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.     

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     

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.     

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.     

The impact of the COSHH regulations on workers with occupational asthma

In the UK, the COSHH Regulations give specific guidance thatemployers have duties to inform, instruct and train their employeesabout occupational risks and provide them with suitable healthsurveillance. The aim of the study was to evaluate the impactof the Regulations on employees with occupational asthma. Onehundred consecutive patients attending an occupational lungdisease clinic completed a questionnaire assessing the implementationof the COSHH Regulations in their workplace. Twenty-eight percent had a pre-employment inquiry about asthma, 31% had regularhealth surveillance by questionnaires and 19% had regular lungfunction assessment at work. Pre-employment spirometry was carriedout in 44% of the workers who were exposed to one of the originalseven prescribed agents, significantly more than those who wereexposed to other agents (19%) (p < 0.05). Moreover, figuresfor spirometry during employment were 31% and 8% respectively(p < 0.05). The patients who worked after ‘COSHH’but before ‘MS25’ had a tendency to be providedwith health surveillance more than those who worked after both‘COSHH’ and ‘MS25’. Ninety-one per centof the patients had never been informed about the risks of gettingasthma at work and 73% had never seen the safety data sheets.The workers who (1) worked after ‘COSHH’ introduction;(2) worked in larger firms and (3) were exposed to one of theoriginal seven prescribed agents, had a tendency to be informed,instructed and trained more than the rest. However, there wereonly significant statistical differences (p<0.05) in termsof the safety data sheet provision between the cases who workedbefore the time of the legislation and those employed afterwards.     

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

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

Evolution of primary health care in Thailand: what policies worked?

Thailand has a long history of primary health care (PHC) developmentwhich started before the Declaration of Alma Ata in 1978. TheNational PHC programme was implemented nation-wide as part ofthe Fourth National Health Development Plan (1977–1981)focusing on the training of ‘grass-root’ PHC workersconsisting of village health communicators and village healthvolunteers. Since then PHC has evolved through many innovativehealth activities: community organization, community self-financingand management, the restructuring of the health system and multisectoralco-ordination. Many of the essential elements of PHC have beenachieved. Improvements in the nutritional status of childrenunder five households accessiblity to clean water, immunizationcoverage, and the availablity of essential drugs have been observed.PHC has been successful in Thailand because of community involvementin health, collaboration between govermment and non-govermmentorganizations, the integration of the PHC programme, the decentralizationof planning and management, intersectors collaboration at operationallevels, resource allocation in favour of PHC, the managementand continuous supervision of the PHC programme from the nationaldown to the district level, and the horizontal teaining of villagersto villagers.     

Effect and stage models in community intervention programmes; and the development of the Model for Management of Intervention Programme Preparation (MMIPP)

Recent years have seen the development of a number of diagrammatic‘models’ bearing on community intervention programmes.There have been two basic types, one involving actual or hypotheticalcausal relationships (effect, or how-it-works models) and theother, sequences of activities or events (stage, or how-to-do-itmodels). A selection of such models, with their roots in differenttheories of social change, health education and health promotion,are reviewed in the light of this distinction. Both types ofmodel are important. Existing stage models for health promotion programmes implyan ordered or cyclical set of activities, in which preparationis followed by implementation, maintenance, evaluation and revision.In the second part of the paper a new and more detailed typeof stage model is presented for the preparatory phase. In practice,this phase involves a series of parallel but interdependentactivity streams. These add up to a complex process that needsto be carefully planned and managed. In such circumstances itis important to be able to convey to the various people andorganisations involved how their different contributions meshtogether. The new model is designed to help with this. It hasbeen developed in the light of experience of planning community-baseddisease prevention programmes in Stockholm and elsewhere, withthe objective of making the lessons learned available for othersin a compact and accessible form.     

Health care as an instrument of Apartheid policy in South Africa

The paper focuses on five central features of health policyin South Africa. These are: (1) the differential expenditureon the health services for Whites, Coloureds, Indians and Africans;(2) the inequality between rural and urban African health services;(3) the structure and financing of rural health services forAfricans; (4) the recent restructuring of the urban health servicesfor Whites, Coloureds and Indians under the New Constitution;and (5) family planning policy. In each case the policy cannotbe adequately explained merely as a symptom of the differentialaccess to political and economic power: health services arealso instruments of the state in achieving Apartheid goals.Firstly, the health services aid in the reproduction of theBlack labour force according to White economic needs. The provisionof health care for Blacks outside the bantustans is geared towardsthe urban population as the supplier of a large and increasinglyskilled, Black workforce, rather than the Black population atlarge. Secondly, the health services support the commitmentto ‘separate development’ in various ways. Theyreproduce an ideology which legitimizes Apartheid. Within thebantustans, they are an important factor in inducing ‘surplus’Africans from ‘White’ areas to return to the bantustans.They help to establish the credibility of the bantustans andtheir leaders, and of the representatives in the new segregatedparliament. They also provide a lever with which the governmentcan pressurize bantustan governments into accepting ‘independence’.Thirdly, the health services are part of a strategy to co-optsome Blacks while dividing the opposition. Thus health policyis shown to be an instrument of the state's twin imperatives:reproducing the conditions of capitalist accumulation and maintainingWhite supremacy.     

ERRATUM

In the article by A. L. Morgan ‘Cholinesterase Problemsarising in a Plant Manufacturing Tri-aryl Phosphates’(Journal of the Society of Occupational Medicine 31, 119–122)on p. 120, the first sentence of Case 1 should read ‘Thisindividual had three split blood samples examined.’     

WHEN ALCOHOLICS DRINK AFTERSHAVE: A STUDY OF NONBEVERAGE ALCOHOL CONSUMERS

A one-year prospective study was conducted to describe nonbeveragealcohol (NBA) consumption (the use of substitutes for traditionalforms of ethanol) among alcoholics. It was found that 11% ofinpatient alcoholics at a veterans' hospital and 8.6% of alcoholicsat a community hospital had consumed NBA. Substances consumedranged from toiletries to organic solvents, often in quantitiesexceeding the theoretical lethal dose. ‘Ready availability’was cited as the primary reason for consumption. Social, demographicand psychiatric parameters were then compared between 48 VAalcoholics who used NBA and 48 nonusing alcoholics. No socialor demographic differences were found, but NBA drinkers drankmore alcohol (P < 0.0001), had higher global alcoholic severityscores (P < 0.0001), more severe withdrawal symptoms (P <0.0001), and a higher frequency of antisocial personality disorder(P = 0.009) and drug abuse (P = 0.005). When NBA drinkers weresubdivided by quantity of NBA consumption and recency of latestingestion, no social or psychological differences were foundbetween groups, except for more frequent and heavier illicitdrug use among ‘heavy’ NBA consumers (P < 0.0001).     

The role of health education versus safety regulations in generating skin cancer preventive behavior among outdoor workers in Israel: an exploratory photosurvey

The present photosurvey corroborated with our 1995–1997evaluation study of a multifaceted skin cancer control programamong outdoor workers of Mekorot—Israel National WaterCompany (Shani et al., 1998, Final Research Report presentedto the Committee for Research and Prevention in OccupationalSafety and Health). While the survey's primary purpose was toinvestigate the impact of health education versus sun-protectionregulations (issued when the project ended) on workers' skincancer preventive behavior (SCPB), it also experimented with‘objective’ tools of data collection. Visiting workingsites and mother-base, 118 workers were approached. Of these,51 former program-involved workers (‘education’group) and 50 former non-participants (technical barriers),and newly recruited ones (‘regulation’ group) whofilled out a one-page questionnaire, had their photographs takenand were measured (spectrophotometer) for melanin presence,were included in the present study. Findings indicated thatparticipants in the ‘regulation’ group had a significantlylower mean years of seniority and a higher number of workersin semi-skilled occupations. Both groups were identical in age,ethnic origin and reported skin type. Consistent and significantbetween-group differences were observed in the SCPB and melaninpresence mean scores, suggesting better SCPB habits among the‘education’ group employees in comparison to theircounterparts. The multiple regression analysis indicated thatformer program-involved participants and older workers weresignificantly more likely than others to comply with desiredSCPB practices. Combined, our previous and present findingssuggest that the educational approach was indispensable forgenerating and sustaining long-term skin cancer control practicesand was preferable to the use of regulations, per se. Thoughno final conclusions could be drawn regarding the validity ofthe spectrophotometer- and camera-related procedures, and bothare limited with regard to uncovering the motivational factorsof behavioral outcomes, it should be recognized that the camerais a low-cost and easily available tool for capturing ‘reality’while overcoming management's claims on workers' time. Resultsare also discussed in terms of practical implications.     

Disturbing distortions: a response to Elihu Richter's response

It was disheartening and sad to read Dr. Elihu Richter's knee-jerkresponse to the publication of our article ‘Imprints onthe Consciousness ... .’ in the European Journal of PublicHealth recently, as he was trying to justify the unjustifiableand distort reality. We are all too aware of the problem offalling into the trap of counting dead bodies and fixating onthe consequences rather than the causes of death, injury andill health in both Palestine and Israel, as the cause     

erratum

JOURNAL OF THE SOCIETY OF OCCUPATIONAL MEDICINE, 24, 87 and88. Table I and Table II were transposed. 81, the first sentenceunder Treatment with.Calcium Gel should have read: ‘Klauderet al. (1955) reported the successful treatment of a late hydrofluoricacid burn by topical 5 per cent calcium gluconate in wool fatcombined with calcium gluconate intravenously’. 84, column1, line 8, ‘articles’ should have read article.     

Testing a conceptual model related to weight perceptions, physical activity and smoking in adolescents

The purpose of this study was to test a conceptual model basedon theoretical and empirically supported relationships relatedto the influences of weight perceptions, weight concerns, desiresto change weight, friends, age and location in relation to physicalactivity (PA) and smoking in adolescents. A total of 1242 malesand 1446 females (mean age = 15.6 ± 1.3) were recruitedfrom rural and urban Canadian schools. Study respondents providedself-reports of PA, ‘smoking’, ‘perceivedbody weight’, ‘desire to change weight’, ‘concernabout weight gain’ and ‘friends' smoking and PAbehaviors’. Results revealed an acceptable fitting model² (40) = 155.63, P < 0.05, root mean square error of approximation= 0.047 and comparative fit index = 0.98. Large effect sizesfor both genders were observed between friends' and adolescents'smoking behavior, and between perceived body weight and desireto change weight. Further, significant differences were identifiedbetween the male and female models [² difference (24) = 65.28,P < 0.05]. Several findings of this study point to the needto design programs to motivate adolescent females to adopt healthyweight-control practices and to target young peoples' socialnetworks to promote health behaviors, especially with regardto smoking. Received on December 22, 2005; accepted on June 15, 2006     

PERCEPTIONS OF DRINKERS AND ABSTAINERS IN A SAMPLE OF SCOTTISH ADULTS

Following Davies and Stacey's investigation (1972, Teenagersand Alcohol, HMSO, London) into perceptions of drinking andabstaining among Scottish teenagers, this study extended theirgeneral method to an investigation of the perceptions of 239Scottish adults. Results showed that the stereotypes of theheavy drinker as ‘tough and rebellious’ and theabstainer as ‘weak and cissy’ persist into adulthood.Heavy drinkers were seen as low on ‘sociability’and ‘sexual attractiveness’ and abstainers wereseen as less ‘sociable’ than moderate drinkers.There was also some evidence of a ‘double standard’in perceptions of male and female drinking roles. Other findingsconcerning the effects on perceptions of subjects sex and drinkingbehaviour are compared to those reported in the earlier studyand implications for the treatment of alcohol problems are discussed.It is concluded that the dimensions described by Davies andStacey represent a relatively stable structure within futureresearch where fresh initiatives in alcohol education may belocated.     

Resistance to peer group pressure: an inadequate basis for alcohol education

saper explores the notion of ‘peer group pressure’as it has been deployed in educational interventions on alcoholfor adolescents. It is argued that ‘peer group pressure’is an inadequate explanation for youthful alcohol use and thatinterventions formulated around the inculcation of resistanceto peer group norms must inevitably be at variance with theeveryday experience of those at whom such interventions areaimed. The paper argues that a reformulation of the conceptof ‘peer group pressure’ opens up its positive featuresand that these offer a strong base for a new range of educationalinitiatives.     

Focus-group methods: effects on village-agency collaboration for child survival

In the West African nation of Togo an essential element of healtheducation in support of child survival is the training of mid-levelhealth workers to conduct focus-group interviews with caretakersof children under 5 years of age. The intent is to develop thecapability of the National Health Education Unit to establishqualitative data bases that complement survey data on maternalpractices related to child health. These data are used to designand evaluate the health education component for programmes ofchildhood immunization, the control of diarrhoeal diseases,and malaria. Following a five-day training programme in late 1986, healthworkers collected and prepared for analysis data from 81 focus-groupinterviews involving a total of 324 mothers living in nine ruralTogolese villages. In addition, two unanticipated effects wereobserved during and after training. First, the focus-group methoddemocratized data gathering by forcing health workers out oftheir perceived roles as experts and teachers, and mothers outof being helpless villagers and learners. Second, by stimulatingthis shift in roles, the focus-group process enhanced the developmentof community competence, thereby promoting collaborative programmeplanning by health workers and target villages. Dramatic increases in childhood immunization rates offer evidencethat focus-group interviews can play an important role in stimulatingthe needed interaction between clients and providers to planand carry out a community education ‘mini-campaign’in each village. It is from such group processes that collectiveawareness of needs, and actions to resolve them, can arise.Child survival projects should consider training mid-level healthworkers to gather focus-group data as an action-research approachto planning, implementing and evaluating their community healtheducation programmes.     

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

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