Community capacity building in practice: constructing its meaning and relevance to health promoters

Community capacity building (CCB) is held up as a benchmark for sustainable health promotion, reflecting the empowering discourse of the Ottawa Charter (WHO 1986). In light of concerns that this language may be that of the presiding bureaucratic elite rather than the realities of those working directly with communities (Laverack & Labonte 2000), we question whether CCB reflects the work of New Zealand health promoters. The aim of this study is to assess what CCB means to health promoters and how relevant it is to their work in New Zealand. Focus groups and interviews were carried out with 64 health promoters between January 2008 and March 2009. The results of this qualitative study indicated that, while the terminology of CCB is poorly established in New Zealand, the overwhelming majority of participants felt that, to be an effective health promoter, they needed the buy-in and support of the communities in which they work. As a result, community-driven approaches have emerged as a core component of good health promotion practice in New Zealand. Yet, the concept of CCB was applied loosely with health promoters adopting language and practices corresponding more with the nuances of community development. The limited use of systematic approaches to building community capacity was accompanied by few successes achieving sustainable health promotion programmes. In prioritising community relationships many health promoters were placed in an ideological bind whereby achieving community ownership over health promotion meant compromising the evidence base of their programmes. Academic discussions of CCB appear to have gained little traction into the realm of health promotion practice in New Zealand highlighting the need for relevant research with a strong grounding in practice.     

Implementation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grant Program: A Process Evaluation

The Community Health Promotion Grants Program, sponsored by the Henry J. Kaiser Family Foundation, represents a major health initiative that established 11 community health promotion projects. Successful implementation was characterized by several critical factors: (1) intervention activities; (2) community activation; (3) success in obtaining external funding; and (4) institutionalization. Analysis of the program was based on data from several sources: program reports, key informant surveys, and a community coalition survey. Results indicate that school-based programs focusing on adolescent health problems were the most successful in reaching the populations they were targeting. The majority of the programs were able to attract external funding, thereby adding to their initial resource base. The programs were less successful in generating health promotion activities and in achieving meaningful institutionalization in their communities.     

The WHO safe community program for injury prevention: evaluation of the impact on injury severity

Despite the fact that injuries consume a considerable amount of health care resources world-wide, 3.5 million people die from unintentional injuries each year. To handle this central public health problem, WHO has introduced the Safe Community accreditation for injury prevention programs. This study was to investigate the impact from a Safe Community program with regard to injury severity. Data were collected in Motala municipality (population = 41 000), Östergötland county, Sweden, during one year before and one year after program intervention, from two sources: registration of trivial (AIS 1) and non-trivial (AIS 2–6) unintentional injuries from all acute care episodes in the area and recollection of hospital bed days from discharge registers. The incidence of non-trivial injuries treated in health care was found to have decreased by 41% (95% confidence interval, 37–45%), while the trivial injuries increased by 16% (9–22%). The larger decrease of non-trivial injuries was observed in all ages and injury event environments. The total number of bed days at emergency hospitals due to injuries decreased by 39% (37–41%) from 1983–84 to 1989, while the hospital bed utilization for other reasons decreased by 9% (8–9%). The study showed that implementation of a WHO Safe Community program led to the harm from unintentional injuries within the community being considerably more reduced than that of the injury incidence. In future assessments of injury prevention programs, classification of injury severity should be included to increase the validity of inter-program comparisons.     

Community-based injury prevention: effects on health care utilization.

BACKGROUND: Worldwide, an estimated 78 million people are disabled each year because of unintentional injuries and about 3 million die. The WHO Safe Community model is a framework for community-based injury prevention programmes. The aim of this study is to evaluate the outcome on health care utilization of a Safe Community programme. METHODS: The incidence of injuries treated at health care facilities in an intervention municipality (pop. 41,000) was compared to the injury incidence in a control municipality (pop. 26,000). The incidence was recorded immediately before and one year after programme implementation from registrations made during all first-contact health care visits and from examination of hospital discharge registers. RESULTS: The incidence of health care treated injuries in the intervention area had decreased by 13% (95% CI: 9-16%) from 119 (95% CI: 115-122) per 1000 population-years to 104 (95% CI: 101-107). In the control area, the corresponding injury incidences were 104 (95% CI: 100-108) and 106 (95% CI: 102-109). The hospital-treated injuries in the intervention area decreased by 15% (95% CI: 7-24%) from 19 (95% CI: 17-20) per 1000 population-years to 16 (95% CI: 15-17), while in the control area, the incidences remained at 13 (95% CI: 11-14) per 1000 population-years. Utilization of acute care in the intervention area for reasons other than injuries increased by 8% (95% CI: 6-10%), while in the control area, the number of visits did not show significant change. CONCLUSION: This first controlled evaluation showed that an injury prevention programme based on local action groups can significantly reduce injuries requiring health care in a community. Local prevention can provide a complement to national level campaigns.     

Impact of social standing on injury prevention in a World Health Organization Safe Community--intervention outcome by household employment contract

BACKGROUND: Although social inequality in health has been an argument for community-based injury prevention programmes, intervention outcomes with regard to differences in social standing have not been analysed. The objective of this study was to investigate rates of injuries treated in health-care among members of households at different levels of labour market integration before and after the implementation of a WHO Safe Community programme. METHODS: A quasi-experimental design was used with pre- and post-implementation data collection covering the total populations <65 years of age during one year in the programme implementation municipality (population 41 000) and in a control municipality (population 26 000). Changes in injury rates were studied using prospective registration of all acute care episodes with regard to social standing in both areas during the study periods. RESULTS: Male members of households categorized as not vocationally active displayed the highest pre-intervention injury rates. Also after the intervention, males in households classified as not vocationally active displayed notably elevated injury rates in both the control and study areas. Households in the study area in which the significant member was employed showed a post-intervention decrease in injury rate among both men (P < 0.001) and women (P < 0.01). No statistically significant change was observed in households in which the significant member was self-employed or not vocationally active. In the control area, only an aggregate-level decrease (P < 0.05) among members of households in which the significant member was employed was observed. CONCLUSIONS: The study displayed areas for improvement in the civic network-based WHO Safe Community model. Even though members of non-vocationally active households, in particular men, were at higher pre-intervention injury risk, they were not affected by the interventions. This fact has to be addressed when planning future community-based injury prevention programmes.     

Quality indicators for implementation of safety promotion: towards valid and reliable global certification of local programmes

The theoretical underpinnings of safety promotion have not yet been integrated with implementation practice to ascertain between-community programme quality. This study sets out to develop a framework for verifying of the quality of community-based safety-promotion programmes in the global context. We analysed the certification indicators deployed in the international Safe Community movement in light of systems theory. Data were collected from focus group interviews with representatives from 10 certified Swedish communities and then analysed by qualitative methods. The community representatives were found to have used the present indicators mainly for marketing the safety-promotion concept to stakeholders rather than as benchmarks for safety practice. When appraised in regard to systems theory, it was found that the indicators did not cover important aspects of health-services implementation. Attainment of outcomes at the population level was not included. Consequently, that information about programme effects in high-risk groups and in risk environments could be neglected. We conclude that programme processes and outcomes at both organisational and population levels must be assessed when the quality of safety-promotion programmes is being certified. A revised set of indicators for certification of safety-promotion programmes fulfilling these criteria is presented.     

Impact of Community-Based Approach as Policy Tool: World Health Organization-Designated Safe Communities of Korea and Health Action Zones of the United Kingdom

Objectives

The aim of this study is to ascertain and identify the effectiveness of area-based initiatives as a policy tool mediated by societal and individual factors in the five World Health Organization (WHO)-designated Safe Communities of Korea and the Health Action Zones of the United Kingdom (UK).

Methods

The Korean National Hospital discharge in-depth injury survey from the Korea Centers for Disease Control and Prevention and causes of death statistics by the Statistics Korea were used for all analyses. The trend and changes in injury rate and mortality by external causes were compared among the five WHO-designated Safe Communities in Korea.

Results

The injury incident rates decreased at a greater level in the Safe Communities compared with the national average. Similar results were shown for the changes in unintentional injury incident rates. In comparison of changes in mortality rate by external causes between 2005 and 2011, the rate increase in Safe Communities was higher than the national average except for Jeju, where the mortality rate by external causes decreased.

Conclusion

When the Healthy Action Zones of the UK and the WHO Safe Communities of Korea were examined, the outcomes were interpreted differently among the compared index, regions, and time periods. Therefore, qualitative outcomes, such as bringing the residents'' attention to the safety of the communities and promoting participation and coordination of stakeholders, should also be considered as important impacts of the community-based initiatives.     

Chasing the dragon: Developing indicators for the assessment of community participation in health programmes

Community participation was identified as one of the key components of Primary Health Care as articulated in the Alma Ata declaration of 1978 and is enjoying a renewal of interest in both low and high income countries. There remains, however, an on-going challenge in how to assess its role in achieving health improvements. This is largely due to the multiplicity of definitions of community participation, which has made it difficult to evaluate its impact on desired programme outcomes, such as uptake and sustainability, as well as broader health improvements. This paper addresses this challenge by first defining a continuum of community participation that captures its many forms, and then incorporates this into an evaluation framework that enables an analysis of the process of participation and links this with health and programme outcomes. The continuum of participation and framework is based upon the spidergram of Rifkin, Muller, and Bichmann (1988), but modified in the light of the growing literature on community participation and also in relation to our original requirements to evaluate the role of community participation in nutrition-related child survival programmes. A case-study is presented to provide a worked example of the evaluation framework and its utility in the evaluation of community participation. While this is a literature-based and retrospective analysis, it demonstrates how the evaluation tool enables a nuanced analysis of the different ways in which communities can participate in the delivery of health-related interventions. It could be used prospectively by those involved in programme design and implementation to further our understanding of community participation and its relationship with health outcomes, as well as key programme outcomes, such as sustainability.     

Injury status and perspectives on developing community safety promotion in China

The objective of this paper is to introduce the epidemiology of injuries in China, and then consider the development of safe communities in regard to injury prevention and safety promotion. The disease spectrum has changed in recent decades in the People's Republic of China. Both in cities and rural areas, injury has become the fifth leading cause of death. At least 800 000 people die from injury each year, and 50 million non-fatal injuries occur, of which 2.3 million lead to disability of varying degrees of severity. The average injury-related death rate in China from 1990 to 1997 was 66 per 100 000, which accounts for 11% of total deaths. The potential years of life lost (PYLL) of injury accounts for 24% of the total, and disability-adjusted life years (DALYs) account for 17%. Main injury causes of death, in descending order, are: suicide, traffic accident, drowning, falling, poisoning, homicide, burn and scald, and iatrogenic injury. Considering China's current injury status and its rapid societal change, injury prevention and safety promotion need to be strengthened further, and there is a special need for the development of Safe Communities programmes. The prevention of injuries through safety promotion has been increasingly focussed on over recent decades. The WHO Safe Community model is recognized as representing an effective and long-term approach to the prevention of injuries at a local level, and has been beneficially applied all over the world. A programme may cover several aspects of injury prevention and safety promotion simultaneously, or only include one or two aspects. In a Safe Community programme in China, children, the elderly, cyclists and their passengers, and farmers should be among the prioritized target populations. However, multi-focussed inter-sectoral programmes have been shown to have additional effects to distinct sectoral programmes.     

Booze and beach bans: turning the tide through community action in New Zealand

Many beach and holiday resorts experience major problems with alcohol-related public disorder. Following an escalation in alcohol-related incidents in the New Zealand beach community of Piha, a community-driven response to address issues of community well-being and safety was initiated by concerned residents. A case study evaluation reported on the development of a community coalition involving community and statutory stakeholders and the successful implementation of local community action strategies. These included a beach alcohol ban, extensive local publicity and a community policing presence over successive summers. An examination of the case study suggests that inter-sectoral collaboration, and multiple level strategies through policy, promotion and enforcement activities are key factors in enabling communities to successfully reduce alcohol-related harm.     

DEVELOPING A RURAL COMMUNITY-BASED DISABILITY SERVICE: (I) SERVICE FRAMEWORK AND IMPLEMENTATION STRATEGY

ABSTRACT: In response to widely recognised dilemmas associated with rehabilitation and disability service provision in remote and rural areas of Australia, a community-based, participatory approach to service development was adapted for a disability service project in central Queensland. The service framework, known as Community Based Rehabilitation (CBR), fosters the involvement of community members in disability service provision. Although this framework has been described previously, few guidelines exist regarding appropriate implementation of such an approach. Consequently, the implementation strategy known as Participatory Rural Appraisal (PRA) was adopted. Participatory Rural Appraisal has been reported to foster the participation and decision-making of community members in community projects. The present article describes the application of this implementation strategy to disability service provision in a relatively under-resourced rural shire. The rationale, framework and process of the pilot are described. A subsequent publication will document the service component, detail evaluation findings and describe the long-term outcomes of this research.     

Safe Communities in China as a Strategy for Injury Prevention and Safety Promotion Programmes in the Era of Rapid Economic Growth

Due to its rapid economic development, China is facing a huge health, social, and economic burden resulting from injuries. The study’s objective was to examine Safe Communities in China as a strategy for injury prevention and safety promotion programmes in the era of rapid economic growth. Literature searches in English and Chinese, which included grey literature, were performed on the Chinese Journal Full-text Search System and Medline, using the words “Safe Community”, “injury”, “economics”, and “prevention”. The results showed that the existing 35 recognized members of the International Safe Community Network have not placed due emphasis on suicide prevention, which is one of the leading problems in both rural and urban China. A few groups, such as children, the elderly, cyclists, and pedestrians, have received due emphasis, while other vulnerable groups, such as migrant workers, motorcyclists, students, players, and farmers have not received the necessary attention from the Safe Community perspective. As the evidence describes, Safe Communities in China can be a very effective strategy for injury prevention, but four aspects need to be strengthened in the future: (1) establish and strengthen the policy and regulations in terms of injury prevention at the national level; (2) create a system to involve professional organizations and personnel in projects; (3) consider the economic development status of different parts of China; and (4) intentional injury prevention should receive greater attention.     

Advocacy as a means to an end: assisting refugee women to take control of their reproductive health needs

Negotiating reproductive rights is particularly complex for resettling migrant women from refugee backgrounds. In our ongoing work with women who have fled from countries in Africa and the Middle East, and have resettled in Australia and New Zealand, subtleties of discrimination and perceptions of human rights discriminations were revealed through the complex interplay between research and advocacy. Community Based Participatory Research (CBPR) has therefore been critical in assisting women to identify their needs and negotiate acceptable solutions with health services. This paper presents qualitative and quantitative findings of research with women from refugee backgrounds in Australia (n = 255) and New Zealand (n = 64). The research questions were a combination of community-driven and researcher initiated issues and the projects developed through a continuous iterative process involving feedback from women in the community. We highlight the essential role of advocacy in CBPR and how that can enhance research quality. We argue for the justification of this approach as not only valid and credible but essential in research with these and other communities.     

Measuring the impact of a school food programme on food sales in New Zealand

The School Food Programme of the Heart Foundation of New Zealandis a health promotion programme which aims to improve the healthof the school community by increasing children's access to foodswhich are nutritious, safe and sufficient in quantity. The programmewas introduced to New Zealand primary and secondary schoolsin 1989. Outcome evaluation undertaken in 1992 concluded thatthe programme had a positive impact in creating healthier schoolenvironments. As a result, programme implementation continued.The objective of this study was to identify whether the schoolfood service has altered, as a result of programme implementation.The main outcome measures were food service staff reports onchanges in sales of specific food items. Two hundred schoolsout of a total of 2730 schools in New Zealand were successfulin achieving Heartbeat Awards by meeting all the programme criteriabetween January 1996 and December 1997. Thirty-two schools achievedawards in successive years, and data from all 232 awards wereincluded in the analysis. Schools were categorized accordingto the number of years that they had participated in the programme.Increasing participation in the programme was found to be significantlyassociated with a reduction in the sales of doughnuts and creambuns (p = 0.01), pies and sausage rolls (p = 0.009), crisps(p = 0.0065) and sweets (p = 0.004), and an increase in salesof sandwiches and filled rolls (p = 0.0005). Other foods allshowed changes in a favourable direction, although the proportionsdid not change significantly over the years. Limitations ofthis study include self-selection bias and the use of self-reporteddata. However, the results of the evaluation indicate that theSchool Food Programme is successful in achieving its aim ofinfluencing the school environment by improving healthy foodchoices, and that improvements have continued over 7 years inthe programme.     

Telehealth in New Zealand: current practice and future prospects

We have surveyed the current state of telehealth in New Zealand. The survey found 22 telehealth projects active in 2003, compared with 12 identified in a previous survey in 2000. Many projects were small, localized and led by enthusiasts. Sustainability was a problem and many projects had failed to enter routine operation. Teleradiology and telepsychiatry services focused on acute hospitals were the most frequent clinical applications. The majority of projects (9 of the 22) were on the North Island, concentrated around Auckland. Telehealth appears to have special potential for rural communities and for the remote treatment (telecare) of chronic disease. However, the provision of telehealth in New Zealand is patchy and meets the same barriers to success as have been identified elsewhere, which make it difficult to move telehealth into routine operation. The obstacles constitute not so much a failure of individual projects as a lack of a driving force to take advantage of the opportunities. It is to be hoped that a suggested strategic framework can help to harness the opportunities.     

Community Engagement in Youth Violence Prevention: Crafting Methods to Context

The purpose of the Youth Violence Prevention Centers (YVPC) Program at the Centers for Disease Control and Prevention is to reduce youth violence in defined high-risk communities through the implementation and evaluation of comprehensive, evidence based prevention strategies. Within this common framework, each YVPC varies in its structure and methods, however all engage communities in multiple ways. We explore aspects of community engagement employed by three centers that operate in very different contexts: a rural county in North Carolina; a suburban area of Denver, Colorado; and an urban setting in Flint, Michigan. While previous research has addressed theories supporting community involvement in youth violence prevention, there has been less attention to the implementation challenges of achieving and sustaining participation. In three case examples, we describe the foci and methods for community engagement in diverse YVPC sites and detail the barriers and facilitating factors that have influenced implementation. Just as intervention programs may need to be adapted in order to meet the needs of specific populations, methods of community engagement must be tailored to the context in which they occur. We discuss case examples of community engagement in areas with varying geographies, histories, and racial and ethnic compositions. Each setting presents distinct challenges and opportunities for conducting collaborative violence prevention initiatives and for adapting engagement methods to diverse communities. Although approaches may vary depending upon local contexts, there are certain principles that appear to be common across cultures and geography: trust, transparency, communication, commitment. We also discuss the importance of flexibility in community engagement efforts.     

Implementing a chronic disease strategy in two remote Indigenous Australian settings: a multi-method pilot evaluation

Objective: To test an evaluation framework designed to evaluate implementation of the North Queensland Indigenous communities between August and December 2005. Setting: Both communities are located in Cape York, North Queensland. Community A has an estimated population of around 600 people; Community B has an enumerated population of 750, although health centre records indicate a higher number. Participants: Process evaluation involved health centre staff in both communities; clinical audits used random samples from the adult population (each sample n = 30); ethnographic fieldwork was conducted with resident population. Main outcome measures: Health centre scores and qualitative findings using a System Assessment Tool; clinical audits – extent to which scheduled services recorded; selected primary health performance indicators; qualitative ethnographic findings. Results: On almost all indicators, implementation of NQICDS had progressed further in Community A than in Community B; however, some common issues emerged, especially lack of linkages between health centres and other groups, and lack of support for client self‐management. Conclusions: The evaluation framework is an effective and acceptable framework for monitoring implementation of the NQICDS at the primary health centre level.     

A critique of contemporary community health promotion approaches: based on a qualitative review of six programs in Maine

PURPOSE. This article reports on a process evaluation of three Planned Approach to Community Health (PATCH) projects and three Community Chronic Disease Prevention Programs (CCDPP) that operated in the State of Maine. PATCH and CCDPP are similar approaches to community health promotion developed and disseminated by the Centers for Disease Control. The evaluators studied how the Planned Approach to Community Health and the Community Chronic Disease Prevention Program models worked as community health strategies across the six field sites. RESEARCH METHODS USED. Qualitative methods were used in a cross-case comparison of the six field sites. In studying each site, the evaluators focused on six stages common to both the Planned Approach to Community Health and the Community Chronic Disease Prevention program models: Stage 1: conducting a community needs assessment; Stage 2: analyzing needs assessment data; Stage 3: setting priorities for the project based on the data; Stage 4: implementing activities; Stage 5: producing process outcomes; and Stage 6: institutionalizing the project. The analysis focused on how each of the six communities traversed these stages. SUMMARY OF FINDINGS. Eight recommendations for refining Planned Approach to Community Health and Community Chronic Disease Prevention strategies resulted from the study: 1) do a community capacity assessment prior to initiating a community needs assessment; 2) do not overly rely on Behavioral Risk Factor Surveys; 3) analyze needs assessment data rapidly for community consumption; 4) allow flexibility and community input in determining priority health objectives; 5) provide technical assistance throughout a project, not just in the beginning; 6) fund at least one full-time local coordinator and extensive capacity building; 7) emphasize multiple interventions around one chronic condition at a time; and 8) emphasize program institutionalization. CONCLUSIONS. Community development approaches like Planned Approach to Community Health and Community Chronic Disease Prevention are promising health promotion strategies. To be optimally effective, however, these strategies need refinement based on systematic study in field settings. Because this study was limited to six sites in Maine, some of these findings may have limited generalizability.     

Youth Empowerment Solutions for Peaceful Communities: combining theory and practice in a community-level violence prevention curriculum

This article describes the development and evaluation of an after-school curriculum designed to prepare adolescents to prevent violence through community change. This curriculum, part of the Youth Empowerment Solutions for Peaceful Communities (YES) program, is guided by empowerment and ecological theories within a positive youth development context. YES is designed to enhance the capacity of adolescents and adults to work together to plan and implement community change projects. The youth curriculum is organized around six themed units: (a) Youth as Leaders, (b) Learning about Our Community, (c) Improving Our Community, (d) Building Intergenerational Partnerships, (e) Planning for Change, and (f) Action and Reflection. The curriculum was developed through an iterative process. Initially, program staff members documented their activities with youth. These outlines were formalized as curriculum sessions. Each session was reviewed by the program and research staff and revised based on underlying theory and practical application. The curriculum process evaluation includes staff and youth feedback. This theoretically based, field-tested curriculum is designed to be easily adapted and implemented in a diverse range of communities.     

Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA)

BACKGROUND: Program budgeting and marginal analysis (PBMA) is a framework for setting priorities in health care, used internationally over the last 25 years in Britain, Australia and New Zealand. However, the framework has undergone limited evaluation, and insight into how such evaluation should even take place is not found in the literature. METHODS: Seven PBMA case studies were conducted in three Canadian health regions to examine the feasibility of applying the PBMA framework. Structured follow-up surveys with the users of the framework were carried out following the priority setting exercises. RESULTS: The PBMA framework was feasibly implemented in three regionalized contexts and was generally viewed favorably by managers and clinicians who participated in the case studies. Numerous methodological lessons were learned and it was found that successful implementation hinges on organizational context. An empirically derived model describing PBMA is outlined and put forth as an evaluation framework for future exercises. CONCLUSIONS: Comparisons to the health care management literature indicate that the derived PBMA model is a novel addition to this broader literature. Overall, managers in health organizations internationally would be well-served to consider PBMA to aid regional decision-making processes, but should do so with explicit consideration of the context in which such activity is to occur.