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.     

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.     

Evaluating health promotion programs in the workplace: behavioral models versus financial models

This paper suggests that the future of occupational health promotionevaluation lies in the creative utilization of behavioral sciencemodels in an integrated manner with financial models of programevaluation. Evaluators must simultaneously ask ‘Does theprogram work?’ and ‘At what cost?’ Economicconditions may well dictate that both of these questions beanswered. Further, it seems clear that researchers need notbe bound to the impracticalities of true experimental designin order to evaluate program effectiveness. In addition, giventhe numerous potential tangible and intangible benefits to firmssponsoring occupational health promotion programs, evaluatorsshould be equally concerned with controlling beta errors asthey are with controlling alpha errors in test design; otherwise,they run the risk of prematurely cancelling potentially profitableinvestments before they come to fruition.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.     

Helping people change--an ethical approach?

This paper is a normative analysis of an empowerment approachin health promotion. In particular it utilizes two increasinglyinfluential idioms of normative analysis (analytic health careethics and Foucauldian analysis) to evaluate the ethics of ‘helpingpeople change’. The HEA pack entitled ‘Helping PeopleChange’ (HPC) is used as an exemplary case study and asa starting point for analysis; but the implications are intendedto be more wide ranging and the purpose of the analysis is two-fold.First, ethical discussion is presented as an important dimensionof the substantive evaluation of HPC-type interventions (i.e.interventions which emphasize support for voluntary change).Second, it is presented as a means of comparing and contrastingthe role of the two normative idioms in such ethical evaluation.The aims and the underlying rationale of the HPC pack are setout. Analytic health care ethics is represented by the well-known‘four principles’ approach and the longest sectionof the paper applies each of these principles in turn (beneficence,non-maleficence, autonomy and justice) to the HPC pack. It isargued that for each principle there are ethical difficultiesattaching to HPC-type interventions. This is (albeit superficially)paradoxical given that such interventions are arguably exemplaryand are self-consciously ‘ethical’. It is here thata Foucauldian perspective presents a sharp contrast. Accordingto such a perspective, it is argued, the idea of helping peoplechange is ‘obviously’ questionable. This is becauseFoucauldian analysis centres around the intimate links betweenempowerment, control and ‘the creation of subjects’.Finally, some of the other contrasts between, and the potentialcomplementarity of, the two normative perspectives are brieflyreviewed.     

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.     

Some problems in health promotion research

It is argued that health promotion research faces three criticalproblems: defining adequate research questions; identifyingappropriate areas for research and developing a theoreticalbasis for problem formulation. it is suggested that if healthpromotion research is to be a vigorous part of the emergingdiscipline of health promotion, rather than simply an evaluativetool, and if health promotion research is to be distinguishedfrom epidemiology, sociology, psychology, politics or economicswith a health promotion angle, then these three problems mustbe resolved The origins of the difficulties associated withproblem definition, priority areas for research and adequatetheoretical tools are traced in the first instance to the idealisticand programmatic nature of health promotion and the conflationof ‘is’ and ‘ought to be’ questionsin the idealism. The ‘ought to be’ nature of healthpromotion carries important implications for behavioural andsocial change. It is argued that for the most part the normativeand scientific issues surrounding change have not been disentangledand that neither have the contributions of the disciplines whichhave studied social and behavioural change had much impact onhealth promotion. These problems manifest themselves in studiesand practice involving empowerment, enablement and healthy publicpolicy. it is concluded that the role of research in healthpromotion must be clarified and a shift away from the pathogenicparadigm encouraged.     

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.     

'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.     

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.     

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.     

Toward an ethic of empowerment for health promotion

This paper lays out a conceptual framework for articulatingsome main ethical issues raised by health promotion and illnessprevention. Building from the concept of ‘enabling’in the Ottawa Charter, the paper articulates and advocates an‘ethic of empowerment’ for health promotion. If health promotion is understood in terms of enabling, thetired ethical debates between freedom and responsibility, orindividual and community, are recast in a new and more productivelight. Health promotion should resist the temptations of eithera coercive, paternalistic ethic or an individualistic, laissez-faireethic in favour of an ethic of enabling or empowerment.     

Resistance to peer group pressure: an inadequate basis for alcohol education

saper explores the notion of ‘peer group pressure’as it has been deployed in educational interventions on alcoholfor adolescents. It is argued that ‘peer group pressure’is an inadequate explanation for youthful alcohol use and thatinterventions formulated around the inculcation of resistanceto peer group norms must inevitably be at variance with theeveryday experience of those at whom such interventions areaimed. The paper argues that a reformulation of the conceptof ‘peer group pressure’ opens up its positive featuresand that these offer a strong base for a new range of educationalinitiatives.     

Continuous quality improvement and health promotion: can CQI lead to better outcomes?

Canadian health promotion organizations currently face two pressures.First, is the desire of health promotion organizations to seekmethods which will help achieve health promotion goals. Second,external funders are increasingly likely to require that healthpromotion organizations adopt ‘quality’ procedures,such as Continuous Quality Improvement (CQI). This paper exploresa set of questions that assess the potential benefits of CQIwith respect to health promotion organizations. These questionsinclude: Is the philosophy of CQI compatible with health promotionprinciples, values and beliefs? Is CQI methodology and approachapplicable to health promotion? If there are no irresolvableconflicts between CQI and health promotion, will implementingCQI processes improve health promotion practice? In addition,the paper highlights several issues that health promotion needsto address before adopting CQI, including: the meaning and relevanceof concepts such as ‘customer’ and ‘customersatisfaction’, within the context of health promotion;and the heavy emphasis that CQI places on data that are measurableand quantifiable. While further exploration and documentationare required before definitive resolution of these issues, apreliminary overview indicates that CQI, with some modifications,is compatible with health promotion in at least some circumstancesand that, if these modifications are implemented, CQI couldhelp health promotion achieve its goals.     

Addressing the costs of quitting' smoking: a health promotion issue for adolescent girls in Canada

While intense efforts have been implemented to address the problemof cigarette smoking, the prevalence of tobacco use among adolescents,in particular young women, remains high. Older adolescent girlsare joining their younger counterparts in taking up the smokinghabit. The literature has examined the reasons for young peoplestarting to smoke; however, little is known about the smokingcessation process in adolescents. This paper reports findingsfrom an in-depth qualitative study of 25 girls ages 18 and 19which uncovered the struggles young women experience as theyattempt to quit smoking. These struggles and losses are referredto as the ‘costs’ of quitting smoking. The ‘costs’reflect not only their ‘real’ experiences when attemptingto quit smoking, but also reflect ‘anticipated’struggles and losses. The study addressed the ‘costs’in relation to the social, emotional and physiological domainsof the adolescent girl's life. Findings from this research projectprovide theoretical direction for the development of comprehensivehealth promotion interventions. If health care professionalsare to assist in reducing cigarette smoking among young women,the ‘costs’ which girls see to quitting smokingmust be considered.     

Building alliances: professional and political issues in community participation. Examples from a health and community development project

The notion of community participation in health finds favourin many circles, since, lacking close definition, it can beinterpreted in such a way as to be acceptable to all politicalpersuasions. This paper explores some of the consequences of these multipleinterpretations and gives examples from a community developmentand health promotion project in Scotland. Professional attitudes and behaviour and bureaucratic structuresare seen as significant barriers to public participation inhealth. Fundamental changes in the state of the public healthare blocked by a medical model which emphasizes individual responsibilityand treatment. It is argued that the public must retain ‘ownership’of the problems they define and the solutions to those problems.Professionals need to share their skills, rather than imposethem, and learn, in their turn, about the world inhabited bydisadvantaged groups.     

Using sponsorship to create healthy environments for sport, racing and arts venues in Western Australia

The development of healthy public policy and the creation ofenvironments that support health are two of the Ottawa Charter'sgoals for health promotion action. The Western Australian HealthPromotion Foundation (referred to as ‘Healthway’)is an independent statutory body funded by a levy raised onthe wholesale sales of tobacco products. Healthway's legislativecharter defines a number of objectives for the Foundation. Theseinclude: funding activities related to the promotion of goodhealth; offering an alternative source of funds for sport, racingand arts activities previously supported by tobacco sponsorship;and supporting sport, racing and arts activities that encouragehealthy lifestyles and advance health promotion programs. Healthwayhas interpreted this charter from a health promotion perspectiveand ties the offer of sponsorship to sport, racing and artsorganisations with policies that create healthy environments.While the major focus of Healthway's healthy public policy interventionshas been the creation of smoke-free environments, importantgains have also been made in the provision of healthy food choices,safe alcohol practices, sun protection policies and access fordisadvantaged groups. This paper describes the results of asurvey of organisations funded by Healthway and explores theprevalence and reach of structural reforms in sport and culturalsettings. The development of structural reform policies amongdifferent types of organisations receiving different levelsof sponsorship is described. While not all of the structuralreforms observed in this survey can be attributed to Healthway,it is clear from the research that Healthway has contributedto the rate of policy development amongst ‘structuralreform laggards’. The implications for ‘active encouragement’of intersectoral co-operation through government sponsored grantsis discussed.     

Thoughts on the ideological origins of health promotion

Health promotion it a relatively new concept and has many implicationsfor both public health and medical sociology. Nonetheless, newideas do not occur in a vacuum, but are part of a context whichit sometimes decipherable and often inscrutable. The followingessay or ‘debate piece’, consists of some ruminationsabout the nature of health promotion, medical sociology andthe ‘new’ public health. It is not intended to provideanswers, but to generate discussion.     

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.     

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.