Government policies as a threat to health: findings from two Toronto community quality of life studies

Community members, service providers, and elected representatives in two Toronto communities were asked to identify community factors influencing the health of community members. Many of the identified barriers to health related to government policies and actions. Cutbacks in federal transfers to provinces and provincial cutbacks in funding for agencies, reductions in social assistance, ending of new social housing, and other policy changes were seen as negatively impacting the health of the community and its members. These perceptions were remarkably consistent with emerging findings concerning the determinants of health. Implications for public health practice were considered.     

The role of community representatives on health service committees: staff expectations vs. reality

Objective This paper examines staff views about legitimacy of different roles for community representatives sitting on health service committees as part of a formal Community Participation Program (CPP) in an Area Health Service (AHS) in Australia. Design A cross‐sectional survey using a self‐completed questionnaire by staff on committees with community representation in the AHS in 2008. Setting The study site has a population of approximately 1.4 million and covers 6000 km². The population is ethnically and socio‐economically diverse. Results There are generally positive staff attitudes at this AHS for community participation as part of the CPP with positive impacts identified, including on service delivery and the conduct of health service meetings. Most saw community representatives having legitimate roles in representing the community, improving communication between the health service and the community and providing constructive feedback. However, staff expectations about the community’s role on committees do not match the reality they say they observe and less than half the staff thought the community and health service agree on the role of community representatives. Conclusions As well as reviewing and enhancing training and support for representatives and staff as part of the CPP, there is a need to question staff expectations about community members who sit on health service committees and whether these expectations are shared by other key stakeholders, most notably the community representatives themselves. These expectations have implications for the CPP and for similar programs designed to engage community members on committees and working groups with health professionals.     

Community participation in action: an analysis of the South Australian Health and Social Welfare Councils

This paper presents an analysis of a health department's efforts to introduce a mechanism to increase community participation into a bureaucracy's decision-making, planning and operations. In the 1980s, South Australia adopted a Social Health Policy and a Primary Health Care Policy. These documents were intended as a means of implementing the state's commitment to 'Health for All by the Year 2000' and the Ottawa Charter for Health Promotion. A key plank of each of these policy statements is the strategy of involving community people who are not professionally involved in the health sector, in the process of promoting health and tailoring health services to the needs of the local people. In South Australia, one of the means by which participation was encouraged in the health system was through the establishment of four pilot Health and Social Welfare Councils (HSWCs) in 1988. This paper describes and analyses the data that were collected for an external review of the HSWC program, conducted in 1991. Data collection was through telephone and self-completion questionnaires administered to key informants and HSWC members. The evaluation data show that the Councils mobilised people to take action on a range of issues and three key themes related to the HSWCs as models for community participation: the structural preconditions for success; issues of representativeness; and the differing power levels between stakeholders. The study points to some important lesions for a successful model of participation. These include: (I) participation is difficult when organisations are restructuring and frequently changing staff; (ii) the need for community participants to set their own agenda; (iii) the need for resources, support and quality leadership; (iv) recognition of the competing demands of bureaucracy and community; and (v) allowing the voice of the marginalised to be heard is a more valuable objective than accurately representing all views. The paper describes the progress of the Councils since the review and notes that they were defunded in December, 1995. Some members of the Council viewed the defunding as one indicator of their success in challenging bureaucratic practices.      

A rapid qualitative assessment of oral cholera vaccine anticipated acceptability in a context of resistance towards cholera intervention in Nampula,Mozambique

IntroductionWhile planning an immunization campaign in settings where public health interventions are subject to politically motivated resistance, designing context-based social mobilization strategies is critical to ensure community acceptability. In preparation for an Oral Cholera Vaccine campaign implemented in Nampula, Mozambique, in November 2016, we assessed potential barriers and levers for vaccine acceptability.MethodsQuestionnaires, in-depth interviews, and focus group discussions, as well as observations, were conducted before the campaign. The participants included central and district level government informants (national immunization program, logistics officers, public health directors, and others), community leaders and representatives, and community members.ResultsDuring previous well chlorination interventions, some government representatives and health agents were attacked, because they were believed to be responsible for spreading cholera instead of purifying the wells. Politically motivated resistance to cholera interventions resurfaced when an OCV campaign was considered. Respondents also reported vaccine hesitancy related to experiences of problems during school-based vaccine introduction, rumors related to vaccine safety, and negative experiences following routine childhood immunization. Despite major suspicions associated with the OCV campaign, respondents’ perceived vulnerability to cholera and its perceived severity seem to override potential anticipated OCV vaccine hesitancy.DiscussionPotential hesitancy towards the OCV campaign is grounded in global insecurity, social disequilibrium, and perceived institutional negligence, which reinforces a representation of estrangement from the central government, triggering suspicions on its intentions in implementing the OCV campaign. Recommendations include a strong involvement of community leaders, which is important for successful social mobilization; representatives of different political parties should be equally involved in social mobilization efforts, before and during campaigns; and public health officials should promote other planned interventions to mitigate the lack of trust associated with perceived institutional negligence. Successful past initiatives include public intake of purified water or newly introduced medication by social mobilizers, teachers or credible leaders.     

Health Disparities,Transportation Equity and Complete Streets: a Case Study of a Policy Development Process through the Lens of Critical Race Theory

Historic disinvestment in transportation infrastructure is directly related to adverse social conditions underlying health disparities in low-income communities of color. Complete Streets policies offer a strategy to address inequities and subsequent public health outcomes. This case study examines the potential for an equity-focused policy process to address systemic barriers and identify potential measures to track progress toward equity outcomes. Critical race theory provided the analytical framework to examine grant reports, task force notes, community workshop/outreach activities, digital stories, and stakeholder interviews. Analysis showed that transportation inequities are entrenched in historically rooted disparities that are perpetuated in ongoing decision-making processes. Intentional efforts to incorporate equity into discussions with community members and representatives contributed to explicit equity language being included in the final policy. The potential to achieve equity outcomes will depend upon policy implementation. Concrete strategies to engage community members and focus city decision-making practices on marginalized and disenfranchised communities are identified.     

Residents' perceptions of effective community representation in local health decision-making

Community participation in local health decision-making has been envisioned as a key strategy to improve the design and delivery of health services in the USA. While much literature has sought to understand this participatory approach, considerably fewer studies have engaged the essential first-order question: How would we know who the appropriate community representatives are? An important first analytic step is to learn from community members themselves what characteristics they feel a ‘good' representative should possess. Two primary research questions are addressed: 1) To what degree can low-income adults identify and articulate what they believe constitutes an effective community health representative and 2) What do low-income adults believe are the specific characteristics an effective community health representative should possess? In-depth, open-ended interviews were conducted with 14 African-American and Latino residents of four low-income communities on the Southside of Chicago, USA. A theoretical sampling strategy was used with residents varying by age, education, employment, and years of residence on the Southside. We found that respondents had difficulty articulating what a community health representative might do or generating the names of potential representatives, but were able to express clear preferences for what would constitute good representation when given meaningful choices. Three primary characteristics were identified: 1) outcomes 2) expertise, and 3) active communication. These characteristics did not operate in isolation but together communicated the trust and commitment that respondents found fundamental to representation. In exploring this essential yet often neglected question, we sought to build an empirical foundation to more fully examine the precursors to effective community health representation. These data provide important clues as to how to build an inclusive process that expands rather than constrains the pool of community-based representatives.     

Implementing community participation through legislative reform: a study of the policy framework for community participation in the Western Cape province of South Africa

ABSTRACT: BACKGROUND: Amidst an evolving post-apartheid policy framework for health, policymakers have sought to institutionalize community participation in Primary Health Care, recognizing participation as integral to realizing South Africa's constitutional commitment to the right to health. With evolving South African legislation supporting community involvement in the health system, early policy developments focused on Community Health Committees (HCs) as the principal institutions of community participation. Formally recognized in the National Health Act of 2003, the National Health Act deferred to provincial governments in establishing the specific roles and functions of HCs. As a result, stakeholders developed a Draft Policy Framework for Community Participation in Health (Draft Policy) to formalize participatory institutions in the Western Cape province. METHODS: With the Draft Policy as a frame of analysis, the researchers conducted documentary policy analysis and semi-structured interviews on the evolution of South African community participation policy. Moving beyond the specific and unique circumstances of the Western Cape, this study analyzes generalizable themes for rights-based community participation in the health system. RESULTS: Framing institutions for the establishment, appointment, and functioning of community participation, the Draft Policy proposed a formal network of communication -- from local HCs to the health system. However, this participation structure has struggled to establish itself and function effectively as a result of limitations in community representation, administrative support, capacity building, and policy commitment. Without legislative support for community participation, the enactment of superseding legislation is likely to bring an end to HC structures in the Western Cape. CONCLUSIONS: Attempts to realize community participation have not adequately addressed the underlying factors crucial to promoting effective participation, with policy reforms necessary: to codify clearly defined roles and functions of community representation; to outline how communities engage with government through effective and accountable channels for participation; and to ensure extensive training and capacity building of community representatives. Given the public health importance of structured and effective policies for community participation, and the normative importance of participation in realizing a rights-based approach to health, this analysis informs researchers on the challenges to institutionalizing participation in health systems policy and provides practitioners with a research base to frame future policy reforms.     

Setting Health Priorities: Community Boards Accurately Reflect the Preferences of the Community's Residents

Setting priorities remains an important part of healthcare planning and program management. Loca! community input is often sought in government or publicly sponsored programs. Community policy/advisory boards are a common vehicle to represent the community's interests in program decisions and direction. Questions remain whether community boards accurately represent their communities' views. As part of a planning effort within Chicago and Cook County, Illinois, local District Health Councils (DHCs) have been created to provide assistance and leadership in systemization and improvement of the healthcare in communities with the poorest health status in the region. We sought to discover how closely the perceptions of health priorities of DHC members agreed with those of community members. A structured five-point Likert scale questionnaire of 22 of the most common diseases and conditions known to impact health were used for a random digit dialing telephone interview with a sample of 286 households from three under-served communities. The same interview was repeated with all DHC members (n = 80) representing those communities. Sociodemographic profiles and health-related behaviors were also collected. The results of this interview indicate a close and substantial agreement in priorities between community members and DHC members. Psychosocial conditions such as violence and substance abuse were ranked as the highest priorities by both groups. In contrast, sociodemographics and healthcare behavior differed significantly between DHC members and community's residents.This study demonstrates that these community policy/advisory boards can closely reflect the views of the communities they represent. Attention to their differences in sociodemographics and healthcare experiences with the community may strengthen their role even more.     

Community-based participatory research: policy recommendations for promoting a partnership approach in health research

Community-based participatory research in public health focuses on social, structural, and physical environmental inequities through active involvement of community members, organizational representatives, and researchers in all aspects of the research process. Partners contribute their expertise to enhance understanding of a given phenomenon and integrate the knowledge gained with action to benefit the community involved. This article presents key principles of community-based participatory research (CBPR), discusses the rationale for its use, and provides a number of policy recommendations at the organizational, community and national levels aimed at advancing the application of CBPR. While the issues addressed here draw primarily upon experiences in the United States, the emphasis throughout this article on the establishment of policies to enhance equity that would serve both to increase the engagement of communities as partners in health research, and to reduce health disparities, has relevant applications in a global context.     

Representation strategies in public participation in health policy: the Aboriginal Community Health Council

Within Canada's Aboriginal population, an ongoing health promotion strategy has been the facilitation of community participation in the development and application of health policy. The Calgary Health Region's Aboriginal Community Health Council has provided a setting for involving the local Aboriginal population in health policy and program development for over a decade. This paper represents the results of a case study to identify the Council's strategies for this work. Data sources included documents, such as meeting minutes and other reports; key informant interviews with past and present Council members and health region representatives; and participant observation of Council functions. Although direct membership in the Council provided a core approach for representing the community, other strategies were actively utilized to involve the public. These included building links and partnerships with community organizations, networking, consultation activities and the identification of special needs groups.     

Health service staff attitudes to community representatives on committees

PURPOSE: This paper sets out to report attitudes of staff on key health service committees towards community participation before and after appointment of community representatives. DESIGN/METHODOLOGY/APPROACH: The paper shows a self-completed questionnaire administered to staff on committees as a baseline measure and 12 months after community representatives had been appointed. FINDINGS: The paper finds that significantly more staff at the follow-up survey reported that they and other staff were clear about the role of community representatives and how to work with them on committees. Significantly more staff at follow-up felt that the health service was ready for this type of initiative. There was no significant increase in the percentage of staff who felt that financial and other supports for community representatives were sufficient and no significant changes in staff views about the potential for community representatives to influence decision making, although there were strong trends in a positive direction. RESEARCH LIMITATIONS/IMPLICATIONS: The study in this paper was conducted in one health service and did not follow changes in attitudes of particular staff over time. Larger samples would be necessary to assess generalisability of findings and future studies should examine in more depth staff beliefs about the role and influence of community members on committees. PRACTICAL IMPLICATIONS: The paper implies that the development of ongoing and constructive relationships between health services and communities clearly takes time and, at least in part, results from direct experience working alongside community members. ORIGINALITY/VALUE: The paper shows that this is the first study examining how the attitudes of health service staff to community participation change over time and as a direct result of interaction with community members on committees. A better understanding of health service staff attitudes to community participation is important for health care managers to effectively address structural and attitudinal barriers to community participation.     

Healthy communications: producing a health report (Infowatch) for monitoring and promoting health in local communities.

In order to bridge the gap between producers and users of community health data, we have developed a standardized format to provide a simple, comprehensive approach to the communication of epidemiologic data at the local level. Infowatch follows a series of format and style rules selected to enhance readability. The four-page format is divided into six sections: introduction and scope; "results" presented as charts, figures and text; policy implications (through consultation with community groups); methodological summary; references for self-study; and, invitation for reader feedback. An editorial committee comprising experts and representatives from local interest groups ensures that the data presented are relevant and of high quality. The content of each Infowatch issue varies depending on community priorities. Infowatch is distributed to 3,000 people, including representatives from health-related, academic, governmental and non-governmental agencies. Five areas assess qualitatively the impact of Infowatch: reader, media, policy, education, and solicited responses. Overall, response from all categories has been favourable with evidence of infiltration into policy.     

Effectiveness of community participation in Municipal Health Councils in Santa Catarina State, Brazil

This article presents a model for the evaluation of community participation in municipal (county) health systems. The theoretical basis for this evaluative study was the existing Brazilian legislation on community participation in drafting health strategies and overseeing health policy implementation. The indicators and measures were validated using the expert consensus technique. The proposed model has 26 indicators divided into five evaluative dimensions that reflect the legislation's adequacy for the structure, organization, representativeness, health planning participation, and autonomy of the Municipal Health Councils. Its applicability was tested in 24 municipalities in Santa Catarina State, Brazil. The data analysis indicated the best results for the dimension "planning system in the Unified National Health System" and the worst for "structure" and "autonomy". Only two municipalities showed good results for the final summary indicator. The study demonstrated the feasibility and adequacy of the proposed evaluation model.     

Strengths and challenges of citizens' participation in local health councils: the cases of Italy, England, and Brazil

This paper focuses on three models for citizens' participation in health (Italy, Great Britain, and Brazil). After discussing the strengths and weakness of the three experiences, the study presents a comparative analysis, highlighting convergences and variations in relation to the main characteristics of social participation in the health sector: (a) organization and composition of health councils; (b) functions played by citizens' representatives (decision-making, advisory, or social control or oversight); and (c) approaches to community participation. The paper then focuses on two critical points emerging from the analysis of experiences with community participation: the issue of representativeness and the difficulty experienced by representatives of health services users in influencing the decision-making by system managers.     

Transforming the urban food desert from the grassroots up: a model for community change

Confronted by continuing health disparities in vulnerable communities, Community Health Councils (CHC), a nonprofit community-based organization in South Los Angeles, worked with the African Americans Building a Legacy of Health Coalition and research partners to develop a community change model to address the root causes of health disparities within the community's African American population. This article discusses how the CHC Model's development and application led to public policy interventions in a "food desert." The CHC Model provided a systematic approach to engaging impacted communities in support of societal level reforms, with the goal to influence health outcomes.     

Perceptions, knowledge and beliefs about prevention of cardiovascular diseases in Villa Nueva, Guatemala

Background

In Guatemala, cardiovascular diseases are becoming the leading cause of mortality and disability. The rising burden of these diseases makes it imperative to formulate effective community-based interventions. The success of these interventions will depend on the felt needs of the community. Therefore, in this study we assessed perceptions, knowledge and beliefs about cardiovascular diseases in community members, health workers and policy makers from Villa Nueva, a community selected by the Ministry of Health of Guatemala as a site to develop a cardiovascular disease prevention programme. This study provides baseline information for designing and implementing the demonstration programme.

Methods

Qualitative methods (focus group discussions and in-depth interviews) were used to elicit the views of community members, health workers, and policy makers on the magnitude, impact, risk factors and prevention of cardiovascular diseases and infrastructure in Villa Nueva.

Results

Community members perceive cardiovascular diseases as a serious health problem that has increased in recent years. They consider cardiovascular diseases to be acute dramatic events of sudden onset. According to health professionals and policy makers, the adoption of Western lifestyles by the population is the most important contributor to the increase of cardiovascular diseases in Guatemala. They indicated that prevention requires education of the population, together with adequate health policies. According to most participants, the infrastructure for the management of cardiovascular diseases at the primary health care level is inadequate.

Conclusion

Findings from this study suggest strategies for context-specific formulation of the cardiovascular prevention programme.     

Adolescent alcohol use and the community health agenda: a study of leaders' perceptions in 28 small towns

The study assessed leaders' perceptions of adolescent alcoholuse as a public health issue in 28 small communities in northernMinnesota, as part of formative evaluation for a community-basedintervention to reduce adolescent alcohol access and consumption.One hundred and eighteen leaders from five key community sectorswere interviewed about their perceptions of social, health andalcohol-related problems in their communities. Analyses indicatedthat school representatives and police chiefs perceived adolescentalcohol use and related problems to be serious; newspaper editorsmentioned other social problems more often; and mayors and businessrepresentatives did not perceive adolescent alcohol problemsto be as serious. In relation to efforts to affect local policy,the study suggested government and business sectors in thesecommunities may need to be educated about the problem to buildits importance on the community agenda of health issues. Thuscommunity leaders in some sectors may comprise a key targetaudience for intervention.     

Community Organizing Network for Environmental Health: Using a Community Health Development Approach to Increase Community Capacity around Reduction of Environmental Triggers

The Community Organizing Network for Environmental Health (CONEH), a project of Community Action Against Asthma, used a community health development approach to improve children’s asthma-related health through increasing the community’s capacity to reduce physical and social environmental triggers for asthma. Three community organizers were hired to work with community groups and residents in neighborhoods in Detroit on the priority areas of air quality, housing, and citizen involvement in the environmental project and policy decision-making. As part of the evaluation of the CONEH project, 20 one-on-one semi-structured, in-depth interviews were conducted between August and November 2005 involving steering committee members, staff members, and key community organization staff and/or community members. Using data from the evaluation of the CONEH project, this article identifies the dimensions of community capacity that were enhanced as part of a CBPR community health development approach to reducing physical and social environmental triggers associated with childhood asthma and the factors that facilitated or inhibited the enhancement of community capacity.     

Nursing and environmental health: possibilities of action for health promotion

This qualitative study aimed at understanding the meanings of participation of the members of the Sub Watershed Committee of the Salgado River, CE, Brazil, subsidizing the health promotion for a sustainable environment as regards water resources; reflecting on the interface between nursing and environment focusing on the component water. The subjects were 18 representatives of the committee. Information were collected through interviews, analyzed by a collective subject's discourse. The understanding of participation by the subjects were summarized in speech synthesis: participation involves social awareness, information, communication in search of solutions that represent the community. The interface of nursing on the committee is presented as a possibility for extension of its object to incorporate the environment in the actions of health promotion.