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.     

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 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.     

Accessibility and Use of Health Care Services in the British Asian Community

British Asians make up 3% of the population. There is evidencethat Asians have difficulty obtaining good quality health care,appropriate to their needs. This article examines some of thisevidence, with examples of specific communities in Britain.In the past, specific health education programmes for Asianshave targeted their ‘special’ needs such as rickets,tuberculosis and thalassaemia. In fact the population itselfperceives its needs differently-improved communication, easieraccess to services, and more information on asthma, diabetes,ischaemic heart disease and skin disorders. It is importantto appreciate that the ‘Asian’ community is madeup of disparate groups with widely differing needs and expectations,and that each community should be considered by health serviceplanners as unique within the context of the health authoritywithin which they lie. Reasons for the mismatch between needand service provision are discussed in the light of the recentreforms in the National Health Service and recommendations forchange are given.     

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.     

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.     

Factor analysis as a tool in community diagnosis

For the family physician, community diagnosis can be likenedto individual diagnosis by the application of methods of informationacquisition and analysis. This paper describes the techniqueof factor analysis, applied to data from an urban inner-cityarea, for reducing a multitude of factors to a manageable numberwithout an appreciable loss of information. The variables wereselected from four broad categories which have been shown toinfluence both health states and health care needs: demography,socioeconomics, social disorganization and morbidity/mortality.A correlation matrix based on 40 of the most accessible indicesserved as input for a principal axes factor analysis. Six factors acounted for 74% of the total variance and wereinterpreted as: ‘Poverty and social disorgan ization’,‘Distribution and problems of the elderly’, ‘Ethniccomposition’, ‘Fertility’, ‘Infant mortality’and ‘Foetal mortality’. Representative indices fromeach factor were then mapped to identify and display censustract differences. Finally, the application of the factors toa specific community illustrated important differences withinthe community and identified areas of high risk and need.     

Health education services in developing countries: the case of Zimbabwe

Little research has been done on the organization of healthservices in developing countries. This study uses a checklistapproach to assess Zimbabwe's health service and combines itwith an historical analysis. The data include interviews withkey staff members of the Department of Community Medicine andobservations by one of the authors during work as a districtdoctor. Policy formulation, organization and management, andresources have developed to a medium level. However, supportof peripheral health workers has been weak. Services on theground, almost exclusively carried out by non-specialists, areunsatisfactory. Improvements in health status have mainly beendue to the success of service delivery programmes such as immunization.Diseases which require behaviour changes have not improved or,as in the case of AIDS, even worsened. Health education serviceshave evolved from a ‘village educator’ to a ‘diplomaeducator’ stage. In order to facilitate the use of moreeffective and participatory methods, a speedy upgrading of theservice to a ‘specialist stage’ is needed togetherwith a further training and re-orientation of health workersat district level.     

Charging for drugs in Africa: UNICEF'S 'Bamako Initiative'

Recession and economic adjustment policies have led to massiveresource shortages in government health systems in many lessdeveloped countries in Africa. There is growing evidence thatthe IMF- and World Bank-sponsored adjustment programmes areresponsible for negative effects on the health of the poor inthese countries. Calls for a New International Economic Orderand 'adjustment' in the industrialized countries have been ignoredand the resource flow from the poor to the rich countries continues.UNICEF is currently promoting ‘Adjustment with a humanface’ as a means of alleviating poverty and minimizingthe negative impact of adjustment on the poor. In the healthsector, this approach concentrates on the GOBI-FFF strategyand the supply of essential drugs to primary level health services.UNICEF is also in the process of launching the ‘BamakoInitiative’ which aims, by introducing drug/treatmentcharges and setting-up revolving drug funds at community level,to finance drg costs, the operational costs of the MCH programmeand the salaries of community health workers at primary level.Quite apart from the debatable long-term impact of the healthstrategy being advocated, the Bamako Initiative poses seriousquestions related to equity and the implementation of fee systemswhich must be answered.     

Which way to sustainability? External support to health projects in developing countries

The purpose of this paper is to analyse the process by whichdonors decide whether or not to support specific primary healthcare projects. First of all, there has to be an ‘eligiblesituation’: an inability to start without external support,coupled with an ability to sustain the project (without suchsupport) once it has started. Secondly there must an ‘eligibleproject’, that is, a project that requires support ofa ‘one-time-only’ nature (for example, capital outlay);or recurrent support to temporary activities (such as salariesfor a temporary campaign), or temporary support to recurrentactivities (for the initial stages of innovative programmes).Proposals for really innovative programmes are seldom readilyavailable, and the most appropriate form of support may thenbe to support an institution charged with the development ofsuch innovative programmes.     

A quality management model for integrated care: results of a Delphi and Concept Mapping study

Objective. The objective of this study is to identify the elements andclusters of a quality management model for integrated care. Design. In order to develop the model a combination of three methodswere applied. A literature study was conducted to identify elementsof integrated care. In a Delphi study experts commented andprioritized 175 elements in three rounds. During a half-a-daysession with the expert panel, Concept Mapping was used to clusterthe elements, position them on a map and analyse their content.Multi-dimensional statistical analyses were applied to designthe model. Participants. Thirty-one experts, with an average of 8.9 years of experienceworking in research, managing improvement projects or runningintegrated care programmes. Results. The literature study resulted in 101 elements of integratedcare. Based on criteria for inclusion and exclusion, 89 uniqueelements were determined after the three Delphi rounds. By usingConcept Mapping the 89 elements were grouped into nine clusters.The clusters were labelled as: ‘Quality care’, ‘Performancemanagement’, ‘Interprofessional teamwork’,‘Delivery system’, ‘Roles and tasks’,‘Patient-centeredness’, ‘Commitment’,‘Transparent entrepreneurship’ and ‘Result-focusedlearning’. Conclusion. The identified elements and clusters provide a basis for a comprehensivequality management model for integrated care. This model differsfrom other quality management models with respect to its generalapproach to multiple patient categories, its broad definitionof integrated care and its specification into nine differentclusters. The model furthermore accentuates conditions for effectivecollaboration such as commitment, clear roles and tasks andentrepreneurship. The model could serve evaluation and improvementpurposes in integrated care practice. To improve external validity,replication of the study in other countries is recommended.     

Health promotion policies in Singapore: meeting the challenges of the 1990s

Health promotion has been proposed as one of the major elementsin national health policies in Singapore by the Review Committeeappointed by the Minister for Health in April 1991. This articlelooks at health promotion policies in Singapore, including theconcept, approach, targets, outreach programmes, and frame-workfor actions, with particular reference to the Ottawa Charterfor Health Promotion and Adelaide Recommendations. The Singaporestrategies focus mainly on healthy lifestyle promotion, whichhas taken the form of a nationwide campaign, in the hope to‘add years to life’ as well as ‘life to years’among Singaporeans.     

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.     

'We won't let them keep us quiet ...' Gendered strategies in the negotiation of power--implications for pupils' health and school health promotion

The aim of this qualitative study was to analyse gendered strategiesamong pupils in the negotiation of power at school, and to discusspossible implications for health. Twenty-seven single-sex focusgroup interviews were conducted with pupils from equal opportunityprojects. The interviews were analysed using grounded theory.The girls used ‘alliance building’ and ‘resistance’,in order to increase their power, while ‘responsibilitytaking’ and ‘withdrawal’ could mean maintainedsubordination. The boys used mastering techniques (various typesof abuse, claiming to be the norm, acting-out behaviour, blamingthe girls, choosing boys only) in self-interest to maintaintheir dominance. The girls' active and democratic actions forincreased power could be of significant importance for theirhealth. The boys' health would benefit if they gave up strivingfor power over others. School health promotion needs to addressthe asymmetric and gendered distribution of power between pupils,as well as to challenge the existing gender regime at an institutionallevel.     

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.     

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.     

Mawas Diri a tool to stimulate community participation

The term ‘community participation’ is popular developmentrhetoric yet it tends to remain a topic of discussion aroundconference tables rather than a reality in most communitiesof the developing world. Political will may be guaranteed butthe tools which can facilitate the process of translating communityparticipation into reality are scarce. To help fill this gapan Indonesian non-governmental organization, Yayasan IndonesiaSejahtera, developed a problem-solving tool called Mawas Diri.The tool is employed by representatives of the target groupand uses indicators directly related to their situation. Itis used by village health workers (VHWs) or others who havebeen trained in its use, to evaluate the healthiness of homesand the neighbourhood in general. With this tool, VHWs have succeeded in collecting reliable datawhich are used for village planning activities and monitoringthe progress of programmes. It has also proved to be an effectivemotivational tool for stimulating people to initiate a widevariety of activities aimed at creating a healthier environmentand life-style. More fundamentally, this problem-solving toolhas reversed the usual procedure of ‘outsiders’determining a community's problems and providing programmesfor their solution. With Mawas Diri the community members aremore aware of the nature and extent of their problems and canthen determine which of these they can solve using their ownresources, and which require government or other outside participation. Experiences with Mawas Diri in Indonesia have illustrated thatvillage communities can play a significant role in planning,implementing and monitoring programmes leading to healthierlives.     

CHWs: are national programmes in crisis?

Community health workers (CHWs) have become the distinguishingfeature of many primary health care schemes. CHW programmesexpanded during the 1970s and early 1980s as long-term evidencefor the effectiveness of small-scale programmes grew. However,there is a growing suggestion of a decline in support for CHWs.Criticisms have grown, evaluations of existing programmes havepointed to difficulties in implementation and a number of reviewshave highlighted weaknesses in key areas. Training of CHWs hasbeen suspended in some countries, and fewer than originallyplanned are being trained in others. In this paper it is arguedthat although the financial recession has affected support forCHW programmes, there are other reasons why they are now underpressure. On the whole they have been implemented as ‘vertical’programmes, against a background of unrealistic expectationsand minimal professional interest. Structural political andeconomic factors have been neglected. Lessons have not beendrawn from the experience of community workers in other sectorssuch as agriculture and community development. The paper analysesall these issues within a health policy perspective concludingthat, unless adjustments are made, CHW programmes will drifttowards demise, not because CHWs themselves cannot deliver,but because the support that makes them effective is, in general,absent.     

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.