Social change or business as usual at city hall? Examining an urban municipal government's response to neighbourhood-level health inequities.

Social Science & Medicine xxx (2014) 1e8

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Social change or business as usual at city hall? Examining an urban municipal government's response to neighbourhood-level health inequities Madelaine C. Cahuas*, Sarah Wakefield, Yun Peng University of Toronto, Canada

a r t i c l e i n f o

a b s t r a c t

Article history: Available online xxx

There is a renewed interest in the potential of municipal governments working collaboratively with local communities to address health inequities. A growing body of literature has also highlighted the benefits and limitations of participatory approaches in neighbourhood interventions initiated by municipal governments. However, few studies have investigated how neighbourhood interventions tackling health inequities work in real-time and in context, from the perspectives of Community Developers (CDs) who promote community participation. This study uses a process evaluation approach and semi-structured interviews with CDs to explore the challenges they face in implementing a community development, participatory process in the City of Hamilton's strategy to reduce health inequities e Neighbourhood Action. Findings demonstrate that municipal government can facilitate and suppress community participation in complex ways. CDs serve as significant but conflicted intermediaries as they negotiate and navigate power differentials between city and community actors, while also facing structural challenges. We conclude that community participation is important to bottom-up, resident-led social change, and that CDs are central to this work. © 2014 Published by Elsevier Ltd.

Keywords: Canada Neighbourhood interventions Health inequities Community participation Development

1. Introduction Globally, there is a renewed interest in the potential of municipal governments and communities working collaboratively to address health inequities at the local level (CSDH, 2008; Hancock, 2009). Municipal governments are strategically positioned to impact Social Determinants of Health (SDOH), and can therefore act to ameliorate or exacerbate health gradients across neighbourhoods (CSDH, 2008; Stafford et al., 2008). Communities also play a key role in reducing health inequities as they can inform strategies by offering critical insights on local assets and challenges (Bradford, 2005; Hancock, 2009). In fact, the Ottawa Charter (WHO, 1986) identified community participation as a significant factor in developing effective health interventions and promoting health equity. However, there are longstanding debates in public policy, political science, urban geography and public health around the strengths and limitations of participatory decision-making models,

* Corresponding author. Department of Geography and Program in Planning, University of Toronto, Sidney Smith Hall, 100 St. George Street, Room 5047, Toronto, ON M5S 3G3, Canada. E-mail address: [email protected] (M.C. Cahuas).

in relation to representative democratic systems (Pateman, 1970, 2012; Young, 1990; Purcell, 2006; Boutilier et al., 2000). Concerns have been raised over the extent to which community participation yields equitable results (Purcell, 2006; Petersen and Lupton, 1996) and whether municipal governments can meaningfully support the participation of residents living in marginalized neighbourhoods as asymmetrical power relations may lead to disempowering “topdown” government-led approaches (Fisher and Shragge, 2000; Raco, 2000). In addition, there is insufficient evaluation of how neighbourhood or place-based interventions targeting health inequities work in real-time and in context with multiple actors (Bradford, 2005; Dunn et al., 2010). This paper addresses this gap in knowledge by examining how one municipal government is attempting to address health inequities through neighbourhood interventions. Over the last two years the City of Hamilton, located in Southwestern Ontario, Canada, has initiated Neighbourhood Action (NA), a city-wide initiative involving eleven neighbourhood interventions (City of Hamilton, 2011). NA uses an Asset-Based Community Development (ABCD) approach in tandem with a municipal planning process in order to strengthen community participation to address health inequities (City of Hamilton, 2011). ABCD involves tapping into community strengths and assets in order to address local challenges collectively

http://dx.doi.org/10.1016/j.socscimed.2014.09.022 0277-9536/© 2014 Published by Elsevier Ltd.

Please cite this article in press as: Cahuas, M.C., et al., Social change or business as usual at city hall? Examining an urban municipal government's response to neighbourhood-level health inequities, Social Science & Medicine (2014), http://dx.doi.org/10.1016/ j.socscimed.2014.09.022

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M.C. Cahuas et al. / Social Science & Medicine xxx (2014) 1e8

from the bottom-up (Hancock, 2009; Green and Haines, 2011; Kretzmann and McKnight, 1993). Community Developers (CDs), have led the ABCD process as their role involves working directly with residents to address local priorities and strengthening resident participation in decision-making and action (City of Hamilton, 2011, 2013). These CDs are uniquely situated, as they are not city employees, but work from community-based organizations to connect municipal government and community actors. Therefore, CDs can be understood as “the fulcrum on which these relationships balance” (Boutilier et al., 2000, p. 271) and their perspectives are incredibly valuable to understanding how municipal government and communities are working together. In this paper we explore how one municipal government collaborates with community groups on NA, from the perspectives of the initiative's five Community Developers. We argue that in this case study, local government works in complex ways to both facilitate and suppress community participation in neighbourhood interventions. We demonstrate that goals of community participation and resident empowerment outlined in NA at times run counter to municipal policies and practices. We also show how CDs serve as important e but conflicted e intermediaries in this process as they navigate power differentials and structural limitations of municipal governments. We discuss the implications of the challenges CDs face in their work and conclude by highlighting the relevance of this research in understanding how municipal governments and local communities can work to effectively reduce health inequities through neighbourhood interventions. 2. Understanding neighbourhood interventions as an approach to reducing health inequities: the role of participation and community development The neighbourhood where one lives is considered a key determinant of health, and is connected to other determinants like income, education and housing (CSDH, 2008). There is a rich literature surrounding the health impacts of physical and social aspects of neighbourhood environments such as residential infrastructure (Dunn and Hayes, 2000), amenities and services (Ellaway et al., 2001) and social cohesion (Veenstra et al., 2005; Rogers et al., 2008; Cattell, 2001). Clearly, neighbourhoods hold important resources for everyday life and shape people's opportunities to lead healthy lives (Macintyre et al., 2002). However, some places provide greater opportunities than others, giving rise to health inequities, “health differences attributable to disparities in advantages, opportunities, or exposures in social, economic, political, cultural” and environmental dimensions (Collins and Hayes, 2010, p. 2). Therefore, neighbourhood interventions that aim to improve the local environment may increase opportunities for health and reduce health inequities. For over two decades, local governments across Canada, the United States and Europe have employed neighbourhood or ‘settings-related’ interventions to transform urban environments in order to improve health outcomes for residents living in deprived neighbourhoods (Bradford, 2005; Dooris and Heritage, 2011; Sharek et al., 2013). Many of these interventions involve local governments and non-governmental actors engaging lay people living in historically marginalized communities around taking action on the social determinants of health (Sharek et al., 2013). The United Kingdom's New Deal for Communities (NDC) is one particularly striking example of a systematic area-based initiative, which directly aims to involve low-income residents in neighbourhood decision-making to improve health, education and the physical environment (Stafford et al., 2008; Sharek et al., 2013). Yet, research studies demonstrate mixed impacts of NDC and other settingsrelated initiatives on resident health (Sharek et al., 2013;

Thomson, 2008). This may be partly explained by the lack of explicit focus on equity and mitigating power differences in community participation efforts, which may deepen health inequities (Sharek et al., 2013; Boutilier et al., 2000; Labonte, 1989). The benefits of participatory governance approaches in relation to representative democratic models have been extensively discussed in the fields of public policy, political science, urban geography and public health (Pateman, 1970, 2012; Young, 1990; Purcell, 2006; Boutilier et al., 2000). In democratic theory, ‘participation’ means “full and open debate of issues and decentered processes of decision-making, allowing for a broad base of citizen involvement in a range of activities” such as service delivery, land use planning, resource management, and social programs (Petersen and Lupton, 1996, p. 147; Pateman, 2012). Young (1990) and Pateman (1970) describe participation as an enabling, citizenship-building process where people learn democratic skills and values. Scholars have also noted that participation can complement and inform, but not necessarily replace representative democratic institutions (Pateman, 2012; Purcell, 2006). Overall, the turn to community participation stems from the realisation that top-down approaches to decision-making by ‘expert’ professionals and politicians have not been effective at addressing local challenges (Hancock, 2009; Pateman, 1970, 2012). For example, neighbourhood groups have served as key intermediaries informing and influencing state policies in ways that support marginalized, low-income communities (Coaffee and Healey, 2003; Lelieveldt et al., 2009; Elwood, 2002; Cowen and Parlette, 2011). At the same time, the ubiquity of the concept of ‘community’ poses challenges for consensus building, as it is unclear which groups of stakeholders should exert more influence in decision-making (Purcell, 2006). Concerns have also been raised over the potential for community participation to facilitate neoliberal agendas of citizen responsibilization (Purcell, 2006; Jessop, 2002). Jessop (2002) warns participatory urban governance structures may leave systemic causes of economic inequality, like neoliberal capitalism, unchallenged and naturalized. For example, at times state-led neighbourhood interventions calling for increased participation have co-opted resident agendas and burdened communities with state responsibilities of service provision (Jessop, 2002; Raco, 2000). Governmental actors have also exerted power in placebased initiatives to channel community participation in ways that were fitting to state agendas instead of resident concerns and values (Masuda et al., 2008; Cowen and Parlette, 2011; Woolrych and Sixsmith, 2013). This can be seen as running counter to models of community participation that hold resident empowerment, leadership and ownership of initiatives as integral goals of participation (Dooris and Heritage, 2011; Hancock, 2009; Gamble, 2010; Kretzmann and McKnight, 1993; cf. Arnstein, 1969). Barriers to promoting community participation in neighbourhood interventions may also have critical health implications (Rogers et al., 2008; Laverack, 2006). Nevertheless, it is important to understand that municipal governments face significant limitations in generating revenue and resources that may hinder their capacity to promote participatory initiatives (Collins and Hayes, 2013; Sancton, 2005). Particularly in the Canadian context, municipal governments are not considered formal orders of government and are allotted responsibilities from the provincial government (Sancton, 2005). Since the 1980s, neoliberal devolution and restructuring has left Canadian urban municipal governments with increasing responsibilities and less capacity to meet residents' needs, relying mainly on property taxes for revenue (Young and Leuprecht, 2006; Collins and Hayes, 2013). Local government actors may also be ill-informed of participatory approaches that can help facilitate “knowledge-sharing, reciprocal dialogue and active listening” with community groups (Woolrych



and Sixsmith, 2013, p. 225). Institutional barriers like rigid bureaucratic policies and practices may also limit the capacity of municipal governments to broadly engage communities (King and Cruickshank, 2010; Raco, 2000). Yet, municipal governments are key sites for promoting health equity (Collins and Hayes, 2010, 2013) and are increasingly working with local communities using Asset-Based Community Development (ABCD) to improve neighbourhood wellbeing (Hancock, 2009; Gamble, 2010). ABCD involves mobilizing community assets and building capacity in order to advance social change as seen by communities (Kretzmann and McKnight, 1993; Hancock, 2009; Leviten-Reid, 2006). However, ‘community’ is a contested concept in community development, but generally refers to social groupings, networks or place-oriented processes that express a shared sense of identity (Theodori, 2005). Boutilier et al. (2000) define community as a “phenomenon of group identity, involving complex sets of relationships within and between groups” (p. 261). In the context of this research study, we refer to ‘community’ as individuals and groups living in low-income neighbourhoods targeted by NA, which is consistent with how the City of Hamilton has defined ‘community’ in NA (City of Hamilton, 2011). Community Developers (CDs) play a key role in implementing ABCD as they seek to improve the quality of life in NA neighbourhoods by promoting resident empowerment and working towards social justice (Shin et al., 2011). Of particular importance, CDs seek to change the relationships between those in positions of power (e.g., state officials) and marginalized community members, by building relationships, working with communities to identify shared issues and facilitating opportunities for collective action based in values of inclusion and equality (Standing Conference for Community Development e SCCD, 2001). Therefore, CDs work to shift power dynamics so that interventions may be more responsive to marginalized communities (Boutilier et al., 2000; Woolrych and Sixsmith, 2013; SCCD, 2001). Due to the nature of their work, CDs' perspectives and experiences are integral to understanding how community participation and power can be fostered in neighbourhood interventions (Boutilier et al., 2000; Woolrych and Sixsmith, 2013). This paper focuses on CDs so as to respond to calls for nuanced, contextual and real-time accounts of neighbourhood interventions (Bradford, 2005; Dunn et al., 2010). 3. Hamilton's Neighbourhood Action (NA) e a communitycentred approach to neighbourhood-level health inequities Formerly a centre of North American steel manufacturing, Hamilton, Ontario has long faced challenges of deindustrialization since the 1970s (Wakefield and McMullan, 2005; Cruikshank and Bouchier, 2004). City planning decisions encouraging suburban growth have led to the spatialisation of social inequities, where in some downtown and northeast neighbourhoods more than half of residents live in poverty (Cruikshank and Bouchier, 2004; Mayo et al., 2012). These neighbourhood-level income inequities are reflected in significant health inequities, including a 21-year gap in average age at death, and a 16-fold difference in per-capita hospital in-patient days between the city's high-income and low-income neighbourhoods (DeLuca et al., 2012). These inequities were exposed in a series of Hamilton Spectator newspaper articles entitled “Code Red” (Buist, 2010). Code Red galvanized public opinion, became a major issue in the subsequent mayoral election, and prompted the City to create a Neighbourhood Development Office responsible for the implementation of NA (DeLuca et al., 2012). NA is jointly funded by the City of Hamilton, the Hamilton Community Foundation (a local funding agency) and the Best Start

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Network (an inter-sectoral coalition promoting child health), and involves many community groups. It is important to note that “action” in Hamilton's neighbourhoods has been ongoing for decades through resident and service-provider-led neighbourhood organizations. In particular, the Hamilton Community Foundation funded “neighbourhood hubs” in several NA neighbourhoods before it began, which have served as a strong foundation for the initiative. Key NA actors include the municipal government (city staff, officials, elected representatives), community (residents), non-profit actors (service providers, funding agencies) and five Community Developers (CDs). CDs were ‘housed’ in different non-profit agencies serving local communities and each were assigned to two neighbourhoods with the exception of one CD assigned to three. CDs reported to city staff coordinating NA efforts and supervisors at their respective agencies. They also shared resident viewpoints during meetings with city officials and non-profit actors, giving them some influence over decision-making processes in NA. For example, when engagement strategies were discussed or service-providers proposed program ideas, CDs provided feedback based on the information residents shared with them (e.g., need for child care at meetings and community spaces). CDs were selected based on their prior experience in community development in neighbourhoods targeted by NA, so many were already known to residents (City of Hamilton, 2011). Four CDs were also residents of NA neighbourhoods, but did not work as CDs in the neighbourhoods they resided in so as to avoid potential conflicts of interest. Nevertheless, the partial ‘insider’ and ‘allied’ positioning of CDs was considered beneficial to the strategy as the city aimed to make NA a participatory, resident-led process (City of Hamilton, 2011, 2013). This also contrasts with similar initiatives where CDs have been employed within government departments (Woolrych and Sixsmith, 2013; Boutilier et al., 2000). CDs were assigned to the following goals: 1) resident participation; 2) neighbourhood plan development with residents; 3) capacity-building (e.g., mentoring and training residents); 4) relationship-building (e.g., building trust, actively listening); 5) communication (e.g., information sharing), and 6) fostering sustainability (e.g., supporting resident leadership). They have tapped into the strengths of existing neighbourhood groups and facilitated the development of resident-led Planning Teams (PTs). Together, PTs and CDs have engaged hundreds of residents in creating Neighbourhood Action Plans (NAPs). The purpose of NAPs is to inform planning and service delivery targeting multiple determinants of health like the physical environment and recreational opportunities (City of Hamilton, 2013). Overall, NA may be understood as an attempt by the municipal government to go beyond superficial consultations and meaningfully engage residents.

4. Methods This paper reports findings of a qualitative process evaluation (Saunders et al., 2005) that examines how municipal government and community actors collaborated in NA to promote community participation from the perspectives of CDs. A process evaluation “is used to monitor and document program implementation, and can aid in understanding the relationship between specific program elements and program outcomes” (Saunders et al., 2005, p. 134). A process evaluation allows for the identification and assessment of important changes in activities, behaviours and relationships across social actors (Saunders et al., 2005). Since CDs hold a unique role in NA as they work across multiple actors, interviews with CDs were an integral part of this evaluation. The five CDs involved in NA were invited to participate in the evaluation via an electronic letter explaining the purposes of the study and informed consent, and all


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agreed to take part. This study received ethics approval from the institution in which it took place. In order to gain a nuanced understanding of CDs' experiences, we conducted weekly, 20e30 min semi-structured interviews with each CD between March 2012 and September 2012 (n ¼ 120), at which point we shifted to 90-min interviews every 4e6 weeks until August 2013 (n ¼ 30). The majority of interviews were conducted over the phone with five in-person interviews and consent was provided each time. We asked CDs about the activities they engaged in, their experiences of the process, and their successes and challenges in promoting community participation and resident-leadership. This allowed us to track how initiatives were unfolding and to further understand how CDs and other actors involved were developing strategies to address challenges. Members of the research team also attended numerous neighbourhood planning meetings and community events in order to better understand participant responses during interviews. A total of 150 interviews and participant observation data were drawn together into an NVivo 9 database and analysed for key themes by the authors. The authors have significant experience in collaborative research with communities and were deeply aware of the need to balance power dynamics in this research. To this end, preliminary results were shared with CDs, which provided opportunities for member-checking and knowledge sharing (Baxter and Eyles, 1997). CDs reaffirmed study findings, pointed to gaps and informed subsequent interview questions. The section below summarizes these findings, presenting information in the CDs' own words where possible.

5. Findings 5.1. Local government works in complex ways to facilitate and suppress community participation Our interviews with Community Developers (CDs) demonstrate that the local municipal government has served to both facilitate and suppress community participation in NA. Since the strategy began, the City of Hamilton has provided significant resources to support resident engagement and participation. First, CDs from local agencies have been recruited to facilitate an ABCD approach. Second, city staff members from various departments (e.g., Planning, Recreation, and Public Health) have regularly attended community meetings to share information on city services, resources, processes and policies with residents and CDs to inform decisionmaking and action. Third, city staff has worked directly with CDs to better align municipal priorities to that of residents. Also, key city officials are advocating for the Neighbourhood Action Plans (NAPs) to be used as a blueprint for future city projects and initiatives. For example, incoming land developers are being assessed at the municipal level as to whether their development project matches residents' interests in the area. In addition, the city commissioned a study on the potential for urban agriculture to improve food security, as a direct response to NAPs that showed resident interest in using urban agriculture to improve access to affordable and healthy food (Urban Agriculture Working Group, 2013). Although these are clear indicators that the city is striving to align their interests with residents' priorities and support community involvement, there are still serious challenges to strengthening community participation, leadership and empowerment. For example, despite city staff's efforts to demystify municipal bureaucracy, municipal policies and by-laws have been identified as barriers to participation by CDs. As one CD explained, city policies and by-laws appear to lack the flexibility or transparency necessary to be useful for resident volunteer groups:

Policies of the city that you don't know or understand, and then they dump them on you, and the city is worried about people suing them so they have to cover all their bases. But it's frustrating for me and residents, and [one resident] she listed all these things that she's having problems with the city with and they're trying to work them out but it's slow and takes a long time and residents don't understand that. … if the city wants to change they need to be flexible and I don't think their policies are very flexible. I know the city is trying to change, but it's not as reassuring to the resident that wants to do something now. Therefore, although the city is adjusting certain policies to be more responsive to residents, other policies and bureaucratic processes are at times what spark frustration and disengagement among residents. CDs, as a central point of connection between the municipal government and residents, felt this tension acutely: I mean, we've woken the giant (the city). We got people involved, got them (residents) interested, and now we say, “Please come, oh and by the way, there are all these barriers!” I have to be the one to tell the residents. This demonstrates how the municipal government works to both facilitate and suppress community participation, as CDs have been engaged by the city to do the work of strengthening resident participation, but municipal bureaucracy frustrates residents and weakens participation. This has been observed by CDs when the municipal government aims to provide funding to resident projects, but the timelines for submitting applications and receiving funding do not correspond with the timelines of resident initiatives. CDs reported that this made it difficult for residents to access resources, leaving many demoralized, unable to promptly implement plans that the city itself had endorsed. Interviews with CDs also showed that the ways in which municipal government staff approach ‘community participation’ may work to both facilitate and suppress resident involvement. For example, CDs characterized city staff involved in NA as focused on service delivery and as committed to “building a plan”; in other words, to concretizing a neighbourhood plan with short and longterm goals to reduce health inequities. Although this approach is very important in constructing a tangible product that can be used to support and justify municipal government decisions and resource allocations, without deeper engagement with residents this approach may suppress community participation. This can be seen in the following quotation, where a CD explained the importance of building relationships with residents: It's the people that we deal with. I'm here to do the plan, but if you want their trust and them sitting at the table you need to help their lives in other ways so they can come to the planning teams and be a productive member. […] There's one woman who comes to talk to me 20 minutes before the meeting and half an hour after the meeting … But what am I supposed to say to her, I can't talk to you because I'm doing the plan? It's also because they've known us forever, we're always here, we're in their community, we're somebody they can trust. They see the help in helping figure out their life and supports and eventually we get the bridge over the creek. There is consensus across CDs that the “time and energy to get to know people, to be with them through the small projects, small initiatives” is extremely important to building community trust:



I really need to go the extra step so they know they can trust me. Another woman told me how (a service provider) wouldn't show up for events and it showed that she really didn't want to be a part of the community. However, CDs felt that this hands-on, background work was not as much of a priority to city staff because it took time and did not immediately lead to “building a plan.” CDs reported feeling torn between building strong and trusting relationships with diverse groups of residents and pushing forward the development of neighbourhood plans with fewer residents in order to meet timelines. In this sense, local government can suppress community participation through their focus on plan development, even while simultaneously creating the documentation that will facilitate the intervention. In addition, the fact that NA was city-led opened the door to a political component that both facilitated and constrained the participation of NA neighbourhood residents. CDs' accounts highlight the integral role of elected City Councillors in the process: CDs reported that City Councillors have the capacity to provide funding, resources and political leverage to support (or not) residents' NAPs. In some cases the Councillors worked to encourage community participation by actively listening to residents and guaranteeing support through writing proposals and pledging funding: [The Councillor] facilitates the meetings but doesn't say much. Just lets the residents speak while he listens, so the residents feel very empowered. The Councillor is finally interacting with the project team and engaging in the planning process in a measurable way. This is legitimizing the process to stakeholders and residents alike, and it is invigorating the planning teams. However, in other cases Councillors took a different approach, using NA community meetings and initiatives as spaces to promote their political platforms instead of supporting residents in developing their plans. CDs have expressed that these interactions led to residents feeling used for political gains, and in turn they lost trust in the municipal government's ability to take their concerns seriously: It's a funny world we get into when we get into politics. It's top down and you're using us to get some good publicity. All of a sudden this thing comes from the Councillor, “We need to get this done.” You can't even say, “No we're not going to do this.” […] Then [the Councillor] will say, “Well, I'm not going to do this thing for you” and … it shouldn't be like this with residents. I understand it's political, but a resident should be able to say no to a Councillor and not be worried. City Councillors, then, can shape neighbourhood interventions in a variety of ways. On the one hand their role in representative democracy can support participatory governance models by bringing important resources and political will to the initiatives of particular community groups. However, as representatives for large constituencies, Councillors, must also gain favour with many different groups across the city, which may brush up against the specific priorities of citizens engaged in participatory governance models (Purcell, 2006; Pateman, 2012) like NA. As these examples show, municipal government actors, policies and practices have at times served as barriers for resident groups, despite a significant investment in increasing community participation. They also show that the city is not a cohesive body,

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but rather a diverse structure wherein different actors, policies and practices can work in contradictory ways to suppress and facilitate community participation. As such, CDs have a particularly challenging role in connecting different actors both within and outside the municipal government. The following section will explore how CDs navigate and negotiate power differentials as they work in the intersection of multiple community groups and local government. 5.2. Community Developers navigate and negotiate power differentials in Neighbourhood Action Our interviews with CDs reveal that they were very active in negotiating relationships among multiple community groups and the city. Their unique positioning allowed them to liaise and relay information across social actors, build connections across different actors, and also develop creative strategies to mediate differences. This was not always a straightforward process, and required considerable sensitivity and persistence on the part of the CDs, particularly in building trust around NA's resident-led process: I was mindful of not trying to take over her work, or take over the neighbourhood's work. I tried to calm people's speculations, telling [them] verbally that I am not taking over things. There was little receptivity toward the (NA) plan at the beginning … I just kept answering all their questions and eventually they started coming to the meeting. I really tried to listen, be the voice of reassurance, let [them] take charge. CDs report that since most of the NAPs have been presented to City Council, NA has generated increasing media attention. Due to the raised profile of NA, additional city staff and other local actors (e.g., service agencies, colleges) have come forward with resources and new ideas to community meetings. This enhanced access to resources has the potential to support residents, but at times may derail NAPs. As one CD expressed, “It's a constant struggle to keep the plans neighbour owned” because of resources being offered by the city and other actors that do not necessarily reflect resident priorities in terms of what they wish to see in their neighbourhoods: One of the big challenges is … the balancing of the neighbourhood's priorities and the city and the community's resources … What I'm seeing now that these plans have been done, lots of people want to get involved, but we have to be careful that their involvement doesn't drive the bus, that resident control is maintained. Often, these other actors (including the municipal government) had more power and resources than neighbourhood residents. In this context, CDs have attempted to negotiate power differences between residents and other actors by continually refocusing attention on the objectives laid out in residents' neighbourhood plans. This also highlights the importance of the documentation in the plans in protecting the priorities of neighbourhood residents. CDs also tried to create alternative decision-making processes with communities that work to bring decisions and power back to community meetings instead of the city in accordance with ABCD and participatory governance models (Kretzmann and McKnight, 1993; Pateman, 1970) that the city itself had committed to (City of Hamilton, 2011): What we are attempting to do is decentralize decision-making, trying to bring decisions back to communities, back to the


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people that are involved in those communities, [but then] we're being asked to go back to the centralized locations [in the city]. In addition, CDs have had to navigate and negotiate relationships between residents and City Councillors. In the following quotation, one CD explained how relationships with the Councillor are navigated: I try to listen to both sides, I don't go in saying this is what the community wants and you have to give it to them, I listen first … [it] feels good to know the information, but I can't take what the Councillor says in confidence and tell the community, because then I won't be able to have his ear anymore. Despite these efforts to remain “impartial,” the relationship between CDs and City Councillors has not always been easy, with CDs feeling pressure to act in alliance with the Councillors even if they do not feel it is in line with the wishes of residents: The close relationship between the city and the Councillor gets muddy because we can't run like that. We can't as CDs work by whatever the Councillor says goes. But now I feel we gotta do what the councillor says, kind of like drones. I don't think the CD workers are the Councillor's ears on the ground, we can't inform them of everything that happens. What would happen to trust if we told them everything we heard? … We should be separated from the city, they shouldn't have that kind of power over us on the field. The tensions surrounding CDs' roles in bridging power differentials between the municipal government and community has resulted in many CDs feeling like they are constantly “walking a delicate tight rope” or that they are “one decision away from being fired” if consensus cannot be reached between groups. This is particularly true of their relations with the City, because their current reporting relationship puts the city in a position of power over the CDs. Ultimately, several CDs questioned their ability to overcome these power relations and create lasting change in communities. They identified the need for broader systemic changes like welfarestate reforms to achieve the long-term goals of reducing health inequities. They also suggest that transforming this context is extremely challenging and outside the scope of individual CD roles. Below, one CD explains that: ...the real issues are so systemic that, you know, to expect that a plan that is developed within the community is going to change poverty is going to eliminate poverty I think is grandiose thinking. I think we can have an impact on the effects of poverty. In order to end poverty it's these bigger things that need to be done. It's the creation of jobs, it's the creation of a living wage, it's the creation of a liveable allowance, [so welfare and disability programs] aren't dead ends, aren't a death sentence because … you're going to get lesser housing, you're going to be able to afford less food, less recreational opportunities, the list continues to grow. So what we attempt to do is help lessen the effects of poverty on those Social Determinants of Health by doing things but the bottom line is we can't get them (residents) more money. Therefore, understanding NA as a poverty elimination strategy may be too high of an expectation and could ignore the significance of smaller successes (e.g., improving physical environment and

building community capacity). CDs also expressed that NA provided residents with opportunities to advocate for marginalized communities and engage government, which may lead to future initiatives that tackle poverty more directly. This also points to the limitations of municipal governments and local participatory governance approaches in bridging health inequities as macro-level policies instituted through representative democratic models may at times be more effective (Purcell, 2006).

6. Discussion The findings of this study demonstrate that the question of ‘social change or business as usual at city hall?’ cannot be answered simply. It is clear that municipal governments can operate in multifaceted and complex ways in neighbourhood interventions that aim to reduce health inequities. The contributions of the City of Hamilton to the intervention e such as facilitating the funding of initiatives, bringing city staff and resources to community planning meetings, garnering political support for resident projects, honouring residents' plans and even attempting an intensive “bottomup” ABCD approach e should be recognized and lauded. However, at times the city served to suppress rather than support community participation. CDs suggested that barriers associated with bureaucratic processes had the potential to derail neighbourhood initiatives and disillusion participants. Also, in some cases elected representatives complemented the work of NA resident groups, but in other cases the priorities of these groups were not supported. Our results also show how CDs navigate power differences and attempt to shift power dynamics within communities in order to advance the interests of low-income residents. At the same time, the work of CDs is constrained by larger structural barriers such as neoliberal restructuring and a weakened welfare state (Jessop, 2002). Our findings resonate with the existing literature, which suggests that CDs can effectively shift power dynamics, but that these efforts may be compromised by ongoing state direction of the project (Boutilier et al., 2000; Masuda et al., 2008; Sharek et al., 2013; Woolrych and Sixsmith, 2013; Cowen and Parlette, 2011). Yet, CDs' narratives show how residents have been able to strongly influence the city by successfully developing neighbourhood plans that have been endorsed by Council. This finding is consistent with literature demonstrating how marginalized community groups can utilize participatory approaches to influence policy, ultimately strengthening democratic decision-making (Elwood, 2002; Coaffee and Healey, 2003; Pateman, 2012; Lelieveldt et al., 2009). In addition, this study demonstrates how community participation is not a straightforward or linear process (Dooris and Heritage, 2011; Gamble, 2010; Hancock, 2009). Lastly, this study points to barriers to promoting equitable participation in municipal strategies, which may compromise health equity goals (Rogers et al., 2008; Laverack, 2006; Sharek et al., 2013). This paper adds to past research by capturing the dynamic tensions between different elements of e and actors within e neighbourhood interventions. First, it was clear that the CDs struggled with the focus on delivering the NAPs in a timely manner, but also used the plans (once developed) themselves to give authority to neighbourhood priorities that were at risk of being diluted. This suggests that, while the focus on the plans limited opportunities to build strong trusting relationships with the widest range of community members, this was a negotiation that did ultimately help to keep some resident issues at the forefront of the initiative. Second, the different rhythms and timelines of the city and community were of concern to the CD workers; interestingly,



both city and neighbourhood stakeholders expected a quicker pace of others (e.g., in developing the neighbourhood plans on the one hand, and changing city policies that limited neighbourhood initiatives on the other) than they did of themselves. The CDs played a necessary (if difficult and not always entirely successful) role in helping to bridge the gap in expectations of different stakeholders. Third, the CDs highlighted how different actors within the city (e.g., staff in different departments, Councillors) either facilitated or compromised NA, and that the role these actors played depended not only on the context and the structures in which they had to work, but also on their individual approaches to the intervention. This highlights the fact that what in other studies has often been seen as monolithic (e.g., as municipal government, full stop) is in fact considerably more nuanced (Elwood, 2002; Pateman, 2012; Petersen and Lupton, 1996), and these internal differentiations have significant impacts for the effectiveness of the intervention in reducing health inequalities. Again, the CDs played an important role in trying to work with different city actors as shown in the community development literature (Boutilier et al., 2000; Shin et al., 2011; Green and Haines, 2011; Kretzmann and McKnight, 1993). However, in this case they were additionally constrained by their reporting relationship (i.e., that city staff were their supervisors and had power over their employment). It should be noted that, as of February 2014, a new reporting structure has been developed for the CDs, partially to respond to concerns raised in this research. The CDs will now all work within e and report to e a local community organization that has been contracted by the municipal government and the Hamilton Community Foundation to oversee the CD component of NA. This new structure will provide a more arms-length relationship between the City and the CDs, hopefully overcoming some of the concerns raised about the CDs ability to act more independently on behalf of residents living in NA neighbourhoods. This change highlights that while important lessons can be learned by looking at a snapshot of an intervention of this magnitude, these initiatives are dynamic and may be able to respond to concerns as they arise. However, longer-term research is needed to understand if and how the intervention is able to respond to challenges and become even more resident-focused. 7. Conclusion In this paper, we explored the perspectives and experiences of Community Developers working within Neighbourhood Action (NA), a city-wide initiative using an Asset-Based Community Development (ABCD) approach in tandem with a municipal planning process to reduce health inequities. We demonstrated how municipal government involvement in NA works in complex ways to both facilitate and suppress community participation, and have shown that CDs serve as important intermediaries in this process. CDs work between multiple social actors in order to strengthen community participation, and this requires that CDs navigate a complicated landscape of power that they can partially shape, but that also in turn shapes their work. Although CDs are uniquely situated to balance different expectations and agendas, they face contradictions in their role. Ultimately, this evaluation highlights a number of strengths in this initiative, not least of which is that there has been a significant commitment to involving residents in neighbourhood interventions that could impact their health, and an interest in responding to concerns to improve NA. At the same time, our findings suggest that there are significant barriers to creating an initiative that is resident-led and participatory. Furthermore, as CDs noted, ending poverty and inequity requires changes to the social welfare and economic system that are beyond the scope of

7

neighbourhood interventions to deliver (Jessop, 2002; Purcell, 2006). Yet, without a sustained effort to support bottom-up, resident-led initiatives, neighbourhood interventions like NA risk applying top-down, government-led approaches that can disempower communities and further negatively impact health (Rogers et al., 2008; Hancock, 2009; Laverack, 2006; Sharek et al., 2013). In conclusion, this research has reinforced the need to understand the complex ways municipal governments may approach community participation and account for how power differences between municipal government and community actors operate in neighbourhood interventions that aim to reduce health inequities. Acknowledgements The authors would like to thank the City of Hamilton, the Hamilton Community Foundation and the members of the Neighbourhood Action Evaluation Team (including Suzanne Brown, James R. Dunn, Hilary Gibson-Wood, Matt Goodman, Paul Johnson, Sara Mayo, Colin McMullan, Evelyn Myrie, and Jeff Wingard) for their assistance and support. We would also like to sincerely thank the Neighbourhood Action Community Developers for their significant commitment, time and energy, as without their insights and feedback this paper would not have been possible. We are also grateful to the two anonymous reviewers who provided very helpful comments. This research was supported by a Canadian Institutes of Health Research Population Health Intervention Research (GIR-127080) grant. References Arnstein, S.R., 1969. A ladder of citizen participation. J. Am. Plan. Assoc. 35 (4), 216e224. Baxter, J., Eyles, J., 1997. Evaluating qualitative research in social geography: establishing “rigour” in interview analysis. Transact. Inst. Br. Geogr. 22 (4), 505e525. Boutilier, M., Cleverly, S., Labonte, R., 2000. Community as a setting for health promotion. In: Poland, B., Green, L.W., Rootman, I. (Eds.), Settings for Health Promotion: Linking Theory and Practice. Sage, Thousand Oaks, CA, pp. 250e308. Bradford, N., 2005, March. Place-based Public Policy: Towards a New Urban and Community Agenda for Canada (Report Fj51). Canadian Policy Research Networks, Ottawa, ON. Buist, Steve, 2010, May, 12. Code Red: Where You Live Affects Your Health (Special Report). In: The Hamilton Spectator. Retrieved February 5, 2014, from: http:// www.thespec.com/news/article/8827-code-red-story-links-to-the-original2010-series. Cattell, V., 2001. Poor people, poor places, and poor health: the mediating role of social networks and social capital. Soc. Sci. Med. 52 (10), 1501e1516. City of Hamilton, 2011. Neighbourhood Development Strategy (CM11007). Retrieved February 5, 2014, from the City of Hamilton Web site: http://www.hamilton.ca/ ProjectsInitiatives/NeighbourhoodDevelopment/. City of Hamilton, 2013. Neighbourhood Action Strategy Annual Report (v1). Retrieved February 5, 2014, from the City of Hamilton Web site: www.hamilton. ca/neighbourhoods. Coaffee, J., Healey, P., 2003. “My voice: my place”: tracking transformations in urban governance. Urban Stud. 40 (10), 1979e1999. Collins, P.A., Hayes, M.V., 2010. The role of urban municipal governments in reducing health inequities: a meta-narrative mapping analysis. Int. J. Equity Health 9 (13), 1e20. Collins, P.A., Hayes, M.V., 2013. Examining the capacities of municipal governments to reduce health inequities: a survey of municipal actors' perceptions in Vancouver. Can. J. Public Health 104 (4), e304ee310. Cowen, D., Parlette, V., 2011. Inner Suburbs at Stake: Investing in Social Infrastructure in Scarborough (Research Paper 220). Retrieved February 6, 2014 from Neighbourhood Change Web site: http://neighbourhoodchange.ca/ publications/research-papers/gentrification-2/inner-suburbs/. Cruikshank, K., Bouchier, N.B., 2004. Blighted areas and obnoxious industries: constructing environmental inequality on an industrial waterfront, Hamilton, Ontario, 1890e1960. Environ. Hist. 9, 464e496. CSDH, 2008. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Retrieved January 15, 2014, from the WHO Web site: http://www.who.int/social_determinants/thecommission/finalreport/en/. DeLuca, P.F., Buist, S., Johnston, N., 2012. The code red project: engaging communities in health system change in Hamilton, Canada. Soc. Indic. Res. 108, 317e327.


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