Lessons from community participation in health programmes

Although primary health care emphasizes community participationand many health care programmes attempt to develop participation,good analysis of these developments is still rare. This paper,based on a review of about 200 case studies, examines some ofthe lessons for planners which are emerging from experiencesof the last decade. These lessons focus on the problems of definingthe term ‘community participation’, of gaining andsustaining broad-based community participation, of failing torecognize the political implications of the concept and of attemptingto develop a management model of community participation forhealth. Based on these lessons, a planning framework is suggestedthat seeks individual programme answers to three questions:‘Why participation?’, ‘Who participates?’,‘How do they participate?’. The answers to thesequestions will help to define a programme's objectives and tomonitor and evaluate its development.     

THE SWEDISH ALCOHOL USE INVENTORY (AVI), A SELF-REPORT INVENTORY FOR DIFFERENTIATED DIAGNOSIS IN ALCOHOLISM

AVI is a self-report inventory intended for standardized anddifferentiated assessment and diagnosis in alcoholism; it includes75 items adapted from Horn and Wanberg's Alcohol Use Inventory(AUI) and an assessment of the alcohol intake during a typicalweek of heavy drinking. The drinking profile is presented infive second-order factor scales: ‘alcohol abuse’,‘psychological benefits’, ‘interpersonal complications’,‘social drinking’ and ‘daily drinking’and in 17 first-order factor scales. The reliability and specificityof the scales are satisfactory. Preliminary norms based on asample of more than 600 alcoholic patients are available. Usingthe original American scoring and norms the results indicateimportant similarities in the alcoholism pattern between Swedenand the U.S.A.     

Promoting school health education: examining the role of a statewide conference for school and community leaders

Improving the delivery of school health education may well belinked to the inclusion of and commitment from high-rankingdecision makers from schools and youth organizations. This studyexamined the role of a statewide school health summit in promotinghealth education among representatives from state and communityorganizations. We conducted the study in two phases: (1) developmentand testing of a measuring instrument, and (2) role examinationvia conference assessment. Overall, the measurement instrumenthelped us investigate two areas: the inclination of an individualleader of a health organization to promote organizational changesto assist school health education and the background of a participantin school health education, which affects his/her likelihoodto take action. Three factors (‘Participant Awarenessand Compatibility’, ‘Draft Plan Development’and ‘Summit Experiences and Satisfaction’) werefound to be important predictors of leaders’ ‘FutureAction’ and ‘Advocate Impact’ (P < 0.01).Future interventions targeted to influence health, educationand social service professionals’ support and adoptionof school health education should be structured to reinforcethese three variables.     

Applying logics of change to the evaluation of community development in health promotion

Evaluation of community-oriented health promotion programs requirethat professional evaluators clearly distinguish between exogenouslyand endogenously defined goals and definitions of ‘success’.Acknowledging the different dynamics which underpin community-ledchange and externally initiated health programs and interventionsis essential to this task. It will be argued that the intersectionof, and boundaries around, exogenous and endogenous change canbest be understood and clarified through the application of‘logics of rationality’, adapted from social theory.Community activity is characterised by what we have called ‘lifeworldrationality’ community-based health promotion interventionsare characterised by ‘formal ratonality’. In addition,we suggest that the value dimensions (‘substantive rationality’)underpinning programs and interventions may be overlooked bypolicy makers, program planners and professional evaluatorsunder pressure to demonstrate cost-effectiveness and efficiency.Key requirements for successful and appropriate evaluation ofcommunity-based programs which are sensitive to the needs andsuccess criteria of communities include a shared understandingby the researchers, program sponsors and community actors ofthe nature of the changes sought. The co-production of healthpromotion standards and of indicators to judge the performanceof the program or intervention by all stakeholders should bepreferred over the trend for establishing community-controlledprocess evaluations to coexist alongside expert-controlled impactevaluations. It is argued that current approaches to standardsetting and indicator development to judge the processes andimpacts of interventions are inadequate and several principlesfor improving their content are given. A locally controlledethnographic approach to evaluate endogenous community-led changeis described in the hope that program planners and evaluatorsmay become more sensitive and receptive to local knowledge.We suggest that engagement with what we have termed the ‘communitystory’ should be a fundamental requirement for the planningand evaluation of community health programs.     

Patient Requests in Family Practice: A Focal Point for Clinical Negotiations

A growing body of literature has stressed the importance ofeliciting the patient's views on the management of health andillness. In particular, it is recognized that patients frequentlyenter into clinical encounters with specific requests for services,that is ideas about how they hope to be helped. The presentinvestigation examined the following two questions: (1) whatkinds of requests do adult patients coming to a family practicecentre have prior to seeing the doctor; and (2) will factoranalysis of a 25-item patient request questionnaire provideevidence of the basic or most common dimensions of patient requestsin this population? Two newly-developed instruments were administeredto a sample of 144 adult patients before their visit to thedoctor. Factor analysis yielded five major request factors—‘medicalinformation’, ‘psycho-social assistance’,‘therapeutic listening’, ‘general health advice’,and ‘biomedical treatment’ —partially replicatingthe findings of an earlier pilot study. The clinical implicationsof eliciting patient requests in the light of current behaviouraland social science research into the doctor-patient relationshipare discussed. Future research directions are also outlined.     

Capturing the meaning of 'community' in community intervention evaluation: some contributions from community psychology

Evaluations of community health promotion can underestimatethe gains that an intervention might make in a community ifthe outcomes reported are limited to aggregates of changes inhealth behaviour or attitude made at an individual level Thenotion of ‘community’ revealed by this type of evaluationis relatively unsophisticated compared to the ‘community’rhetoric which often accompanies program definition. Even thoseevaluations which report policy changes or evaluations of howcommunities became involved, often fail to capture the improvementsa community intervention can make on the problem-solving capacitiesof a community and its competence in tackling the issues whichface it. The essence of what some interventions (intentionallyor unintentionally) achieve is, therefore, missed. Empowerment is usually described as a process. But it can beconsidered as an outcome variable in community interventionsif capacity-building is a major activity of an intervention.To capture this in the evaluation design, evaluators shouldbe using active strategies to (i) articulate what empowermentactually means and (ii) challenge what intervention successreally means in interactive dialogues with program workers andthe community. Active and interactive strategies must be usedto clarify program values and intentions because evaluatorswill be misled or confused by words like ‘community involvement’,‘community development’ or ‘community participation’in program documents. These words mean different things to differentgroups. Similarly, ‘empowerment’ must be translatedinto aspects which are recognisable within the life of the programor period of interest. Community psychology is introduced in this paper as a fieldwhich may have much to offer in this analysis. Community psychologyis a field within psychology which should be distinguished fromthe more traditional approaches in community-based health promotionwhich are the legacy of behavioural health psychology.     

Health, human development and the community ecosystem: three ecological models

Health, as both an expres and a component of human development,has to be seen in an ecological way as ‘the pattern thatconnects’ and the radical and subversive nature of anecological approach needs to be recognized. Three ecologicalmodels are presented, that of health, the links between health,environment and economy (or between ‘health for all’and sustainable development); and the social, environmentaland eco nomic dimensions of a healthy and sustainable com munity. The ‘Mandala of Health’, as a model of the humanecosystem, presents the determinants of health as a set of nestedinfluences, ranging from the biological and personal to theecological and planetary, including the social and political The health-environment-economy model shows the crucial linksbetween health (or social wellbeing) and environmental and economicwellbeing with a particular focus on two key public health principles—equityand sustainabilizy. The final model applies these concepts atthe community level, introducing such issues viability, convivialityand liveabilily. These models could be used to better understand health, to definekey criteria for hea Ithier public policies and to define somekey action areas for healthy city projects. It is in their applicationthat their value—and their ‘subversiveness’—willbe tested.     

Strategies, guidelines, policies and standards: the search for direction in community health promotion

In this paper, the authors respond on behalf ofa panel representingthe American Public Health Association in the USA to criticismsfrom Canada (by Higgins and Green, two health education researchersfrom British Columbia) regarding the relevance and adequacyof a set of criteria developed in the USA for guiding the developmentof health promotion programs in other developed countries, suchas Canada. The US criteria included a specific focus on riskfactors of disease or untoword health conditions, the characteristicsof an intervention's target group(s), the appropriateness ofan interivention for a given target group or socio-culturalsituation, the optimum use of available resources, and the abilityto evaluate intervention effects. The Canadian criticisms were that these criteria do not allowforor give proper appreciation to the process through which communitiescoalesce around specific problems or issues of importance to‘health’, and there is strong exception taken tothe focus by US groups on ‘risk factor reduction’.There is a preference among Canadians for the tenn ‘riskcondition’, which is defined as ‘local conditionshaving an impact on the health of neighborhoods’. Through a series of case illustrations, the Canadian authorsattempt to show the narrowness of the US criteria, thereforearguing for a broader set of criteria which would allow fora programatic focus on community-based health problems whichare not ‘"carefully deflned measureable, modifiable" riskfac tors’. In response, the authors of this paper argue that their Canadiancritics have misinterpreted the purpose and utility of the APHAguidelines, therefore over-interpreting the implications ofthese criteria for the specific Canadian community health promotioninitiatives they hoped to evaluate. The conclusion reached isthat the APHA criteria continue to represent a useful approachto guiding the consideration of pos sible health promotion investmentson the part of communities or organizations.     

'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

Can One be a Good Doctor and have a Sexual Relationship with One's Patient?

This paper presents a qualitative exploration of social andsexual contact between general practitioners and their patients.Social contacts have been implicated in the development of sexualrelationships between members of the mental health professionsand their patients. However, there has been little examinationof the implications for general practitioners. Six focus groupswere conducted by teleconference with New Zealand general practitioners.Participant anonymity was maintained. Questions focused on issuesof social and sexual contact in general practice. Major themeswere extracted from the data. A range of definitions of ‘patient’,‘sexual contact’ and ‘social contact’were offered by the participants which demonstrated that ‘greyareas’ existed for them in relation to social and sexualrelationships with patients. Mandatory reporting of colleaguesfor alleged sexual misconduct was not supported, informal mechanismsbeing preferred. General practitioners need to be aware of potentialboundary violations in their practice. These issues are alsoimportant to address in the teaching of medical students, continuingmedical education, and in the development of appropriate guidelinesfor general practice.     

Measurement of Outcomes of General Practice: Comparison of Three Health Status Measures

The broad range of medical problems seen in general practicemeans that the assessment of health outcomes shares much withthe assessment of health status in the general community. Thelast two decades have seen considerable progress in health statusmeasurement for this purpose. This paper reports the use ofthree such measures in a general practice setting. The ‘Randhealth insurance study battery’, the ‘sickness impactprofile’ and the ‘general health questionnaire’were tested in two general practices in Sydney, Australia, todetermine patient compliance, to assess the range of scoresand discriminative ability of the instruments, and to comparethe different instruments. There was a high degree of acceptanceof the questionnaires, showing that patients visiting theirgeneral practitioners are prepared to complete such questionnaires.The range of scores obtained was less skewed for the Rand measuresthan for the sickness impact profile or the general health questionnaire,suggesting that the Rand measures should be the preferred generalhealth status measure.     

Predicting the intention to eat healthier food among young adults

The purpose of this study was to investigate which factors predictedthe intention to eat healthier food. The empirical data stemfrom a questionnaire survey carried out among 527 young adultsaged 23–26 years living in Oslo, Norway. The study wascarried out in September 1991. The Theory of Planned Behavior(TPB) was used as a guiding theoretical framework. The componentsof the TPB accounted for 32% of the variance in behavioral intention.Attitude was the strongest predictor, followed by perceivedbehavioral control. Subjective norm received the lowest weightA detailed analysis of the underlying cognitive structures revealedthat the outcomes which discriminated most strongly betweenthose who intended to eat healthier food, those who were undecidedand those who had no intention, were that healthier food wouldimprove the shape of the body, increase enjoyment of food andreduce weight. In addition, the control beliefs ‘weight’,‘able to make healthier dishes’, ‘social eating’and ‘busy’ discriminated mostly between the threeintender groups. These outcomes might preferably be addressedin persuasive communications to change intentions to eat healthierfood.     

A case of two paradigms within health education

The article outlines two different paradigms which influenceschool health education. The first of these is the moralisticparadigm which is dominant in many current health educationprogrammes in schools. It will be argued that the moralisticand totalitarian paradigm may actually be an obstacle for developinga democratic school in a democratic society. The second paradigmfocuses on democratic health education and is advocated in thispaper as a valuable alternative to the moralistic paradigm.An overview of the major characteristics of the two paradigmis followed by an analysis of several concepts which characterizedemocratic health education, including ‘action competence’,‘action’ and ‘holism’. These conceptsillustrate that health and environment have to be closely linkedin teaching if students are to acquire a coherent understandingof the dynamics behind health issues and health problems. Finally,the ‘IVAC’ approach is suggested as a way of developingaction competence in relation to health and environmental issues.Experiences and examples from the Danish Network of Health PromotingSchools are used to illustrate the thesis presented in thispaper.     

Information disclosure, smoking and health protection: A critique of the European directive on the labelling of tobacco products

European Directive 89/622, which came into operation in January1992, made it obligatory to display health warnings on the packetsof cigarettes marketed in the European Union and to displaytar and nicotine yields, in numerical form, on such packets.The directive can be seen as involving a two-pronged healthprotection strategy: the health warnings were designed to encouragesmokers to stop, while the tar and nicotine yields were partof a policy to induce those who could not give up to switchto ‘low tar’ brands. This article critically analysesthe approach to health protection taken in the Directive. Itargues that, as research evidence indicates that smokers frequentlymisperceive yield data as indicating maximum intake levels,two dangers stem from the directive: brands with ‘low’tar numbers may be seen as ‘safe’, thus negatingthe health warning and smokers who ‘switch down’are likely to have an exaggerated view of their likely reductionin tar intake as they are not alerted to the significance ofsmoking patterns for intake levels.     

Principles and strategies of effective community participation

A framework is offered for understanding the conceptual basisand the strategic implications of community participation, inachieving Health for All goals. Special focus is given to themeaning, settings and levels of participation in official decision-makingstructures and at the community level. Questions such ‘howis participation facilitated?’, ‘who participates?’and ‘what are the benefits and obstacles to participation?’are geared primarily towards the needs of individuals who functionat the city level and expect practical strategic advice andguidance. The structure of the 1989 WHO Healthy Cities Symposiumwhich was devoted to community action was based on the frameworkand conceptual approach of this paper.     

A critical analysis of different leadership approaches to community health work in Kirseberg, Sweden

This paper examines some dilemmas of both professional and communityled approaches in health promotion with reference to an alcoholreduction programme implemented in Kirseberg, Sweden. A ‘traditional’health education programmed designed at changing life-stylehabits was combined with a community action design. The processby which the public health messages were sent to and receivedby the residents was explored in a qualitative study. The study focused on the possibly contradictory relationshipbetween the ‘professional’ concept of public healthand individuals' personal concepts of health. it is argued thatif the ‘top down’ and ‘bottom up’ approachesare combined without detailed consideration being given to thepossible connecting links the risk is that the result will bethe operation of two parallel strategies which do not interact. The process of making health a collective issue within a communityaction programme is illustrated with examples from the Kirsebergproject and discussed with reference to the chief aim of achievingequity in health provision.     

Empowerment: the holy grail of health promotion?

Potentially, empowerment has much to offer health promotion.However, some caution needs to be exercised before the notionis wholeheartedly embraced as the major goal of health promotion.The lack of a clear theoretical underpinning, distortion ofthe concept by different users, measurement ambiguities, andstructural barriers make ‘empowerment’ difficultto attain. To further discussion, this paper proposes severalassertions about the definition, components, process and outcomeof ‘empowerment’, including the need for a distinctionbetween psychological and community empowerment. These assertionsand a model of community empowerment are offered in an attemptto clarify an important issue for health promotion.     

Health promotion in the market place: constraints and opportunities

An emerging trend internationally is for health promo tion servicesto be privatised and organised through a division of ‘purchaser’and ‘provider’ functions. This paper examines theconstraints and opportunities for health promotion in the marketplace through a discus sion often ‘vital signs’drawing on British experience where appropriate. If the marketis not closely managed there are considerable concerns thathealth inequalities could increase, that ethical issues couldbe ignored, and that health promotion practice could be seriouslycom promised. Nevertheless, there are also potential benefitsfrom a market economy, but these will only be realised if thereis a shared understanding of the purchaser/provider roles, adequateskills and resources for the purchaser function, earmarked fundingfor health promotion investment, effective monitoring and refereeingby government as ‘regulator’, and training for thenew tasks and responsibilities. To improve pe, formance a distinctionshould be made between health promotion Design, Development,and Delivery-the three ‘Ds’ of health promotionpractice. Tasks for the three stages are described, togetherwith the potential roles of govern ment, public sector agencies,professional bodies, voluntary organisations and private sectorcompanies. Long-and medium-term time scales are essential foreffective implementation.     

Uncertainty and lack of trust with Parkinson's disease

‘Uncertainty’ is frequently observed in researchon the chronically III. The present research confirms this finding.In 20 out of 23 life stories of men and women diagnosed as havingParkinson's disease for more than 3 years, indications of uncertaintycould be found. The research question is whether a specificexplanation for this uncertainty can be found in the life stories.One such explanation, a condition and a specification were detected.In 12 of the 20 life stories in which the informants speak ofuncertainty, a specific and differentiated context of the uncertaintywas found: ‘a problem of trust’, located in thecapacities of ‘the body’, in ‘themselves’and in ‘the world outside the home’. These relatedtrust problems are presented by the informants as explanationsfor their uncertainty. Two conditions for the trust problemwere presented by the informants: ‘declining naturalness’and ‘unpredictability’ of the functioning of thebody. The explanation could also be specified. The trust problemis located socially. The Interpretations of trust are primarilysituated in ‘the world outside the home’.     

Value of the Diagnostic Sodium Calcium Edetate Mobilization Test as a Criterion of Lead Absorption

Among the laboratory tests available for the follow-up of lead-exposedworkers, the EDTA mobilization test is presently underestimatedin the diagnosis of lead intoxication. The authors present theresults of regression comparison between the urinary lead excretion3 h (PbU 3) or 6 h (PbU 6) after EDTA injection and blood lead(PbB), urinary aminolaevulinic acid (ALAU) and urinary lead(PbU). The results were collected from 133 medical examinationsof workers exposed to lead, who put in a claim for compensationto the ‘Fund of Occupational Diseases’ in Belgium.On the basis of the regression curves, PbU 3 and PbU 6 limitvalues are calculated for different cut-off values of PbB inexcessive lead absorption and lead intoxication. For each ofthese values the ‘sensitivity’, ‘specificity’and ‘validity’ are calculated. As a result the authorsstill consider the EDTA mobilization test as a valuable parameterin the diagnosis of lead absorption. Requests for reprints should be addressed to: Dr D. Lahaye, Fund of Occupational Diseases, Sterrenkundelaan 1, 1030, Brussels, Belgium