked participants to rank a list of chal-lenges and goals. The results showed that volunteers considered that poorunderstanding of the project, lack of community awareness, membership andcommunity territoriality were the four most important project challenges. Thelisting of these four challenges as most important indicate concerns amongst thevolunteers about lack of single project vision, volunteer committment, and ten-sion amongst communities in the project. At the Tri-City level, communityawareness and ownership, communications and co-operation ranked high on alist of future goals. At the Community level, getting specific projects going andcommunity awareness and responsibility were perceived to be the most impor-tant goals.While the strategy survey was being conducted and analyzed, the Co-ordinatingCommittee was also developing a list of overall project goals, objectives andindicators, and asking for similar information from the local Steering Commit-tees. This compilation of goals also helped to clarify future directions amonggroups at both levels.Until November 1992, each community worked on developing their localprojects, addressing the health issues identified in earlier stages. As in the firstyear however, late Autumn proved to be a difficult time for Tri-City. By earlyNovember the issue of project vision and participation rose again, and SheilaO'Shea, the third Nelson Facilitator, resigned. Her reasons for leaving the projectwere similar to those of the previous facilitator, Sarah Sherk, who had resignedin March. Ms. O'Shea stated that she perceived an unwillingness on the part ofsome of her Steering Committee members to provide direction or resources oncommunity projects or on Tri-City activities. She felt that staff, instead ofCommittee members, were driving the project, and did not feel comfortable inthis role.45In December, the Nelson Steering Committee decided that for the time-being itwould undertake individual community projects by contract, rather than hire anew facilitator for the final six months of the project. The first of these contractprojects was a Youth survey in the local junior high- and high-schools conductedby the Castlegar facilitator, Marilyn Gauthier. Also during December, a seconddraft of the project history was circulated throughout the committees, incorpo-rating the revisions submitted by Castlegar and Trail. The Nelson Committee didnot provide any input into revisions.At the end of 1992, all of the committees were planning their objectives for thefinal six months of the project, and aiming at completion of their community ini-tiatives by the project end-date in June.5.5 Preliminary Conclusions - Documentary AnalysisConclusions drawn from the documentary analysis of the Tri-city project comeunder two headings: Project Vision, and Project Structure.(a) Project VisionThe documents generated by the Tri-City project in 1991/92 indicate an emer-gence of two opposing perspectives on the purpose of the project, and how itshould be carried out.On one hand, the Castlegar and Trail Steering Committees and the Co-ordinatingCommittee had adopted a process-orientation, with a strong research theme;these groups considered that evaluation should be based as much on the processof achieving their objectives as on the outputs of the process. This viewpoint wasalso supported by the Evaluation consultant, whose original proposal to BCHRFand project workshop materials used a process model.46On the other hand, the Nelson Steering Committee held the view that end-resultsof community action were the most important component of the project, and thatevaluation should be based primarily on the outputs of the local project, ratherthan on the process of achieving the outputs.This is not to say that there was consensus among all committee participantsabout the standpoint taken by their committee. It is clear from documents on filethat there were several perspectives represented in each community. The twopositions that emerged, however, reflect the general philosophy and directiontaken by each committee.The stumbling block of opposing project visions has affected the project in gen-eral because of a perception that all groups must have a similar vision in order towork in a regional context. This has slowed local initiatives in the Nelson group,as they have tried to grapple with their role in the larger framework, and hasdiverted time and resources of the other committees away from their communitywork and into efforts to resolve this issue. In addition, it has complicated theactivities of the Tri-City Co-ordinating Committee (e.g. on project history workand the Evaluation Task Force), because of inconsistent levels of participationfrom the Nelson group.(b) Project StructureGrassroots or Top-down?The friction experienced by these groups is partly due to the discrepancybetween the philosophy of the project and the design of the project structure. Thematerials related to this project show an aspiration for a participatory, commu-nity development process, which can been seen in such statements as: "The47community development approach to health promotion emphasizes process:enabling people and communities to have increased control through full partici-pation in planning and implementation" (Project Grant Proposal, p.6), and: "Thecommunity more broadly will be permanently enhanced. The concept of controlover health determinants, as a means to increase control over individual healthand well-being, is very powerful, and once developed, enduring" (Project GrantProposal, p. 7).The structure that was used, however, supports a more stream-lined, task-oriented approach, where community leaders used their experienceand skills to resolve community problems, or fill gaps in service. The grant pro-posal describes potential Steering Committee members as being "for example,from advocates of the disadvantaged; city councils; the Union Board of Health;hospitals; home support; industries; the Ministries of Health, Social Services andHousing, Regional Development, and Environment; the Community College;Community Services and school districts" (Project Grant Proposal p. 5). It iseasy to see how two conflicting opinions about vision may have emerged; bothare encouraged, either by the community development tone of proposal materi-als, or by the committee structure, which tends to impose top-downdecision-making This discrepancy may have contributed to the evident confu-sion amongst many participants about the project's purpose and the processesused.Interview respondents state that because the structure used in the Tri-City projectis based on a series of committees made up of key individuals in the community,it inhibits the participation of regular community members on the centraldecision-making body, and tends to limit their role to that of information source.In this kind of committee structure, community members may be discouragedfrom participating for several reasons: they never hear about the project at all;they feel excluded by the clique of other committee members, by meeting rules,or lack of verbal skills; they perceive that they have nothing valuable to contrib-ute; they are unable to attend meetings because of work or childcare constraints48or because of transportation costs.Both the healthy communities concept and the Royal Commission on HealthCare and Costs, Closer to Home suggest that members of the community knowbest what their health needs are, and advocate that the community should begiven increased control over decisions affecting its members' health. The litera-ture also suggests that service providers who represent marginalized groups,such as persons with low-income, single parents, youth, seniors, and ethnicgroups, may have perceptions about problems and solutions that are differentfrom those of the actual members of those groups.The Tri-City project, at both regional and community levels, was driven bycommunity leaders rather than by "grassroots" members, because of its tradi-tional committee design, and because of participation on those committees bygovernment representatives, business leaders, agency heads and service provid-ers. In this way, it followed a conventional provider/client model, where serviceproviders and planners gather information from a client group, and then planservices for them.Consequently, the community Steering Committees and the Co-ordinatingCommittee had to bridge a gap between themselves (people with professionaljobs, valued skills, leadership, power) and the people they were trying to help. Ina bottom-up, participatory process, there is no gap between the decision-makersand the target groups, and the project is driven by those it most affects, ratherthan by persons with very different life experiences. The risk that the decision-makers are focusing on the wrong issues for these groups is then minimized.Some ways of encouraging a strong representation of grassroots members onproject committees are: preliminary education of the community about theproject, design of the recruitment plan to include members from various con-49stituencies as well as the general public, selection of committee members at acommunity public meeting, removal of some of the barriers to participation (e.g.childcare and transportation costs).While Tri-City is clearly not a bottom-up participatory process, it does includesome positive elements which improve on the traditional top-down form ofproject that has made people of many communities so suspicious of planners andgovernments. Some of these positive contributions are the use of alternative andcreative information gathering techniques, such as the "kitchen table" discussionsand the Youth Speakouts, as well as the establishment of sustainable communityresources, such as the Community Services Databases.5.6 ConclusionIn chapter five, documents were examined to outline the history of the Tri-CityHealth Promotion Project between May 1991 and December 1992. A number ofissues emerged during these months of the project, such as the apparent divisionover project vision and the conflict between the aspirations of the project and itsdesign. These themes form the basis of the key informant interview guide for theinterviews in Chapter 6, which will augment the conclusions drawn from thedocuments with personal observations and experiences.50CHAPTER 6 - PERCEPTIONS OF PROJECT STAFF6.1 The InterviewsThe purpose of the interviews in the case study of the Tri-City Health PromotionProject is to enable project staff to comment on issues which emerged in thedocumentary analysis, and to expand on the information from the documentswith their personal observations. This allowed for some clarification and infor-mation verification, but also became a source of creative ideas and suggestionsfrom persons with hands-on experience working within this particular projectdesign, and with these committee members. These are key informant interviews,and are not meant to represent a statistical sample of project participants. Therole of the interviews is to add to the documentary research with expert observa-tions and perceptions.Interviews were held with each of the three Community Facilitators and with theproject Co-ordinator. The interviews lasted between 45 minutes and 1 1/2 hours.Two were conducted in person, two by telephone. An interview guide with eightpoints was used to facilitate discussion (see Appendix A), but the interview fol-lowed an open format to allow respondents to respond in the context which theyfelt was most appropriate. The Facilitators and the Co-ordinator were each askedto comment on the experience of the committee they worked with. The interviewguide touched on several issues about the project as a whole, but also elicitedcomment about the development of each community process, to determine thekey features of each one.Issues which were explored in the interview research were:- the different perceptions of project vision.- the effect that the problem of different project visions had on staff and on the51work of the Steering Committees.- the apparent discrepancy between project philosophy and project structure.- the advantages/disadvantages of the collaborative regional framework.- unexpected advantages or obstacles encountered.- additional comments or suggestions about process, structure or vision.6.2 Interview Results(a) Issue of Project VisionAll of the respondents agreed that Tri-City had experienced some difficulty withproject vision, and most felt that this was an issue which had never been com-pletely resolved. Specifically, the respondents perceived a rift between theNelson Steering Committee and the other two Steering Committees over whatthe vision of the project was, and how the objectives of the project should bemet. Two informants stated that the causes of the differing standpoints were thevagueness of the project materials, and a lack of continuing leadership fromthose who had initiated the project. "Even though they wanted the project to begrassroots one, the initiators should not have stepped back once it got going, butshould have stayed involved in the project, because they had the best idea ofwhat it was all about." Another respondent suggested that personality conflictsmay have contributed to difficult group dynamics: "Process- and project-orientedpeople were locking horns instead of complementing each other to make a goodmixture."(b) Vision: Effect on Committees and StaffAll of the respondents stated that the division between groups had affected themin some way, whether marginally, as a nuisance, or in a larger way, contributingto job dissatisfaction. The Facilitators and the project Co-ordinator participated52in the workshops and meetings held to sort out project problems in the winterand spring of 1991-92. Facilitators from Trail and Castlegar stated that the prob-lems caused by differences in project vision affected them because theirattendance at emergency meetings took time away from their work on commu-nity projects, and that the conflicts were distracting and frustrating for theircommittees, but did not hamper them otherwise. "Actually, it was hard to get mycommittee involved in the issue because they didn't see the problem; they saidthat if the other committees do things differently that's up to them, it's not our jobto sort things out. Their Steering Committee must decide what their vision is."The Nelson Steering Committee was clearly hindered by this difference in vision,however, because they were unable to reconcile the approach and objectives ofthe other Steering Committees and the Co-ordinating committee with their own.Respondents stated that Sarah Sherk, the Facilitator working for the NelsonSteering Committee at that time, found herself pulled between the conflictingrequirements of her Steering Committee and the Co-ordinating Committee.The Co-ordinating Committee was also affected, as its activities depended onrepresentation from all Steering Committees and did not always receive inputfrom Nelson. Project-wide procedures and ongoing evaluation were to bedeveloped at the Co-ordinating Committee level, and varying degrees of partici-pation from the Nelson Steering Committee produced delays and bottlenecks inthe process.(c) Comments About Project Philosophy and StructureAll respondents commented on the project structure at length, and the gapbetween the structure used and the aims of the project was discussed. Onerespondent stated: "This is not a grassroots project, accept that. It's a top-downapproach. The project uses a top-down model with dreams of being grassroots;53but you can't mix the models." None of the participants felt that their committeeswere made up of a grassroots membership, or had ever aimed to be. Rather, thegoal in recruiting members had been to develop committees with a broad base ofrepresentation from a number of community interests: service agencies, interestgroups (eg. seniors' organizations, women's groups), government and business.They each felt that community leaders or heads of organizations were well rep-resented amongst the committee members. One respondent commented on theresulting gap between decision-makers and target groups, when committee par-ticipants are primarily key members of the community. "It's kind of like forminga group for disabled people or persons of colour, and you're not. How do youbridge the gap between you and them; your goals and theirs?" Another discussedthe problem of having so many leaders in a hierarchical structure: "Who's goingto be the leader in a group of leaders?"Most of the participants felt that one way of making the Tri-City committeestructure more effective would be to recruit members from lower in the ranks ofcommunity organizations - assistants or community workers, for example. It wassuggested that these types of members would have more time to devote to theproject, would be closer to the "front lines", more in touch with the needs of thetarget groups in the community, and also more familiar with the steps usedbetween goal-setting and achievement of the end results.Some respondents suggested that the contributions of community leaders wouldhave been better utilized if they filled a less central role; providing support toothers in the process, rather than running it. Key players could then use theirskills in co-ordination, leadership, advocacy, management, grantsmanship andbrokerage to further the efforts of community members gathering information andmaking decisions. One participant suggested a Resource Board model, wherecommittee members would contribute what they could from their jobs, such asmeeting space, clerical help or supplies, or new information from conferences or54their work, to support the activities of groups already active in the community.She felt that more open communication and interplay between groups may havedispelled some resentment from smaller, struggling organizations providing coreservices who had been in competition with Tri-City for funding, and who arenow wondering what role Tri-City is able to play in community change.(d) Other Suggestions About StructureOne respondent suggested a different process for developing a regional project.She felt that four years would be needed for a collaborative project. An initial6-8 month stage would include the selection of a regional management commit-tee to look at different models and planning structures. This committee wouldexplore egalitarian models, ones which allow for consensus decision-making (asopposed to using methods such as voting), and which do not discourage varyingand sometimes conflicting opinions from being aired. The committee wouldfocus on models which would let those who will be affected by the process par-ticipate; provide lots of time and as many opportunities for participation aspossible. The respondent describes this kind of process as "big, messy, and cha-otic, but issues start to boil down." This exploration of different project designswould replace the imposition of one model on participants. "It's like putting amanagement style on somebody. It might look great, but if you're not that kind ofmanager, it won't work."Another respondent suggested an alternate approach. Instead of trying to achievesustainable community development objectives by setting up a two or four yearproject, she suggested the establishment of a permanent Community Co-ordinator. The Community Co-ordinator would be supported by communityfunds (eg. community/hospital partnership etc.), with no political or agencyaffiliation, who would act as a resource person for community groups or projectsmobilizing around an issue. A Community Co-ordinator would provide continu-55ity, co-ordination of activities, information, contacts, familiarity with existingdata, files and resources. She would also be able to identify and involve groupsaffected by or interested in an issue (eg. affordable housing).(e) Advantages and Disadvantages of the Regional Collaboration.All of those interviewed felt that the regional framework was a good idea, andthat in general, it had yielded positive results. The distance between communitieswas considered to be inconvenient for staff meetings, but the benefits of infor-mation sharing and mutual support outweighed the discomfort of having to meetin a central location. One respondent felt that for the Steering Committees tofully benefit from the Tri-City collaboration there should have been more team-building between communities in the initial stages, to encourage trust andcommunication. One suggestion for team-building was to have a volunteersweekend, assembling participants from all committees. She also recommendedthat inter-community communication be improved, via a central "informationclearing-house", to minimize the effect of differing perceptions on information.Another participant said that the Tri-City approach might have worked better ifthe Co-ordinating Committee had taken on the role of a central hub for ideas andinspiration, with members who maintained the vision and dynamism of theproject, attracting key players to the process. Instead, the Co-ordinating Com-mittee is described as an administrative body, where financial and personnelpolicies are developed, information is dispersed and evaluation tasks carried out.(f) Unexpected Advantages and Obstacles EncounteredIn general, all of the respondents made positive comments about the members ofthe committees they worked for. Each identified personalities on their commit-tees and in the community who had made their jobs easier, and others who had56made things more difficult. The mixture of personalities on committees was alsoidentified as either a strength or a detriment; some committees were described ashaving a combination of personalities which improved their performance, otherswhich hampered work. One respondent said that she had expected that hercommittee members would have brought more news and resources from theirjobs to the Tri-City process, and would have communicated more about Tri-Cityto outside contacts.One disadvantage pointed out by a staff member is the lifestyle of the Kootenays- how difficult it is to reach participants in the summer months, and again duringthe winter, because people spend significant amounts of time pursuing leisureactivities out of town. Lifestyle was then identified as a strength by this samerespondent, because she felt that people are more likely to take on work in arelaxed way, and are more patient with time-consuming processes.(g) Additional CommentsOne staff member noted how much more difficult it is to recruit members andhave a clear purpose when the process starts off with issue-identification ratherthan with a pre-targeted issue. She stated that it is much easier to mobilizearound an existing problem, which provides a focus at the beginning. Sheremarked on the apparent success of some community development projectspresented at a SPARC conference in Victoria in the autumn of 1992, all of whichhad focused on one issue from the beginningOther comments referred to finance and personnel policies, which staff membersfelt should be in place from the start of the project, rather than being developedalong the way. "Writing a personnel policy for yourself is very interesting". Onthe question of mechanisms in the project for staff support or grievances, onestaff member remarked "What staff support?"57Concern about financial procedures was also evident amongst most respondents.Some felt that financial decisions were not made in a structured or proceduralway. "In my other jobs, I've had to worry about spending $20, in this one, muchlarger financial decisions were made with seemingly less attention to usual pro-cedures, like putting an item out to tender in all three communities and thenchoosing the best bid." "When there is turnover on the society (Union Board ofHealth) Steering Committees, Finance Subcommittees, things fall between thecracks, cheques don't get sent."6.3 ConclusionThe key informant section of the case study has gathered a substantial number ofcreative ideas about the present state of the Tri-City Health Promotion Projectand the possibilities for other projects. The particular concern among respon-dents about both project vision and design confirms the documentary conclusionsthat these are two significant issues in the experience of the Tri-City project. Inaddition, personality mix on committees, the early establishment of policies andprocedures, and support for staff members were identified as important featuresin this section of the study.58CHAPTER 7 - CONCLUSIONS7.1 IntroductionAs was stated in chapter 1, the purpose of this thesis is to identify features whichmay contribute to or detract from a regional Healthy Communities project reach-ing its own objectives, whatever those may be.In the case of the Tri-City Health Promotion project, the issue of what exactlythose goals and objectives are is a complex one, because the three communitieseach have their own goals, and these are also intertwined with those of the Tri-city project as a whole. This complex relationship between community andproject-wide goals makes it difficult to pinpoint which features are helping orhindering success, because it is hard to say whether the elements which make upthe individual process are most important, or if it is the relationship between thecommunity group and the rest of the project which matters the most.(a) AssumptionsWhen I began this study of the Tri-City Health Promotion Project, and heardabout the tension between committees in the project and the apparent lack ofproductivity of the Nelson Steering Committee, I made some assumptions aboutwhat was contributing to these difficulties. After sifting through all of the pos-sible features which might be contributing to or detracting from success, theindividual approaches used by the committees seemed to be the element worthexamining in detail. After all, other aspects of the projects were similar acrossthe board. Each committee was made up of bright and experienced people with aconcern for their community. They shared the same funding, the same evaluationconsultant, the same committee structure, the same number of staff, and had the59same access to information. They all had support from the people in their com-munities. Of course, individual personalities may have helped or hinderedprogress, and also the mix of personalities on each committee may have been acontributing factor. These must certainly be acknowledged as important. Yet themost clear division between these communities seemed to be their individualcommittee styles or approaches, so I focused on examining these.Fresh from graduate courses in Planning where I had read and heard that com-munity mobilization and participatory planning exercises must pay carefulattention to process, and not focus only on end-results, I made a quick diagnosisthat the apparent "task-orientation" of the Nelson Steering Committee was hin-dering its success in becoming a productive community development project.The Nelson Steering Committee appeared to be creating a rather conventionalkind of community project, an action-oriented approach which had been suc-cessful in previous cases. I felt that this type of project would not be as effectiveas it might have been previously, because times had changed, and people in thecommunity expected more involvement. Too little initial planning and the omis-sion of community participation steps appeared to be the big problems.It seemed to me that the other committees, using their exploratory, introspectiveapproach, were outstripping the Nelson group in achieving their objectives pri-marily because of that approach; the tortoises were overtaking the hare. I sawthis project as composed of two communities who were developing true "HealthyCommunities" bottom-up, process-oriented projects and one which was emerg-ing as a top-down, task oriented project. This perception was supported byseveral project participants with whom I spoke.Having analyzed the documents and spoken to each of the staff members work-ing on Tri-City, my perspective has changed somewhat. My perceptions may not60correspond with those of some project participants, and should not be taken asthe opinions of all of the persons with whom I spoke. I hope, however, that theywill raise some issues for discussion.(b) New PerceptionsFirst of all, this is not a debate between bottom-up and top-down planning pro-cesses. None of the communities in Tri-City has developed a bottom-up,participatory process, except in a very limited definition of the term "participa-tory". None of the community Steering Committees has a significant number ofgeneral community members, or members of targd groups in their membership.Instead, each committee is mainly composed of senior agency personnel, gov-ernment members, business representatives, etc. The "grassroots" are limited intheir involvement to a role as information-source, and do not have a strong pres-ence as decision-makers or drivers of this project. Therefore, we cannot say thatthis project empowers community members to collectively take responsibility fortheir own health issues, and learn skills and confidence to address them in thefuture. Rather, in the Tri-City project, community leaders have assembled incommittees to collaborate on a project which gathers information from commu-nity members and then attempts to improve services, programs or resources forthose people. There is a significant distance between those in control of theproject and the people it is meant to serve. If the project's goal was to have alarge grassroots representation, then different recruitment methods for all com-mittee members would have been necessary.Having said this, I would like to refer back to chapter 2, which explored thequestion "what is a healthy community?" In this section of the thesis it becameapparent that there are many different perceptions about what a Healthy Com-munity really is, and that each project should be evaluated as successful or notaccording to its own objectives. Healthy Communities projects need not all fol-61low the same rules, guidelines or approaches; in fact, lack of rigid, generalizablegoals is one of the strengths of the Healthy Communities concept. The Tri-Cityproject need not be judged harshly in its inability to provide grassroots represen-tation on its Steering Committees. Although the project materials often refer toparticipatory process, empowerment and enabling, these same materials did notrequire recruitment of grassroots community members. Tri-City aims were lessambitious: to gain a broadly based membership of groups representing membersof the community and the target groups.By these criteria, it is also acceptable for the Nelson Steering Committee to havehad different goals and a different approach from the other committees. Nelson'sgoals may have been more limited than the others; they were more of a gap-finding and -filling exercise than an exploratory process. But Nelson did notseem able to achieve even these more conventional aims with much success.Was this because of the approach they used, or was it because of the way theircommunity process coincided (or didn't) with those of the rest of the project?Nelson's goals did not fit comfortably within the process-oriented framework ofthe project, and I believe that this contributed more to their lack of productivitythan did their ends-results approach. They were, essentially, odd-man out in aproject design which demanded a single vision; a vision which was not theirown. The struggle between Nelson and the other committees over project visionwas time-consuming and contributed to confusion, tension and discouragementon the part of volunteers and staff in all committees, but especially amongst thoseon the Nelson Steering Committee and the Facilitators who worked for them. Iam convinced that it was this struggle between communities, and the lack ofunited vision in the project which contributed the most to Nelson's difficulties.Similarly, I believe that the other community committees gained some strengthand solidarity from the perception that they were on the right track (as evidenced62by the project materials and the evaluation consultant).While the collaboration between the three communities has provided some ben-efits, (inter-community comparability, regional context, shared evaluator,information sharing etc.), a regional framework which allowed each communityto follow different paths may have been more productive. Each community couldthen have chosen its own course of action, and still have profited from the net-work with the other communities. In a looser framework, less time would havebeen needed to sort out and maintain a single project vision, and more time couldhave been allotted to the objectives of the project.(c) Implications for PlannersThe information gathered in the case study of the Tri-City Health PromotionProject suggests that a number of factors should be considered by planners tak-ing a role in the development of a regional healthy communities project. Some ofthese factors are: the approach used by the participants, the resources and con-straints peculiar to each community, the context from which the project grew, theability of the participating communities to work co-operatively, and the relation-ship between community and regional bodies within the project structure.The individualistic nature of regional healthy communities projects means thateach will develop differently, and consequently, some of these factors will have agreater influence on future projects than others. In the case of the Tri-City HealthPromotion Project, the achievement of objectives by the community SteeringCommittees and by the Co-ordinating Committee was influenced by: theapproaches used, the personalities of the participants, the context from which theproject grew, the ability of the communities to work co-operatively and the rela-tionship between community and regional bodies within the project structure. Itis this last factor which has had the greatest influence on the achievement of63objectives in the Tri-City case. The participants interviewed in this study wereunanimous in their support for a regional network among the three communitiesin the Tri-City project, but all felt that the positive features of regional collabora-tion were diminished somewhat by the struggles which it caused.If a regional healthy communities project is to be successful, the model for theregional collaboration must be carefully chosen to best enhance the activities ofthe participating communities. This is especially crucial for healthy communitiesprojects, because they experiment with a different kind of regional process; onewithout a centralized, top-down decision-making design. In Tri-City, the com-munities developed local initiatives with support from the regional body, ratherthan direction from the region; this bottom-up orientation is clearly a new type ofregional process.Planners taking a role in the development of a regional healthy communitiesproject must explore different possibilities for co-operative work between com-munities, and tailor the project design to fit the participants. In the Tri-City case,this tailoring could have been achieved in the early stages of the project, beforethe terms of reference for each committee had been finalized. Had the threecommunities developed independent projects with a less formal collaborativearrangement (perhaps information-sharing only, for example), or had theyworked within a design which allowed for a variety of visions and approaches,all of the committees would have spent less time sorting out project-wide issues,to the benefit of each community project. This is not to assure success in achiev-ing all community objectives, but at least one major impediment would havebeen removed.(d) Implications for Further ResearchAs was stated in chapter one, this thesis concentrates on the factors which plan-ners and other professionals should consider when assisting commuities in the64process of developing a healthy community. Because of this focus on the role ofthe planner, and because planners are often involved as staff members in healthycommunities projects, the emphasis in this study was on the staff perspective.Thethesis also attempted to avoid repeating the efforts of the Tri-City EvaluationTask Force, which is conducting an ongoing evaluation process. For these rea-sons, the perceptions of the Steering- and Co-ordinating Committee memberswere not included in this study. Further research into the area of regional plan-ning for healthy communities must address the various perspectives of these keydecision-makers, to examine their different contributions to project developmentand management. In addition, research is needed on the "opportunity cost" ofdeveloping projects such as Tri-City, to examine the extent of their impact on thecommunity, and to assess their effectiveness in creating change for a healthiercommunity.7.2 ConclusionThe goals of the Tri-City Health Promotion Project, as stated in a recent reportto City Councils are: to foster partnerships in each community to increase capac-ity for community action and health promotion, to develop a well-documentedhealth promotion model and to provide testable propositions about health pro-motion processes in small communities. Analysis of project documents andinterviews with staff have shown that for the most part, these goals are beingmet. Exploration of alternative project structures in the early stages of the Tri-City project could have perhaps enhanced the efforts of the individual SteeringCommittees and the Co-ordinating Committee.The Tri-City Health Promotion Project has made headway in the quest forimproved community action projects. Participants have experimented with cre-ative forms of information-gathering, have raised community awareness abouthealth and have developed new, accessible health information resources. They65have tackled a Health Planning exercise using a broadened version of the term"Health". They have documented their experience in several ways, which will aidother Healthy Communities projects to leap over landmines they might otherwisehit. The knowledge generated by the Tri-City project will also inform the activi-ties of the West Kootenay Regional Health Plan, which is currently entering itscritical public participation phase in 1993.While Tri-City may not have reached the heights of community control andbottom-up planning advocated by the Healthy Communities literature and theRoyal Commission on Health Care and Costs Closer to Home, it did exploresome new territory in Community Health Planning. The struggles and growingpains of Tri-City will contribute significantly to our knowledge about the factorswhich contribute to, or detract from, a regional Healthy Communities Projectachieving its own goals.66APPENDIX A: INTERVIEW GUIDEWhat do you think are the most important features of the (Trail, Castlegar, Nel-son, Tri-Cities) project? Strengths and weaknesses?Prompts:- Steering Committee? What is it about them?- Process? What about it?- Community?Do you feel that the objectives of your project are being met? If not, Why not?Other people have said that one of the hardest things to do in a Healthy Com-munities project is to get a broad representation from the community on theSteering Committee.- Do you have that on yours?- Why, Why not? Can you think of ways to help make it more representative?Have you encountered any other unexpected or unusual obstacles or strengths?This project seemed to go through a tough period last year at about this time; didyou feel the effects of that? Can you tell me what you think the most importantissues were then?Do you feel that those issues have been resolved?- which have?- which haven't?What are your general impressions of this project?Do you have any other information or comments about Tri-City that might behelpful for other projects to know about?67BIBLIOGRAPHYAltman, David G., Jerry Endres, Juliette Linzer, Kate Lorig, Beth Howard-Pitneyand Todd Rogers. "Obstacles to and Future Goals of Ten ComprehensiveCommunity Health Promotion Projects." Journal of Community Health, 16:6,December 1991, pp. 299-314.Antonovsky, Aaron. Health. Stress and Coping. San Francisco: Jossey-Bass,1979.Ashton, John and Seymour, Henry. The New Public Health. Milton Keynes:Open University Press, 1988.Berlin, Susan. "The Canadian Healthy Communities Project" Challenge Change1:1 1989, pp.1-4.Biddle, William H. and Loureide J. Biddle. The Community Development Pro-cess: the Rediscovery of Local Initiative. New York: Holt, Rinehart and WinstonInc., 1965.Boothroyd, Peter and Margaret Eberle. "Healthy Communities: What They Areand How They're Made" CHS Research Bulletin., Centre for Human Settlements,University of British Columbia, August 1990.Bracht, Neil ed. Health Promotion at the Community Level. Newbury Park,Cal.: Sage Publications Inc., 1990.British Columbia Economic and Statistical Review. Victoria: Ministry of Financeand Corporate Relations, 1990.British Columbia Regional Index. Victoria: Ministry of Regional Developmentand Ministry of Financial and Corporate Relations, 1989."Central Kootenay Tri-City Health Promotion Project." Castlegar, B.C.: CentralKootenay Health Unit, 1990.Connecting: a Handbook on Abuse of the Elderly. Victoria: Ministry of Healthand Ministry Responsible for Seniors, 1992.Duhl, Leonard. "The Healthy City: It's Function and Its Future." Health Promo-tion (Oxford), 1:1, 1986, pp.55-60.Epp, Jake. Achieving Health for All: a Framework for Health Promotion.68Ottawa: Health and Welfare Canada, 1986."An Exploration of the Connection Between Healthy Communities and Sustain-able Development". Vancouver: UBC Centre for Human Settlements. October1989.Farrant, Wendy. "Building Healthy Public Policy: The Healthy CommunitiesMovement as an Entry Point." Vancouver: Social Planning and Research Coun-cil, 1991.Forester, John. Planning in the Face of Power. Berkeley: University of CaliforniaPress, 1989.Friedmann, John. Planning in the Public Domain . From Knowledge to Action.Princeton, N.J.: Princeton University Press, 1987.Green, Lawrence W. and Marshall W. Kreuter. Health Promotion Planning: anEducational and Environmental Approach. Mountain View, Cal.: Mayfield Pub-lishing Company, 1991.Green, Lawrence W. and John Raeburn. "Contemporary Developments in HealthPromotion: Definitions and Challenges" in Bracht, Neil ed. Health Promotion atthe Community Level. Newbury Park, Cal.: Sage Publications Inc., 1990, pp.29-44.Hancock, Trevor. "Beyond Health Care: From Public Health Policy to HealthyPublic Policy" Canadian Journal Of Public Health, Supplement to vol.76, 1985,pp.9-11.Hancock, Trevor. "Healthy Cities: the Canadian Project" Health Promotion.Summer 1987, pp. 2-4, 27.Hancock, Trevor. "The New Public Health" Plan Canada, 29:4 1989, pp. 51-52.Healthy Communities 1991 Yearbook. Victoria: Office of Health Promotion,B.C. Ministry of Health and Ministry Responsible for Seniors, 1991.Healthy Communities, the Process. Victoria: B.C. Ministry of Health, 1989.Healthy Toronto 2000. Board of Health for the City of Toronto Health Unit,1988Hendler, Sue. "The Canadian Healthy Communities Project: Relevant orRedundant?" Plan Canada, 29:4 1989, pp. 32-34.69Kootenay Development Region: Regional Health Plan Report. Health Manage-ment Resource Group, 1989.Konkin, Barry G. "The Health Indicators Process in British Columbia." UBCTask Force on Healthy and Sustainable Communities, September 1991.Lalonde, Marc. A New Perspective on the Health of Canadians. Ottawa: Minis-ter of Supply and Services, 1974.Lane, Barbara J. "Healthy Cities in the U.K.: Implications for Canadian HealthyCommunities Projects."  Plan Canada., 29:4 1989, pp.5-12.McClandish, J. Labour Market Information Analyst, Canada Employment Cen-tre, Nelson B.C., Personal Communication, 1992.Manson Willms, Sharon and Leslie Gilbert. "Healthy Community Indicators:Lessons from the Social Indicator Movement" Centre for Human Settlements,University of British Columbia, March 1990.Manson Willms, Sharon and Leslie Gilbert. "Social Indicators for Health Plan-ning• a Selected Bibliography of the Social Indicators and Health IndicatorsLiterature" CHS Bibliography, Centre for Human Settlements, University ofBritish Columbia, September 1990.Martin, Sharon. "B.C. Healthy Communities Network - An Overview", PlanningInstitute of British Columbia. PIBC News., 33:5, December 1991.Mathur, Brijesh. "Community Planning and the New Public Health" PlanCanada, 29:4 1989, pp.35-38.Milio, Nancy. Promoting Health Through Public Policy. Philadelphia: F.A. Davisand Company, 1981.Minlder, Meredith. "Improving Health Through Community Organization." InGlanz, K., F.M. Lewis and B.K. Rimer eds. Health Behavior and Health Educa-tion: Theory, Research and Practice. San Francisco: Jossey-Bass, 1990.Nelson: A Proposal for Urban Heritage Conservation. Victoria: Ministry of Pro-vincial Secretary and Government Services, Heritage Conservation Branch,1981.New Directions for a Healthy British Columbia. Victoria: Ministry of Health andMinistry Responsible for Seniors, February, 1993.70Olds, Kris and Sharon Martin. "The Mount Pleasant Healthy Community Project:A Vancouver Case Study" Centre for Human Settlements, University of BritishColumbia, October 1990.Ottawa Charter for Health Promotion. International Conference on Health Pro-motion, Ottawa, Canada, 1986.Reid, Donald G. "Changing Patterns of Work and Leisure and the HealthyCommunity" Plan Canada, 29:4 1989, pp.45-49.Roberts, Hayden. Community Development: Learning and Action. Toronto:University of Toronto Press, 1979.Report of the Royal Commission on Health Care and Costs, Closer to Home.Victoria: Ministry of Health, 1991.Spasoff, R.A. and Trevor Hancock. "Canada: Maintaining Progress ThroughHealth Promotion". in Tarimo, E. and A. Creese eds. Achieving Health For AllBy the Year 2000: Midway Reports of Country Experiences. Geneva: WorldHealth Organization, 1990, pp. 30-53.Stachtchenko, Sylvie and Milos Jenicek. "Conceptual Differences Between Dis-ease Prevention and Health Promotion: Research Implications for CommunityHealth Programs" Canadian Journal Of Public Health, 81, 1990, pp. 53-59.Statistics Canada. Profile of Census Divisions and Subdivisions in BritishColumbia, part A.  Ottawa: Supply and Services Canada, 1992.Toews, Judy, Nutrition/Health Promotion, Central Kootenay Health Unit. Per-sonal Communication, 1993.Together for Health. Central Kootenay Community Profile. Central KootenayHealth Unit, Castlegar, B.C., 1990.Tools for Building Healthy Communities: Skills, Resources and Models forAction. Conference Report, Social Planning and Research Council of B.C.,1990.Walker, Tom. "Making Healthy Public Policy: a Review of Recent Literature."Vancouver: Social Planning and Research Council of B.C., December, 1991.Warren, Roland L. Social Change and Human Purpose: Toward Understandingand Action. Chicago: Rand McNally College Publishing Co., 1977.71"Working Towards a Healthier Burnaby." Unpublished Report by the Centre forHuman Settlements, Vancouver, 1990.World Health Organization. Global Strategy for Health for All by the Year 2000. Geneva: World Health Organization, 1981.World Health Organization. Health Promotion: Concepts and Principles inAction, A Policy Framework. Geneva: World Health Organization, 1986.72

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