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.     

Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion

This paper considers the conceptual basis of intersectoral collaboration(ISC) in health promotion. It summarises concepts and perspectiveswithin literature loosely labelled as ‘interorganisationalrelations’. These are applied to health promotion, specificallythe development of healthy public policy at local level. Whilethe importance of collaboration and working together at practitionerlevel is acknowledged, the main emphasis is on strategic levelcollaboration and policy coordination. The aim is to consolidateunderstanding of the concept, its features and its ‘determinants’.Ways in which collaboration might be fostered are considered.     

Towards a framework for outcome assessment of health intervention: Conceptual and methodological considerations

We provide a framework for assessing the outcome of community-basedintervention programmes for the promotion of cardiovascularhealth at local level. Particular attention is therefore givento conceptual components connected with community participationin health programmes and to methodological approaches in theevaluation of cardiovascular disease (CVD)-prevention programmes.In a search of the literature covering more than 20 years (1966–1988)in 2 databases (MEDLINE and SOCA), we found that the conceptsof ‘community participation’ and ‘communityinvolvement’ have mainly been used during the latter halfof the study period. The concepts were often used interchangeablyand with no statement as to their precise meanings. The methodologicalexamination of 2 well-known community-based CVO-preventive programmesrevealed that most of the scientific papers from these programmesdealt with health behavioural and/or medical effects. The suggestedframework presented in this study is designed as a longitudinalprocess analysis focusing on critical key steps along the pathfrom input to output. The suggested research strategy is problem-orientated,inter-disciplinary and based on a multi-method approach.     

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.     

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.     

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.     

Who gets what: politics, evidence, and health promotion

Science journal, starting with its July 2005 issue, presentsits readers with 125 questions and problems yet to be resolvedby the scientific community. These range from the deceptivelysimple (‘what is the structure of water?’), theobvious (‘what triggers puberty?’ or ‘whatare the roots of human culture?’), to the amazingly esoteric(‘do mathematically interesting zero-value solutions ofthe Riemann zeta function all have the form of a+bi?’). More than half of these issues have     

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.     

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.     

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.     

The Wellness Guide: towards a new model for community participation in health promotion

This paper describes how community participation came to playa central role in developing the Wellness Guide Project, a majornew health promotion initiative of the State of California.The Guide itself was to be a simple document that would giveinformation on how to stay well and where to find help on health-relatedtopics. It was to be sensitive to the needs of people of allethnic and social backgrounds, and suitable for distributionto all households in the State (10 million). The metamorphosisof the Guide is described, from early drafts, prepared by healthand welfare specialists and covering traditional behavioralrisk factors, to the final product, a large-format, illustrated80-page book, written with diverse community involvement, andaddressing a wide range of personal and social topics. Telephonecompanies and information and referral services participatedin developing a cross-referral system from the Guide to new‘Community Services’ listings in phone directoriesthroughout the State. The community also participated in preparinga Spanish adaptation of the Guide. The project outcomes—aunique health education document, a novel referral system, andthe beginnings of a new model for community participation inhealth promotion—are discussed.     

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.     

A 'component circuit approach' to needs assessment and strategy selection in health promotion

An approach to formative research in health promotion is describedwhereby significant ‘components’ in the field areidentified and involved as part of a circuit, to test and generateideas. The underlying model is similar to corporate planningprocedures whereby relevant ‘stakeholders’ are identified,and their need and interactions taken into account in generatingthe organization strategic plans for achieving its corporategoals. The process involves aspects of quantitative and qualitativeresearch, the mix of which can vary according to the requirementsof the situation. The use of the process for developing nutritionstrategies for the ‘Health for All Committee’ inone State of Australia is described.     

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.     

General Practitioners' Strategies and Tactics of Communication with the Terminally III

Interviews with 22 randomly selected general practitioners (GPs)investigated their communication with terminally ill patients.In interview analysis a conceptual distinction was drawn betweenobjectives, strategies and tactics. When treating terminal patients,GPs expressed the objectives of keeping the patient comfortable,painfree, happy and maintaining dignity. A strategy is a planand mode of approaching patients existing over an extended timeperiod. Three strategies were described by GPs for use wheninteracting with terminally ill patients. These are characterizedas ‘try to disclose’, ‘let the patient decide’and ‘avoid disclosing’. Tactics refer to behavioursused within a single consultation, as part of a strategy. Sixtactics are described: evasion, denial, uncertainty, hints andprompts, euphemism and reassurance. Different strategies implyquite different forms of consultation. Thus to understand aconsultation we must place it into the context of the series.     

Primary health care: why has water been neglected?

Since primary health care became ‘selective’ theneed for clean water sources has largely been neglected. Thispaper highlights both the economic and philosophical necessityto look again at the approach to primary health care. An observationalstudy from Nigeria is used to exemplify a community where aclean water source was the most urgent need, yet was ignored.Guinea worm infestation therefore caused serious disabilityin the community and resulted in a reduced uptake of the veryforms of ‘selective’ primary health care that havebeen favoured internationally - breastfeeding, immunizations,malaria treatment and oral rehydration therapy. In particular,the effect of such disability on women - who have prime responsibilityfor the health and welfare of their families - was seriouslyunderestimated, to the detriment of child health and survival.A clean, convenient water supply should be an essential componentof primary health     

Doctors' drinking and fitness to practise

Rosta and Aasland's paper (2005) ‘Female surgeons’alcohol use: A Study of a Nation-wide Sample of Norwegian Doctorsadds to the evidence that doctors are at increased risk of becomingdependent at some point in their career. The finding that detrimental drinking by surgeons was more prevalentthan might be expected may point to important fitness-to-practiseconsiderations. The questions ‘Who cares about doctors as individuals?’and ‘Who cares for doctors apart from family and friends?’seem still to be difficult to answer. A doctor's independence and ability to become immersed in apatient's plight are key components for     

Keeping the {heartsuit} Beat in Grampian--a case study in community participation and ownership

In the Grampian Region of Scotland, a new 10 year heart healthinitiative, ‘Keeping the Beat in Grampian’ waslaunched in October 1991. Although this programme is based ona number of well-tested health promotion principles it is uniquein a number of aspects. The concepts of community ownership,corporate identity and people empowerment have been extendedto a much greater degree. The programme is registered as a privatecompany with charitable status so that management, decision-makingand budgetary control are vested totally in the community.     

Errata

In the Lucas Lecture 1981, ‘Professional Ethics—ForWhose Benefit’, by Paul Sieghart (32, 4–14) the following errors occurred. The author's position is Barrister not Barrister-at-Law. The following lines should read: p. 4, column 2, line 2: ‘troubled Dr Conor Cruise O'Brien(1980).’ p. 5, column 1, line 32: ‘regard it as the study of morality,that is, the’. p. 9, column 1, line 27: ‘conflicts? Of all the specialties,that of. p. 9, column 2, line 4: ‘order of a competent court ortribunal’. p. 12, column 2, line 16: ‘himself of that obligationbecause another’.