Principles and strategies of effective community participation

A framework is offered for understanding the conceptual basisand the strategic implications of community participation, inachieving Health for All goals. Special focus is given to themeaning, settings and levels of participation in official decision-makingstructures and at the community level. Questions such ‘howis participation facilitated?’, ‘who participates?’and ‘what are the benefits and obstacles to participation?’are geared primarily towards the needs of individuals who functionat the city level and expect practical strategic advice andguidance. The structure of the 1989 WHO Healthy Cities Symposiumwhich was devoted to community action was based on the frameworkand conceptual approach of this paper.     

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.     

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.     

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.     

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     

Coding effects in comparative research on definitions of health: A qualitative validation study

In the frame of a comparative study of ‘expressive’and ‘instrumental’ dimensions of the definitionof health, a comparison was made between populations in TheNetherlands and Canada (Toronto, Ontario). The open-ended question‘What is according to you the best definition of health?’was answered by 776 respondents in The Netherlands and 785 inCanada. In both countries the answers were coded by 3 coders.In order to safeguard the comparability between the 2 sets ofdata, the 2 groups of coders received an ‘identical’coder training. The definitions of health among the Canadianrespondents appeared to be more instrumental than among theDutch. This difference remained constant through all the subgroupsin terms of sex, age, education and income. However, a detailedqualitative study of the coder training and the coding processshowed that this difference was caused by differences in thecoding practices rather than by differences between the respondents'answers. An implication of this finding is that quantitativestudies must entail a detailed qualitative assessment of theirown procedures.     

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

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

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     

Patient Requests in Family Practice: A Focal Point for Clinical Negotiations

A growing body of literature has stressed the importance ofeliciting the patient's views on the management of health andillness. In particular, it is recognized that patients frequentlyenter into clinical encounters with specific requests for services,that is ideas about how they hope to be helped. The presentinvestigation examined the following two questions: (1) whatkinds of requests do adult patients coming to a family practicecentre have prior to seeing the doctor; and (2) will factoranalysis of a 25-item patient request questionnaire provideevidence of the basic or most common dimensions of patient requestsin this population? Two newly-developed instruments were administeredto a sample of 144 adult patients before their visit to thedoctor. Factor analysis yielded five major request factors—‘medicalinformation’, ‘psycho-social assistance’,‘therapeutic listening’, ‘general health advice’,and ‘biomedical treatment’ —partially replicatingthe findings of an earlier pilot study. The clinical implicationsof eliciting patient requests in the light of current behaviouraland social science research into the doctor-patient relationshipare discussed. Future research directions are also outlined.     

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.     

Achieving health for all: a proposal from the African Region of WHO

In spite of the disappointment that followed the various ‘short-cut’attempts to implement primary health care (PHC), there is stilla general consensus that PHC is a relevant and, indeed, an appropriatestrategy for achieving health for all (HFA). This, therefore,calls for a need to develop an appropriate framework that wouldreplace the ‘short-cut methods’ and that would alsofacilitate the implementation of PHC. The essence of this paperis to provide such a framework, which tries to resolve somebasic issues before adopting a 'prescribed' organizational frameworkand overcoming major obstacles. It is our belief that, withthe adoption and/or adaptation of this framework, countriescould return to our intended destination of ‘Health forall’.     

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.     

A case of two paradigms within health education

The article outlines two different paradigms which influenceschool health education. The first of these is the moralisticparadigm which is dominant in many current health educationprogrammes in schools. It will be argued that the moralisticand totalitarian paradigm may actually be an obstacle for developinga democratic school in a democratic society. The second paradigmfocuses on democratic health education and is advocated in thispaper as a valuable alternative to the moralistic paradigm.An overview of the major characteristics of the two paradigmis followed by an analysis of several concepts which characterizedemocratic health education, including ‘action competence’,‘action’ and ‘holism’. These conceptsillustrate that health and environment have to be closely linkedin teaching if students are to acquire a coherent understandingof the dynamics behind health issues and health problems. Finally,the ‘IVAC’ approach is suggested as a way of developingaction competence in relation to health and environmental issues.Experiences and examples from the Danish Network of Health PromotingSchools are used to illustrate the thesis presented in thispaper.     

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.     

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.     

Ethics and Epidemiology: The Income Debate

This paper reviews the epidemiological debate between the relativeincome hypothesis and the absolute income hypothesis. The disputebetween these rival hypotheses has to do with whether an adequateaccount of the relationship between income and life expectancyrequires the definition of ‘income’ to include anycomparative element. I discuss the evidence offered for therelative hypothesis (which answers, ‘yes’), as wellas two important criticisms that have been levelled againstthis evidence. I also offer some critical reflections on thedebate from a philosophical standpoint concerned with the ethicsof population health. Both hypotheses agree that a redistributionof income towards the worst off will improve their life expectancy.     

'If I let a goal in, I'll get beat up': contradictions in masculinity, sport and health

This paper presents a critical exploration of the relationshipbetween masculinity, sport and health by reporting findingsfrom a wider qualitative study on lay men’s and healthprofessionals’ beliefs about masculinity and preventativehealth care. Recent years have seen a surge of interest in relationto ‘men’s health’. In particular, the Departmentof Health has highlighted how men’s connection to sport,fitness and competitiveness can be used in health promotioninitiatives to introduce facets of health. In contrast, workin the sociological and feminist literature has raised issuesof concern about the relationship between men, masculinity andsport, particularly the links to aggression, misogyny and homophobia.It would appear then that a straightforward ‘men + sport= health’ relationship cannot be assumed. Focus groupsand interviews with health professionals and men, includinggay and disabled men, were undertaken to facilitate examinationof the socially integrative meanings of sport and masculinity,and their relationship to health. Socializing, ‘macho’culture and the body emerged as three main themes, and the implicationsof these empirical findings for health promotion are discussed.     

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.     

Health promotion in the market place: constraints and opportunities

An emerging trend internationally is for health promo tion servicesto be privatised and organised through a division of ‘purchaser’and ‘provider’ functions. This paper examines theconstraints and opportunities for health promotion in the marketplace through a discus sion often ‘vital signs’drawing on British experience where appropriate. If the marketis not closely managed there are considerable concerns thathealth inequalities could increase, that ethical issues couldbe ignored, and that health promotion practice could be seriouslycom promised. Nevertheless, there are also potential benefitsfrom a market economy, but these will only be realised if thereis a shared understanding of the purchaser/provider roles, adequateskills and resources for the purchaser function, earmarked fundingfor health promotion investment, effective monitoring and refereeingby government as ‘regulator’, and training for thenew tasks and responsibilities. To improve pe, formance a distinctionshould be made between health promotion Design, Development,and Delivery-the three ‘Ds’ of health promotionpractice. Tasks for the three stages are described, togetherwith the potential roles of govern ment, public sector agencies,professional bodies, voluntary organisations and private sectorcompanies. Long-and medium-term time scales are essential foreffective implementation.     

Measurement of Outcomes of General Practice: Comparison of Three Health Status Measures

The broad range of medical problems seen in general practicemeans that the assessment of health outcomes shares much withthe assessment of health status in the general community. Thelast two decades have seen considerable progress in health statusmeasurement for this purpose. This paper reports the use ofthree such measures in a general practice setting. The ‘Randhealth insurance study battery’, the ‘sickness impactprofile’ and the ‘general health questionnaire’were tested in two general practices in Sydney, Australia, todetermine patient compliance, to assess the range of scoresand discriminative ability of the instruments, and to comparethe different instruments. There was a high degree of acceptanceof the questionnaires, showing that patients visiting theirgeneral practitioners are prepared to complete such questionnaires.The range of scores obtained was less skewed for the Rand measuresthan for the sickness impact profile or the general health questionnaire,suggesting that the Rand measures should be the preferred generalhealth status measure.