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.     

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.     

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.     

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.     

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.     

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.     

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.     

Promoting school health education: examining the role of a statewide conference for school and community leaders

Improving the delivery of school health education may well belinked to the inclusion of and commitment from high-rankingdecision makers from schools and youth organizations. This studyexamined the role of a statewide school health summit in promotinghealth education among representatives from state and communityorganizations. We conducted the study in two phases: (1) developmentand testing of a measuring instrument, and (2) role examinationvia conference assessment. Overall, the measurement instrumenthelped us investigate two areas: the inclination of an individualleader of a health organization to promote organizational changesto assist school health education and the background of a participantin school health education, which affects his/her likelihoodto take action. Three factors (‘Participant Awarenessand Compatibility’, ‘Draft Plan Development’and ‘Summit Experiences and Satisfaction’) werefound to be important predictors of leaders’ ‘FutureAction’ and ‘Advocate Impact’ (P < 0.01).Future interventions targeted to influence health, educationand social service professionals’ support and adoptionof school health education should be structured to reinforcethese three variables.     

Evaluation at the local level: the roles of outsiders and the community

This paper summarizes the findings of a study designed to evaluatewhether primary health care (PHC) was being implemented in oneof the poorest, most remote Tibetan refugee settlements in Indiasome time after the main international aid donations and projectshad ended. There have been too few comprehensive or specificevaluations of relief aid in general and refugee health in particular.The findings highlight the feasibility and desirability of undertakinga combination of participatory and technical methods of evaluation,and illustrate how ‘outsiders’ working with thecommunity can be partners in an evaluation. The implicationsthis has for undertaking an evaluation at the local level arediscussed. A lack of an institutional memory seems evident from recentrefugee experiences where the international community all toocommonly seems to have a half-hearted approach to creating ‘tolerable’camps in the anticipation that they are only a ‘temporary’phenomenon. Such camps are creating more chaos and problemsthan they solve. The development philosophy as applied to theTibetans has illustrated that rhetoric can become reality andthat PHC, as opposed to the provision of solely acute medicaland surgical services, is feasible. The evaluation revealedthe inadequacy of evaluations that focus solely on the restructuringof the health care system to support PHC activities. While sucha focus is of course very important, the main concern of therefugees was for economic and environmental improvements.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.     

Health education services in developing countries: the case of Zimbabwe

Little research has been done on the organization of healthservices in developing countries. This study uses a checklistapproach to assess Zimbabwe's health service and combines itwith an historical analysis. The data include interviews withkey staff members of the Department of Community Medicine andobservations by one of the authors during work as a districtdoctor. Policy formulation, organization and management, andresources have developed to a medium level. However, supportof peripheral health workers has been weak. Services on theground, almost exclusively carried out by non-specialists, areunsatisfactory. Improvements in health status have mainly beendue to the success of service delivery programmes such as immunization.Diseases which require behaviour changes have not improved or,as in the case of AIDS, even worsened. Health education serviceshave evolved from a ‘village educator’ to a ‘diplomaeducator’ stage. In order to facilitate the use of moreeffective and participatory methods, a speedy upgrading of theservice to a ‘specialist stage’ is needed togetherwith a further training and re-orientation of health workersat district level.     

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     

Evaluating health promotion programs in the workplace: behavioral models versus financial models

This paper suggests that the future of occupational health promotionevaluation lies in the creative utilization of behavioral sciencemodels in an integrated manner with financial models of programevaluation. Evaluators must simultaneously ask ‘Does theprogram work?’ and ‘At what cost?’ Economicconditions may well dictate that both of these questions beanswered. Further, it seems clear that researchers need notbe bound to the impracticalities of true experimental designin order to evaluate program effectiveness. In addition, giventhe numerous potential tangible and intangible benefits to firmssponsoring occupational health promotion programs, evaluatorsshould be equally concerned with controlling beta errors asthey are with controlling alpha errors in test design; otherwise,they run the risk of prematurely cancelling potentially profitableinvestments before they come to fruition.     

'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

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.     

Mawas Diri a tool to stimulate community participation

The term ‘community participation’ is popular developmentrhetoric yet it tends to remain a topic of discussion aroundconference tables rather than a reality in most communitiesof the developing world. Political will may be guaranteed butthe tools which can facilitate the process of translating communityparticipation into reality are scarce. To help fill this gapan Indonesian non-governmental organization, Yayasan IndonesiaSejahtera, developed a problem-solving tool called Mawas Diri.The tool is employed by representatives of the target groupand uses indicators directly related to their situation. Itis used by village health workers (VHWs) or others who havebeen trained in its use, to evaluate the healthiness of homesand the neighbourhood in general. With this tool, VHWs have succeeded in collecting reliable datawhich are used for village planning activities and monitoringthe progress of programmes. It has also proved to be an effectivemotivational tool for stimulating people to initiate a widevariety of activities aimed at creating a healthier environmentand life-style. More fundamentally, this problem-solving toolhas reversed the usual procedure of ‘outsiders’determining a community's problems and providing programmesfor their solution. With Mawas Diri the community members aremore aware of the nature and extent of their problems and canthen determine which of these they can solve using their ownresources, and which require government or other outside participation. Experiences with Mawas Diri in Indonesia have illustrated thatvillage communities can play a significant role in planning,implementing and monitoring programmes leading to healthierlives.     

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.     

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.     

Some problems in health promotion research

It is argued that health promotion research faces three criticalproblems: defining adequate research questions; identifyingappropriate areas for research and developing a theoreticalbasis for problem formulation. it is suggested that if healthpromotion research is to be a vigorous part of the emergingdiscipline of health promotion, rather than simply an evaluativetool, and if health promotion research is to be distinguishedfrom epidemiology, sociology, psychology, politics or economicswith a health promotion angle, then these three problems mustbe resolved The origins of the difficulties associated withproblem definition, priority areas for research and adequatetheoretical tools are traced in the first instance to the idealisticand programmatic nature of health promotion and the conflationof ‘is’ and ‘ought to be’ questionsin the idealism. The ‘ought to be’ nature of healthpromotion carries important implications for behavioural andsocial change. It is argued that for the most part the normativeand scientific issues surrounding change have not been disentangledand that neither have the contributions of the disciplines whichhave studied social and behavioural change had much impact onhealth promotion. These problems manifest themselves in studiesand practice involving empowerment, enablement and healthy publicpolicy. it is concluded that the role of research in healthpromotion must be clarified and a shift away from the pathogenicparadigm encouraged.     

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.