The contradictory effects of timelines on community participation in a health promotion programme

Timelines are universal features of health promotion programmes, which often receive little in the way of detailed analysis. Prospectively, timelines form supportive structures; they assist in planning and provide key milestones. However, they may also simultaneously constrain action or force the prioritization of some actions over others. This article uses the case of one health promotion programme to explore the multiple timelines in action: the contract, evaluation, usual programme phases and specific to a community garden project in the programme, the seasons. This exploration demonstrates the complexity of these timelines and how they affected programme implementation and were reflected in community participation. The discussion also demonstrates the importance of skilled facilitation of programmes, especially those based on a community development approach.     

Primary health care in developing countries: The case of Nigeria,Sri Lanka and Tanzania

The country health programmes reviewed in this paper are aimed at meeting the World Health Organization's (WHO) target of providing basic health services for all by the year 2000.In accordance with the objective of the programme, each of the country health programme is expected to focus on the mechanisms for expanding health facilities and strenthening the health planning machinery in order to achieve an equitable distribution of health facilities in the foreseeable future as part of social development and in the spirit of social justice.Although there are marked differences in the approach to the realization of the objectives of the various country programmes revied in this paper, the primary aim is to bridge the widening gap between the health ‘haves’ and the health ‘have-nots’ in the respective countries. A substantial part of the resources of these countries are now being set aside for the implementation of the health care programmes so as to meet the health aspirations of their people.It is our belief that the health programmes of these countries are laudable and if properly implemented they will meet the health needs of the people of the various countries. A continuous evaluation of the programmes will enable each country to assess the sucesses and failure of the schemes and the organizational bottlenecks that may make the realization of stated objectives a well nigh impossible task.     

HEALTH PROMOTION: CAN IT REDRESS THE HEALTH EFFECTS OF SOCIAL DISADVANTAGE?

Social disadvantage is an entrenched feature of contemporary New Zealand society and has a deleterious influence on health. Traditional health promotion activities, with their focus on the individual, have had only a limited impact. The World Health Organization is fostering a new approach to health promotion based on the Ottawa Charter, the two most important strategies being: building healthy public policy and strengthening community action. The new health promotion has great potential, especially with its emphasis on ‘empowerment’, but as yet only indirect evidence supports the effectiveness of this approach. Several current New Zealand community-based initiatives hold promise for the future and three of these are discussed. The greatest challenge is to ensure that the ‘empowering’ approach to health promotion continues to be developed by Area Health Boards and that this type of health promotion becomes a major priority at all levels of society. As social scientists, we need to support this approach and assist in the production of evidence to show whether it is capable of redressing the health effects of social disadvantage.     

Global Health Diplomacy, ‘Smart Power’, and the New World Order

Both the theory and practice of foreign policy and diplomacy, including systems of hard and soft power, are undergoing paradigm shifts, with an increasing number of innovative actors and strategies contributing to international relations outcomes in the ‘New World Order’. Concurrently, global health programmes continue to ascend the political spectrum in scale, scope and influence. This concatenation of circumstances has demanded a re-examination of the existing and potential effectiveness of global health programmes in the ‘smart power’ context, based on adherence to a range of design, implementation and assessment criteria, which may simultaneously optimise their humanitarian, foreign policy and diplomatic effectiveness. A synthesis of contemporary characteristics of ‘global health diplomacy’ and ‘global health as foreign policy’, grouped by common themes and generated in the context of related field experiences, are presented in the form of ‘Top Ten’ criteria lists for optimising both diplomatic and foreign policy effectiveness of global health programmes, and criteria are presented in concert with an examination of implications for programme design and delivery. Key criteria for global health programmes that are sensitised to both diplomatic and foreign policy goals include visibility, sustainability, geostrategic considerations, accountability, effectiveness and alignment with broader policy objectives. Though diplomacy is a component of foreign policy, criteria for ‘diplomatically-sensitised’ versus ‘foreign policy-sensitised’ global health programmes were not always consistent, and were occasionally in conflict, with each other. The desirability of making diplomatic and foreign policy criteria explicit, rather than implicit, in the context of global health programme design, delivery and evaluation are reflected in the identified implications for (1) international security, (2) programme evaluation, (3) funding and resource allocation decisions, (4) approval systems and (5) training. On this basis, global health programmes are shown to provide a valuable, yet underutilised, tool for diplomacy and foreign policy purposes, including their role in the pursuit of benign international influence. A corresponding alignment of resources between ‘hard’ and ‘smart’ power options is encouraged.     

An epidemic of orthodoxy? Design and methodology in the evaluation of the effectiveness of HIV health promotion

This paper examines the epidemic of orthodoxy affecting the evaluation of current health promotion work. This has resulted in the privileging of certain methods, in particular, experimental method and the randomized control trial. Problems identified by public health researchers are discussed but the major focus of our critique concerns the ways in which the experimental method and, especially, the randomized control trial, assume that the audience of any health promotion message comprises a number of asocial individuals who occupy non-discursive space in ahistorical time. An alternative approach is advocated which focuses attention on the programme of health promotion and education rather than on any one individual health promotion initiative or intervention. Attention is also given to educational and health promotion practices; it is here, we argue, that some of the answers to ‘what works’ are to be sought. We illustrate our argument with reference to a number of recent Australian health promotion campaigns, including ‘Condoms Every Time’ and ‘Negotiated Safety’ .     

Country‐wide community participation for nutrition improvement: Lessons learned from Thailand

This case study highlights a community‐based programming approach, based on the Thai experience. Several essential elements need to be present for this approach to be successful including a strong community participation and empowerment, inter‐sectoral collaboration within the context of poverty reduction and development, nutritional improvement as an important policy goal and political support at national and local level, and effective social mobilisation which emphasises the mobilisation of the community's human resources. Capacity building empowers the community to take appropriate decisions and implement effective actions to reach a common goal of nutrition improvement among vulnerable groups in the community. A combined ‘top‐down’ and ‘bottom‐up’ planning and implementation process identifies, implements and evaluates programmes and activities that fit the community's needs and circumstances. More than 95% of villages use basic minimum needs indicators to guide programme development and monitor and evaluate programme impacts.     

Social transformation,collective health and community-based arts: ‘Buen Vivir’ and Ecuador's social circus programme

ABSTRACT

Worldwide, interest is increasing in community-based arts to promote social transformation. This study analyzes one such case. Ecuador's government, elected in 2006 after decades of neoliberalism, introduced Buen Vivir (‘good living’ derived from the Kichwan sumak kawsay), to guide development. Plans included launching a countrywide programme using circus arts as a sociocultural intervention for street-involved youth and other marginalised groups. To examine the complex ways by which such interventions intercede in ‘ways of being’ at the individual and collective level, we integrated qualitative and quantitative methods to document relationships between programme policies over a 5-year period and transformations in personal growth, social inclusion, social engagement and health-related lifestyles of social circus participants. We also conducted comparisons across programmes and with youth in other community arts. While programmes emphasising social, collective and inclusive pedagogy generated significantly better wellbeing outcomes, economic pressures led to prioritising productive skill-building and performing. Critiques of the government's operationalisation of Buen Vivir, including its ambitious technical goals and pragmatic economic compromising, were mirrored in social circus programmes. However, the programme seeded a grassroots social circus movement. Our study suggests that creative programmes introduced to promote social transformation can indeed contribute significantly to nurturing a culture of collective wellbeing.     

Letter – Is a unified definition of health promotion coterminous with the ‘new public health’?

Introduction: Howat et al. advocate for a clear definition of health promotion, providing one such definition which they characterised as “consistent with identified competencies for the Australian health promotion workforce”, and welcomed the contributions of others. My contributions are as follows: First, health promotion is generally regarded as the ‘new public health’, a perspective not explicitly subscribed to in Howat's article. Are the authors concurrently attempting to define the ‘new public health’? Incidentally, a unified definition of contemporary public health remains elusive. Consensus on whether contemporary health promotion and the ‘new public health’ are coterminous should precede a definitional consensus, in part to prevent duplication.     

Older men’s participation in community‐based men’s sheds programmes

The purpose of this qualitative study was to investigate the lived experience of older men taking part in community‐based shed programmes. Five men, aged 65 and over, who attended two different community sheds participated in semi‐structured in‐depth interviews in 2007. Data were analysed thematically with six main themes emerging as follows: ‘company of fellas’; ‘everybody’s got a story to tell’; ‘still got some kick’; ‘passing on your experiences’; ‘get on your goat’ and; ‘nobody’s boss’. Participation in community‐based men’s sheds positively influences the health and well‐being of older Australian men through provision of a ‘men’s space’ in which meaningful activities occur. Provision of community‐based men’s shed programmes as among a range of activity options in the community may contribute positively to the physical, mental, social and occupational health of older men.     

Wege zur Evaluation gesundheitsfördernder Maßnahmen

Since 1992, the health promotion programmes of a medical insurance company in Berlin have been evaluated by means of questionnaires. Participants are questioned at the beginning and end of the programme and again six months later. The sex, age, social background and health risks of the patients are registered along with their assessment of the programme, changes in their behaviour prompted by the programme and the degree to which they are bothered by personal problems or worries. The following article describes the methods used in this evaluation and outlines some of the 1992 findings. It provides a critical reflection of these methods and proposes a few additional questions to complement those used in the survey. This study is one step towards a comprehensive evaluation of health programmes. It also offers important ideas for developing effective health promotion programmes.     

‘Don't fix what ain't broke’: evaluating the effectiveness of a Men's Shed in inner‐regional Australia

Men's Sheds and similar community programmes are known to encourage help‐seeking behaviour and thus improve the health and well‐being outcomes for the men who attend. This paper investigates this issue through a community needs assessment of a Men's Shed programme in inner‐regional Australia. The immediate purpose of this research was to help direct future funding initiatives, and provide recommendations for potential changes and improvements to the programme. A community‐level needs assessment is a systematic process used to determine and address gaps or needs between current and desired conditions within a particular community. We sought to explore how particular formats and structures of Men's Sheds programmes contribute to improve social and medical well‐being, and whether there are key programme characteristics that could be emulated. In total, 22 surveys and 20 interviews were conducted with the men who participated in the programme. The report finds 95% of men are satisfied with the current running of the programme. While there were areas that have been identified for improvement, most men reported that they are content with the current format and would not like to see major changes to its implementation. The results of this research confirm the known benefits of these types of programmes. This paper provides other community programmes with some insight into the key success factors for running a Men's Shed.     

The end of death in late modernity: An emerging public health challenge

Health promotion discourses often assume that death and loss are someone else's business—usually palliative care or bereavement care. Palliative care and bereavement care, in their turn, provide direct service, acute care approaches to death and loss. Between these two approaches, little health promotion is evidenced. This paper critiques the assumptions both make about death in late modernity arguing that death and loss are increasingly social experiences for people that require active support and community development from the ‘new’ public health. The past therapeutic emphasis and the secularized view of death are receding. A new approach to death and loss is needed and the new public health may have an important major role to play in addressing these changes.     

Who is ‘in’ and who is ‘out’? Participation of older persons in health research and the interplay between capital,habitus and field

Abstract

Inclusion and exclusion processes in community engagement do not take place in a vacuum, but are embedded in social, political and institutional contexts. To better capture the interplay between the individual agency of community participants and organizational structures in health research, we use a Bourdieusian framework. The notions of capital, habitus and field allow us to analyse how inclusion and exclusion of older persons in a Dutch healthcare research- and improvement programme are processually shaped overtime. The findings demonstrate that due to the influence of the medical and policy field, older persons with social, cultural and symbolic capital were included in target group panels. Frail older persons lacking these types of capital were often excluded. Despite the high amount of capital, the formally ‘included’ participants still experienced difficulties in engaging effectively in a medical research setting. We distinguish various strategies that older persons developed during the course of the programme to deal with this problem: (1) professionalization, (2) responsibilization, (3) pluralization, (4) opting out. Using these strategies older participants were able to incrementally change the medical field by shifting the focus to quality of life and welfare. We conclude that it is by definition impossible to ‘exclude exclusion’ at the start of care improvement programmes. It is only in the many pragmatic and mundane choices of ‘doing participation’ that more inclusive engagement can be realized.     

Establishing the economics of engaging communities in health promotion: what is desirable,what is feasible?

Over the last 30 years, there has been a growing recognition of the potential for community-based efforts to improve public health. However, the costs and ‘added value’ of community engagement approaches remain unclear. This paper reports findings from a systematic review of the economic evidence relating to planning, design, delivery or governance of health promotion interventions. Key databases were searched, review bibliographies were checked and experts in the field of economics of public health were consulted. To be eligible for inclusion, studies needed to report community engagement or community development approaches for primary health promotion; to include a control or suitable comparator group; and to assess both health outcomes and costs. Data were extracted and studies were quality assessed. Of the 4405 references screened, 152 records (3%) were potentially relevant and eight studies met the inclusion criteria for the review. Seven studies reported positive findings, but no study was designed to evaluate the impact or cost-effectiveness of a specifically ‘community-engagement’ component. The review found tentative evidence that community engagement as part of a multifaceted approach to health promotion may have positive effects and could be cost-effective. To improve the evidence base for community engagement, future studies need to involve communities more closely at all stages of the research in order to fully capture the community's priorities and perspectives, and appropriately assess the value added and opportunity cost of engagement.     

Maintaining evaluation designs in long term community based health promotion programmes: Heartbeat Wales case study.

STUDY OBJECTIVE--To examine the difficulties of developing and maintaining outcome evaluation designs in long term, community based health promotion programmes. DESIGN--Semistructured interviews of health promotion managers. SETTING--Wales and two reference health regions in England. PARTICIPANTS--Nine health promotion managers in Wales and 18 in England. MEASUREMENTS AND MAIN RESULTS--Information on selected heart health promotion activity undertaken or coordinated by health authorities from 1985-90 was collected. The Heartbeat Wales coronary heart disease prevention programme was set up in 1985, and a research and evaluation strategy was established to complement the intervention. A substantial increase in the budget occurred over the period. In the reference health regions in England this initiative was noted and rapidly taken up, thus compromising their use as control areas. CONCLUSION--Information on large scale, community based health promotion programmes can disseminate quickly and interfere with classic intervention/evaluation control designs through contamination. Alternative experimental designs for assessing the effectiveness of long term intervention programmes need to be considered. These should not rely solely on the use of reference populations, but should balance the measurement of outcome with an assessment of the process of change in communities. The development and use of intervention exposure measures together with well structured and comprehensive process evaluation in both the intervention and reference areas is recommended.     

Evaluating health promotion - progress, problems and solutions

Several issues of current debate in health promotion evaluation are examined. These include the definition and measurement of relevant outcomes to health promotion, and the use of evaluation methodologies which assess both the outcome achieved and the process by which it is achieved. Considerable progress is being made in understanding the complexity of health promotion activity, and in the corresponding need for sophisticated measures and evaluation research designs which reflect this complexity. The more powerful forms of health promotion action are those which are long term, and least easily predicted, controlled and measured by conventional means. Against this, important and valued advances in knowledge and credibility have come from more tightly defined and controlled interventions, which have been evaluated through the application of more traditional experimental designs. This tension between 'scientific rigour' and the perceived advantages (in long-term effectiveness and maintenance) coming from the less-well-defined content and methods of community controlled programmes continues to pose technical problems in evaluation. It is important to foster and develop evaluation designs which combine the advantages of different research methodologies, quantitative with qualitative, in ways which are relevant to the stage of development of a programme. The use of a diverse range of data and information sources will generally provide more illuminating, relevant and sensitive evidence of effects than a single 'definitive' study. Evaluations have to be tailored to suit the activity and circumstances of individual programmes-no single methodology is right for all programmes.     

Evaluation of health policy intervention on the community level--the "Neighborhood Coordination of Health and Social Care" Model Project in North Rhine-Westphalia

Between October 1995 and December 1998 the pilot project 'Local Coordination of Health and Social Care' was conducted in 28 communities of the state of North Rhine-Westphalia. The project has been evaluated by two university research teams. The aim of the project was basically to establish new structures of health planning and coordination at the community level, in order to improve health reporting and health care as well as health promotion. To realize this aim round tables, working groups and project-offices were implemented in the communities. The evaluation was focused on the following question: What were the conditions (structures) and processes that influenced the project outcomes? Qualitative and quantitative methods were applied (interviews, standardised self-administered questionnaires, analyses of documents) to this end. Evaluation of structures showed that most communities succeeded in integrating relevant health policy actors into the newly created round tables and working groups. Working climate and achievements were evaluated favourably by most of the involved actors. All communities succeeded in developing and enacting recommendations for programmes, and about 40% of these programmes were implemented during the project. The probability of programme implementation was particularly high if the programme was based on reliable local data and if execution was effected only on the community level. The possibly beneficial effects on health care and welfare produced by the new programmes could not be assessed within the short project period. The paper concludes with a brief discussion of practical consequences for future health policy at community level.     

Building capable communities: experiences in a rural Fijian context

This paper discusses the design of a methodology for 'building capable communities' in a health promotion programme context. The design of the methodology builds upon previous work and offers a new approach, through the use of nine 'operational domains', for the assessment and strategic planning of community empowerment. The purpose is to go beyond the rhetoric of participation and empowerment, and to provide a better understanding of how community empowerment goals can be made to be operational in a health promotion programme context. The experiences of implementing the methodology in two rural Fijian communities are discussed briefly. The common themes for the successful application of the methodology have been identified. The paper will be of interest to the planners and evaluators of health promotion programmes that aim to build community capacity and promote empowerment.     

Designing community sports-based programmes for men with mental illness: A qualitative study of the Offload rugby league programme

Despite the increasing appeal of community sport programmes which focus on men's mental health, the key design characteristics of these programmes, and the roles played by delivery staff in their conception and development, have not yet been systematically or widely studied. In this qualitative paper we address this gap in knowledge by reporting on interviews with stakeholders (n = 18) from north-west of England involved in designing a men's rugby league community-based mental health programme, Offload. Findings suggest that tacit forms of knowledge, developed through years of professional practice and co-production activity, was critical to how men's mental health was conceptualised and the use of existing non-clinical community assets (e.g. professional club stadia) as delivery sites for the programme. The use of non-stigmatising language, supported by opportunities for men to engage in non-threatening and solutions-focused activities, were central to programme design. The use of former professional sportspeople who recall their own lived experience of mental illness, and personal adversity, in programme sessions was deemed important for engendering trust among men and enabling them to engage in modelling alternative forms of masculine behaviour which can enhance mental health and encourage greater help-seeking. The paper concludes by arguing for a relational understanding of community sport and mental health programmes, since our data indicate that by focusing on the networks of relationships involved in Offload and the social contexts in which it was to be delivered, the programme designers effectively leveraged the benefits of their collective expertise to maximise men's engagement.