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Topics: Health

Healthy Boston Builds Strong Communities, continued

Index

Case Study Plus: Healthy Boston Builds Strong Communities

Introduction
Chapter 1: Summary of Key Findings
Chapter 2: Evaluation Methodology
Chapter 3: Description of Healthy Boston - History
Chapter 4: Project Outcomes and Evaluation Findings
Chapter 5: Evaluation Team Recommendations
Chapter 6: Round-One Community and Coalition Profiles
Chapter 7: List of Coalition Accomplishments
Appendix A: Evaluation guidelines and questions

Contents

Chapter 4: Project Outcomes and Evaluation Findings
Chapter 5: Evaluation Team Recommendations

Chapter 4: Project Outcomes & Evaluation Findings

Introduction

The project outcomes and evaluation findings are presented in two major sections. The first section evaluates outcomes based on the six major goals of the Healthy Boston initiative. The second section analyzes the implementation of the initiative and how the implementation helped or hindered the initiative in reaching its goals.

Goal 1. Create Vehicles (Community Coalitions) for Collective Community Voice and Action

The coalition development picture is a fluid one. Over the year that the evaluation team observed the coalitions, some that were previously operating at a very high level lost their focus, while others that were clearly marginal later showed real strength and development. Although many factors go into successful coalition development, changes in leadership had the most dramatic effect on coalition effectiveness. The evaluation team observed that a successful leadership formula included knowledgeable volunteers committed to the principles of Healthy Boston who had time to commit to coalition activities. Another important part of the formula was very effective and experienced staff working productively with the volunteer leadership. Changes in staffing and in the availability and recruitment of volunteer leadership made all of the coalitions vulnerable to fluctuations in performance. The few coalitions that have had the same staff over the life of the initiative have greatly benefited from the resulting stability and experience.

Effective coalition coordinators were particularly critical to the success of the coalitions and brought a broad array of strengths and skills to the job. These staff had primary responsibility for articulating and operationalizing the often vague and broad purpose of Healthy Boston. This task was particularly difficult early in the initiative when the concept was new and most community members were confused about expectations and possibilities. Coordinators had the regular start-up problems of any new organization in an intensely political and turf-oriented city. They also had the management, resource development, and board development problems that any nonprofit organization must contend with. Additionally, the coordinators had to contend with the organizational tensions of navigating coalition development through old animosities, entrenched turf, member organizations that were not necessarily committed to operating in a different way, and, at many points in their development, an unsure future based on political changes. The skill and flexibility that coordinators brought to this multitude of tasks (while simultaneously operating in the national, citywide, funding, agency, and resident arenas) have been a major factor in the success of the coalitions.

The dependence on coalition coordinators as the key communicators and implementors of the project was identified earlier as a problem for the initiative. [8] Successful efforts have been made over the past 6 months to involve the volunteer co-chairs more heavily and directly in the work of the overall effort in order to broaden the communication network.

Having said that, it is also of note that two coalitions chose not to have a coordinator and developed creative adaptations for staffing their coalitions. The Egleston Square coalition, for example, had a previous experience of community organizations divesting when staff was hired. To insure the full commitment of participating organizations, coalition members rotated coordinator responsibilities. This worked quite successfully. Eventually a staff person was hired to work on youth programming, and, although that person eventually took over some of the coordinator responsibilities, many are skill shared among members. A less successful, but interesting approach to staffing was in the South End. An existing organization took responsibility for the coordinator functions. Although coalition programming has benefited the community in many ways, the coalition agenda often tended to be heavily influenced by the organization's imperatives which limited the coalition's ability to draw on other strong institutions in the community.

One of the most important accomplishments of the coalitions was the development of a negotiation table which allowed each multifaceted community to come together and define who they are, what they want to be, and how they will better mobilize the resources of the community to make their communities healthier. Ideally, residents, businesses, organizations, institutions, and agencies come together to collaborate rather than compete for funds to better the community. For many of these communities this represented the first time a diverse group of stakeholders—often with varying interests -were all sitting down together to air, negotiate, and work through their differences. [9] This is not to imply that all the coalitions were balanced and representative of all factions in the community. An ironic finding is that 48% of the surveyed participants [10] identified quality of membership and 42% identified diversity of membership as the primary strengths of their coalitions, while 33% identified problems with outreach to specific groups as a primary weakness of their coalition. These findings, reinforced by the independent interviews, indicate that much successful work was done to bring people together, but much work still remains to bring in representation from non-participating groups.

The coalitions also provided another mechanism for government to hear community needs and interests. Though not the unitary voice that was originally envisioned by the planners of Healthy Boston, the coalitions have provided city, state, federal, and nonprofit groups with a systematic way to inform and get information from communities in Boston. Having a vehicle to get input and disseminate information is extremely valuable for the everyday functioning of the city. Although not the only groups that are contacted, coalitions have been useful in several city efforts including the Boston Police Department's strategic planning process and the Department of Health and Hospitals' Health Data Roll Out, in which the coalitions were used as the major vehicle to get critical health data to the communities and to hear community feedback. However, not all coalitions are equal. Some coalitions are very successful and others are not. Some are good at one aspect of coalition building; others are strong in another. The variations have discouraged more extensive reliance on the coalitions for organizing and disseminating functions by the city and others. Although Healthy Boston has "minimum requirements" for funding coalitions, which were judged by coalition coordinators to be very helpful in their coalition development, no minimum performance standards are articulated for their dealing with outside entities such as city departments or other community organizations and initiatives.

Coalition development is a very complex effort. Coalition development requires building trust and maintaining and developing relationships with a variety of different constituencies which include community residents, local agencies and institutions, local and national funders, the city government, and the larger national and international Healthy Cites movement. Coalition development, therefore, took longer than had been anticipated. In a focus group of coalition coordinators, coordinators emphasized the importance of slow development in their communities to mitigate against coalition development threatening other existing organizations in their communities. At the same time, many independent interviewees observed that the coalition building process took much longer than they thought it should have and was more difficult than they had envisioned.

The constellation of constituencies represented in the coalition often put them in the position of managing community tensions. They had to balance the relatively long relationship building processes with more urgent, often citizen-driven calls for action. They attempted to include established, busy leaders with newer residents who were often unfamiliar with the "way things work" in Boston. They needed to maintain a broad focus and comprehensiveness while creating recognizable programs to which the community could relate. They had to overcome and work with their turf issues to move toward a collective perception of the community where collaboration was possible. Coalitions had to work against often long held distrust of the city to create a new kind of partnership. They had to balance local needs with city and movement generated priorities. Even the most able coalition staff and leadership struggled with these issues.

In an open-ended survey question, coalition members identified why they would recommend the coalition meetings and activities to colleagues, friends, and neighbors. The results were clear and telling. The major reason (27% of the responses) was that people felt that a diverse forum is necessary in their communities. The next three answers had approximately the same number of responses. They were: meeting people (21%), educational (19%), potential for change (19%). In the evaluation team's observations, the same issues revealed themselves. Coalitions which provided a diverse forum that allowed people to meet each other and to learn about issues which were important in their community, and which provided a vehicle for action and change were the most successful.

The evaluation research indicated that it was particularly difficult to develop coalitions in neighborhoods where coalition members perceived that their community was relatively unsafe. Coalition membership rated their communities on a variety of measures of community cohesion and infrastructure such as participation, community leadership, working together, relationship with city government, and safety. (The community perception questions and rankings are included in the Appendices E-F.) The evaluation team correlated those ratings to coalition performance based on the evaluation team's ranking of high, mid, and low performing coalitions. The only statistically significant positive correlation between the 17 indicators and performance level of the coalitions concerned the perception of safety in their communities. Coalitions that perceived their communities to be relatively unsafe tended to be lower performing coalitions. This finding suggests much but leaves many unanswered questions. The team believes that the relatively low safety assessment indicates all kinds of community problems—particularly of distrust—and those communities are just harder to work in, need more resources, and require more time. However, it was also observed that the assistance available to all Healthy Boston coalitions was often not used by struggling coalitions in these communities. This suggests that a different kind or method of assistance was needed in those neighborhoods. Or it may suggest that the model used for coalition building, while generally judged to be a good one (as reported in the coalition staff focus groups), needed to be altered for communities that were struggling with the problems of safety. Perhaps the heavy dependence on meetings for coalition development in those neighborhoods may be too difficult and spreading people too thin.

Although coalition members' perception of the community's ability to work with and/or put aside turf issues did not turn out to be a statistically significant determinant in the success of the coalitions, the evaluation team observed that, in communities where key players had developed working relationships previous to Healthy Boston, those relationships greatly facilitated the development of the coalition. There existed an understanding of the benefits of working together, and relationship-building had been started. Those communities had a head start.

One issue is clear in assisting coalitions: no one support strategy is necessarily best for all the coalitions. Community conditions, coalition development, history, and personalities all create a unique challenge which requires creative and varied action strategies. The principles and goals need to guide the activities rather than a particular formula for support. For example, the evaluation team observed that resources for staff were very helpful in coalition development. However, in the case of Jamaica Plain, which was defunded to merge with the BAD coalition, the Jamaica Plain Tree of Life coalition returned stronger after the non-funded time period and was refunded in the next round. Egleston Square, fearing an over dependence on staff, rely on their coalition members to carry out many of the functions of a coordinator, which has served that coalition well. As its history demonstrates, generally Healthy Boston central operations have been flexible and understanding of communities, which has generally been beneficial to the communities. The community review panel often provided bridge and provisional funding and, in a few cases, money was held in escrow for a community coalition to reorganize. This flexibility has allowed coalitions to mutate and combine in order to optimize the availability of outside funding and meet the developmental needs of the communities. However, even within this environment, some coalitions found it difficult or impossible to meet the minimum standards of Healthy Boston.

Goal 2. Serve As a Catalyst to Increase Collaboration to Improve Services and Optimize Resources

Healthy Boston has inspired some collaboration within city departments, but its influence has been limited. The interdepartmental team which started as an upper level administrative group to link Healthy Boston to the workings of the city quickly became a middle manager's working group that could share information but had little effect on the overall running of the city. However, the working group's collaborative efforts did lead to successful grant writing projects and coordination of efforts on various projects. But, without support for Healthy Boston to tie into main line planning and implementation processes of the city, either through the Mayor's office or a cabinet level position, Healthy Boston did not play a central role in planning or influencing the future vision for Boston. This inability to establish Healthy Boston as an integral force in the eyes of local government left Healthy Boston isolated from the decision makers' planning for Boston's future.

Among Agencies, Institutions, Organizations, and Residents:
As mentioned under goal 1, one of the most important accomplishments of the Healthy Boston initiative has been to stimulate, through the coalitions, the development of a negotiation table for each multifaceted community to come together and define who they are, what they want to be, and how they will better mobilize the resources of the community to make their community healthier. For the communities that had some relationships with stakeholders already established, Healthy Boston offered the opportunity to build and develop them into a stronger network. Collaboration has emerged as a powerful way for many communities to better use their resources. In an open-ended question on the coalition member survey, 26% of responders identified collaboration and networking as the major strength of their coalition.

In this respect, the area where the coalitions have been particularly successful is in bringing agencies, institutions, and organizations to the table within the Healthy Boston communities. Coalition participants rated both their agency and institutional participation to be very high. 95% of the responders rated their agency participation in coalition activities and meetings as moderate or high and, only slightly less, 85% rated their institutional participation as moderate or high. This is not surprising since the coalitions were initially formed around these sectors and were the places where the initiative's resources provided a possible, direct benefit to participating agencies and institutions.

There are numerous examples of coalitions optimizing the resources available to the community and eliminating duplication of services through organizational networking and collaboration. Some Healthy Boston agency and institutional members changed the way they deliver services to be more sensitive to the experience and needs of residents. The forum of Healthy Boston allowed those agencies and institutions to learn more about their ever changing community and alter their activities accordingly. 70% of surveyed agency coalition members reported that their agency had modified the focus of its work and 56% reported that their agency had modified the way it operates. In an open-ended follow-up question, respondents specifically noted that their agencies modified their work to be more collaborative with other groups, conduct more outreach, improve resident involvement, utilize more multicultural approaches, and focus their efforts on youth and the underserved.

Involving residents in coalitions has been more difficult, but Healthy Boston's accomplishments are respectable. Approximately 64% of regular attendees identify themselves as neighborhood residents. Some coalitions have developed exemplary approaches to involving residents but no coalition is "satisfied" with their resident involvement. All coalitions have members who identified lack of resident involvement as a weakness in their coalition. A consistent criticism of several coalitions is that they are "agency dominated," which was a valid criticism in light of the coalition membership survey. While 7 of the 16 coalitions surveyed had over 50% of their members identifying themselves as agency representatives, 4 of those 7 had a majority of members who were residents. In these coalitions, many participating agency members were also residents. In total, 44% of the surveyed coalition members identified themselves to be a representative from an agency or institution, which is substantial, but residents are not outnumbered by agency representatives except in a few cases. [11] Overall the data suggest that inclusive resident involvement is never easy and Healthy Boston has had some degree of success in this area.

Although most of the participants in the coalitions have been involved in other efforts, the coalitions drew in a substantial percentage of previously uninvolved people; 21% of those answering the coalition survey reported that they were new to community building activities.

Representation was not balanced in the coalitions. All coalitions are continuing to do outreach or need to do outreach to non-participating groups. A paradoxical findings is that the coalitions identify their major strength as representation from a variety of groups in their communities, but all coalitions also note a group or groups that they still need to involve. In 11 of the 16 surveyed coalitions, over 50% of the responders judged the participation of youth and elderly in coalition meetings and activities to be low or nonexistent; 10 of the 16 judged their business participation to be low or nonexistent, and 7 of the 16 judged their church participation to be low or nonexistent.

Aside from being able to better utilize existing resources within their communities, coalitions have also been able to draw in substantial outside money for their efforts. The funding community is relying more and more on the use of community collaboratives to carry out community development work, and Boston has proven to be extremely competitive because of its strong and coordinated community-based infrastructure. The coalitions, strong and weak alike, have been a natural match for several foundation. state and federal initiatives involving community collaboratives.

Even weak or defunct coalitions, as reported in city staff interviews, have established a base of relationships and experience within their communities which has proven valuable to other initiatives in those neighborhoods. And, as grudgingly stated by an overworked coalition coordinator, many of the Healthy Boston mandated coalition activities, such as creating community assessments and action plans and including diverse membership, have made applying for grants much easier. Successful grant awards include:

• An Annie E. Casey Foundation grant of $3,000,000 which leveraged another $3,000,000 in State EOHHS funds for child mental health in Mission Hill, Lower Roxbury, and Washington Park/Highland Park;

• A Safe Futures Federal grant of $1,400,000 and a $40,000 United Way grant for youth gang and drug prevention in Mattapan, Grove Hall, and Franklin Hill/Franklin Field;

• A Pew Charitable Trust grant with local matches from the Boston Foundation and others of $1,050,000 for neighborhood preservation in East Boston;

• An Americorps grant of $200,000 for community service around environmental initiatives in Franklin Hill/Franklin Field;

• A State Department of Public Safety grant of $ 128,500 for juvenile delinquency prevention in 4 housing developments or areas in Jamaica Plain and Egleston Square;

• A Heinz Foundation grant of $75,000 and a Peabody Foundation grant of $42,000 for youth activities in Egleston Square;

• A Juvenile Justice planning grant of $85,000 for youth gang prevention in Columbia Point;

• A State Attorney General's Office grant of $75,000 for microenterprise education and training in Field's Corner;

• A total of $64,500 from a variety of local sources to fund year 3 of the LINCS program in Allston-Brighton;

• A State Department of Social Services grant of $25,000 for family preservation in Jamaica Plain;

• A State Executive Office of Education grant of $23,000 for School Linked Services in Allston-Brighton; and

• Smaller grant awards which total approximately $100,000 have been utilized by various coalitions for community projects.

Goal 3. Create a New Kind of Partnership Between the Community and City Government

The initiative dealt with many obstacles. Some of the difficulties were circumstantial. As noted in the history, the initiative started under one mayoral administration, lost its primary architect when Judith Kurland resigned, went into limbo under the interim administration, and now has support, but no strong advocacy, during the current administration. For example, the cabinet level department of human services which could have served as a high-level advocate for Healthy Boston was vacant for several months. Other barriers were more substantive and involved key city staff who did not see the value of Healthy Boston to their operations or had questions about its efficacy, often based on the wide-range of performance of the individual coalitions. Healthy Boston was not perceived to be in department heads' interest, and it was never mandated that city departments work with Healthy Boston. Conversely, a major factor undermining coalition development was many coalitions' inability to get a membership-identified and sometimes minor task addressed by the city. These factors, coupled with two years of leadership transitions, fueled confusion and cynicism on the community level, causing the initiative to lose credibility with community members that was difficult to regain. Without a strong mandate from the mayor, the initiative lacked the clout to mobilize city resources around the coalition's identified needs.

Another major barrier was the nature of the two entities. When asked if there were aspects of city government that have made the goals of Healthy Boston more difficult to achieve, many city staff members just laughed and said, "You've got to be kidding." Getting a large politically motivated and categorically oriented bureaucracy to partner with an ever-changing, emergent, and organic system such as a community is a Herculean feat.

Though the promise and potential for Healthy Boston as a city partner has yet to be fully realized, the initiative did have several substantive successes and developed inroads toward a better relationship between the community and the city bureaucracy.

• Through the coalitions, the city gained access to a broader network of citizens, agencies, and institutions which increased the community participation in city government.

• The coalitions provided a vehicle for city agencies to "get the word out" to community groups and residents. Many presentations are made at coalition coordinators' business meetings where valuable program information is shared and disseminated. On a larger scale, a few departments within City Hall used the infrastructure of the Healthy Boston coalitions to access the community with vital information or for collaborative community work.

• 67% of the active coalitions judged their current relationship with city hall to be more positive than the one they historically enjoyed. This suggests a trend of improving relationships between the city and the community as perceived by the coalition membership.

• 72% of the coalition membership surveyed judged that Healthy Boston had been a significant or modest factor in improving their ability to access the city bureaucracy. Although not implying partnership, it does imply better working knowledge and sophistication about the city bureaucracy.

• As mentioned earlier, Boston became much more competitive for grants requiring community-based collaboratives or partnerships. The development of the coalitions put Boston "far away and ahead" as stated by a city staffer, in competition with other cities. City departments responsible for developing those proposals often relied heavily on the work of Healthy Boston. Even in the neighborhoods where formal coalitions no longer existed, the infrastructure developed by Healthy Boston was helpful in moving ahead on other projects. (A complete list of grants are included in the discussion of goal 2.)

Goal 4. Embrace a Set of Values: Encouraging Work That is Community-Based and Empowering, Collaborative, Multicultural, and Inclusive

The Healthy Boston coalitions have also proven to be fertile ground for developing more committed and effective community participants and leaders. On a variety of measures, a majority of the coalition members surveyed attributed increases in involvement and capacity to their Healthy Boston activities. Through the activities of the coalitions, 70% of regular attendees report more time spent on community activities, 45% report greater involvement in leadership roles, 52% report more effectiveness, 80% attribute an increase in confidence to Healthy Boston involvement, 61% report increased ability to access funders, 72% report increased ability to access the city government, 87% report an increase in knowing who to ask, and 92% credit Healthy Boston with improving their understanding of local issues. Healthy Boston has solid success in drawing new people into coalition activities; 21% of those answering the coalition survey were new to community building activities.

Healthy Boston has utilized two general and overlapping strategies to develop leadership and encourage participation in communities. The first is through the coalition structure itself, which provides community members with a vehicle for working through issues and doing projects. The second is a targeted programmatic approach to bring together community members to focus on their immediate interests and introduce them to working on larger community issues. An example of the targeted approach is the LINCS program in Allston/Brighton which also involves the class in coalition activities.

Collaborative
Collaboration has been a major strength of the initiative; many coalitions report, and the evaluation team observed, the use of collaborative approaches to address issues in Healthy Boston communities. Independent observers also noted that the benefit of the coalition to their community has been increased collaboration. As mentioned in the focus group of coalition coordinators, one of the most difficult challenges in building their coalitions was to educate the community and individual agencies to work in a different way. Agencies, as members of a Healthy Boston coalition, had to start looking beyond their individual organizational boundaries and to recognize the benefits associated with collaboration. And for community members, it necessitated that they view the city and other entities as partners rather than adversaries. Much progress was made in altering behavior and increasing collaboration.

Inclusive and Multi-cultural
Another particularly notable outcome of the project has been the progress made by coalitions towards inclusiveness and multi-culturalism. In all the surveyed coalitions, participants judged the coalition meetings to be as diverse as other meetings in their community and, in 44% of the coalitions, most participants reported that the coalition meetings were more diverse than other meetings in their communities. Coalition activities helped people learn to work with different groups and 87% of coalition participants surveyed attributed Healthy Boston activities with improving their ability to work with diverse people.

Coalitions were generally perceived to be open to diverse thinking as well as diverse kinds of people. 84% of surveyed participants judged their coalition to be open and respectful of people with differing opinions and 15% judged them to be somewhat open.

Clearly progress was made within the coalitions to be more inclusive. Since working with these issues is sensitive and often difficult, the evaluation team observed many dynamics that are worthy of note.

As those who have worked in local government with neighborhoods will attest, communities generally are very conservative and often resistant to change. When confronted with an influx of new people who act, relate, look, and raise their families differently, common responses are defining turf and unease. The evaluation team's observations reinforced the survey findings that coalitions in general were making concerted efforts to include diverse members of their communities. The team also noted, however, that the racial, social, and class issues of the larger community were often reflected in the coalitions. Both traditionally white and traditionally black communities struggled with issues of inclusion. The following examples demonstrate some of these issues:

• The Charlestown coalition, which is located in a predominantly white neighborhood, has been very successful in drawing in new residents to their coalition activities. The coalition is successfully working to bridge a major split in that community which has existed between longtime residents and newer residents. In terms of involving African American and other racial participants in coalition activities, the Charlestown coalition has made real efforts to do so, and is just starting to make progress.

• The Upham's Corner coalition, located in a predominantly black neighborhood, has a few strong social service agencies forming the core of the coalition. The coalition leadership understood the value of multicultural inclusiveness but did not have sustained success in drawing diverse elements of the community into leadership positions.

• The Hyde Park coalition, which is located in a traditionally white community -which now includes more people of color, successfully involved both black and white participants. The coalition members are mostly homeowners who share many similar community values and aspirations. It was a successful strategy as far as it went, but it excluded people in other social classes in the community.

• The Mission Hill coalition, which is located in a racially and socioeconomically mixed community, involved a very broad range of community members in their coalition—the range was so broad that the coalition never had the overall ability to manage the tensions. Their work was often undermined by the intense conflicts in the coalition which were based in substantive issues, values differences, racism, interracism, and class conflicts. The coalition has never created a consensus and the leadership struggles have hampered its further development.

• The United in Spirit coalition (Washington Park/Highland Park) successfully met the challenge of inclusion along various dimensions of race, socioeconomic status, religious affiliation, and institutional presence. Located in a predominately African American community, United in Spirit established a solid based of long-term residents, newer residents, and diverse institutional partners. The coalition has successfully involved a wide range of racial and ethnic and religious groups. Their philosophy of inclusiveness and dissemination of power was so ingrained within the coalition that their by-laws were developed to support it.

Goal 5. Embrace a Vision of "Health" That Goes Beyond the Medical Definition to Encompass Economic Development, Housing, Education, Employment as Well as the Broader Issues of Community Fabric

When looking at the reported outcomes of the coalition and citywide activities, a mixture of more traditionally "health" oriented themes was blended with issues of community fabric and community development. Changes coalition members noted in their communities, which they attributed to Healthy Boston, included community cohesion with more collaboration and communication between various groups.

Leadership enhancing functions like identification of community direction and more focused action were evident in the comments as was work in specific areas such the arts, crime and violence prevention, housing, parks, employment, education (including ESL), and intergroup understanding. Increased involvement of residents and youth was also noted. More traditional health related activities included healthy lifestyle education, more access and awareness of health services as well as increased services, including such projects as asthma education and intervention, Health and Hospitals' Health Data Roll Out, enrollment of children in the state health insurance program.

The evaluation team observed that, based on their experience, coalition members naturally moved toward articulating their issues in a holistic fashion with traditional health issues being a small component of the larger issues. As part of the evaluation, all the coalitions identified and prioritized their two year indicators for success in the spring of 1995. When viewing the indicators in total, some common categories emerged. Most of the indicators were generically related to "social capital," [12] strengthening the bonds and connections between people and organizations. Even services that were mentioned or projects that were articulated were ones that would provide places or programs for community members to come together. There was particular emphasis on youth and the need for their constructive engagement in the community through mentoring, work, and educational programs; in other words, the need for connecting youth to the community. Another set of indicators identified specific strategies to deal with barriers to engagement such as ESL programs, educational and training programs, and child care opportunities. More traditional community development themes such as employment and home ownership, safety and crime prevention activities were also identified. The final theme that emerged was the strengthening of the coalition itself as a viable place for people to come together. Specific indicators, such as more people attending meetings, economic self-sufficiency of the coalition, and more involvement of specific groups or agencies were all seen as specific indicators of their success.

Coalitions and their membership had an intuitive sense of the interconnectedness of the issues and the importance of "social capital" to have a healthy community. The initiative allowed for and encouraged participants to think non-categorically and, based on both the outcome and the indicator of success data, they did.

While the coalitions were able to articulate and work on their issues holistically, it is not clear that bureaucracies that are organized categorically, like the city, private funders, and state and federal programs are prepared and able to respond and support more holistic community development.

Goal 6. Create Healthy Communities: Improve the Quality of Life in Boston Neighborhoods

The coalitions have provided a wide array of activities that have served their diverse communities. Examples include: Sister Talk in Field's Corner, a program for adolescent girls to visit with potential role models; the Nurturing Program in Columbia Point, which teaches parenting skills to residents; the Economic Town Meetings in Chinatown, providing forums on employment and economic issues relevant to the community; and the 'Spring Fling' street fair in East Boston, which combined a food and music fun fair with the distribution of critical health information for the community. (A list of the all the major coalition programs and accomplishments are included in Chapter 7 of the report.)

Along with the regular maintenance of the coalitions, Healthy Boston funded several implementation projects that were initiated and designed by coalitions and improved the quality of life in those communities. The completed projects include the previously mentioned and ongoing LINCS program in Allston-Brighton and Positive People in Codman Square. LINCs is a national and local award winning program which is both innovative and effective. It provides ESL and community organizing opportunities to a diverse group of residents while linking their activities to several service providers in the neighborhood for mutual learning. The program increased participants' language and community organizing skills as well as increased their commitment to the community, and participating agencies benefited from the outreach services of the students to better provide for the community. The program and the coalition worked together synergistically to support their individual program goals in that many LINCS graduates became active in coalition work and LINCS students' work was shared with coalition members. Positive People targeted high risk youth for skill development in the building trades within the context of a building renovation project. The renovation project was completed and the building is now available for community use. The training component of the project had mixed reviews. The dropout rate for the project (35%) was considered high, but understandable considering the multiple problems of the targeted population. The work of the project and coalition development was never integrated but took place on parallel tracks, therefore, never utilizing assets to strengthen their overall effort in the community. The more recently funded and obviously unevaluated implementation projects are for family support and youth development in Chinatown, asthma education and intervention program in Egleston Square, and a safe homes project for gay and lesbian homeless youth.

Healthy Boston initiated two citywide projects which have proven to be very successful. [13] These projects have drawn participants from beyond the coalition activities and increased the citywide recognition of Healthy Boston. The first project focused on enrolling children in a state health insurance program. 250 children were enrolled in the program before it quickly reached the limit on state funding. The second, "Speak Easy", was a citywide ESL initiative which created video tapes, cable television programs, and local study groups to reach some of the thousands of people on waiting lists for ESL classes. The study groups were organized through the Healthy Boston coalitions and many other sites around the city.

Healthy Boston Implementation

Healthy Boston's Relationship to City Government
The Healthy Boston Initiative is by choice a part of City Hall politics and at the same time, staff have worked hard to protect the project from political pressure. The initiative is part of a city department, now the Office of Community Partnerships, subject to departmental requirements and budgetary review by the City Council, but funded by federal dollars. Located in a city office, all of its staff members work with city employees daily. Being inside city government has given the initiative some distinct advantages and challenges. There are inherent contradictions in placing a community empowerment model in City Hall. The benefits of this location to the coalitions include central staff access to city activities and the ability to involve the coalitions in city activities whenever the opportunity arises. Being part of the city has helped Healthy Boston work with city government to inspire policy changes which are consistent with the Healthy Boston philosophy.

There are many ways in which Healthy Boston staff has succeeded in establishing and maintaining independence from traditional political pressures. For example, the funding decisions for the coalitions are made by an independent community review panel, made up of diverse group of knowledgeable people in the community who are not directly involved in coalition activities. The panel has operated with integrity and understanding in their funding decisions. These decisions have never been changed by political pressure. Nor have the coalitions been pressured to hire specific staff, but have been free to chose staff they deem appropriate.

In a few circumstances the political and bureaucratic nature of city hall and the community-based nature of the coalitions came into direct conflict. When coalitions played a strong advocacy role in their communities, they were sometimes at odds with the policies of city hall. Significant tensions surfaced in the city and in the coalitions when coalitions challenged city hall or were portrayed in the press as not supporting the work of the city. Another area that caused problems was the reluctance of the central staff to candidly discuss the political difficulties of the initiative with the coalitions because of confidentiality issues with superiors. Important dialogue that could have provided the coalitions with a greater level of understanding and appreciation for Healthy Boston's position did not occur. As a result, false assumptions and expectation of what Healthy Boston could accomplish have lead to a "business as usual" perception by some coalitions.

Overall, the hybrid position that Healthy Boston has in relationship to city hall integrated and optimized the strengths of both positions and served the project extremely well but, because it was a new model, it was often confusing.

Citywide Agenda
Although, in general, the initiative structure honored the "bottom up" development process, citywide and coalition agendas were not always complementary. In an open-ended survey question about what hindered coalition development, 15% of the respondents identified "imposing or usurping their agenda" and 11% noted lack of understanding of coalition priorities, and a few noted that too much was demanded of the coordinator. These responses speak to occasional but occasionally profound mismatches between city or funder goals and coalition capability. Sometimes, coalitions were called on to participate in projects that they were just not ready to handle. An extreme example has been the Casey project. This project, designed to address the complex systemic issue of mental health service delivery to children, involves three of the coalitions. It has required high levels of coordination, tremendous coalition staff capacity, and an inordinate amount of time and assistance from the central staff. The Casey project has moved ahead, but it offers a clear warning—a developing coalition can easily be overloaded with externally imposed tasks and demands which can hamper its development.

Support for Coalition Development
A major weakness of the initiative has been the lack of adequate resources to provide creative support to floundering coalitions. The initiative's flexibility, which was helpful in many ways, challenged all the coalitions and often compounded the problems of struggling coalitions. The guidance, training, and technical assistance provided through the Healthy Boston central staff were identified by many coalition coordinators and members as very helpful and, in fact, essential to the success of the coalitions, but, in many cases, it just wasn't enough. (A general outline of budget categories is included in the Appendix I.) For example, the approach to technical assistance—contracting out for a range of assistance to be available to the developing coalitions—worked relatively well, but only 4% of the budget was allocated for training and technical assistance. [14] In viewing the total budget allocations for the project, it is clear that great effort was made to use as many resources as possible directly on community projects. That goal was admirable and successful with roughly 64% of the budget allocated to coalitions, coalition projects, and citywide initiatives, while 17% was allocated for central staff. However, the evaluation team judged that the assistance budget was inadequate to address the coalitions' struggles, and at least one more staff person would have been helpful to work directly with the coalitions. Overall, the data suggest that more intensive hands-on and creative assistance was needed for floundering coalitions.

Role of Central Staff
Three members of the central staff served a key role in the development of the initiative. They provided guidance for the overall effort, provided support for coalitions (which included numerous grant submissions), and contracted with trainers and technical assistance providers to help coalitions. In general the coalitions judged the central staff to be helpful. In the coalition membership survey, 21% of responders stated that the central staff was always helpful, 26% said they were often helpful, 47% said they were sometimes helpful, and 6% said they were never helpful. In the 110 responses to an open ended question, which asked in what ways central staff had been helpful to their development, 33% of responders identified general support, guidance and availability, 14% identified information, 13% identified training, 12% identified funding and 10% identified that they attend meetings. Respondents valued staff's role in communication, resolving of disputes, evaluation, surveys, technical assistance, and a few specifically noted their open minded and creative way of operating. Respondents noted that most problems with central staff seemed linked to the ambiguities of their position in city hall.

For example, 30% of the responses identified "lack of clarity and decisiveness" and 16% noted lack of timely communication. Although the evaluation team observed sometimes overly verbose explanations and believe that a more candid approach to sharing political difficulties might have been appropriate, much of the confusion and lack of decisiveness attributed to central staff was out of their control. As noted earlier, the hiatus of the initiative caused by city leadership transitions had major ramifications at the community level—stopping momentum and causing questioning of the city's commitment to the initiative. Similarly, coalitions criticized the lack of timely knowledge of funding opportunities. Central staff often communicated these opportunities as soon as possible, and often it was too late or caused deadlines that were difficult or impossible for coalitions to meet.

Chapter 5: Evaluation Team Recommendations

Toward the Future

The conditions and trends that inspired the original principles of Healthy Boston are still present. In fact, they may be even more compelling today.

• The pool of public dollars is shrinking. With devolution of funds from the Federal level to the states and localities there will need to be greater collaboration around the use of funds. For example, block granting of federal programs is a real possibility in the near future. Block grants will require that states allocate moneys for services that had previously been run through federal programs. States will require guidance in prioritizing needs. If communities can have a mechanism to identify their priorities it would be tremendously helpful in guiding state allocations.

• Funders continue to look to community-based coalitions for community development projects which emphasize linking resources and capitalizing on the asset base of the community.

• Boston continues to have substantial numbers of new residents, many of whom are new to the country and the traditions of democracy and self-determination. Roughly half of Boston residents are new to the city in the last 10 years. In order to provide services effectively with fewer dollars, the city needs to have the help and support of local residents who are knowledgeable and committed to their communities.

• The health care industry is going through major changes. One example of these changes is that hospitals are now required to make contributions to the communities in which they serve in order to maintain their nonprofit status. These community benefits should be allocated in ways which support the development of the communities and should be negotiated and identified at the local level. Healthy Boston has had impressive accomplishments. They include an extensive community-based infrastructure with links to the resources of the city; long and difficult but largely successful coalition and relationship building; and a negotiation table for participating communities to work through their differences and identify common ground. Collaboration has emerged as a powerful way for many communities to better use resources in their neighborhoods. New and established leaders are using the vehicle of the coalitions to look comprehensively at the community, define their needs, and work on projects together. Strong coalitions have proven to be valuable partners on city initiated projects. The coalitions have developed many relationships and projects that have made their communities healthier.

Recommendations

For the city:
The city should make a policy commitment at the highest levels to the next iteration of Healthy Boston. Our experience of successful initiatives in other cities indicates that strong support from top leadership is essential to fully utilize a community based infrastructure such as this project has begun to create. The city government has much to gain from support of the Healthy Boston principles and coalitions. Community based infrastructure can help city departments identify neighborhood priorities and streamline service delivery. Strong coalitions have proven to be good partners for the city efforts and are an effective mechanism to draw outside funding to the city. Though seemingly in conflict, the collaborative and the political mode of operating can, in fact, complement each other to better serve constituencies.

For the funding community:
More resources should be allocated to the task of assisting community-based coalition development. Creative technical assistance should be provided and alternative models explored for coalition functions generally and particularly in more troubled neighborhoods. The shortcomings of Healthy Boston efforts in such communities point to the work that needs to be done, and the need for additional sustained funding to support this work.

Whoever is providing maintenance support for the coalitions needs to develop clear behavioral expectations for coalitions, their staff and their leadership, and any central support for the coalitions. These expectations need to be negotiated with coalition staff, coalition membership, and coalition leadership.

Funding sources need to think creatively about how to best respond to and support holistic and community driven development that blurs traditional categorical lines. Opportunities should be sought for funders and community coalition members and staff to have sustained dialogue to this end.

For the coalitions:
Leadership development and inclusive resident involvement should continue to be a primary focus for coalitions. At this time, individual coalitions can capitalize on what all the coalitions have learned about leadership development and successful resident involvement. They should continue to draw in residents for policy-making and projects and also look at the viability of targeted leadership development programs in their communities.

A framework needs to exist in Boston to continue to develop and support resident community leadership, community mobilization, and service coordination of agencies, city services, and funders. The immediate future promises to be tumultuous and conflictual with changes in how programs are run, changes in funding patterns, changes in the health care delivery system, and dramatically changed and changing city demographics. A further step toward a coordinated infrastructure that links communities, funders, institutions, agencies, and the city government would position Boston to benefit greatly from the emerging landscape. Coalitions need to be able to work in tandem with other city agencies to address some of the root problems manifesting themselves in various forms throughout communities in Boston.

Based on the current assessment of opportunities for Boston, one observer of Healthy Boston commented, "If Healthy Boston didn't exist we would have to invent it." Boston is in the enviable position of not having to invent but to ask how to reinvent Healthy Boston. The next iteration of Healthy Boston, whatever it may be called, can even more fully realize the original principles of inclusion, community control, collaboration, and empowerment.

Notes

7. The history section of the report includes a detailed description of the funding cycles and changing status of the various coalitions.

8.This issue was highlighted in the preliminary findings for the Healthy Boston evaluation in June of 1995.

9. In some communities, as in Egleston and Codman Square, coalitions of service agencies were previously working together which formed the core of their Healthy Boston coalitions.

10. All percentages refer to the survey (207 completed surveys), which was administered at coalition meetings with regular attending coalition members of the 16 coalitions which were available at that time; see Chapter 2: Evaluation Methodology for more information and Appendix D for complete survey data.

11. These data are somewhat misleading in a few instances: Egleston Square: while clearly agency dominated (100% of the coalition membership are agency or organizational representatives) the organization of the coalition is such that neighborhood associations are members of the coalition and efforts to involve residents is through organizational representation a strategy with some critics and some defenders. Chinatown: although a distinct geographical area, the coalition serves the larger Asian community, therefore many members are not necessarily residents. Coalition for Gay, Lesbian, Bisexual and Transgender Youth: the geographical distinctions are irrelevant, since the coalition draws membership from the entire city.

12. In Making Democracy Work, Robert Putnam defines the idea of "social capital" as being the most significant factor in the differences in development and prosperity in the various regions in Italy.

13. These two citywide programs were ongoing during the data gathering period of the evaluation. The evaluation team did not collect data from the participants of the projects, but was limited to interview and observational data. "Kids Can't Fly", another citywide project of the Healthy Boston initiative was finishing at the time the evaluation began.

14. This figure includes training and consultant contracts and does not include the program evaluation contract.

Index

Introduction
Chapter 1: Summary of Key Findings
Chapter 2: Evaluation Methodology
Chapter 3: Description of Healthy Boston—History
Chapter 4: Project Outcomes and Evaluation Findings
Chapter 5: Evaluation Team Recommendations
Chapter 6: Round-One Community and Coalition Profiles
Chapter 7: List of Coalition Accomplishments
Appendix A: Evaluation guidelines and questions

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