community development approaches to health promotion

8/9/2019 Community Development Approaches to Health Promotion

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and health care, usually individual, for e*ample attempts to reduce ris of contracting disease"educating smoers, vaccinating$. /nd upstream we have health promotion including socialpolicies and health promotion programmes, such as ta*es on tobacco, smoe free legislationand advertising bans. )his may include health education, which aims to reduce ill6health andincrease positive health influencing peopleEs beliefs, attitudes and behaviour. HealthPromotion has a dual role to prevent ill health and promote positive health. #, 0

:Health promotion is the process of enabling people to increase control over, and to improve,their health. )o reach a state of complete physical, mental and social well6being, an individualor group must be able to identify and to realiFe aspirations, to satisfy needs, and to change orcope with the environment. Health is, therefore, seen as a resource for everyday life, not theobGective of living. Health is a positive concept emphasiFing social and personal resources, aswell as physical capacities. )herefore, health promotion is not Gust the responsibility of thehealth sector, but goes beyond healthy life6styles to well6being.B !ttawa Charter for HealthPromotion, irst International Conference on Health Promotion, !ttawa, % ovember %&'( 6WH!JHP-JH1PJ.% (&

/ refined definition might be, Khealth promotion is the process of enabling individuals andcommunities to increase control over the determinants of health and thereby to improve their

health.K /mong other things, this definition suggests that in our efforts to evaluate healthpromotion efforts, we should obtain evidence on process as well as outcome, on theempowerment of individuals and communities, on the interventions directed at theKdeterminants of healthK and on positive health outcomes as well as the prevention ofnegative ones. It also implies that we might consider using the evaluation process itself as ameans to improve the capacities of individuals and communities to increase control over thedeterminants of health. 20

/nother refining definition, :health promotion is about helping people to have more controlover their lives, and thereby improve their health. It occurs through processes of enablingpeople, advocacy, and by mediating among sectors. In essence, health promotion actioninvolves helping people to develop personal sills, creating supportive environments,strengthening communities, influencing governments to enact healthy public policies, andreorientating and improving health services.B %0

Common Themes:

Health promotion involves the whole population in the conte*t of everyday life

1nabling

Control or 1mpowerment

Promoting Wellbeing "rather than dealing with :illnessB$

@uilding capacity

ItEs a process not Gust an outcome

Directed towards action on determinants or causes of healthJdisease. Wide definition

of determinants of health.

Community Development

Put another way=Health PromotionL aims to gain effective public participation%L aims to=

9 L create a supportive environment% L build healthy public policy L strengthen community action0 L develop personal sills2 L empower local people# L improve e+uity and ine+uality

( L re6orientate health service3 L advocate for health #


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)hree words describe the role of practitioners involved in integrated health promotionprograms=L Enable= Integrated health promotion focuses on achieving e+uity in health. / maGor aspect ofthe wor of integrated health promotion is to provide the opportunities and resources thatenable people to increase control over and improve their health. )his includes developingappropriate health resources in the community and helping people to increase their health

nowledge and sills, to identify the determinants of their own health, to identify actions bythemselves and others, including those in power, that could increase health, and to demandand use health resources in the community.L Advocate= /ction for health often re+uires health worers to spea out publicly or write onbehalf of others, calling for changes in resources, policies and procedures. )he CancerCouncil lobbying for a ban on smoing in all enclosed spaces is an e*ample, as is a localcommunity health worer writing letters to the local paper calling on the council to improvefacilities for physical activity for older people.L ediate= ;any sectors of the community, such as government departments, industry, non6government organisations, volunteer organisations, local government and the media taeaction that has an impact on peopleEs health, sometimes acting to support one another,sometimes disagreeing about what should be done. Health worers play a role in mediatingbetween these different groups in the pursuit of health outcomes for the community, or in

mediating between the health re+uests of different sectors of the community.

!. Approaches to Health Promotion

How can one go about KdoingK health promotion?

)he following strategies, which are often combined, are commonly used=

Creating supportive environments= /ctivities aimed at establishing policies that

support healthy physical, social and economic environments "WH!, %&&'$.

Health education= Consciously constructed opportunities for learning designed to

facilitate changes in behavior towards a predetermined goal, and involving some form

of communication designed to improve health literacy, nowledge, and life sillsconducive to individual and community health "P/H!, %&&(M WH!, %&&'$.

Health communication= / strategy to inform the public about health concerns and

place important health issues on the public agenda achieved through the use of themass and multimedia, and other technological innovations that disseminate usefulhealth information to the public, increase awareness of specific aspects of individualand collective health, as well as increase awareness of the importance of health indevelopment "WH!, %&&'$.

5elf6help= /ctions taen by lay persons to mobiliFe the necessary resources to

promote, maintain or restore the health of individuals or communities through self6care activities such as self6medication, self6treatment and first aid in the normal socialconte*t of peopleNs everyday lives "WH!, %&&'$.

!rganisational development= / process typically used in industry although applicable

to other settings such as communities, to improve performance, productivity andmorale issues, and attain an optimally functioning organiFation, with a high level ofcohesion, well6being and satisfaction on the part of all those involved "-aeburn 8-ootman, %&&'$.

Community development J action= / process of collective community efforts directed

towards increasing community control over the determinants of health, improvinghealth and becoming empowered to apply individual and collective sills to addresshealth priorities and meet respective health needs "WH!, %&&'$.

Healthy public policy= ormal statements that demonstrate concern for heath and

e+uity and which mae healthy choices possible or easier for citiFens, throughcreating supportive social and physical environments that enable people to leadhealthy lives "P/H!, %&&(M WH!, %&&'$.

/dvocacy= / combination of individual and social actions designed to gain politicalcommitment, policy support, social acceptance and systems support for a particularhealth goal or program "P/H!, %&&(M WH!, %&&'$.


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-esearch= Information which lins theory and practice through the investigation of the

real world and which is informed by values about the issue under investigation,follows agreed practices, is sensitive to ethical implications, ass meaningful+uestions and is systematic and rigorous "aidoo 8 Wills, %&&'$. 1valuation researchis formal or systematic activity, where assessment is lined to original intentions andis fed bac into the planning process "aidoo 8 Wills, 999$.K

;edical approach= ocused on disease and biomedical e*planations of health.arrow concept of disease "ignore socialJenvironmental dimensions$ e.g.immunisation, screening ##, #

E"amples o# approaches to health promotion $E%les & 'imnet( 1))*+ #

Aim Appropriate ethod E"ample , 'mo-in

1. Health a%arenessoal

-aising awareness, orconsciousness, of healthissues

talsgroup wormass mediadisplays and e*hibitionscampaigns

1ncourage people to see earlydetection and treatment ofsmoing6related disorders

!. Chanin attitudesand behaviour

Changing the lifestyles ofindividuals

group worsills trainingself help groupsone6to6one instructiongroup or individual therapywritten materialadvice

Persuasive education to preventnon6smoers from starting andpersuade smoers to stop

/. 0mprovin -no%lede

Providing information

one6to6one teachingdisplays and e*hibitionswritten materialsmass mediacampaigns

group teaching

Oiving information to clientsabout the effects of smoing.Helping them to e*plore theirown values and attitudes andcome to a decision. Helping

them to learn how to stopsmoing if they want to

2. 'el# empo%erin

Improving self6awareness, self6esteem,decision6maing

group worpractising decision6maingvalues clarificationsocial sills trainingstimulation, gaming and role playassertiveness trainingcounselling

Clients identify what, if anything,they want to now about it

#.'ocietalenvironmentalchane

Changing the physical orsocial environment

positive action for under6servedgroupslobbyingpressure groupscommunity developmentcommunity6based woradvocacy schemesenvironmental measuresplanning and policy maingorganisational changeenforcement of laws andregulations

o smoing policy in publicplaces. Cigarette sales lessaccessible, especially tochildrenM promotion of non6smoing as social norm.@anning tobacco advertising andsports sponsorship


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Integrated health promotion service delivery can be organised from one or more differentangles, depending on the ey priorities identified and the problem definition, including=

health or disease priorities, for e*ample, mental health, heart disease, diabetes, oral

health

lifestyle factors, such as physical activity and nutrition, tobacco use, safe se*

population groups, for e*ample, culturally and linguistically diverse groups, same6se*attracted youth, adolescents, older people living alone

settings, for e*ample, health promoting schools, health promoting worplaces, health

promoting hospitals, council estates.

)he ey re+uirement for +uality practice is how programs are planned, delivered andevaluated. @y definition, +uality practice is=

enabling it is done by, with and for people, not on themM it encourages participation

involves the population in the conte*t of their everyday lives, rather than focusing Gust

on the obvious lifestyle ris factors of specific diseases

directed to improving peopleEs control over the determinants of their health

a process 6 it leads to something, it is a means to an end.

/. Policy Environment

In %&3&, the thirty6second World Health /ssembly launched the Olobal 5trategy for health forall the year 999 thereby endorsing the -eport and Declaration of the InternationalConference on Primary Health care, held in /lma6/ta, A55- in %&3'. )he commitment to theachievement of KHealth for /ll by the ear 999K was accepted by the %#9 member states andbecame the basis of all the WH! 6 related new developments in the field of health care in theworld. / modern movement termed Health Promotion emerged out of the historical need for afundamental change in strategy to achieve and maintain health. )he Health PromotionProgramme at the regional office for 1urope of World Health !rganisation "WH!$ wasestablished in %&'2 bringing to fruition the obGectives outlined in the policy documents that the

-egional !ffice for 1urope had developed over the previous five years.

)he first International Conference on Health Promotion met in %&'( in !ttawa to present acharter for action in order to wor towards the achievement of Health for /ll by the ear 999and beyond. )he action plan of the %&'( 2tta%a Charter advises that health promotionstrategies and programmes should be adapted to the local needs and possibilities ofindividual countries and regions to tae account of differing social, cultural, political andeconomic systems. )he declaration and programme for action is predicated upon thefundamental prere+uisites for health i.e. peace, shelter, education, food, income, sustainableresources, a stable ecosystem, social Gustice and e+uity. /t the heart of this health promotionaction programme lies the ey concerns with advocacy, enablement and mediation.

Identification of priority issues is only one dimension of the !ttawa /ction plan. )he role ofthose engaged in health promotion is to put into effect, within an integrated philosophy, thesefollowing aspects of the health promotion action programme=

i$ 1ndeavouring to build a healthy public policyii$ Woring to create supportive environmentsiii$ Helpin to strenthen community action in various settinsiv$ 5triving to develop personal sillsv$ Woring together to re6orientate Health 5ervices ((

2tta%a Charters 3ive strateies)he %&&3 World Health !rganisation "WH!$ >aarta Declaration on Health Promotion into the%st Century e*plicitly acnowledges the demonstrated effectiveness of health promotion in

the following statement= Health promotion maes a difference. -esearch and case studiesfrom around the world provide convincing evidence that health promotion wors. Health


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Community development sees to empower individuals and groups of people, with the sillsthey need to advocate on their own behalf, improve their lives, and provide communities withaccess to resources. ((

!r put another wayQ.

Community development, in very simple terms, is the process of developing social capital. Itis a process that emphasises the importance of woring with people as they define their owngoals, mobilise resources, and develop action plans for addressing problems they havecollectively identified.

Definition of social capital "Putnam %&&0$= )he community cohesion resulting from high levelsof civic identity and the associated phenomenon of trust, reciprocity and civic engagement.our characteristics= the e*istence of community networs, formal or informal, civicengagement "particularly in networs$, local identity and a sense of solidarity and e+uality withother community networs, and norms of trust and reciprocal help and support. #

5ocial capital and community development=

Participating in social and civic activities, such as community group meetings, child carearrangements with neighbours, neighbourhood watch schemes and voting, all wor toproduce a resource called social capital. 5ocial capital is critical to the health, wealth andwellbeing of populations.00It is a ey indicator of the building of healthy communities throughcollective and mutually beneficial interaction and accomplishments. 02-ecent research haslined these types of activities to improved health outcomes.0#, 0(, 03, 0'

00. Putnam, -. "%&&0$, ;aing Democracy Wor, Princeton Aniversity Press, Princeton, ew>ersey.02. @aum, ., Palmer, C., ;odra, C., ;urray, C. and @ush, -. "999$, Ramilies, social capitaland healthE, in Winter, I. "ed.$, 5ocial Capital and Public Policy in /ustralia, /ustralian Instituteof amily 5tudies, ;elbourne.0#. @erman, 4. and 5yme, 5. "%&3&$, R5ocial networs, host resistance, and mortality= / nine6

year follow6up study of /lameda County residentsE, /merican >ournal of 1pidemiology, vol.%9&, no. , pp. %'(90.0(.


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vegetable garden or woring with the local sporting club to encourage all parts of thecommunity to participate in sporting activities.

4./ What are Community Development Approaches to Health Promotion? $5iteratureAbstracts+

The evidence suests that there has been a shi#t to loo-in at the social( economic(political( and environmental determinants o# health because other methods o# ill,healthreduction have #ailed.There#ore( the arument oes( it is necessary to develop communities themselves tota-e control o# their o%n health aenda to tac-le these health issues #rom the source.Ho%ever( developin communities brins its o%n problems6 problems o# de#inition6and tensions bet%een the various aenda setters and resource holders.The suestion is( in much o# the literature( althouh not clearly proven( that the only%ay le#t to o #or%ard is community development( and some %riters suest thatpartnerships can be and need to be #ored bet%een communities( health serviceproviders( and academics.7elo% are some abstracts #rom the literature revie%( theorisin about communitydevelopment approaches and its barriers. This is #ollo%ed by a discussion on the lac-

o# comparable evidence and the di##iculty in de#inin e##ectiveness or success inloo-in at interventions6 some e"amples o# speci#ic interventions6 a discussion o# %hatcommunity development approaches should or must include6 and #inally some noteson empo%erment and partnership.

/gain there is a problem of definition=

Community Development= the process by which a community identifies its needs, develops anagenda with goals and obGectives, then builds the capacity to plan and tae action to addressthese needs and enhance community well6being.Community Organisation= the process of involving and mobilising maGor agencies, institutionsand groups in a community to wor together to coordinate services and create programmesfor the united purpose of improving the health of the community=

Community-based= the process of agency development of solutions for health problems whichincorporate community consultation and input thus allowing adaptation of the implementationto suit local needsJcircumstances. %

/ Community Development approach to health Q is a process by which a community definesits own health needs to bring about change. )he emphasis is on collective action to redressine+ualities in health and enhance access to health care."Community Development and Health etwor, orthern Ireland$ 3Northern Ireland is one area where Community Development pproaches have beenadopted strongly

'ocial( political( economic and environmental determinants o# health:-ecent epidemiological analysis of health, disease and disability in the populations of most

developed countries confirms the role of social, economic and environmental factors indetermining increased ris of disease and adverse outcomes from disease. 2

Health status is influenced by individual characteristics and behavioural patterns "lifestyles$but continues to be significantly determined by the different social, economic andenvironmental circumstances of individuals and populations. 2

)hrough the Charter, health promotion has come to be understood as public health actionwhich is directed towards improving peopleNs control over all modifiable determinants ofhealth. )his includes not only personal behaviours, but also the public policy, and living andworing conditions which influence behaviour indirectly, and have an independent influenceon health. 2


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")his more sophisticated approach to public health action is reinforced by accumulatedevidence concerning the inade+uacy of overly simplistic interventions of the past. )o tae aconcrete e*ample, efforts to communicate to people the benefits of not smoing, in theabsence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, aredoomed to failure. / more comprehensive approach is re+uired which e*plicitly acnowledgessocial and environmental influences on lifestyle choices and addresses such influences

alongside efforts to communicate with people. )hus, more comprehensive approaches totobacco control are now adopted around the world. /longside efforts to communicate the rissto health of tobacco use, these also include strategies to reduce demand through restrictionson promotion and increases in price, to reduce supply by restrictions on access "especially tominors$, and to reflect social unacceptability through environmental bans. )his morecomprehensive approach is not only addressing the individual behaviour, but also some of theunderlying social and environmental determinants of that behaviour.$ 2

0nsu##iciency o# education aloneIt is now well understood from e*periences in addressing specific public health problems oftobacco control, inGury prevention and prevention of illicit drug use, and the more generalchallenge of achieving greater e+uity in health, that education alone is generally insufficient toachieve maGor public health goals. 2

:;ore recently, researchers have called for a renewed focus on an ecological approach thatrecognises that individuals are embedded within social, political and economic systems thatshape behaviors and access to resources necessary to maintain health. %'

5uch an approach corresponds with increased interest in understanding the comple* issuesthat compromise the health of people living in marginaliFed communities. 1mphasis has alsobeen placed on the need for e*panded use of both +ualitative and +uantitative researchmethods "e.g. Israel et al$M greater focus on health and +uality of lifeM and more translation andintegration of basic, intervention, and applied research. %'

Oreater community involvement in processes that shape research and interventionapproaches, e.g., through partnerships between academic, health services and community6based organisations is one means towards these ends. %'"%'$

Community development and health:1ssentially, community development wor acnowledges that health is as affected by thesocial conditions of peopleEs lives such as damp housing, unemployment, or poor access tofacilities, as it was by lifestyle choices. ;aGor policy documents including )owards a Healthier5cotland "%&&&$ and !ur ational Health "999$ highlight the importance of considering lifecircumstances alongside lifestyle choices and disease in promoting health and wellbeing. 0%

/ World Health !rganisation "WH!$ position paper "%&&%$ directly lined communityparticipation to empowerment as a means in itself of promoting healthier individuals and

environments. urthermore, research has recognised the significance of powerlessness andempowerment to the health of individuals and communities "Wallerstein %&&0$. )he concept ofhealthy communities as developed by the WH! regards active community participation asessential to creating healthy communities=:)he formation of local social capital can thus lead to the promotion of shared values and acommon vision, integrated planning and resource utiliFation, and ultimately to systemicchange.B ";urray, 999, p%9%$ 0%

)here is a growing body of literature showing that being part of a social networ of contacts isprotective for health "isher 99%$. )he effects derive from improved self6esteem, trust andincreased feelings of being in control. 0%

Community Development 0ssues


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:Current health promotion policy and practice places a high value on community developmentwor because it aims to enable communities to identify problems, develop solutions andfacilitate change. 09

)he overt ideological agenda of community development is to remedy ine+ualities and toachieve better and fairer distribution of resources for communities. )his is achieved ideally

through participatory processes and bottom6up planning. 1mpowering communities to havemore say in the shaping of policies influencing health represents a brea with earlier traditionsof public health associated with top6down social engineering. 09

However, community development means different things to different people and can operateon different levels "5ee /rnsteinEs ladder, %&3%$. Community development has, for e*ample,been lined to community organisation, community6based initiatives, community mobilisation,community capacity building and citiFen participation. 09

)here is, however, a common understanding of core principles, which inform communitydevelopment wor, two of which are participation and empowerment. )hese principles canand are, however, operationalised differentially in different types of community development

wor. 09

Despite consensus that community participation should engender active processes involvingchoice, and the potential for implementing that choice, implementation has proven difficult.or e*ample, when formal health services adopt an empowerment framewor, their formalstructures are not necessarily conducive to participation. 09

/lthough it is commonly agreed that appropriate leadership and effective organisationalstructures are crucial to successful community participation, this re+uires a political climatethat nurtures and facilitates the approach. 09

:Community development uses a variety of methods and activities such as self help wor,outreach, local action groups, lobbying, peer wor, festivals and events, information,

advocacy, group wor, networ building and pump priming community initiatives with smallgrants. 0%

)he ey characteristic of community development is that it starts from the e*periences andperspectives of communities. In terms of health, local people need to be enabled or supportedto identify the factors that impinge on their health and the solutions. It is argued that genuineparticipation is only possible when there is involvement in decision6maing and evaluation.0%

Community development approaches challenge the definition of health as an individualproblem for which there are individual solutions, and health care systems that treat thesymptoms and not the root causes of ill health. Instead, such approaches emphasise the

nowledge and e*pertise of individuals and communities living through an e*perience and thecentrality of drawing on this source of e*pertise to define problems and solutions andultimately to design more effective services. )he main benefits of community developmentapproaches have been summarised as=

L Improving networs in a community, which has been shown to have a protective effect onhealth.L Identifying health needs from usersE point of view, in particular disadvantaged and sociallye*cluded groups.L Change and influence, as it enhances local planning and delivery of services.L Developing local services and structures that act as a resource.L Improving self6esteem and learning new sills that can aid employment.L Widening the boundaries of the health care debate by involving people in defining their

views on health and local services.L )acling underlying causes of ill health and disadvantage. 0%


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Health 0ne8ualities( C7P9 & Community)here is increasing empirical evidence that a comple* set of conte*tual factors "includingsocial, economic and physical environmental factors, such as poverty, air pollution, racism,inade+uate housing, and income ine+ualities$ play a significant role in determining healthstatus. )hese factors contribute to the disproportionate burden of disease e*perienced by

marginalised communities. )here is also considerable evidence suggesting that numerousresources, strengths and sills e*ist within communities "e.g. supportive interpersonalrelationships, community6based organisations$ that can be engaged in addressing problemsand promoting health and well6being. )his understanding of the factors associated with healthand disease has contributed to calls for more comprehensive and participatory approaches topublic health research and practice, and a rise in partnership approaches, variously referredto as SSparticipatory action researchE E, SSparticipatory researchE E, SSaction researchE E, andSScommunity6based researchE E. Policy changes at the organiFational, community and nationallevels are needed to help address barriers and challenges to the adoption of suchapproaches and to support their increasing use. %(

Challenes o# community development)he community development approach encounters particular challenges in the conte*t of

health care. While support for the idea of e*tending community development approaches intomainstream health services and other public services has grown, in reality organisations arenot always receptive to the idea of a longer term ongoing dialogue which might lead to maGorchanges within the organisation or into areas that the organisation had not previouslyconsidered. )he conclusion of a DH55 "orthern Ireland$ "%&&&$ document was thatcommunity development is still at a relatively early stage of development within mainstreamagencies. It found most H5 )rusts and @oards did not have a stated policy for a communitydevelopment approach, and there was a lac of focus for this wor and few instances oftraining for staff in this area. 0%

)he way of woring with and not Gust on behalf of individuals and communities that is centralto the community development approach, sits uneasily with traditional western medicine andthe Rmedical modelE in which professionals now what the problem is as well as the solution.

)he challenge is not to the value of medical e*pertise per se, but rather to its dominance inrespect of health nowledge and the allocation of resources. 0%

ew health service professionals are fluent with community development approaches andways of woring with, rather than on behalf of, people. In describing a public healthprogramme set up to lin new mothers with e*perienced mothers and Public Health urses inIreland during the %&'9s, >ohnstone "%&&0$ concluded= :amiliarisation of all health careworers with changes in policy and the bacground of research and development and aims ofpolicy would eliminate some of the frustrations and create a more supportiveenvironment...)he community based approach has proved more effective in achieving changewhere this is indicated and is liely to be a more useful model for empowerment and self6carethen the traditional type of health care approach.B "p##$ 5ubse+uently, >ohnstone "%&&0$advocated that the education and training of health care worers should include the possibilityof woring in partnership with people rather than for people. Community and user groups andhealth and social services professionals need to perceive each other interacting in differentsets of roles and relationships. ;c


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gap between health promotion research and practice. )he authors suggest that a disGuncturee*ists between the multiple theories and models of health promotion and the practitionerNsneed for a more unified set of guidelines for comprehensive planning of programs. 2'

4.4 5ac- o# Evidence re Community Development 0ntervention 2utcomes

Kor the purposes of this review, researchers defined an intervention as an organiFed andplanned effort to change individual behavior, community norms or practices, organiFationalstructure or policies, or environmental conditions.K 03

:Despite the fact that community development approaches have been used by several of themaGor community6based heart health initiatives, evidence of their use and usefulness remainssparse.B %

:)he health effects of social interventions have rarely been assessed and are poorlyunderstood. 5tudies are re+uired to identify the possible positive or negative health impactsand the mechanisms for these health impacts. )he assessment of indirect health effects ofsocial interventions draws attention to competing values of health and social GusticeB #'

:)he Woring Oroup also debated what is meant by KevidenceK in the conte*t of healthpromotion, with several members arguing that the concept of KevidenceK may in fact be aninappropriate one in this conte*t. !ne of the ey arguments for this position is that theconcept of Krules of evidenceK in science tends to be related to particular disciplines, andsince health promotion is by nature Kmulti6disciplinary,K it is not clear whose rules of evidenceit should follow. However, most members of the group felt that it was impractical to tae thisstance given the fact that relevant policymaers, including members of the World Health/ssembly, were demanding Kevidence6basedK health promotion. 5everal members suggestedthat it would be prudent if, at least for the time being, we accept the use of the termKevidenceK within health promotion. /s suggested by


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0ntervention 'port , evidence:Despite a comprehensive search for literature relating to the effectiveness of policyinterventions implemented through sporting organisations for promoting healthy behaviourchange, no evidence in the form of well6designed and evaluated interventions was found. )heability to provide clear directions or strategies for future health promotion interventions istherefore limited. It is liely that these types of interventions are rarely evaluated or published,

or that such evaluations are only available through contacting each sporting club, sportingassociation, health promotion agency or other agencies with a remit for sport "e.g. localcouncils$. /n internet search identified a number of case studies in this area. )hese includedpost6data only, and evidence on outcomes was typically anecdotal. It is essential that sportingor health promotion agencies that conduct such interventions evaluate the interventions,publish the results and disseminate them widely. )his will enable practitioners to more readilyand the available evidence, and conse+uently, to implement effective interventions. In future,funding for evaluation should be built into sporting programs. However, as noted in the reviewby Payne "Payne 990$ there is a limited capacity to carry out evaluation in sportingorganisations. Payne suggests that academic6based researchers should wor in partnershipwith the sport and recreation industry to ensure that sporting programs are evaluated in auseful way. )his may simply involve the introduction of data collection toolsJdatabases inorder to evaluate programs in a +uasi6e*perimental manner. Practitioners therefore need to

form relationships with the tertiary education sector.B '

:It is important to recognise that these conclusions are drawn from a wide range of researchacross many different issues. 1stablishing evidence for the effectiveness of interventionsdealing with specific issues, however, can be more problematic in some cases than for others,particularly in areas such as nutritional status and obesity which have comple* andmultifactorial etiologies and which re+uire long time frames for measurable changes to occur.)his must be taen into account in considering the material provided in this report.B %#

Evidence mental health( healthy eatin( and physical activity in schoolsindings= )his synthesis identified good +uality systematic reviews that covered mentalhealth, aggressive behaviour, healthy eating, physical activity, substance use and misuse,driver education, and peer approaches. -eviews of programmes that promoted mental health

in schools "including preventing violence and aggression$ show these programmes to beamong the most effective ones in promoting health. !f these programmes, the ones that weremost effective were of long duration and high intensity, and involved the whole school. ewreviews that focused on promoting healthy eating and physical activity confirmed an earlierreview, which found that multifactorial interventions, particularly those involving changes tothe school environment, were effective. our new reviews of programmes that focused onpromoting the prevention of substance use confirmed previous findings that theseprogrammes are relatively ineffective. /lso, programmes on preventing suicide reducedsuicide potential, depression, stress and anger, but less rigorous studies suggested apotential harmful effect in young males. In some "but not all$ studies, peer6delivered healthpromotion was found to be effective, compared with teacher6led interventions, and thisapproach was highly valued by the young people involved. )he systematic review, whichevaluated health outcomes of programmes that used elements of the health promoting

schools approach, included small studies of variable +uality. It found apparent benefits to thesocial and physical environment of the school, and some studies found the programmesbenefited health6related behaviour "dietary intae and physical fitness$. o reviews evaluatedthe costeffectiveness of the programmes or interventions.B %&

There is a clear lac- o# comparative data in measurin e##ectiveness o# di##erentapproaches to health promotion.

4.* Di##iculties in de#inin success or e##ectiveness

De#inition o# oals o# intervention $%hat to measure+:-each is defined as the percent of potentially eligible individuals who participate in theintervention study, and how representative they are of the target population from which they

are drawn. 1fficacyJeffectiveness is the intended positive impact of the intervention and itspossible unintended conse+uences on +uality of life and related factors. -each and


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efficacyJeffectiveness operate at the individual level. /doption is the percent of potentialsettings and intervention agents that participate in a study and how representative they are oftargeted settingsJagents. Implementation refers to the +uantity and +uality of delivery of theinterventionEs various components. /doption and implementation are setting6level dimensions.inally, the maintenance dimension includes individual6 and setting6level indices. /t theindividual level, maintenance is defined as the longer6term efficacyJeffectiveness of an

intervention. !utcomes at ( months post6intervention contact reflect longer6term individualmaintenance. )he setting level definition of maintenance refers to the institutionalisation of aprogram and is assessed according to the percent of settings that continue the interventionprogram, in part or in whole, beyond the study duration "Olasgow et al., %&&&M Olasgow et al.,99%$.B %

K)here is increasing evidence emerging regarding the effectiveness of community6basedinGury prevention programmes. )he use of multiple interventions implemented over a period oftime can allow inGury prevention messages to be repeated in different forms and conte*ts andcan begin to develop a culture of safety within a community. Important elements ofcommunity6based programmes are a long6term strategy, effective and focused leadership,multi6agency collaboration, the use of local surveillance to develop locally appropriateinterventions and tailoring interventions to the needs of the community. )ime is also needed to

coordinate e*isting networs, and to develop new ones. However, a positive and sustainedimpact of community6based programmes on inGury rates has not yet been demonstratedconclusively. )here is a need to develop valid and reliable indicators of impact and outcomeappropriate to community studies. Where pro*y measures are used for inGury outcomes, it isimportant that there is clear evidence of the association between the pro*y "e.g. haFardremoval, nowledge gain or behaviour change$ and inGury ris ")owner et al., %&&(Oo$. )hereis also an urgent need to develop and monitor indicators to assess and monitor a culture ofsafety, programme sustainability and long6term community involvement. Community6basedinGury prevention programmes have been hampered by the lac of resources allocated to boththeir programme development, and appropriate and rigorous evaluation.K 0(

:Health promoting schools and health promotion in schools= two systematic reviewsU 1nsure that process evaluation which describes the way in which programmes have been

implemented is undertaen and reported in all studies of health promotion in schools.U Develop valid and reliable measures for evaluating the outcome of the health promotingschool initiatives, particularly those measuring mental and social well6being for children andadults. Incorporate these in all studies of health promotion in schools.K (3

4.; 'ome e"amples o# Community Development Approaches to Health Promotion

1. Community development( user involvement( and primary health careCommunity development recognises the social, economic, and environmental causes of illhealth and lins user involvement and commissioning to improve health and reduceine+ualities. Communities can be geographicalVsuch as particular housing estatesVorcommunities of interest, such as user groups. )rained community development worers bringlocal people together to=

identify and support e*isting community networs, thus improving healthM identify health needs, in particular those of marginalised groups and those sufferingine+ualityM wor with other relevant agencies, including community groups, to tacle identified needsM encourage dialogue with commissioners to develop more accessible and appropriateservices.

;any e*amples of these activities e*ist. 5tudies show that community support through socialnetwors is protective of peopleEs health. High levels of trust and density of groupmembership are associated with reduced mortality. Conversely, lac of control, lac of selfesteem, and poor social support contribute to increased morbidity.


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Community involvement varied in different stages of the research. )here was stronginvolvement in recruiting study participants, designing and implementing the intervention, andinterpreting findings. ;any authors argued that community involvement "especially in thesesareas$ leads to=

Oreater participation rates.

Increased e*ternal validity.

Decreased loss of follow up. Increased individual and community capacity.

)he disadvantages of community involvement were not fre+uently reported, but they mayinclude=

)he introduction of selection bias "bias in recruitment$.

Decreased "and sometimes an absence of$ randomiFation.

)he potential selection of highly motivated intervention groups not representative of

the broader population. 03

/. =ood Practice ental Healthrom mid >uly %&&' to the end of ;ay %&&&, /useinet provided seed funding and intensivesupport to eight agencies that provided services to children and young people to reorient anaspect of their service to an early intervention approach to mental health. )he aim was to givethe agencies the opportunity to build their capacity by developing a range of tailored,potentially sustainable strategies.

/ll agencies made %or-#orce developmentthe foundation of their reorientation process. /smost of the agencies were not primarily mental health focused, enhancing the mental healthliteracy of staff was a vital first step in reorientation. )hey informed staff about the mentalhealth issues faced by the young people who used their service, gave them the sills torecognise ris factors and early warning signs, and established procedures for appropriate

referral. )he training programs were documented to guide future training needs and to provideresources for staff.

/ll of the proGects showed evidence of oranisational development. ;anagement supportwas demonstrated by the formation of steering committees, reference groups and umbrellagroups. Policy development occurred within as well as between agencies. !ne proGectdeveloped an early intervention policy outlining referral and support mechanisms and othersdeveloped recommendations for incorporating early intervention into new policies. )woproGects developed formal interagency agreements and policies. )he development ofpartnershipswas one of the most successful aspects of the reorientation proGects. ;ost ofthe agencies established new networs or strengthened e*isting ones by including guestspeaers and staff from other agencies in their training programs. 5everal of the proGectsdeveloped successful formal partnerships. )wo of the larger proGects were collaborations

between influential agencies and had the resources to allow the proGects to e*pand beyondtheir original scope. /ll of the agencies allocated resourcesto the proGects and several of thelarger agencies contributed additional funds to employ the reorientation officer full6time. /fter/useinet funding had ceased, most of the agencies had allocated funds to sustain or e*pandthe reorientation process or to tae it in a new direction.

;ost agencies had sustained or e*panded their early intervention activities two and a halfyears after the reorientation proGect. )he e*tent of reorientation ranged from conceptual shiftsin staff nowledge and increased awareness and identification of mental health problems,through to e*tensive implementation of mental health promotion, prevention and earlyintervention programs and the development of partnerships with other agencies and thecommunity. In five of the eight agencies, further early intervention proGects were conducted,the agencies were better able to detect mental health problems and target referrals, there was

an increase in mental health awareness and literacy within the organisation and in thecommunity, and increased support from the community. !ne agency noted that while thestrategies developed in the reorientation proGect had not been sustained, the proGect had led


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to different ways of implementing early intervention activities and subse+uent success withother proGects. )he remaining two proGects noted a mared change in early intervention waysof thining and referrals although they did not have the resources to continue concreteproGects. 5everal of the agencies reported that the reorientation proGect had given them theconfidence to undertae other proGects or apply for further funding. ;ost of the agenciesconsidered that the reorientation proGects served as a useful platform from which to either

begin or e*pand early intervention activities.

7arriers'ta## over%or-ed>:;ost of the reorientation officers thought that the resources allocated to the proGect wereinsufficient and that they had insufficient time in which to achieve the obGectives of the proGect.5everal of the reorientation officers in the non6government agencies especially found theirworload demanding because they were employed on a half6time basis. 5ome of the staffwere initially reluctant to be involved in the reorientation proGects because of their alreadyheavy worloads. Oenerally, as staff became involved in the training they became moreenthusiastic about the proGect and prioritised their time to enable greater involvement.

'ustainable 3undin

:;any of the barriers identified in the original reorientation proGects are still evident. High staffturnover rates are a reality in many agenciesM therefore time and resources need to bedevoted to training new staff in early intervention. )he heavy worloads of staff remained anissue, although some of the agencies developed strategies to reframe rather than add toe*isting worloads. ;ost of the agencies felt that the sustainability of the proGects was largelydependent on funding. 5eed funding was perceived as being useful for platform activities, butall identified the mared need for more funding to sustain and e*pand early interventionactivities. ;any of the agencies reported that their involvement in the /useinet proGect hadhelped them to secure funding from other sources.

ew barriers were identified at follow6up, when many of the agencies were applying earlyintervention approaches directly with clients. They o#ten #ound it di##icult to re#er clients%ith early sins o# mental health problems to mental health services because the latter

typically #unction #rom a crisis intervention model. In addition, mental health servicesalready have high demands on their services and are often not able to tae on new referrals.

4. Wor-place E"ample@eyond the organisation participating in the present study, it is hoped that individuals andgroups involved in worplace health promotion can use the findings to help overcome two ofthe ey barriers to adopting the health promoting settings approach. )hese barriers are= "i$ alac of information on the relationship between wor characteristics and employee healthM and"ii$ not having the confidence or nowledge to identify and address organiFational6levelissues. @oth +ualitative and +uantitative methods were employed in the audit, and the resultsrevealed that there was a close relationship between several wor characteristics andemployee well6being. Worbased support, Gob control and time6related pressures were

identified as three wor characteristics that offer valuable opportunities for boosting thehealth6promoting value of the organiFation participating in the present study. 0

*. Plenty o# e"amples o# lare company %or-place health promotion %orld %ide

;odel of good practice= )he 5hanghai ProGect 5hanghai is the largest industrial city in China,with a population of over %0.# million people. In collaboration with WH!, and supported by theOovernment of the PeopleEs -epublic of China, the 5hanghai ;unicipal Health @ureau andthe 5hanghai Health 1ducation Institute conducted a pilot worplace health6promotion proGectfrom %&&0 to %&. )he proGect involved % (%0 worers in four worplaces= WuGing ChemicalComple*, 5hanghai Hudong 5hipyard, 5hanghai o. 02 Cotton ;ill and 5hanghai @aoshan5teel Company.

@ased on data gathered through a baseline survey conducted in early %&&0, and guided bymembers of the 5hanghai Health 1ducation Institute and an occupational health e*pert


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advisory reference group, each worplace developed, implemented and evaluated worplacehealth6promotion programs.

)he proGect adopted an integrative model of worplace health promotion and sought toaddress identified organisational, environmental and behavioural factors that were negativelyimpacting upon the health of the worers. Health6promotion programs employed multiple

strategies in line with the !ttawa Charter and sought to develop healthy policies andregulations, create safe and supportive environments, strengthen preventive health services,facilitate worersE participation and educate worers to promote healthy behaviour. Initiativesundertaen included the establishment of health education and health6promotion committees,drafting and implementing worplace standards for identified occupational haFards, improvedmanagement of worplace sanitation and hygiene, and improved occupational health haFardmonitoring and control "e.g. noise, dust and chemical leaage$. !ther initiatives included thesupply of nutritious foodstuffs and the reduction of salt in food in worplace canteens, plantingtrees and flowers, cigarette smoing and alcohol cessation programs, cervical screening andthorough follow6up treatments, improved preventive health services for worers, and greaterworer participation in the identification and control of occupational haFards.

During the proGect, particular attention was given to such issues as staff mobiliFation andtraining, establishing co6ordinating and networing mechanisms, and regular consultation withworers, management and e*pert reference groups. )hese measures ensured that allinterested parties were involved in the planning of the proGect and that they were givenopportunities to participate in its implementation. urthermore, there was an emphasis onmulti6sectoral involvement and the integration of health promotion into management practices.

)he proGect was closely monitored, and an evaluation carried out in %& showed e*cellentmeasurable outcomes, e.g.=L reduced incidence of wor6related inGuries by %99TML reduced diseases and related health care costs "e.g. pharyngitis, from %(T to %9T$ML improved health and safety nowledge and practices "the use of safety devices or protectivee+uipment increased from 909T to 39&9T$M

L reduced ris behaviour "reduction of salt consumption, cigarette smoing$ML reduced levels of sic leave by #9T.

!ther notable proGect achievements included= improved company image and managementpractices, a cleaner and safer worplace environment and wor conditions, increased housingprovision, recreation facilities and even transport in the case of the Hudong shipyard.4earning from this pilot proGect, the proGect team has since developed what they have proudlycalled the R5hanghai ;odelE of worplace health promotion. )he modelEs four distinctivefeatures are= comprehensive, integrative, a system of management and multi6sectoralnetwors, and a multiplicity of intervention strategies. 5ince then, the 5hanghai ProGect teamhas developed draft Chinese language guidelines for worplace health promotion, and hasbeen funded by the World @an to wor with %9 more worplaces.

5uccessful factors for worplace health promotion= /ction and criteria models currentlyavailable point uniformly to the following factors as ey indicators of a successful worplacehealthpromotion initiative.Participation: all sta## must be involved in all phases. &

;. 5ee ote %#. Public Health Division, Department of Human 5ervices, ;elbourne, Xictoria,/ustraliaHealth Promotion 5trategies for Community Health 5ervices. /n 1vidence6@ased Planningramewor for utrition, Physical /ctivity, and Healthy WeightebpfYnutrition.pdf4ots of e*amples of utrition( Physical Activity( and Healthy Weiht Pro@ects

. utrition: E##ective Components #or utrition 0nterventions , 'ummary


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In December of %&&&, the Prevention Anit within the Division of Preventive !ncology atCancer Care !ntario commissioned a review of international literature on nutritioninterventions, in the areas of policy, programs and media. )he purpose of the review, whichincluded literature from >anuary %&>anuary 999, was to consolidate e*isting nowledge ofnutrition intervention effectiveness in order to inform the development of a nutrition andhealthy body weight strategy for cancer prevention for the province.

ifteen interventions studies were included in the review, %9 of which reported positiveoutcomes, and # reporting negative outcomes, in well6designed studies "i.e. controlled trialswith or without randomiFation$. /mong those reporting positive outcomes, five componentswere common=%L theoretically based "5orenson, OlanF, Perry, 4i+uori, iclas, orester$L Involvement of the family as a source of supportM "5orenson, OlanF, 4i+uori, Perry, Coates,

Havas$0L Ase of participatory models for planning and implementing interventionsM "Perry, 4i+uori,

Havas, iclas, 5orenson, OlanF$2L Provision of clear messages for media campaignsM "!wen, -eger, orum$#L Provision of ade+uate training and support to intervenors "@eresford, Perry, 4i+uori, Havas,

orester$

/ number of lessons were learned by those reporting negative study outcomes including=%L 1nsuring sufficient intensity and duration of the intervention to bring about change and

behaviour maintenance. -epeated and on6going contact is necessary throughout theintervention including post follow6up "Olasgow, -esnicow, effrey$

L ;aing environments conducive to support behaviour change, in particular modification offood service policies for worsites and schools "Olasgow, -esnicow$

0L Ensurin particpatory mechanisms for planning, such as steering committees and,"Olasgow, -esnicow$

2L Delivering school6based interventions either before the school day begins or during schoolhoursM afterhours results in lower attendance "-esnicow$

Intervention settings, such as schools, worplaces "5orenson, OlanF$ and health care

institutions, offered prime channels to employ these principles, especially when developingand implementing interventions for large groups of people. Community settings wor well forwomen whose learning is enhanced by a family friendly atmosphere. )he review suggeststhat these settings should be regarded as ideal places to focus a nutrition interventionstrategy within !ntario. )he principles derived from this review e+uipped Cancer Care !ntariowith the information necessary to develop a nutrition and healthy body weight strategy for theprovince of !ntario. )his included establishing a reference group "nown as the !ntarioCollaborative Oroup on Diet and Cancer$ with a mandate to lin practitioners in the areas ofpolicy, community and public health programs and research and use them as a referencegroup. )he Anit too the lead in developing a program logic model for the overall strategy"with guidance from the Collaborative Oroup$ and invested in developing a behaviouralchange pilot proGect K)ae #K to increase vegetable and fruit consumption among women withchildren under the age of %2, based on staeholder feedbac, and is currently being piloted.

%3

B. 'ee ote !/ 'tories that can chane your li#e: communities challenin healthine8ualities $Health0ne8ualities.pd#+5ots o# =ood Practice E"amples and =reat


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/t strategic level, there is increasing evidence that community development is seen to be animportant part of any participatory strategy and more resources are gradually being divertedto this end. However, although the rhetoric is spreading, the change in attitudes andorganisational re6arrangements are slower to gain ground. )he Craigavon and @anbridgeCommunity Health and 5ocial 5ervices )rust in orthern Ireland is an e*ceptional e*ample ofa Health 5ervice )rust which has accepted that community development has to inform its

whole approach. "5H, 99%cM ;c5hane and !Eeill, %&&&$)he )rust accepted the contribution of community development to the core business of Healthand 5ocial 5ervices by mainstreaming this approach across all its programmes of care. )heimportance of increasing community development awareness and sills for other managersand staff was also recognised and the )rust was actively committed to a training strategy. Itviewed this as a core feature of implementing the OovernmentEs strategy on social inclusion,social Gustice and partnerships for health and wellbeing. )he )rustEs Community DevelopmentAnit has actively wored with different community groups, ensuring that broader aspects ofhealth are highlighted. or instance, a -apid Participatory /ppraisal was conducted bringingtogether various parties such as nursing, community wor, social wor staff and local people.)his enabled issues to do with housing, the local economy and community infrastructure to beincluded and wored at to improve the wellbeing of the community.The Addie%ell Pro@ect

!ne e*ample of local communities becoming involved in setting the agenda around healthwas that of the /ddiewell )as Oroup "/ddiewell -esearch ProGect, 999$. In a Goint initiativebetween local residents, West 4othian Council and the Aniversity of 1dinburgh, the /ddiewell)as Oroup developed indicators and measures to do with health and wellbeing that wereseen as important by the community. )he Health Anit based within the local Council woredalongside local people to ensure their participation in the identification, definition andproposals for measuring health indicators. )he wor was founded on the principle that thebest people to decide what issues and indicators were important were local peoplethemselves.Wor-in toether: 5earnin toether/ two year training programme, Woring )ogether= 4earning )ogether, was set up as part ofthe 5cottish 1*ecutiveEs R4istening to CommunitiesE programme, to provide training inunderstanding social e*clusion, partnerships and Woring for Communities Pathfinders in

5cotland. )he programme aims to ensure that communities are involved in :genuine,meaningful partnership where they can e*ert real influenceB "Woring )ogether= 4earning)ogether website 6 www.wtltnet.org.u$. )here are (9 partnerships and &99 peopleparticipating in training from agencies and communities led by a consortium of organisationsincluding the 5cottish Community Development Centre, Community 4earning 5cotland, the5cottish Council for Xoluntary !rganisations, the Poverty /lliance, and the Aniversity ofDundee. 0%

1F. utrition: Database o# 0nternational utrition 0nterventionsIncludes Intervention ;ethodology, 1valuation ;ethod, 8 Impact /chievedK%9. utrition education5eptember, 990 %9.% Oeneral community nutrition programmes

%9. ;ass media nutrition education %9.0 5chool6based nutrition educationKhttp=JJwww.hubley.co.uJ%nutrition.htm 02

11.Database o# 'chool,based interventionsIncludes Intervention ;ethodology, 1valuation ;ethod, 8 Impact /chievedKInterventions using schools5eptember 990Khttp=JJwww.hubley.co.uJ%schools.htm

1!. 0llicit drus: e##ective prevention re8uires a health promotion approachK)here is an emerging evidence base for interventions that tacle particular ris and protective

factors. In the A5/, for e*ample, the ;idwestern Prevention ProGect, conducted by PentF andco6worers, e*amined the effectiveness and replicability of a multi6component, community6based drug misuse prevention programme. )he study looed at the effectiveness of school
http://www.hubley.co.uk/1nutrition.htmhttp://www.hubley.co.uk/1schools.htmhttp://www.hubley.co.uk/1nutrition.htmhttp://www.hubley.co.uk/1schools.htm


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interventions in the conte*t of broader community mobiliFation strategies. 5ignificantreductions in tobacco and cannabis use occurred amongst students followed up at ears &and %9. However, training for community leaders and the use of mass media was lesseffective when not teamed with school6based and parenting programmes.

/nother A5 study, ProGect orthland, led by Perry and colleagues, used similar school6 and

community6based approaches to reduce alcohol and other drug use in orth West ;innesota.)he research found statistically significant reductions in drug use, changed peer norms andimproved parentchild communication. )he case can be made from both of these studies forwhole6community approaches that complement individual6focused interventions.

)he Oatehouse proGect in /ustralia aims to reduce the rates of depression and self6harmamongst young people. )his school6based programme emphasises the importance of positiveconnectedness between the individual and both teachers and peers. It has identified threepriority areas for action= "i$ building a sense of security and trustM "ii$ enhancing sills andopportunities for good communicationM and "iii$ building a sense of positive regard throughvalued participation in aspects of school life. Drawing on the !ttawa Charter framewor, theproGect aims to create a healthy environment rather than concentrating on individuals./lthough still at an early stage, the proGect has already demonstrated a reduction in the rate ofsmoing in intervention schools compared with non6intervention schools.

When people become socially disconnected they may see comfort and a sense of securitythrough drug use, and find support and ready acceptance from other drug users. In the A


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subse+uently conducted interviews, held focus groups or collected narrative accounts of theirpractice. )he data is being analyFed, considered in light of former nowledge and newmethods are being chosen to generate further evidence about how to practice in a way that iswomen6centred.

a-in Connections: urturin Adolescent =irls 'trenths $7annister( in process+

)his community based research proGect, funded by the @ritish Columbia Health -esearchoundation "@CH-$, was created in direct response to concerns articulated by adolescentgirls who identified the importance of peer support and mentoring relationships as a means toenhance their ability to handle relationships. 1ffective relationships were viewed as the focalpoint for building self6esteem and enhancing health. / participatory action research "P/-$framewor is being used to understand adolescent girlsN "ages %26%&$ e*periences ofrelationships and to facilitate action. our groups of girls, each of which has direct lins to anadvisory committee, have been meeting weely for %' wees. )he advisory committee servesas a forum for the girls to present their health related concerns and to generate further action.)he adolescent girls are involved in analyFing the data. )he girls report that they are learningnew ways of interacting, thereby enhancing their ability to handle relationships. In year two ofthe proGect, it is intended that the girls will use their learning and reflections to create action toinfluence policy6maers and practitioners who are woring with adolescent girls.

'harin 9esources To Alleviate 'carce 9esources5everal non profit organisations ased a researcher to wor with them because of theirconcern about current funding structures that have created a competitive situation for non6profit agencies in the community 6 agencies that previously had wored together to resolveissues in order to sustain a healthy community. )he methodology of co6operative in+uiry"Heron, %&&(M -eason, %&''$ is being used to develop a model of inter6agency collaboration,a transformative model for practice that will afford community agencies the ability to evolvetogether within new funding conte*ts. / critical incident techni+ue was the initial method bywhich the current successful and unsuccessful collaborative relationships were e*amined. @yreflecting on their current practice, the members of the in+uiry group not only have begun toarticulate the essential components of a collaborative model but also have reported that theirrelations with each other have improved. )heir emergent model, which is based on thee*periential, representational, propositional and practical nowledge of those engaged inliving the model, is significantly different from theoretical models, which tend to be reduced toadministrative models.K 0&

14. Health Education 7oard #or 'cotland: Health promotion pro@ects: mental healthKHealth promotion proGects listKhttp=JJwww.hebs.scot.nhs.uJtopicsJmentalhealthJmentproGect.cfm22

1*. ental Health PromotionK)he ational 5ervice ramewor 5tandard !ne= ;ental Health PromotionOuidance or Oood PracticeKhttp=JJwww.dementiaplus.org.uJlibraryJregionalpapersJdeliveryofstandardonecontinuation(.ht

m 2#

1;. Health Education 7oard #or 'cotland publication section: Community developmentapproaches in primary care: options #or obesity manaementKCommunity development approaches in primary care= options for obesity managementKhttp=JJwww.hebs.scot.nhs.uJtopicsJtopicsection.cfm?topicZdiet8)*t)CodeZ098)*t5oZ%#8)/ZtopictitlesT(9 23

1. The 3ood Trust: 0mprovin health( promotin ood nutrition( increasin access tonutritious #ood and advocatin better public policyK@uilding 5trong Communities )hrough Healthy ood)he ood )rustNs mission is to ensure that everyone has access to affordable, nutritious food.ounded in %&&, the )rust wors to improve the health of children and adults, promote goodnutrition, increase access to nutritious foods, and advocate for better public policy.K
http://www.hebs.scot.nhs.uk/topics/mentalhealth/mentproject.cfmhttp://www.dementiaplus.org.uk/library/regionalpapers/deliveryofstandardonecontinuation6.htmhttp://www.dementiaplus.org.uk/library/regionalpapers/deliveryofstandardonecontinuation6.htmhttp://www.hebs.scot.nhs.uk/topics/topicsection.cfm?topic=diet&TxtTCode=302&TxtSNo=15&TA=topictitles%60http://www.hebs.scot.nhs.uk/topics/topicsection.cfm?topic=diet&TxtTCode=302&TxtSNo=15&TA=topictitles%60http://www.hebs.scot.nhs.uk/topics/mentalhealth/mentproject.cfmhttp://www.dementiaplus.org.uk/library/regionalpapers/deliveryofstandardonecontinuation6.htmhttp://www.dementiaplus.org.uk/library/regionalpapers/deliveryofstandardonecontinuation6.htmhttp://www.hebs.scot.nhs.uk/topics/topicsection.cfm?topic=diet&TxtTCode=302&TxtSNo=15&TA=topictitles%60http://www.hebs.scot.nhs.uk/topics/topicsection.cfm?topic=diet&TxtTCode=302&TxtSNo=15&TA=topictitles%60


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In eeping with its organiFational mission, )he ood )rust evaluates the success of itsprograms and initiatives by its effectiveness in=

Improving communitiesN access to affordable and healthy fresh foodsM

Increasing awareness among at6ris consumers of the value of proper nutrition and

its relation to individual healthM and

1ffecting positive behavioral change among children and adults, as relates to healthy

eating habits.

http=JJwww.thefoodtrust.orgJ 2&

1B. Healthy livin : The Department o# Health: Health topics: Healthy livin

KHealthy living= Promoting healthy lifestyles for people in 1ngland and Wales is an importantgovernmental responsibility. DH runs initiatives to help people +uit smoing, eat better ande*ercise more, as well as health screening proGects and training and sills programmes.Khttp=JJwww.dh.gov.uJPolicy/ndOuidanceJHealth/nd5ocialCare)opicsJHealthy4ivingJfsJen #(

1). Community development and its impact on health: 'outh Asian e"perience ,,Hossain et al. /!B $44/+: B/F ,, 7GKCommunity development and its impact on health= 5outh /sian e*perienceKhttp=JJbmG.bmGGournals.comJcgiJcontentJfullJ0'J3220J'09 (0

!F. Welcome to atPaCTKWhere PC)s grow by sharing information, e*periences, and achievements.Khttp=JJwww.natpact.nhs.uJ (#

*. Any Community Development Approaches to Health Promotion must have the#ollo%in elements

Process( Community,based Participatory 9esearch( Capacity 7uildin

The Community =uide , A 9esource #or Public Health Pro#essionals'tep 1: Assess the primary health issues in your community


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"($ / funding pool for interventions will need to be established early, allocating a notionalamount for each possible interventions, to include research, implementation, training 8capacity building, evaluation, and costs of administering any partnership."3$ unding for interventions should be sustainable not short6term.

'tep !: Develop measurable ob@ectives to assess proress in addressin these health

issues


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L )here is community and organisational development 6 citiFens need to become moreinformed and e*perienced, but organisational systems and practices also need to change.L Partnerships are formed with other local agencies, for e*ample, 5ocial InclusionPartnerships and 4ocal /uthorities, to ensure coordination and cost efficiency.L o single approach or techni+ue constitutes involvement of users and public.L Xarious techni+ues can be used, which must be chosen according to the purpose of the

initiative.L )he resource implications of involvement are acnowledged 6 for e*ample, training, venues,cr[che facilities etc.L )angible gains from participating can be identified and these can be demonstrated andcommunicated.L Communication mechanisms are set up to ensure regular feedbac in accessible formats.L Involvement strategies need to be evaluated and constantly reviewed as part of a dynamicprocess of continuous learning. 0%

Health 5ervice providers also need capacity building=KWe recogniFed that CC@ could only be effective if our own organiFation, D)H-, had theability to support its community partners. We could not rightfully evaluate outcomes at thecommunity level without reflecting on our own capacity to nurture such wor. We were

obliged, to use ;adine vanderPlaatEs insightful phrase, to :turn the evaluative gaFe inwardB.K00

Participatory research approaches:With many of the methods discussed in the previous 5ection, control of the process is stillinvested in the authority or organisation. RParticipatory researchE approaches grew out ofdissatisfaction with traditional power relationships between RresearcherE and RresearchedE anda demand from disabled people in particular, for more empowering models "!liver %&&($. 0%

Community development worers in countries in 5outh /merica, /frica and /sia pioneeredparticipatory approaches in the early %&'9s ">ones and >ones, 99$. In contrast to traditionalresearch, Rparticipatory researchE approaches sought to address the gap between theconcepts and models as perceived by professionals or academics and the ways in which

individuals and groups in the community perceive reality. )he philosophy underlying suchapproaches is that in order to provide anti6oppressive research fulfilling a social Gusticeagenda, it is fundamental that the views, perceptions, direct e*periences and definitions ofnowledge held by people on the receiving end of services are taen account of, valued andacted upon "@randon, 99%$. 0%

)he main purpose of participatory approaches was to raise awareness and ensure that thoseaffected by the research retained control over the whole process from the start. /s !liver"%&&$ argued in relation to disability research, research should not be understood as a set oftechnical obGective procedures carried out by professionals but :part of the struggle bydisabled people to challenge the oppression they currently e*perience in their livesB. )heresearch +uestion or problem, decisions about who should be involved and who theinformation was for, were to be decided by community groups as part of a longer termprocess of investigation, reflection and community action. )he degree of user involvementcould be affected by a number of barriers including discriminatory attitudes, access barriers,issues around resources and representativeness "@randon, 99%$. evertheless, there is nowevidence of research and evaluation being carried out by users and user organisations"@eresford, 999$. People with learning disabilities for e*ample, have been involved asoriginators of research ideas, advisers and consultants to research proGects as well asinterviewers and analysers of research findings. 1*amples such as the e*perience of thePilton Health ProGect serve to confirm that the way issues are defined, articulated and tacledhave a direct bearing upon the levels and +uality of participation and the importance of thisapproach ">ones, %&&'$. 0%

7uilds on strenths and resources %ithin the community.

Community based participatory research sees to identify and build on strengths, resources,and relationships that e*ist within communities of identity to address their shared healthconcerns. )hese may include individual sills and assets 6 sometimes called human capitalM


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networs of relationships characterised by trust, cooperation and mutual commitment 6sometimes called social capitalM and mediating structures within the community such aschurches and other organisations where community members come together. Community6based participatory research e*plicitly recognises and sees to support or e*pand socialstructures and social processes that contribute to the ability of community members to wortogether to improve health, and to build on the resources available to community members

within those social structures.

3acilitates collaborative( e8uitable involvement o# all partners in all phases o# theresearch.Community6based participatory research involves a collaborative partnership in which allparties participate as e+ual members and share control over all phases of the researchprocess, e.g., problem definition, data collection, interpretation of results, and application ofthe results to address community concerns. Communities of identity contain many individualand organisational resources, but may also benefit from sills and resources available fromoutside the immediate community of identity. )hus, C@P- efforts often involve individuals andgroups who are not members of the community of identity, including representatives fromhealth and human service organiFations, academia, community6based organiFations, and thecommunity6at6large. )hese partnerships focus on issues and concerns identified by

community members, and wor to create processes that enable all parties to participate andshare influence in the research and associated change efforts.

0nterates -no%lede and action #or mutual bene#it o# all partners.Community6based participatory research sees to build a broad body of nowledge related tohealth and well6being while also integrating that nowledge with community and socialchange efforts that address the concerns of the communities involved. Information is gatheredto inform action, and new understandings emerge as participants reflect on actions taen.C@P- may not always incorporate a direct action component, but there is a commitment tothe translation and integration of research results with community change efforts with theintention that all involved partners will benefit.

Promotes a co,learnin and empo%erin process that attends to social ine8ualities.

Community6based participatory research is a co6learning and empowering process thatfacilitates the reciprocal transfer of nowledge, sills, capacity, and power. or e*ample,researchers learn from the nowledge and :local theoriesB of community members, andcommunity members ac+uire further sills in how to conduct research. urthermore,recognising that socially and economically marginalised communities often have not had thepower to name or define their own e*perience, researchers involved with C@P- acnowledgethe ine+ualities between themselves and community participants, and the ways thatine+ualities among community members may shape their participation and influence incollective research and action. /ttempts to address these ine+ualities involve e*plicit attentionto the nowledge of community members, and an emphasis on sharing information, decision6maing power, resources, and support among members of the partnership.

0nvolves a cyclical and iterative process.

Community6based participatory research involves a cyclical, iterative process that includespartnership development and maintenance, community assessment, problem definition,development of research methodology, data collection and analysis, interpretation of data,determination of action and policy implications, dissemination of results, action taing "asappropriate$, specification of learnings, and establishment of mechanisms for sustainability.

Addresses health #rom both positive and ecoloical perspectives.Community6based participatory research addresses the concept of health from a positivemodel that emphasises physical, mental, and social well6being "WH! %&2($. It alsoemphasises an ecological model of health that encompasses biomedical, social, economic,cultural, historical, and political factors as determinants of health and disease.

Disseminates #indins and -no%lede ained to all partners.

Community based participatory research sees to disseminate findings and nowledgegained to all partners involved, in language that is understandable and respectful, and :where


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ownership of nowledge is acnowledgedB. )he ongoing feedbac of data and use of resultsto inform action are integral to this approach. )his dissemination principle also includesresearchers consulting with participants prior to submission of any materials for publication,acnowledging the contributions of participants and, as appropriate, developing co6authoredpublications.

0nvolves a lon,term commitment by all partners.Oiven the emphasis in community6based participatory research on an ecological approach tohealth, and the focus on developing and maintaining partnerships that foster empoweringprocesses and integrate research and action, C@P- re+uires a long6term commitment by allthe partners involved. 1stablishing trust and the sills and infrastructure needed forconducting research and creating comprehensive approaches to community changenecessitates a long time frame. urthermore, communities need to be assured that outsideresearchers are committed to the community for the long haul, after initial funding is over.

0n summary(community6based participatory research involves a collaborative partnership ina cyclical, iterative process in which communities of identity play a lead role in= identifyingcommunity strengths and resourcesM selecting priority issues to addressM collecting,interpreting, and translating research findings in ways that will benefit the communityM and

emphasiFing the reciprocal transfer of nowledge, sills, capacity and power. /s appropriate,such partnerships may involve individuals and groups who are not members of the communityof identity, for e*ample, representatives from health and human service agencies, oracademia. However, the focus of the partnership is driven by issues and concerns identifiedby members of the community of identity. %' 6 Paper includes policy recommendations forincreasing community6based participatory research see headings below

unding -esearch Partnerships

Planning grants.

4ong6range funding.

Initial and ongoing funding for infrastructure.

unding directly to community6based organiFations as well as universities.

unding for comprehensive approaches that e*tend beyond categorical perspectivesand traditional research designs.

Orant application and review process.

Capacity @uilding and )raining for C@P- Partners

Pre and post doctoral training and continuing education.

)raining programs for community members.

Institutional support for continuing education and community service.

1ducational opportunities for members of traditionally marginalised communities.

@enefits and -eward 5tructures for C@P- Partners

)enure and promotion process.

-oles, responsibilities and recognition of community partners involved in

C@P-.

Public Health Division, Department of Human 5ervices, ;elbourne, Xictoria, /ustralia= HealthPromotion 'trateies #or Community Health 'ervices. An Evidence,7ased Plannin3rame%or- #or utrition( Physical Activity( and Healthy Weiht "ebpfYnutrition.pdf$

igure 2. contains -oles and -esponsibilities in a -egional Health Promotion 5ystem. P3%#

7ene#its o# C7P9Overall !enefits of C!P"&

1nhances data +uality and +uantity, by establishing trust.

;oves beyond categorical approaches.

Improves research definition and direction.


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1nhances translation and sustainability of research findings.

Improves the communityNs health, education and economics, by sharing nowledge

obtained from proGects.

!enefits to Schools of Public Health

ulfills missions of schools of public health.

@rings together disciplines that have historically operated in their own research silo.

Increases student interest and participation in research.

!enefits to State and local Health Departments

Increases patient contact, primary care, and self6management.

acilitates development and implementation of more effective public health

interventions.

1nhances behavioural change and decreases costs to health departments.

!enefits to Public and Private %unding Institutions

Cost effectiveness of C@P-.

Increased trust from communities.

on6categorical nature allows for greater fle*ibility in support.

In addition to outlining benefits of C@P-, the Conclusions and -ecommendations sectionhighlights challenges facing C@P- and offers possible solutions to overcome them. )hreeprincipal challenges identified by participants included= development o# university,community partnerships, institutional commitment, and trainin. (

De#inition o# C7P9Community6based participatory research "C@P-$ is committed to social change and strives to

enhance health and +uality of life in urban communities. C@P- is methodologically sound,rigorous research that respects and encourages varied research methods and adheres tostandard ethical review processes. C@P- proGects are driven by community needs andpriorities to answer relevant +uestions, build programs, and affect public policy. -ather than aspecific research method, C@P- is a widely respected RprocessE for conducting research thatvalues the lived e*perience of community members and welcomes and encourages theircontributions at the levels of input "initiation of ideas$, process "during data collection, analysisand interpretation phases$, and outcome "implementing action6oriented recommendations$.-ecognising that there are barriers to both community and academic involvement in C@P-,e+uitable partnerships between staeholders are established "with clear terms of reference$to guide C@P- proGects. Data generated through these proGects are Gointly owned andaccessible to all partners. /ttention to trust6building, decision6maing, power and resource6sharing, and reciprocal capacity6building "where the nowledge bases and sill sets of all

research partners are enhanced as a result of the research process$ are e*pected outcomesin all C@P- proGects. %2

Community,partnered approaches to researchCommunity6partnered approaches to research promise to deepen our scientific base ofnowledge in the areas of health promotion, disease prevention, and health disparities.Community6partnered research processes offer the potential to generate better6informedhypotheses, develop more effective interventions, and enhance the translation of the researchresults into practice. 5pecifically, involving community and academic partners as researchcollaborators may improve the +uality and impact of research by=

;ore effectively focusing the research +uestions on health issues of greatest relevance tothe communities at highest risM

1nhancing recruitment and retention efforts by increasing community buy6in and trustM


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1nhancing the reliability and validity of measurement instruments "particularly survey$through in6depth and honest feedbac during pre6testingM Improving data collection through increased response rates and decreased socialdesirability response patternsM Increasing relevance of intervention approaches and thus lielihood for successM )argeting interventions to the identified needs of community members

Developing intervention strategies that incorporate community norms and values intoscientifically valid approachesM Increasing accurate and culturally sensitive interpretation of findingsM acilitating more effective dissemination of research findings to impact public health andpolicyM Increasing the potential for translation of evidence6based research into sustainablecommunity change that can be disseminated more broadly.

or the purpose of this P/-, community refers to populations that may be defined by=geographyM raceM ethnicityM genderM se*ual orientationM disability, illness, or other healthcondition

community development approaches to health promotion

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