Community Development Approaches to Health Promotion

In this literature review, it has become apparent that there are problems with definitions at
every turn. What is Health Promotion? What is community? What is Community
Development? What are community development approaches to health promotion?
It is also clear that the policy environment has progressively moved, both nationally and
internationally, towards a policy of community development approaches accelerated since
the adoption of the Ottawa Charter (and its 5 Principles) in 1986.
However, the translation of policy into practice has proved problematic, and solutions to these
problems are still in development.
The first part of this review attempts to extract some definitions which can set the way to
understanding this process, and briefly visits the policy environment.
The second part lifts abstracts from the literature in order to address the questions of
community development approaches to health promotion, the need and barriers, looks at the
problems of defining effectiveness or success of interventions, suggests requisites necessary
in designing or implementing any community development approach, and finally briefly
discussing the issues of empowerment and partnership.
It must be emphasised that these are weighty issues, and the time allocated has not allowed
for detailed analysis. Rather, the abstracts, sometimes repetitive, have been extracted and
placed in an order that can begin to make some sense although this process is in no way
complete.
1. What is Health Promotion? Page 1
2. Approaches to Health Promotion Page 3
3. Policy Environment Page 6
4. Community Development Approaches to Health Promotion Page 7
4.1 What is Community? Page 8
4.2 What is Community Development? Page 8
4.3 What are Community Development Approaches to Health Promotion? (Literature
Abstracts) Page 9
4.4 Lack of Evidence re Community Development Intervention Outcomes Page 14
4.5 Difficulties in defining success or effectiveness Page 16
4.6 Some examples of Community Development Approaches to Health Promotion Page 17
5. Any Community Development Approaches to Health Promotion must have the following
elements - Page 29
6. Questions of Community Empowerment & Partnership Page 40
1. What is Health Promotion?
McKinlay tells the story: He was sitting by the river one nice sunny day when he heard a
shout and saw someone in the middle of the river clearly struggling to stay afloat. He dived in
and rescued them . they had taken in a fair bit of water so required resuscitation, which he
duly performed. Just as that person was ok, he heard another shout and lo and behold
another person was in trouble. Of course he dived in and rescued that person too. Just as
they were coming around, another shout! A third person had to be rescued. This went on for
some time until he became exhausted and started to think about what was going on upstream
that was causing all these people to end up in the river in such distress. So he headed up for
a look. This is, in essence, what health promotion is. Of course people need to be rescued
and brought back to full health BUT someone also needs to go upstream and figure out why
there are so many people needing to be rescued. [32]
Health Promotion occurs upstream with the aim of preventing people falling in or being
pushed. Downstream we have secondary (aim to detect disease early so that treatment can
be started before irreversible damage occurs e.g. screening), and tertiary prevention and
health care (management of established disease e.g. to minimise disability and prevent
complications e.g. foot care for people with diabetes). Mid-stream we have primary prevention

and health care, usually individual, for example attempts to reduce risk of contracting disease
(educating smokers, vaccinating). And upstream we have health promotion including social
policies and health promotion programmes, such as taxes on tobacco, smoke free legislation
and advertising bans. This may include health education, which aims to reduce ill-health and
increase positive health influencing peoples beliefs, attitudes and behaviour. Health
Promotion has a dual role to prevent ill health and promote positive health. [25, 32]
Health promotion is the process of enabling people to increase control over, and to improve,
their health. To reach a state of complete physical, mental and social well-being, an individual
or group must be able to identify and to realize aspirations, to satisfy needs, and to change or
cope with the environment. Health is, therefore, seen as a resource for everyday life, not the
objective of living. Health is a positive concept emphasizing social and personal resources, as
well as physical capacities. Therefore, health promotion is not just the responsibility of the
health sector, but goes beyond healthy life-styles to well-being. [Ottawa Charter for Health
Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986 WHO/HPR/HEP/95.1] [69]
A refined definition might be, "health promotion is the process of enabling individuals and
communities to increase control over the determinants of health and thereby to improve their
health." Among other things, this definition suggests that in our efforts to evaluate health
promotion efforts, we should obtain evidence on process as well as outcome, on the
empowerment of individuals and communities, on the interventions directed at the
"determinants of health" and on positive health outcomes as well as the prevention of
negative ones. It also implies that we might consider using the evaluation process itself as a
means to improve the capacities of individuals and communities to increase control over the
determinants of health. [43]
Another refining definition, health promotion is about helping people to have more control
over their lives, and thereby improve their health. It occurs through processes of enabling
people, advocacy, and by mediating among sectors. In essence, health promotion action
involves helping people to develop personal skills, creating supportive environments,
strengthening communities, influencing governments to enact healthy public policies, and
reorientating and improving health services. [13]
Common Themes:

Health promotion involves the whole population in the context of everyday life
Enabling
Control or Empowerment
Promoting Wellbeing (rather than dealing with illness)
Building capacity
Its a process not just an outcome
Directed towards action on determinants or causes of health/disease. Wide definition
of determinants of health.
Community Development

Put another way:

Health Promotion
aims to gain effective public participation
1 aims to:
0 create a supportive environment
1 build healthy public policy
2 strengthen community action
3 develop personal skills
4 empower local people
5 improve equity and inequality
6 re-orientate health service
7 advocate for health [25]

Three words describe the role of practitioners involved in integrated health promotion
programs:
Enable: Integrated health promotion focuses on achieving equity in health. A major aspect of
the work of integrated health promotion is to provide the opportunities and resources that
enable people to increase control over and improve their health. This includes developing
appropriate health resources in the community and helping people to increase their health
knowledge and skills, to identify the determinants of their own health, to identify actions by
themselves and others, including those in power, that could increase health, and to demand
and use health resources in the community.
Advocate: Action for health often requires health workers to speak out publicly or write on
behalf of others, calling for changes in resources, policies and procedures. The Cancer
Council lobbying for a ban on smoking in all enclosed spaces is an example, as is a local
community health worker writing letters to the local paper calling on the council to improve
facilities for physical activity for older people.
Mediate: Many sectors of the community, such as government departments, industry, nongovernment organisations, volunteer organisations, local government and the media take
action that has an impact on peoples health, sometimes acting to support one another,
sometimes disagreeing about what should be done. Health workers play a role in mediating
between these different groups in the pursuit of health outcomes for the community, or in
mediating between the health requests of different sectors of the community. [22]
2. Approaches to Health Promotion
How can one go about "doing" health promotion?
The following strategies, which are often combined, are commonly used:

Creating supportive environments: Activities aimed at establishing policies that

support healthy physical, social and economic environments (WHO, 1998).
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, knowledge, and life skills
conducive to individual and community health (PAHO, 1996; WHO, 1998).
Health communication: A strategy to inform the public about health concerns and
place important health issues on the public agenda achieved through the use of the
mass and multimedia, and other technological innovations that disseminate useful
health information to the public, increase awareness of specific aspects of individual
and collective health, as well as increase awareness of the importance of health in
development (WHO, 1998).
Self-help: Actions taken by lay persons to mobilize the necessary resources to
promote, maintain or restore the health of individuals or communities through selfcare activities such as self-medication, self-treatment and first aid in the normal social
context of people's everyday lives (WHO, 1998).
Organisational development: A process typically used in industry although applicable
to other settings such as communities, to improve performance, productivity and
morale issues, and attain an optimally functioning organization, with a high level of
cohesion, well-being and satisfaction on the part of all those involved (Raeburn &
Rootman, 1998).
Community development / action: A process of collective community efforts directed
towards increasing community control over the determinants of health, improving
health and becoming empowered to apply individual and collective skills to address
health priorities and meet respective health needs (WHO, 1998).
Healthy public policy: Formal statements that demonstrate concern for heath and
equity and which make healthy choices possible or easier for citizens, through
creating supportive social and physical environments that enable people to lead
healthy lives (PAHO, 1996; WHO, 1998).
Advocacy: A combination of individual and social actions designed to gain political
commitment, policy support, social acceptance and systems support for a particular
health goal or program (PAHO, 1996; WHO, 1998).

Research: Information which links 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, asks meaningful
questions and is systematic and rigorous (Naidoo & Wills, 1998). Evaluation research
is formal or systematic activity, where assessment is linked to original intentions and
is fed back into the planning process (Naidoo & Wills, 2000)."
Medical approach: Focused on disease and biomedical explanations of health.
Narrow concept of disease (ignore social/environmental dimensions) e.g.
immunisation, screening [55, 25]

Examples of approaches to health promotion (Ewles & Simnet, 1995) [25]

Aim

Appropriate Method

Example - Smoking

1. Health awareness
goal

talks
group work
mass media
displays and exhibitions
campaigns

Encourage people to seek early

detection and treatment of
smoking-related disorders

group work
skills training
self help groups
one-to-one instruction
group or individual therapy
written material
advice

Persuasive education to prevent

non-smokers from starting and
persuade smokers to stop

one-to-one teaching
displays and exhibitions
written materials
mass media
campaigns
group teaching

Giving information to clients

about the effects of smoking.
Helping them to explore their
own values and attitudes and
come to a decision. Helping
them to learn how to stop
smoking if they want to

group work
practising decision-making
values clarification
social skills training
stimulation, gaming and role play
assertiveness training
counselling

Clients identify what, if anything,

they want to know about it

positive action for under-served

groups
lobbying
pressure groups
community development
community-based work
advocacy schemes
environmental measures
planning and policy making
organisational change
enforcement of laws and
regulations

No smoking policy in public

places. Cigarette sales less
accessible, especially to
children; promotion of nonsmoking as social norm.
Banning tobacco advertising and
sports sponsorship

Raising awareness, or
consciousness, of health
issues
2. Changing attitudes
and behaviour
Changing the lifestyles of
individuals

3. Improving knowledge
Providing information

4. Self empowering
Improving selfawareness, self-esteem,
decision-making

5.
Societal/environmental
change
Changing the physical or
social environment

Integrated health promotion service delivery can be organised from one or more different
angles, depending on the key priorities identified and the problem definition, including:

health or disease priorities, for example, mental health, heart disease, diabetes, oral
health
lifestyle factors, such as physical activity and nutrition, tobacco use, safe sex
population groups, for example, culturally and linguistically diverse groups, same-sex
attracted youth, adolescents, older people living alone
settings, for example, health promoting schools, health promoting workplaces, health
promoting hospitals, council estates.

The key requirement for quality practice is how programs are planned, delivered and
evaluated. By definition, quality practice is:

enabling it is done by, with and for people, not on them; it encourages participation
involves the population in the context of their everyday lives, rather than focusing just
on the obvious lifestyle risk factors of specific diseases
directed to improving peoples control over the determinants of their health
a process - it leads to something, it is a means to an end. [22]

3. Policy Environment
In 1979, the thirty-second World Health Assembly launched the Global Strategy for health for
all the year 2000 thereby endorsing the Report and Declaration of the International
Conference on Primary Health care, held in Alma-Ata, USSR in 1978. The commitment to the
achievement of "Health for All by the Year 2000" was accepted by the 150 member states and
became the basis of all the WHO - related new developments in the field of health care in the
world. A modern movement termed Health Promotion emerged out of the historical need for a
fundamental change in strategy to achieve and maintain health. The Health Promotion
Programme at the regional office for Europe of World Health Organisation (WHO) was
established in 1984 bringing to fruition the objectives outlined in the policy documents that the
Regional Office for Europe had developed over the previous five years.
The first International Conference on Health Promotion met in 1986 in Ottawa to present a
charter for action in order to work towards the achievement of Health for All by the Year 2000
and beyond. The action plan of the 1986 Ottawa Charter advises that health promotion
strategies and programmes should be adapted to the local needs and possibilities of
individual countries and regions to take account of differing social, cultural, political and
economic systems. The declaration and programme for action is predicated upon the
fundamental prerequisites for health i.e. peace, shelter, education, food, income, sustainable
resources, a stable ecosystem, social justice and equity. At the heart of this health promotion
action programme lies the key concerns with advocacy, enablement and mediation.
Identification of priority issues is only one dimension of the Ottawa Action plan. The role of
those engaged in health promotion is to put into effect, within an integrated philosophy, these
following aspects of the health promotion action programme:
i) Endeavouring to build a healthy public policy
ii) Working to create supportive environments
iii) Helping to strengthen community action in various settings
iv) Striving to develop personal skills
v) Working together to re-orientate Health Services [66]
Ottawa Charters Five strategies
The 1997 World Health Organisation (WHO) Jakarta Declaration on Health Promotion into the
21st Century explicitly acknowledges the demonstrated effectiveness of health promotion in
the following statement: Health promotion makes a difference. Research and case studies
from around the world provide convincing evidence that health promotion works. Health

promotion strategies can develop and change lifestyles, and the social, economic and
environmental conditions which determine health. Health promotion is a practical approach to
achieving greater equity in health. There is now clear evidence that:
Comprehensive approaches to health development are the most effective - those which use
combinations of the Ottawa Charter's five strategies are more effective than single track
approaches.
Settings offer practical opportunities for the implementation of comprehensive strategies these include mega-cities, islands, cities, municipalities, and local communities, their markets,
schools, workplaces, and health care facilities.
Participation is essential to sustain efforts - people have to be at the centre of health
promotion action and decision- making processes for it to be effective.
Health learning fosters participation - access to education and information is essential to
achieving effective participation and the empowerment of people and communities.
These strategies are core elements of health promotion and are relevant for all countries
(WHO, 1997). [15]
The theoretical drive for WHO's action programme is based upon a shift in emphasis from
issues to settings. The shift has been from infectious diseases to behavioural diseases and
risk factors followed by an increasing emphasis on the environmental factors that create and
maintain health. The aim now is to influence the context of health actions and make the social
and physical environment supportive to health and to provide individuals with strategies of
health improvement and maintenance that can be integrated with meaning into a person's
overall life pattern. [66]
Improving health and reducing health inequalities are now cross-cutting UK Government
priorities, with national targets agreed by various departments (public service agreements), as
part of the Government Intervention in Deprived Areas (GIDA). There are now unprecedented
national policy drivers to involve communities in local decision-making across sectors. [21]
1999 Saving Lives: Our Healthier Nation is a comprehensive government-wide public health
strategy for England. Its goals are to improve health and to reduce the health gap (health
inequalities). The strategy aims to prevent up to 300,000 untimely and unnecessary deaths by
the year 2010. Targets, including health inequalities, will be tailored to local needs through
needs assessments in association with local authorities.
2004 Choosing Health: Making healthy choices easier is a government white paper, which
sets out the key principles for supporting the public to make healthier and more informed
choices in relation to their health. [26]
4. Community Development Approaches to Health Promotion
Definitions
4.1 What is Community?
The US Government 2010 Healthy People report defines community as a specific group of
people, often living in a defined geographical area, who share a common culture, values and
norms, and who are arranged in a social structure according to relationships the community
has developed over a period of time (World Health Organization, 1998; US Department of
Health and Human Services, 2000). Members of a community gain their personal and social
identity by sharing common beliefs, values and norms which have been developed by the
community in the past and may be modified in the future. They exhibit some awareness of
their identity as a group, and share common needs and a commitment to meeting them. [1,
28]
4.2 What is Community Development?

Community development seeks to empower individuals and groups of people, with the skills
they need to advocate on their own behalf, improve their lives, and provide communities with
access to resources. [66]
Or put another way.
Community development, in very simple terms, is the process of developing social capital. It
is a process that emphasises the importance of working with people as they define their own
goals, mobilise resources, and develop action plans for addressing problems they have
collectively identified. [22]
Definition of social capital (Putnam 1993): The community cohesion resulting from high levels
of civic identity and the associated phenomenon of trust, reciprocity and civic engagement.
Four characteristics: the existence of community networks, formal or informal, civic
engagement (particularly in networks), local identity and a sense of solidarity and equality with
other community networks, and norms of trust and reciprocal help and support. [25]
Social capital and community development:
Participating in social and civic activities, such as community group meetings, child care
arrangements with neighbours, neighbourhood watch schemes and voting, all work to
produce a resource called social capital. Social capital is critical to the health, wealth and
wellbeing of populations.33 It is a key indicator of the building of healthy communities through
collective and mutually beneficial interaction and accomplishments. 34 Recent research has
linked these types of activities to improved health outcomes. 35, 36, 37, 38 [22]
[33. Putnam, R. (1993), Making Democracy Work, Princeton University Press, Princeton, New
Jersey.
34. Baum, F., Palmer, C., Modra, C., Murray, C. and Bush, R. (2000), Families, social capital
and health, in Winter, I. (ed.), Social Capital and Public Policy in Australia, Australian Institute
of Family Studies, Melbourne.
35. Berkman, L. and Syme, S. (1979), Social networks, host resistance, and mortality: A nineyear follow-up study of Alameda County residents, American Journal of Epidemiology, vol.
109, no. 2, pp. 186203.
36. Kawachi, I., Kennedy, B., Lochner, K. and Prothrow-Smith, D. (1997), Social capital,
income inequality, and mortality, American Journal of Public Health, vol. 87, no. 9, pp. 1491
8.
37. Baum, Palmer, Modra, Murray and Bush, op. cit.
38. Kawachi, I., Colditz, G., Ascherio, A., Rimm, E., Giovannucci, E., Stampfer, M. and Willet
(1996), A prospective study of social networks in relation to total mortality and cardiovascular
disease in men in the USA, Journal of Epidemiology and Community Health, vol. 50, pp. 245
51.]
The notion of social capital represents a way of thinking about the broader determinants of
health and about how to influence them through community-based approaches to reduce
inequalities in health and wellbeing. 39 A focus on social capital supports a balance of
strategies that address behaviour and those that focus on the settings in which people live,
work and play. The implication for integrated health promotion is that more emphasis is
needed on efforts to strengthen the mechanisms by which people come together, interact and,
in some cases, take action to promote health. Simple measures, such as providing space for
people to meet, may be as health promoting as providing health information in an effort to
change behaviour. [22]
[39. Gillies, P. (1998), Effectiveness of alliances and partnership for health promotion, Health
Promotion International, vol. 13, no. 2.]
Service providers can also enhance the social capital within a community by supporting
community projects that bring neighbours together to achieve a mutually beneficial goal, such
as beautifying the environment of a public housing estate, establishing a community fruit and

vegetable garden or working with the local sporting club to encourage all parts of the
community to participate in sporting activities. [22]
4.3 What are Community Development Approaches to Health Promotion? (Literature
Abstracts)
The evidence suggests that there has been a shift to looking at the social, economic,
political, and environmental determinants of health because other methods of ill-health
reduction have failed.
Therefore, the argument goes, it is necessary to develop communities themselves to
take control of their own health agenda to tackle these health issues from the source.
However, developing communities brings its own problems; problems of definition;
and tensions between the various agenda setters and resource holders.
The suggestion is, in much of the literature, although not clearly proven, that the only
way left to go forward is community development, and some writers suggest that
partnerships can be and need to be forged between communities, health service
providers, and academics.
Below are some abstracts from the literature review, theorising about community
development approaches and its barriers. This is followed by a discussion on the lack
of comparable evidence and the difficulty in defining effectiveness or success in
looking at interventions; some examples of specific interventions; a discussion of what
community development approaches should or must include; and finally some notes
on empowerment and partnership.
Again there is a problem of definition:
Community Development: the process by which a community identifies its needs, develops an
agenda with goals and objectives, then builds the capacity to plan and take action to address
these needs and enhance community well-being.
Community Organisation: the process of involving and mobilising major agencies, institutions
and groups in a community to work together to coordinate services and create programmes
for the united purpose of improving the health of the community:
Community-based: the process of agency development of solutions for health problems which
incorporate community consultation and input thus allowing adaptation of the implementation
to suit local needs/circumstances. [12]
A Community Development approach to health is a process by which a community defines
its own health needs to bring about change. The emphasis is on collective action to redress
inequalities in health and enhance access to health care.
(Community Development and Health Network, Northern Ireland) [27]
[Northern Ireland is one area where Community Development Approaches have been
adopted strongly]
Social, political, economic and environmental determinants of health
Recent epidemiological analysis of health, disease and disability in the populations of most
developed countries confirms the role of social, economic and environmental factors in
determining increased risk of disease and adverse outcomes from disease. [42]
Health status is influenced by individual characteristics and behavioural patterns (lifestyles)
but continues to be significantly determined by the different social, economic and
environmental circumstances of individuals and populations. [42]
Through the Charter, health promotion has come to be understood as public health action
which is directed towards improving people's control over all modifiable determinants of
health. This includes not only personal behaviours, but also the public policy, and living and
working conditions which influence behaviour indirectly, and have an independent influence
on health. [42]

(This more sophisticated approach to public health action is reinforced by accumulated

evidence concerning the inadequacy of overly simplistic interventions of the past. To take a
concrete example, efforts to communicate to people the benefits of not smoking, in the
absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are
doomed to failure. A more comprehensive approach is required which explicitly acknowledges
social and environmental influences on lifestyle choices and addresses such influences
alongside efforts to communicate with people. Thus, more comprehensive approaches to
tobacco control are now adopted around the world. Alongside efforts to communicate the risks
to health of tobacco use, these also include strategies to reduce demand through restrictions
on promotion and increases in price, to reduce supply by restrictions on access (especially to
minors), and to reflect social unacceptability through environmental bans. This more
comprehensive approach is not only addressing the individual behaviour, but also some of the
underlying social and environmental determinants of that behaviour.) [42]
Insufficiency of education alone
It is now well understood from experiences in addressing specific public health problems of
tobacco control, injury prevention and prevention of illicit drug use, and the more general
challenge of achieving greater equity in health, that education alone is generally insufficient to
achieve major public health goals. [42]
More recently, researchers have called for a renewed focus on an ecological approach that
recognises that individuals are embedded within social, political and economic systems that
shape behaviors and access to resources necessary to maintain health. [18]
Such an approach corresponds with increased interest in understanding the complex issues
that compromise the health of people living in marginalized communities. Emphasis has also
been placed on the need for expanded use of both qualitative and quantitative research
methods (e.g. Israel et al); greater focus on health and quality of life; and more translation and
integration of basic, intervention, and applied research. [18]
Greater community involvement in processes that shape research and intervention
approaches, e.g., through partnerships between academic, health services and communitybased organisations is one means towards these ends. [18]
(18)
Community development and health
Essentially, community development work acknowledges that health is as affected by the
social conditions of peoples lives such as damp housing, unemployment, or poor access to
facilities, as it was by lifestyle choices. Major policy documents including Towards a Healthier
Scotland (1999) and Our National Health (2000) highlight the importance of considering life
circumstances alongside lifestyle choices and disease in promoting health and wellbeing. [31]
A World Health Organisation (WHO) position paper (1991) directly linked community
participation to empowerment as a means in itself of promoting healthier individuals and
environments. Furthermore, research has recognised the significance of powerlessness and
empowerment to the health of individuals and communities (Wallerstein 1993). The concept of
healthy communities as developed by the WHO regards active community participation as
essential to creating healthy communities:
The formation of local social capital can thus lead to the promotion of shared values and a
common vision, integrated planning and resource utilization, and ultimately to systemic
change. (Murray, 2000, p101) [31]
There is a growing body of literature showing that being part of a social network of contacts is
protective for health (Fisher 2001). The effects derive from improved self-esteem, trust and
increased feelings of being in control. [31]
Community Development Issues

Current health promotion policy and practice places a high value on community development
work because it aims to enable communities to identify problems, develop solutions and
facilitate change. [30]
The overt ideological agenda of community development is to remedy inequalities and to
achieve better and fairer distribution of resources for communities. This is achieved ideally
through participatory processes and bottom-up planning. Empowering communities to have
more say in the shaping of policies influencing health represents a break with earlier traditions
of public health associated with top-down social engineering. [30]
However, community development means different things to different people and can operate
on different levels (See Arnsteins ladder, 1971). Community development has, for example,
been linked to community organisation, community-based initiatives, community mobilisation,
community capacity building and citizen participation. [30]
There is, however, a common understanding of core principles, which inform community
development work, two of which are participation and empowerment. These principles can
and are, however, operationalised differentially in different types of community development
work. [30]
Despite consensus that community participation should engender active processes involving
choice, and the potential for implementing that choice, implementation has proven difficult.
For example, when formal health services adopt an empowerment framework, their formal
structures are not necessarily conducive to participation. [30]
Although it is commonly agreed that appropriate leadership and effective organisational
structures are crucial to successful community participation, this requires a political climate
that nurtures and facilitates the approach. [30]
Community development uses a variety of methods and activities such as self help work,
outreach, local action groups, lobbying, peer work, festivals and events, information,
advocacy, group work, network building and pump priming community initiatives with small
grants. [31]
The key characteristic of community development is that it starts from the experiences and
perspectives of communities. In terms of health, local people need to be enabled or supported
to identify the factors that impinge on their health and the solutions. It is argued that genuine
participation is only possible when there is involvement in decision-making and evaluation.
[31]
Community development approaches challenge the definition of health as an individual
problem for which there are individual solutions, and health care systems that treat the
symptoms and not the root causes of ill health. Instead, such approaches emphasise the
knowledge and expertise of individuals and communities living through an experience and the
centrality of drawing on this source of expertise to define problems and solutions and
ultimately to design more effective services. The main benefits of community development
approaches have been summarised as:
Improving networks in a community, which has been shown to have a protective effect on
health.
Identifying health needs from users point of view, in particular disadvantaged and socially
excluded groups.
Change and influence, as it enhances local planning and delivery of services.
Developing local services and structures that act as a resource.
Improving self-esteem and learning new skills that can aid employment.
Widening the boundaries of the health care debate by involving people in defining their
views on health and local services.
Tackling underlying causes of ill health and disadvantage. [31]

Health Inequalities, CBPR & Community

There is increasing empirical evidence that a complex set of contextual factors (including
social, economic and physical environmental factors, such as poverty, air pollution, racism,
inadequate housing, and income inequalities) play a significant role in determining health
status. These factors contribute to the disproportionate burden of disease experienced by
marginalised communities. There is also considerable evidence suggesting that numerous
resources, strengths and skills exist within communities (e.g. supportive interpersonal
relationships, community-based organisations) that can be engaged in addressing problems
and promoting health and well-being. This understanding of the factors associated with health
and disease has contributed to calls for more comprehensive and participatory approaches to
public health research and practice, and a rise in partnership approaches, variously referred
to as ``participatory action research , ``participatory research , ``action research , and
``community-based research . Policy changes at the organizational, community and national
levels are needed to help address barriers and challenges to the adoption of such
approaches and to support their increasing use. [16]
Challenges of community development
The community development approach encounters particular challenges in the context of
health care. While support for the idea of extending community development approaches into
mainstream health services and other public services has grown, in reality organisations are
not always receptive to the idea of a longer term ongoing dialogue which might lead to major
changes within the organisation or into areas that the organisation had not previously
considered. The conclusion of a DHSS (Northern Ireland) (1999) document was that
community development is still at a relatively early stage of development within mainstream
agencies. It found most NHS Trusts and Boards did not have a stated policy for a community
development approach, and there was a lack of focus for this work and few instances of
training for staff in this area. [31]
The way of working with and not just on behalf of individuals and communities that is central
to the community development approach, sits uneasily with traditional western medicine and
the medical model in which professionals know what the problem is as well as the solution.
The challenge is not to the value of medical expertise per se, but rather to its dominance in
respect of health knowledge and the allocation of resources. [31]
Few health service professionals are fluent with community development approaches and
ways of working with, rather than on behalf of, people. In describing a public health
programme set up to link new mothers with experienced mothers and Public Health Nurses in
Ireland during the 1980s, Johnstone (1993) concluded: Familiarisation of all health care
workers with changes in policy and the background of research and development and aims of
policy would eliminate some of the frustrations and create a more supportive
environment...The community based approach has proved more effective in achieving change
where this is indicated and is likely to be a more useful model for empowerment and self-care
then the traditional type of health care approach. (p255) Subsequently, Johnstone (1993)
advocated that the education and training of health care workers should include the possibility
of working in partnership with people rather than for people. Community and user groups and
health and social services professionals need to perceive each other interacting in different
sets of roles and relationships. McKnight (2001) also highlighted core differences between the
shape and function of communities and service systems: communities were based around
individuals and families, informal relationships, as well as formal groups, and relationships
defined by choice. Service systems on the other hand, had hierarchical structures designed to
ensure a few people could control a lot of people to produce goods or services. Such
structures ensured uniformity and that goods and services met the same standards. Each
kind of structure has its own (very different) rationale, ways of working and communicating,
and the two kinds of system therefore often find it very difficult to engage constructively
together. The central concern identified by McKnight (2001) was that of ensuring people were
at the centre and influencing what happens. [31]
"Although there is general agreement about the complex interplay among individual-, family-,
organizational-, and community-level factors as they influence health outcomes, there is still a

gap between health promotion research and practice. The authors suggest that a disjuncture
exists between the multiple theories and models of health promotion and the practitioner's
need for a more unified set of guidelines for comprehensive planning of programs. [48]
4.4 Lack of Evidence re Community Development Intervention Outcomes
"For the purposes of this review, researchers defined an intervention as an organized and
planned effort to change individual behavior, community norms or practices, organizational
structure or policies, or environmental conditions." [37]
Despite the fact that community development approaches have been used by several of the
major community-based heart health initiatives, evidence of their use and usefulness remains
sparse. [12]
The health effects of social interventions have rarely been assessed and are poorly
understood. Studies are required to identify the possible positive or negative health impacts
and the mechanisms for these health impacts. The assessment of indirect health effects of
social interventions draws attention to competing values of health and social justice [58]
The Working Group also debated what is meant by "evidence" in the context of health
promotion, with several members arguing that the concept of "evidence" may in fact be an
inappropriate one in this context. One of the key arguments for this position is that the
concept of "rules of evidence" in science tends to be related to particular disciplines, and
since health promotion is by nature "multi-disciplinary," it is not clear whose rules of evidence
it should follow. However, most members of the group felt that it was impractical to take this
stance given the fact that relevant policymakers, including members of the World Health
Assembly, were demanding "evidence-based" health promotion. Several members suggested
that it would be prudent if, at least for the time being, we accept the use of the term
"evidence" within health promotion. As suggested by Keith Tones, perhaps the best way to
think of it is within a judicial paradigm: "We should assemble evidence of success using a kind
of 'judicial principle' - by which I mean providing evidence which leads to a jury committing
[itself] to take action even when 100% proof is not available." This approach has several
advantages: it is a concept of "evidence" which most people can understand, it provides
scope for considering a broad range of sources and types of evidence, it implies that
evidence differs in quality and it implies that one must take the "weight of evidence" into
account. However, this approach does not give us any guidance regarding what evidence is
needed in the context of health promotion." [43]
Health outcomes in populations are the product of three factors: (1) the size of effect of the
intervention; (2) the reach or penetration of an intervention into a population and (3) the
sustainability of the effect.(4). There are few written accounts of the adoption of community
development approaches within the fields of statutory health care, while there is a thriving
literature about the community development approach to health (Jones, 1998). This picture is
bound to change as the emphasis on adopting community development approaches
increases. [31]
There is a well recognised gap between research findings and the implementation of
evidence based prevention strategies in community settings (McGinnis and Foege, 2000).
Research should inform community leaders or facilitate using proven intervention strategies in
community environments. However, community leaders and health promotion experts suggest
that a barrier to the adoption of research-based, efficacious interventions is that these
strategies may not meet community needs (Green and Mercer, 2001). Interventions may be
too complex, difficult or costly to integrate with existing activities. Part of the problem may be
researchers attempts to find the most efficacious program rather than a program that could
be implemented and delivered with limited resources to many people. [1]
The low level of individual participation rates in studies that recruited from a representative
targeted population raises questions about generalisability. [1]

Intervention Sport - evidence

Despite a comprehensive search for literature relating to the effectiveness of policy
interventions implemented through sporting organisations for promoting healthy behaviour
change, no evidence in the form of well-designed and evaluated interventions was found. The
ability to provide clear directions or strategies for future health promotion interventions is
therefore limited. It is likely that these types of interventions are rarely evaluated or published,
or that such evaluations are only available through contacting each sporting club, sporting
association, health promotion agency or other agencies with a remit for sport (e.g. local
councils). An internet search identified a number of case studies in this area. These included
post-data only, and evidence on outcomes was typically anecdotal. It is essential that sporting
or health promotion agencies that conduct such interventions evaluate the interventions,
publish the results and disseminate them widely. This will enable practitioners to more readily
and the available evidence, and consequently, to implement effective interventions. In future,
funding for evaluation should be built into sporting programs. However, as noted in the review
by Payne (Payne 2003) there is a limited capacity to carry out evaluation in sporting
organisations. Payne suggests that academic-based researchers should work in partnership
with the sport and recreation industry to ensure that sporting programs are evaluated in a
useful way. This may simply involve the introduction of data collection tools/databases in
order to evaluate programs in a quasi-experimental manner. Practitioners therefore need to
form relationships with the tertiary education sector. [8]
It is important to recognise that these conclusions are drawn from a wide range of research
across many different issues. Establishing evidence for the effectiveness of interventions
dealing 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 complex and
multifactorial etiologies and which require long time frames for measurable changes to occur.
This must be taken into account in considering the material provided in this report. [15]
Evidence mental health, healthy eating, and physical activity in schools
Findings: This synthesis identified good quality systematic reviews that covered mental
health, aggressive behaviour, healthy eating, physical activity, substance use and misuse,
driver education, and peer approaches. Reviews of programmes that promoted mental health
in schools (including preventing violence and aggression) show these programmes to be
among the most effective ones in promoting health. Of these programmes, the ones that were
most effective were of long duration and high intensity, and involved the whole school. New
reviews that focused on promoting healthy eating and physical activity confirmed an earlier
review, which found that multifactorial interventions, particularly those involving changes to
the school environment, were effective. Four new reviews of programmes that focused on
promoting the prevention of substance use confirmed previous findings that these
programmes are relatively ineffective. Also, programmes on preventing suicide reduced
suicide potential, depression, stress and anger, but less rigorous studies suggested a
potential harmful effect in young males. In some (but not all) studies, peer-delivered health
promotion was found to be effective, compared with teacher-led interventions, and this
approach was highly valued by the young people involved. The systematic review, which
evaluated health outcomes of programmes that used elements of the health promoting
schools approach, included small studies of variable quality. It found apparent benefits to the
social and physical environment of the school, and some studies found the programmes
benefited health-related behaviour (dietary intake and physical fitness). No reviews evaluated
the costeffectiveness of the programmes or interventions. [19]
There is a clear lack of comparative data in measuring effectiveness of different
approaches to health promotion.
4.5 Difficulties in defining success or effectiveness
Definition of goals of intervention (what to measure)
Reach is defined as the percent of potentially eligible individuals who participate in the
intervention study, and how representative they are of the target population from which they
are drawn. Efficacy/effectiveness is the intended positive impact of the intervention and its
possible unintended consequences on quality of life and related factors. Reach and

efficacy/effectiveness operate at the individual level. Adoption is the percent of potential

settings and intervention agents that participate in a study and how representative they are of
targeted settings/agents. Implementation refers to the quantity and quality of delivery of the
interventions various components. Adoption and implementation are setting-level dimensions.
Finally, the maintenance dimension includes individual- and setting-level indices. At the
individual level, maintenance is defined as the longer-term efficacy/effectiveness of an
intervention. Outcomes at 6 months post-intervention contact reflect longer-term individual
maintenance. The setting level definition of maintenance refers to the institutionalisation of a
program and is assessed according to the percent of settings that continue the intervention
program, in part or in whole, beyond the study duration (Glasgow et al., 1999; Glasgow et al.,
2001). [1]
"There is increasing evidence emerging regarding the effectiveness of community-based
injury prevention programmes. The use of multiple interventions implemented over a period of
time can allow injury prevention messages to be repeated in different forms and contexts and
can begin to develop a culture of safety within a community. Important elements of
community-based programmes are a long-term strategy, effective and focused leadership,
multi-agency collaboration, the use of local surveillance to develop locally appropriate
interventions and tailoring interventions to the needs of the community. Time is also needed to
coordinate existing networks, and to develop new ones. However, a positive and sustained
impact of community-based programmes on injury rates has not yet been demonstrated
conclusively. There is a need to develop valid and reliable indicators of impact and outcome
appropriate to community studies. Where proxy measures are used for injury outcomes, it is
important that there is clear evidence of the association between the proxy (e.g. hazard
removal, knowledge gain or behaviour change) and injury risk (Towner et al., 1996Go). There
is also an urgent need to develop and monitor indicators to assess and monitor a culture of
safety, programme sustainability and long-term community involvement. Community-based
injury prevention programmes have been hampered by the lack of resources allocated to both
their programme development, and appropriate and rigorous evaluation." [36]
Health promoting schools and health promotion in schools: two systematic reviews
# Ensure that process evaluation which describes the way in which programmes have been
implemented is undertaken and reported in all studies of health promotion in schools.
# Develop valid and reliable measures for evaluating the outcome of the health promoting
school initiatives, particularly those measuring mental and social well-being for children and
adults. Incorporate these in all studies of health promotion in schools." [67]
4.6 Some examples of Community Development Approaches to Health Promotion
1. Community development, user involvement, and primary health care
Community development recognises the social, economic, and environmental causes of ill
health and links user involvement and commissioning to improve health and reduce
inequalities. Communities can be geographicalsuch as particular housing estatesor
communities of interest, such as user groups. Trained community development workers bring
local people together to:
* identify and support existing community networks, thus improving health;
* identify health needs, in particular those of marginalised groups and those suffering
inequality;
* work with other relevant agencies, including community groups, to tackle identified needs;
* encourage dialogue with commissioners to develop more accessible and appropriate
services.
Many examples of these activities exist. Studies show that community support through social
networks is protective of peoples health. High levels of trust and density of group
membership are associated with reduced mortality. Conversely, lack of control, lack of self
esteem, and poor social support contribute to increased morbidity.

Needs assessment that is focused on communities can identify solutions as well as problems.
Results of such initiatives include a new post of youth health adviser to support youth centred
health activities across practices in Lewisham, which has led to improved learning about
contraception and sexual health, improved liaison with practices, and changes in practice
provision to make services more appropriate for the young people they serve. In St Peters
Ward, a deprived area of Plymouth, a community development approach has resulted in free
pregnancy testing in a local community project, the setting up of a parentwise project that
draws on resources within the community, changes in health visitors working, and the
provision of more acceptable antenatal classes. The more involved the community is in needs
assessment, the more likely changes are to ensue. These assessments can provide
representative views, particularly if quantitative approaches are used to triangulate these
views, and there is little evidence that patients make unreasonable demands.
Community development can also lessen the impact of poverty on health. In Torquay concern
about nutrition has led to the setting up of a food cooperative managed by local people that
makes available cheap, healthy food. Community development can reduce social exclusion
by ensuring that marginalised groups influence health services. In Bradford such an approach
increased the uptake of cervical and breast screening among women from ethnic minorities.
Minority ethnic communities, disabled people, adolescents, and elderly people have all been
involved in the commissioning process in Newcastle, where a community development
worker, accountable to the community, brings together community groups with purchasers
and providers to implement change.
Examples of community development interagency activity include the work of a safety group
in Torquay which resulted in policy changes within the housing department, play areas, and
other borough and police services. While health professionals prescribed drugs to patients in
their hilly area in Lewisham, a community development solution was found through a new bus
service. By involving the local authority, it was possible, in a single intervention, to respond in
a practical way to issues of loneliness, isolation, and problems of exercise tolerance." [61]
2. Outcomes of Community-based Participatory Research
Improved Research Quality Outcomes
When the EPC researchers looked at the influence of community involvement on the quality
of interventional studies, they discovered 11 of the 12 completed intervention studies had
reported enhanced intervention quality. Just two studies reported improved outcomes, while
eight noted enhanced recruitment efforts, four reported improved research methods and
dissemination, and three described improved descriptive measures. Very little evidence of
diminished research quality resulting from CBPR was reported.
Community and Research Capacity
Of the 60 studies reviewed, 47 reported improved community involvement, including
additional grant funding and job creation, as an outcome associated with the study. The
authorstypically academicsgenerally focused on the increased capacity of the participant
community, rather than that of the research community.
Health Outcomes
Among the 12 studies evaluating completed interventions that play a role in health outcomes,
two dealt with physiologic health outcomes, three with cancer screening behavior, and four
addressed other behavioral changes (including alcohol consumption, immunization rates, and
safer sex behavior). Finally, three studies measured the impact of the intervention on
emotional support, empowerment, and employee well-being.
Given the highly varied health outcomes, measurement strategies, and intervention
approaches used, the EPC researchers were unable to perform a direct comparison of
studies and their relative impact on health outcomes. Moreover, an absence of costeffectiveness data precluded any comparison of outcomes from CBPR studies and those of
more traditional research studies.
Level of Community Involvement

Community involvement varied in different stages of the research. There was strong
involvement in recruiting study participants, designing and implementing the intervention, and
interpreting findings. Many authors argued that community involvement (especially in theses
areas) leads to:
Greater participation rates.
Increased external validity.
Decreased loss of follow up.
Increased individual and community capacity.
The disadvantages of community involvement were not frequently reported, but they may
include:

The introduction of selection bias (bias in recruitment).

Decreased (and sometimes an absence of) randomization.
The potential selection of highly motivated intervention groups not representative of
the broader population. [37]

3. Good Practice Mental Health

From mid July 1998 to the end of May 1999, Auseinet provided seed funding and intensive
support to eight agencies that provided services to children and young people to reorient an
aspect of their service to an early intervention approach to mental health. The aim was to give
the agencies the opportunity to build their capacity by developing a range of tailored,
potentially sustainable strategies.
All agencies made workforce development the foundation of their reorientation process. As
most of the agencies were not primarily mental health focused, enhancing the mental health
literacy of staff was a vital first step in reorientation. They informed staff about the mental
health issues faced by the young people who used their service, gave them the skills to
recognise risk factors and early warning signs, and established procedures for appropriate
referral. The training programs were documented to guide future training needs and to provide
resources for staff.
All of the projects showed evidence of organisational development. Management support
was demonstrated by the formation of steering committees, reference groups and umbrella
groups. Policy development occurred within as well as between agencies. One project
developed an early intervention policy outlining referral and support mechanisms and others
developed recommendations for incorporating early intervention into new policies. Two
projects developed formal interagency agreements and policies. The development of
partnerships was one of the most successful aspects of the reorientation projects. Most of
the agencies established new networks or strengthened existing ones by including guest
speakers and staff from other agencies in their training programs. Several of the projects
developed successful formal partnerships. Two of the larger projects were collaborations
between influential agencies and had the resources to allow the projects to expand beyond
their original scope. All of the agencies allocated resources to the projects and several of the
larger agencies contributed additional funds to employ the reorientation officer full-time. After
Auseinet funding had ceased, most of the agencies had allocated funds to sustain or expand
the reorientation process or to take it in a new direction. [2]
Most agencies had sustained or expanded their early intervention activities two and a half
years after the reorientation project. The extent of reorientation ranged from conceptual shifts
in staff knowledge and increased awareness and identification of mental health problems,
through to extensive implementation of mental health promotion, prevention and early
intervention programs and the development of partnerships with other agencies and the
community. In five of the eight agencies, further early intervention projects 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 the
community, and increased support from the community. One agency noted that while the
strategies developed in the reorientation project had not been sustained, the project had led

to different ways of implementing early intervention activities and subsequent success with
other projects. The remaining two projects noted a marked change in early intervention ways
of thinking and referrals although they did not have the resources to continue concrete
projects. Several of the agencies reported that the reorientation project had given them the
confidence to undertake other projects or apply for further funding. Most of the agencies
considered that the reorientation projects served as a useful platform from which to either
begin or expand early intervention activities. [2]
Barriers
Staff overworked!
Most of the reorientation officers thought that the resources allocated to the project were
insufficient and that they had insufficient time in which to achieve the objectives of the project.
Several of the reorientation officers in the non-government agencies especially found their
workload demanding because they were employed on a half-time basis. Some of the staff
were initially reluctant to be involved in the reorientation projects because of their already
heavy workloads. Generally, as staff became involved in the training they became more
enthusiastic about the project and prioritised their time to enable greater involvement. [2]
Sustainable Funding
Many of the barriers identified in the original reorientation projects are still evident. High staff
turnover rates are a reality in many agencies; therefore time and resources need to be
devoted to training new staff in early intervention. The heavy workloads of staff remained an
issue, although some of the agencies developed strategies to reframe rather than add to
existing workloads. Most of the agencies felt that the sustainability of the projects was largely
dependent on funding. Seed funding was perceived as being useful for platform activities, but
all identified the marked need for more funding to sustain and expand early intervention
activities. Many of the agencies reported that their involvement in the Auseinet project had
helped them to secure funding from other sources. [2]
New barriers were identified at follow-up, when many of the agencies were applying early
intervention approaches directly with clients. They often found it difficult to refer clients
with early signs of mental health problems to mental health services because the latter
typically function from a crisis intervention model. In addition, mental health services
already have high demands on their services and are often not able to take on new referrals.
[2]
4. Workplace Example
Beyond the organisation participating in the present study, it is hoped that individuals and
groups involved in workplace health promotion can use the findings to help overcome two of
the key barriers to adopting the health promoting settings approach. These barriers are: (i) a
lack of information on the relationship between work characteristics and employee health; and
(ii) not having the confidence or knowledge to identify and address organizational-level
issues. Both qualitative and quantitative methods were employed in the audit, and the results
revealed that there was a close relationship between several work characteristics and
employee well-being. Workbased support, job control and time-related pressures were
identified as three work characteristics that offer valuable opportunities for boosting the
health-promoting value of the organization participating in the present study. [3]
5. Plenty of examples of large company workplace health promotion world wide
Model of good practice: The Shanghai Project Shanghai is the largest industrial city in China,
with a population of over 13.5 million people. In collaboration with WHO, and supported by the
Government of the Peoples Republic of China, the Shanghai Municipal Health Bureau and
the Shanghai Health Education Institute conducted a pilot workplace health-promotion project
from 1993 to 1995. The project involved 21 613 workers in four workplaces: Wujing Chemical
Complex, Shanghai Hudong Shipyard, Shanghai No. 34 Cotton Mill and Shanghai Baoshan
Steel Company.
Based on data gathered through a baseline survey conducted in early 1993, and guided by
members of the Shanghai Health Education Institute and an occupational health expert

advisory reference group, each workplace developed, implemented and evaluated workplace
health-promotion programs.
The project adopted an integrative model of workplace health promotion and sought to
address identified organisational, environmental and behavioural factors that were negatively
impacting upon the health of the workers. Health-promotion programs employed multiple
strategies in line with the Ottawa Charter and sought to develop healthy policies and
regulations, create safe and supportive environments, strengthen preventive health services,
facilitate workers participation and educate workers to promote healthy behaviour. Initiatives
undertaken included the establishment of health education and health-promotion committees,
drafting and implementing workplace standards for identified occupational hazards, improved
management of workplace sanitation and hygiene, and improved occupational health hazard
monitoring and control (e.g. noise, dust and chemical leakage). Other initiatives included the
supply of nutritious foodstuffs and the reduction of salt in food in workplace canteens, planting
trees and flowers, cigarette smoking and alcohol cessation programs, cervical screening and
thorough follow-up treatments, improved preventive health services for workers, and greater
worker participation in the identification and control of occupational hazards.
During the project, particular attention was given to such issues as staff mobilization and
training, establishing co-ordinating and networking mechanisms, and regular consultation with
workers, management and expert reference groups. These measures ensured that all
interested parties were involved in the planning of the project and that they were given
opportunities to participate in its implementation. Furthermore, there was an emphasis on
multi-sectoral involvement and the integration of health promotion into management practices.
The project was closely monitored, and an evaluation carried out in 1995 showed excellent
measurable outcomes, e.g.:
reduced incidence of work-related injuries by 1020%;
reduced diseases and related health care costs (e.g. pharyngitis, from 16% to 10%);
improved health and safety knowledge and practices (the use of safety devices or protective
equipment increased from 2030% to 7090%);
reduced risk behaviour (reduction of salt consumption, cigarette smoking);
reduced levels of sick leave by 50%.
Other notable project achievements included: improved company image and management
practices, a cleaner and safer workplace environment and work conditions, increased housing
provision, recreation facilities and even transport in the case of the Hudong shipyard.
Learning from this pilot project, the project team has since developed what they have proudly
called the Shanghai Model of workplace health promotion. The models four distinctive
features are: comprehensive, integrative, a system of management and multi-sectoral
networks, and a multiplicity of intervention strategies. Since then, the Shanghai Project team
has developed draft Chinese language guidelines for workplace health promotion, and has
been funded by the World Bank to work with 10 more workplaces.
Successful factors for workplace health promotion: Action and criteria models currently
available point uniformly to the following factors as key indicators of a successful workplace
healthpromotion initiative.
Participation: all staff must be involved in all phases. [29]
6. See Note 15. Public Health Division, Department of Human Services, Melbourne, Victoria,
Australia
Health Promotion Strategies for Community Health Services. An Evidence-Based Planning
Framework for Nutrition, Physical Activity, and Healthy Weight
ebpf_nutrition.pdf
Lots of examples of Nutrition, Physical Activity, and Healthy Weight Projects
7. Nutrition: Effective Components for Nutrition Interventions - Summary

In December of 1999, the Prevention Unit within the Division of Preventive Oncology at
Cancer Care Ontario commissioned a review of international literature on nutrition
interventions, in the areas of policy, programs and media. The purpose of the review, which
included literature from January 1995-January 2000, was to consolidate existing knowledge of
nutrition intervention effectiveness in order to inform the development of a nutrition and
healthy body weight strategy for cancer prevention for the province.
Fifteen interventions studies were included in the review, 10 of which reported positive
outcomes, and 5 reporting negative outcomes, in well-designed studies (i.e. controlled trials
with or without randomization). Among those reporting positive outcomes, five components
were common:
1 theoretically based (Sorenson, Glanz, Perry, Liquori, Nicklas, Forester)
2 Involvement of the family as a source of support; (Sorenson, Glanz, Liquori, Perry, Coates,
Havas)
3 Use of participatory models for planning and implementing interventions; (Perry, Liquori,
Havas, Nicklas, Sorenson, Glanz)
4 Provision of clear messages for media campaigns; (Owen, Reger, Norum)
5 Provision of adequate training and support to intervenors (Beresford, Perry, Liquori, Havas,
Forester)
A number of lessons were learned by those reporting negative study outcomes including:
1 Ensuring sufficient intensity and duration of the intervention to bring about change and
behaviour maintenance. Repeated and on-going contact is necessary throughout the
intervention including post follow-up (Glasgow, Resnicow, Kristal, Jeffrey)
2 Making environments conducive to support behaviour change, in particular modification of
food service policies for worksites and schools (Glasgow, Resnicow)
3 Ensuring particpatory mechanisms for planning, such as steering committees and,
(Glasgow, Resnicow)
4 Delivering school-based interventions either before the school day begins or during school
hours; afterhours results in lower attendance (Resnicow)
Intervention settings, such as schools, workplaces (Sorenson, Glanz) and health care
institutions, offered prime channels to employ these principles, especially when developing
and implementing interventions for large groups of people. Community settings work well for
women whose learning is enhanced by a family friendly atmosphere. The review suggests
that these settings should be regarded as ideal places to focus a nutrition intervention
strategy within Ontario. The principles derived from this review equipped Cancer Care Ontario
with the information necessary to develop a nutrition and healthy body weight strategy for the
province of Ontario. This included establishing a reference group (known as the Ontario
Collaborative Group on Diet and Cancer) with a mandate to link practitioners in the areas of
policy, community and public health programs and research and use them as a reference
group. The Unit took the lead in developing a program logic model for the overall strategy
(with guidance from the Collaborative Group) and invested in developing a behavioural
change pilot project "Take 5" to increase vegetable and fruit consumption among women with
children under the age of 14, based on stakeholder feedback, and is currently being piloted.
[17]
8. See Note 23 Stories that can change your life: communities challenging health
inequalities (Health_Inequalities.pdf)
Lots of Good Practice Examples and Great Quotes from Southampton City PCT Ujala
Health Project, Middlesbrough PCT Football Community Project, Blyth Valley Food
Cooperative Limited, The Foyer Federation and health projects, Rotherham PCT Healthy
Hearts Project, Easington PCT transport initiative, Northamptonshire Heartlands PCT Older
Persons Health Forum, Thurrock PCT Community Mothers, Slough PCT Health Activists
9. Community development at strategic level
In the next few paragraphs, actual examples of the adoption of a community development
approach in relation to health are documented.
Craigavon and Banbridge Community Health and Social Services Trust

At strategic level, there is increasing evidence that community development is seen to be an

important part of any participatory strategy and more resources are gradually being diverted
to this end. However, although the rhetoric is spreading, the change in attitudes and
organisational re-arrangements are slower to gain ground. The Craigavon and Banbridge
Community Health and Social Services Trust in Northern Ireland is an exceptional example of
a Health Service Trust which has accepted that community development has to inform its
whole approach. (SHF, 2001c; McShane and ONeill, 1999)
The Trust accepted the contribution of community development to the core business of Health
and Social Services by mainstreaming this approach across all its programmes of care. The
importance of increasing community development awareness and skills for other managers
and staff was also recognised and the Trust was actively committed to a training strategy. It
viewed this as a core feature of implementing the Governments strategy on social inclusion,
social justice and partnerships for health and wellbeing. The Trusts Community Development
Unit has actively worked with different community groups, ensuring that broader aspects of
health are highlighted. For instance, a Rapid Participatory Appraisal was conducted bringing
together various parties such as nursing, community work, social work staff and local people.
This enabled issues to do with housing, the local economy and community infrastructure to be
included and worked at to improve the wellbeing of the community.
The Addiewell Project
One example of local communities becoming involved in setting the agenda around health
was that of the Addiewell Task Group (Addiewell Research Project, 2000). In a joint initiative
between local residents, West Lothian Council and the University of Edinburgh, the Addiewell
Task Group developed indicators and measures to do with health and wellbeing that were
seen as important by the community. The Health Unit based within the local Council worked
alongside local people to ensure their participation in the identification, definition and
proposals for measuring health indicators. The work was founded on the principle that the
best people to decide what issues and indicators were important were local people
themselves.
Working together: Learning together
A two year training programme, Working Together: Learning Together, was set up as part of
the Scottish Executives Listening to Communities programme, to provide training in
understanding social exclusion, partnerships and Working for Communities Pathfinders in
Scotland. The programme aims to ensure that communities are involved in genuine,
meaningful partnership where they can exert real influence (Working Together: Learning
Together website - www.wtltnet.org.uk). There are 60 partnerships and 900 people
participating in training from agencies and communities led by a consortium of organisations
including the Scottish Community Development Centre, Community Learning Scotland, the
Scottish Council for Voluntary Organisations, the Poverty Alliance, and the University of
Dundee. [31]
10. Nutrition: Database of International Nutrition Interventions
Includes Intervention Methodology, Evaluation Method, & Impact Achieved
"10. Nutrition education
September, 2003
10.1 General community nutrition programmes
10.2 Mass media nutrition education
10.3 School-based nutrition education"
http://www.hubley.co.uk/1nutrition.htm [34]
11. Database of School-based interventions
Includes Intervention Methodology, Evaluation Method, & Impact Achieved
"Interventions using schools
September 2003"
http://www.hubley.co.uk/1schools.htm
12. Illicit drugs: effective prevention requires a health promotion approach
"There is an emerging evidence base for interventions that tackle particular risk and protective
factors. In the USA, for example, the Midwestern Prevention Project, conducted by Pentz and
co-workers, examined the effectiveness and replicability of a multi-component, communitybased drug misuse prevention programme. The study looked at the effectiveness of school

interventions in the context of broader community mobilization strategies. Significant

reductions in tobacco and cannabis use occurred amongst students followed up at Years 9
and 10. However, training for community leaders and the use of mass media was less
effective when not teamed with school-based and parenting programmes.
Another US study, Project Northland, led by Perry and colleagues, used similar school- and
community-based approaches to reduce alcohol and other drug use in North West Minnesota.
The research found statistically significant reductions in drug use, changed peer norms and
improved parentchild communication. The case can be made from both of these studies for
whole-community approaches that complement individual-focused interventions.
The Gatehouse project in Australia aims to reduce the rates of depression and self-harm
amongst young people. This school-based programme emphasises the importance of positive
connectedness between the individual and both teachers and peers. It has identified three
priority areas for action: (i) building a sense of security and trust; (ii) enhancing skills and
opportunities for good communication; and (iii) building a sense of positive regard through
valued participation in aspects of school life. Drawing on the Ottawa Charter framework, the
project aims to create a healthy environment rather than concentrating on individuals.
Although still at an early stage, the project has already demonstrated a reduction in the rate of
smoking in intervention schools compared with non-intervention schools.
When people become socially disconnected they may seek comfort and a sense of security
through drug use, and find support and ready acceptance from other drug users. In the UK,
particular emphasis has been placed on structural issues that exacerbate this problem, such
as poor housing, low income, unemployment, poor education and high crime environments.
Prime Minister Tony Blair has set up a Social Exclusion Unit within the Cabinet Office to focus
on key points of transition when young people are at greatest risk of becoming excluded and
marginalized. Action is centred on truancy, homelessness, neighbourhood renewal, teenage
pregnancy, and opportunities for young people not in education, employment or training. Such
joined up solutions to joined up problems are very much at the centre of the Ottawa Charter's
healthy public policy domain.
In Australia, the Centre for Adolescent Health has recently completed a report on evidencebased approaches to promoting adolescent health. The work reviewed 178 research articles
and assigned weightings to signify the confidence with which programmes can be
implemented. The best buys comprise a broad set of health promotion approaches, including
health promoting schools, social marketing, peer intervention, parent support and community
strengthening. The Victorian government, upon the advice of its Drug Policy Expert
Committee, has endorsed these approaches and has announced that substantial funding,
representing at least 10% of the total drug budget, will be allocated to prevention. Strategies
are likely to include the following elements." [38]
13. Community-based research: creating evidence-based practice for health and social
change
"In the following section, three examples of community-based research are provided to
demonstrate how community-based research generates evidence from practice.
James Bay Midlife Project (Hills, Mullett and Burgess, in progress).
This project was generated by a local community health centre in order to create a program
for women that would maximize their participation in and control of making health decision in
their midlife. The inquiry group consists of two university researchers from the Community
Health Promotion Coalition, University of Victoria (the authors of this paper), program
planners and staff from the James Community Health Project, and women of the community,
including a physician, a homeopath, a naturopathic physician, an editor, teachers, counsellors
and social workers. This group is in the process of generating evidence about ways of being
that are "women-centred". The group is exploring women-centred care in several different
contexts such as education programs, support groups, physician/client interactions and
informal groups. To date it has used a critical incident method to collect accounts from group
members own experiences about what constitutes women centred care in midlife. Members

subsequently conducted interviews, held focus groups or collected narrative accounts of their
practice. The data is being analyzed, considered in light of former knowledge and new
methods are being chosen to generate further evidence about how to practice in a way that is
women-centred.
Making Connections: Nurturing Adolescent Girls' Strengths (Bannister, in process)
This community based research project, funded by the British Columbia Health Research
Foundation (BCHRF), was created in direct response to concerns articulated by adolescent
girls who identified the importance of peer support and mentoring relationships as a means to
enhance their ability to handle relationships. Effective relationships were viewed as the focal
point for building self-esteem and enhancing health. A participatory action research (PAR)
framework is being used to understand adolescent girls' (ages 14-19) experiences of
relationships and to facilitate action. Four groups of girls, each of which has direct links to an
advisory committee, have been meeting weekly for 18 weeks. The advisory committee serves
as a forum for the girls to present their health related concerns and to generate further action.
The adolescent girls are involved in analyzing the data. The girls report that they are learning
new ways of interacting, thereby enhancing their ability to handle relationships. In year two of
the project, it is intended that the girls will use their learning and reflections to create action to
influence policy-makers and practitioners who are working with adolescent girls.
Sharing Resources To Alleviate Scarce Resources
Several non profit organisations asked a researcher to work with them because of their
concern about current funding structures that have created a competitive situation for nonprofit agencies in the community - agencies that previously had worked together to resolve
issues in order to sustain a healthy community. The methodology of co-operative inquiry
(Heron, 1996; Reason, 1988) is being used to develop a model of inter-agency collaboration,
a transformative model for practice that will afford community agencies the ability to evolve
together within new funding contexts. A critical incident technique was the initial method by
which the current successful and unsuccessful collaborative relationships were examined. By
reflecting on their current practice, the members of the inquiry group not only have begun to
articulate the essential components of a collaborative model but also have reported that their
relations with each other have improved. Their emergent model, which is based on the
experiential, representational, propositional and practical knowledge of those engaged in
living the model, is significantly different from theoretical models, which tend to be reduced to
administrative models." [39]
14. Health Education Board for Scotland: Health promotion projects: mental health
"Health promotion projects list"
http://www.hebs.scot.nhs.uk/topics/mentalhealth/mentproject.cfm [44]
15. Mental Health Promotion
"The National Service Framework Standard One: Mental Health Promotion
Guidance For Good Practice"
http://www.dementiaplus.org.uk/library/regionalpapers/deliveryofstandardonecontinuation6.ht
m [45]
16. Health Education Board for Scotland publication section: Community development
approaches in primary care: options for obesity management
"Community development approaches in primary care: options for obesity management"
http://www.hebs.scot.nhs.uk/topics/topicsection.cfm?
topic=diet&TxtTCode=302&TxtSNo=15&TA=topictitles%60 [47]
17. The Food Trust: Improving health, promoting good nutrition, increasing access to
nutritious food and advocating better public policy
"Building Strong Communities Through Healthy Food
The Food Trust's mission is to ensure that everyone has access to affordable, nutritious food.
Founded in 1992, the Trust works to improve the health of children and adults, promote good
nutrition, increase access to nutritious foods, and advocate for better public policy."

In keeping with its organizational mission, The Food Trust evaluates the success of its
programs and initiatives by its effectiveness in:

Improving communities' access to affordable and healthy fresh foods;

Increasing awareness among at-risk consumers of the value of proper nutrition and
its relation to individual health; and
Effecting positive behavioral change among children and adults, as relates to healthy
eating habits.

http://www.thefoodtrust.org/ [49]
18. Healthy living : The Department of Health: Health topics: Healthy living
"Healthy living: Promoting healthy lifestyles for people in England and Wales is an important
governmental responsibility. DH runs initiatives to help people quit smoking, eat better and
exercise more, as well as health screening projects and training and skills programmes."
http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/HealthyLiving/fs/en [56]
19. Community development and its impact on health: South Asian experience -Hossain et al. 328 (7443): 830 -- BMJ
"Community development and its impact on health: South Asian experience"
http://bmj.bmjjournals.com/cgi/content/full/328/7443/830 [63]
20. Welcome to NatPaCT
"Where PCTs grow by sharing information, experiences, and achievements."
http://www.natpact.nhs.uk/ [65]
5. Any Community Development Approaches to Health Promotion must have the
following elements
Process, Community-based Participatory Research, Capacity Building
The Community Guide - A Resource for Public Health Professionals
Step 1: Assess the primary health issues in your community
Kevin Sheridan (KS): How do you do this?
(1) Collect Data.
(2) Carry out qualitative and quantitative research ask community members what the
primary health issues are? Also ask health service providers what they are? Do these
coincide or not? How do you collect this research in an increasingly cynical or over-consulted
environment? By forming a partnership with community organisations in the research area
who can reach target groups. Any partnership should be equal all partners to consensually
set agenda for research. Train community members to carry out fieldwork.
(3) On basis of this research, partners (which could include health service providers) can
decide on interventions. Questions to be asked should include how would it be easier for you
to change your lifestyle or get involved in changing your lifestyle?, how would it be easier for
you to receive communications on the issues? Community feedback should be built into any
research process.
(4) It will also be essential to assess the capacity of both community organisations, academic
researchers, and health service providers to carry out research, interventions, and
partnership, both in terms of funding and knowledge, and to address any gaps in capacity at
the earliest stage.
(5) Another point to consider is who initiates all this obviously the focus of the work has
been set in the first instance by the funders, and then perhaps by the recipients of the funds.
A general call out to community organisations to suggest research and intervention projects
would be useful, and if this does not produce, a more proactive engagement with community
organisations will be needed. Or else, either the academic researchers, fund-recipients, or
health service providers, or a combination in partnership, will need to identify geographical
and/or focus groups to be approached to take the project forward.

(6) A funding pool for interventions will need to be established early, allocating a notional
amount for each possible interventions, to include research, implementation, training &
capacity building, evaluation, and costs of administering any partnership.
(7) Funding for interventions should be sustainable not short-term.
Step 2: Develop measurable objectives to assess progress in addressing these health
issues
KS: It is essential from the beginning to have an understanding about how success or
effectiveness of any chosen interventions will be measured or evaluated. Evaluation should
be built into the process and funding from the outset.
Step 3: Select effective interventions to help achieve these objectives
Step 4: Implement the selected interventions
Step 5: Evaluate the selected interventions
KS: It would be useful to develop a cross-referenced internet resource of good practice. Clear
headings and navigation will have to be established. [57]
Community-based research
*Many of the guidelines for Community-based Research can also be applied to
Community Development itself.
Community-based research: creating evidence-based practice for health and social
change
Definition and Principles of Community-Based Research
Community-based research is becoming increasingly important in the health care field as
communities are being required to take greater ownership and control over decisions affecting
the health of the people in the communities. Community-based research is first and foremost
about people. [40]
Community-based research is a collaboration between community groups and researchers for
the purpose of creating new knowledge or understanding about a practical community issue
in order to bring about change. The issue is generated by the community and community
members participate in all aspects of the research process. Community-based research
therefore is collaborative, participatory, empowering, systematic and transformative. [40]
Community-based research is guided and defined by the following set of principles:

Community-Based Research is a Planned Systematic Process: Community-based

research is a systematic process requiring careful planning of each stage. Most
community workers begin researching by asking questions about their programs, the
needs of their clients, the effectiveness of their work, whether new ideas are feasible,
possible solutions to existing community problems, and so on. These issues become
community-based research by formalizing the community issue into a researchable
question and systematically planning for "data" collection and analysis. This
formalized research process creates new knowledge upon which to base practice. It
is the focus on knowledge development that distinguishes community-based research
from community development.
Community-Based Research is Relevant to the Community: Community-based
research must have a high degree of relevance to the community. Community-based
research focuses the research endeavour in the context of daily work activities in
order to solve problems and help make those activities more effective and ultimately
more satisfying. The research should result in decision-making by the community (i.e.
individuals, community agencies, health units, program managers, etc.) or provide
information which is in some other way directly useful to the community in which it is
initiated.

It involves asking questions such as: What are the practical problems we are facing in
our work in the community? What are some questions and concerns regarding the
community and health-related activities within that community? What issues are the
focus of community attention? Questions such as these guide the selection of
meaningful research topics and provide for the development of appropriate research
questions for community-based research.
Community-Based Research Requires Community Involvement: In community-based
research, the community is actively involved in and understands the research
process. The research is driven by a partnership between the community and
researchers, and tends to be multi-disciplinary in nature. It is a collaborative effort
involving the community at all stages of the research process. The level of community
and/or researcher involvement may vary at each stage of the research, but
community-based research involves joint responsibility and decision-making during
every step. It requires the researcher(s) and the community stakeholders to share
power and control of decision-making throughout the process. In a community-based
research process, the distinction between the researcher and the researched may be
minimized or eliminated. Rather than viewing participants as making "equal"
contributions, in the sense of doing the same thing, community-based research
emphasizes the unique strengths and contributions of the participants. It goes beyond
respect and trust for the person and includes valuing the work and perspectives of
each participant. It is a synergistic alliance that maximizes the contributions of each
participant and it focuses on shared responsibility for the research and research
process.
Community-Based Research Has a Problem-Solving Focus: Effective communitybased research is usually designed to illuminate and solve practical problems. This
problem-solving focus means that the research deals with a problem or practical
issue which has been identified by the community as being important to the life/health
of that community. The primary objective is frequently to guide decision-making, so
effective community-based research focuses on gains to the community through both
the results and the research process itself. It focuses on change by creating solutions
for existing problems and identifying future actions and policies that will most likely
contribute to the health of the community.
Community-Based Research Focuses on Societal Change: Unlike conventional
orthodox research which focuses on prediction or understanding alone, communitybased research seeks to bring about change. It is premised on the fact that engaging
in a participatory, collaborative research process, and being involved the decisionmaking about that process is empowering and transforming. Engagement in the
process allows people to develop new ways of thinking, behaving and practising.
Community-Based Research is About Sustainability: With orthodox research and
many forms of qualitative research, as the research ends, so too does the project.
Community based research makes a lasting contribution to the community. This may
be in the form of a new program that is ongoing, or a new service that is delivered. At
times products such as manuals or workbooks may be created. One of the most
significant contributions is the enhanced capacity of the community to continue to
engage in future research or evaluation. The acquisition of new skills and knowledge
related to research and evaluation is an essential component of community-based
research.

These principles distinguish community-based research from other more orthodox forms of
research including other forms of community research that are done in or for communities. In
addition, these key principles situate community-based research in a different paradigm than
orthodox research and determine, to a large extent, what methodologies and methods are
used. [40]
More Key points
Good user and public involvement has the following key elements:
Involvement becomes a core activity, not an add on or a top down approach.
A strategic approach is adopted across the whole organisation with strong leadership from
senior management.

 There is community and organisational development - citizens need to become more

informed and experienced, but organisational systems and practices also need to change.
Partnerships are formed with other local agencies, for example, Social Inclusion
Partnerships and Local Authorities, to ensure coordination and cost efficiency.
No single approach or technique constitutes involvement of users and public.
Various techniques can be used, which must be chosen according to the purpose of the
initiative.
The resource implications of involvement are acknowledged - for example, training, venues,
crche facilities etc.
Tangible gains from participating can be identified and these can be demonstrated and
communicated.
Communication mechanisms are set up to ensure regular feedback in accessible formats.
Involvement strategies need to be evaluated and constantly reviewed as part of a dynamic
process of continuous learning. [31]
Health Service providers also need capacity building:
"We recognized that CCB could only be effective if our own organization, DTHR, had the
ability to support its community partners. We could not rightfully evaluate outcomes at the
community level without reflecting on our own capacity to nurture such work. We were
obliged, to use Madine vanderPlaats insightful phrase, to turn the evaluative gaze inward."
[33]
Participatory research approaches
With many of the methods discussed in the previous Section, control of the process is still
invested in the authority or organisation. Participatory research approaches grew out of
dissatisfaction with traditional power relationships between researcher and researched and
a demand from disabled people in particular, for more empowering models (Oliver 1996). [31]
Community development workers in countries in South America, Africa and Asia pioneered
participatory approaches in the early 1980s (Jones and Jones, 2002). In contrast to traditional
research, participatory research approaches sought to address the gap between the
concepts and models as perceived by professionals or academics and the ways in which
individuals and groups in the community perceive reality. The philosophy underlying such
approaches is that in order to provide anti-oppressive research fulfilling a social justice
agenda, it is fundamental that the views, perceptions, direct experiences and definitions of
knowledge held by people on the receiving end of services are taken account of, valued and
acted upon (Brandon, 2001). [31]
The main purpose of participatory approaches was to raise awareness and ensure that those
affected by the research retained control over the whole process from the start. As Oliver
(1992) argued in relation to disability research, research should not be understood as a set of
technical objective procedures carried out by professionals but part of the struggle by
disabled people to challenge the oppression they currently experience in their lives. The
research question or problem, decisions about who should be involved and who the
information was for, were to be decided by community groups as part of a longer term
process of investigation, reflection and community action. The degree of user involvement
could be affected by a number of barriers including discriminatory attitudes, access barriers,
issues around resources and representativeness (Brandon, 2001). Nevertheless, there is now
evidence of research and evaluation being carried out by users and user organisations
(Beresford, 2000). People with learning disabilities for example, have been involved as
originators of research ideas, advisers and consultants to research projects as well as
interviewers and analysers of research findings. Examples such as the experience of the
Pilton Health Project serve to confirm that the way issues are defined, articulated and tackled
have a direct bearing upon the levels and quality of participation and the importance of this
approach (Jones, 1998). [31]
Builds on strengths and resources within the community.
Community based participatory research seeks to identify and build on strengths, resources,
and relationships that exist within communities of identity to address their shared health
concerns. These may include individual skills and assets - sometimes called human capital;

networks of relationships characterised by trust, cooperation and mutual commitment sometimes called social capital; and mediating structures within the community such as
churches and other organisations where community members come together. Communitybased participatory research explicitly recognises and seeks to support or expand social
structures and social processes that contribute to the ability of community members to work
together to improve health, and to build on the resources available to community members
within those social structures.
Facilitates collaborative, equitable involvement of all partners in all phases of the
research.
Community-based participatory research involves a collaborative partnership in which all
parties participate as equal members and share control over all phases of the research
process, e.g., problem definition, data collection, interpretation of results, and application of
the results to address community concerns. Communities of identity contain many individual
and organisational resources, but may also benefit from skills and resources available from
outside the immediate community of identity. Thus, CBPR efforts often involve individuals and
groups who are not members of the community of identity, including representatives from
health and human service organizations, academia, community-based organizations, and the
community-at-large. These partnerships focus on issues and concerns identified by
community members, and work to create processes that enable all parties to participate and
share influence in the research and associated change efforts.
Integrates knowledge and action for mutual benefit of all partners.
Community-based participatory research seeks to build a broad body of knowledge related to
health and well-being while also integrating that knowledge with community and social
change efforts that address the concerns of the communities involved. Information is gathered
to inform action, and new understandings emerge as participants reflect on actions taken.
CBPR may not always incorporate a direct action component, but there is a commitment to
the translation and integration of research results with community change efforts with the
intention that all involved partners will benefit.
Promotes a co-learning and empowering process that attends to social inequalities.
Community-based participatory research is a co-learning and empowering process that
facilitates the reciprocal transfer of knowledge, skills, capacity, and power. For example,
researchers learn from the knowledge and local theories of community members, and
community members acquire further skills in how to conduct research. Furthermore,
recognising that socially and economically marginalised communities often have not had the
power to name or define their own experience, researchers involved with CBPR acknowledge
the inequalities between themselves and community participants, and the ways that
inequalities among community members may shape their participation and influence in
collective research and action. Attempts to address these inequalities involve explicit attention
to the knowledge of community members, and an emphasis on sharing information, decisionmaking power, resources, and support among members of the partnership.
Involves a cyclical and iterative process.
Community-based participatory research involves a cyclical, iterative process that includes
partnership 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 taking (as
appropriate), specification of learnings, and establishment of mechanisms for sustainability.
Addresses health from both positive and ecological perspectives.
Community-based participatory research addresses the concept of health from a positive
model that emphasises physical, mental, and social well-being (WHO 1946). It also
emphasises an ecological model of health that encompasses biomedical, social, economic,
cultural, historical, and political factors as determinants of health and disease.
Disseminates findings and knowledge gained to all partners.
Community based participatory research seeks to disseminate findings and knowledge
gained to all partners involved, in language that is understandable and respectful, and where

ownership of knowledge is acknowledged. The ongoing feedback of data and use of results
to inform action are integral to this approach. This dissemination principle also includes
researchers consulting with participants prior to submission of any materials for publication,
acknowledging the contributions of participants and, as appropriate, developing co-authored
publications.
Involves a long-term commitment by all partners.
Given the emphasis in community-based participatory research on an ecological approach to
health, and the focus on developing and maintaining partnerships that foster empowering
processes and integrate research and action, CBPR requires a long-term commitment by all
the partners involved. Establishing trust and the skills and infrastructure needed for
conducting research and creating comprehensive approaches to community change
necessitates a long time frame. Furthermore, communities need to be assured that outside
researchers are committed to the community for the long haul, after initial funding is over.
In summary, community-based participatory research involves a collaborative partnership in
a cyclical, iterative process in which communities of identity play a lead role in: identifying
community strengths and resources; selecting priority issues to address; collecting,
interpreting, and translating research findings in ways that will benefit the community; and
emphasizing the reciprocal transfer of knowledge, skills, capacity and power. As appropriate,
such partnerships may involve individuals and groups who are not members of the community
of identity, for example, representatives from health and human service agencies, or
academia. However, the focus of the partnership is driven by issues and concerns identified
by members of the community of identity. [18 - Paper includes policy recommendations for
increasing community-based participatory research see headings below

Funding Research Partnerships

Planning grants.
Long-range funding.
Initial and ongoing funding for infrastructure.
Funding directly to community-based organizations as well as universities.
Funding for comprehensive approaches that extend beyond categorical perspectives
and traditional research designs.
Grant application and review process.
Capacity Building and Training for CBPR Partners
Pre and post doctoral training and continuing education.
Training programs for community members.
Institutional support for continuing education and community service.
Educational opportunities for members of traditionally marginalised communities.
Benefits and Reward Structures for CBPR Partners
Tenure and promotion process.
Roles, responsibilities and recognition of community partners involved in
CBPR. ]

Public Health Division, Department of Human Services, Melbourne, Victoria, Australia: Health
Promotion Strategies for Community Health Services. An Evidence-Based Planning
Framework for Nutrition, Physical Activity, and Healthy Weight (ebpf_nutrition.pdf)
Figure 4. contains Roles and Responsibilities in a Regional Health Promotion System. P27
[15]
Benefits of CBPR
Overall Benefits of CBPR:

Enhances data quality and quantity, by establishing trust.

Moves beyond categorical approaches.

Improves research definition and direction.

Enhances translation and sustainability of research findings.

Improves the community's health, education and economics, by sharing knowledge

obtained from projects.

Benefits to Schools of Public Health

Fulfills missions of schools of public health.

Brings together disciplines that have historically operated in their own research silo.
Increases student interest and participation in research.

Benefits to State and local Health Departments

Increases patient contact, primary care, and self-management.

Facilitates development and implementation of more effective public health
interventions.
Enhances behavioural change and decreases costs to health departments.

Benefits to Public and Private Funding Institutions

Cost effectiveness of CBPR.

Increased trust from communities.
Non-categorical nature allows for greater flexibility in support.

In addition to outlining benefits of CBPR, the Conclusions and Recommendations section

highlights challenges facing CBPR and offers possible solutions to overcome them. Three
principal challenges identified by participants included: development of universitycommunity partnerships, institutional commitment, and training. [6]
Definition of CBPR
Community-based participatory research (CBPR) is committed to social change and strives to
enhance health and quality of life in urban communities. CBPR is methodologically sound,
rigorous research that respects and encourages varied research methods and adheres to
standard ethical review processes. CBPR projects are driven by community needs and
priorities to answer relevant questions, build programs, and affect public policy. Rather than a
specific research method, CBPR is a widely respected process for conducting research that
values the lived experience of community members and welcomes and encourages their
contributions at the levels of input (initiation of ideas), process (during data collection, analysis
and interpretation phases), and outcome (implementing action-oriented recommendations).
Recognising that there are barriers to both community and academic involvement in CBPR,
equitable partnerships between stakeholders are established (with clear terms of reference)
to guide CBPR projects. Data generated through these projects are jointly owned and
accessible to all partners. Attention to trust-building, decision-making, power and resourcesharing, and reciprocal capacity-building (where the knowledge bases and skill sets of all
research partners are enhanced as a result of the research process) are expected outcomes
in all CBPR projects. [14]
Community-partnered approaches to research
Community-partnered approaches to research promise to deepen our scientific base of
knowledge in the areas of health promotion, disease prevention, and health disparities.
Community-partnered research processes offer the potential to generate better-informed
hypotheses, develop more effective interventions, and enhance the translation of the research
results into practice. Specifically, involving community and academic partners as research
collaborators may improve the quality and impact of research by:
* More effectively focusing the research questions on health issues of greatest relevance to
the communities at highest risk;
* Enhancing recruitment and retention efforts by increasing community buy-in and trust;

* Enhancing the reliability and validity of measurement instruments (particularly survey)

through in-depth and honest feedback during pre-testing;
* Improving data collection through increased response rates and decreased social
desirability response patterns;
* Increasing relevance of intervention approaches and thus likelihood for success;
* Targeting interventions to the identified needs of community members
* Developing intervention strategies that incorporate community norms and values into
scientifically valid approaches;
* Increasing accurate and culturally sensitive interpretation of findings;
* Facilitating more effective dissemination of research findings to impact public health and
policy;
* Increasing the potential for translation of evidence-based research into sustainable
community change that can be disseminated more broadly.
For the purpose of this PAR, community refers to populations that may be defined by:
geography; race; ethnicity; gender; sexual orientation; disability, illness, or other health
condition; or to groups that have a common interest or cause, such as health or service
agencies and organisations, health care or public health practitioners or providers, policy
makers, or lay public groups with public health concerns. Community-based organisations
refer to organisations that may be involved in the research process as members or
representatives of the community. While not an exhaustive list, organizations as varied as
Tribal governments and colleges, state or local governments, independent living centers,
other educational institutions such as junior colleges, advocacy organisations, health delivery
organisations (e.g., hospitals), health professional associations, non-governmental
organizations, and federally qualified health centers are possible community partners." [50]
Community empowerment is a community development strategy
Community development initiatives seek to increase the capacity and resources of
communities. The classic typology, formulated by Rothman and Tropman, includes social
planning by outside experts, locality development or participatory development of goals and
programs, and social action or advocacy. Strategies used include grassroots organising,
professional organizers, coalitions, census development, problem solving, political and
legislative action, and nonviolent confrontation. A more recent typology excludes social
planning and promotes the value of community building from peoples strengths and assets, in
addition to community organising methods.
Community empowerment is a community development strategy that derives from the work of
the Brazilian educator Paulo Freire. This approach uses nontraditional educational methods to
enable individuals to understand their goals independent of the prevailing social order and to
develop capacities to realize these goals. Applications to health focus on enhancing
awareness of needs, promoting effective problem solving, and developing capacities for
implementing solutions in high-risk communities. A related strategy is media advocacy, which
seeks to create leverage for broader policy change by influencing public opinion. Because the
goals and approaches used in participatory community interventions cannot be fully specified
in advance, evaluations rely on action research methods and qualitative or mixed methods.
Some evaluations also use experimental strategies, such as group-level randomized trials.
Charles and DeMaio established a framework to judge the degree of community participation.
More recent reviews suggest that greater community involvement may promote intervention
adoption and sustainability.
In participatory research, skills are required in developing trust with community members and
leaders and dealing with differences in authority. Conflicts may arise over priorities for
sustaining interventions versus identifying experimental effects and for outcomes such as
neighborhood safety versus health. Community interventions shift the focus away from
individuals and toward the process of engagement and impacts on communities, entailing a
different measurement and assessment process.
Community research can require substantial developmental time, and the evaluation phase
may be of long duration. The feasibility of achieving change in communities may be affected

by political and social factors. Hence, community research requires long-term commitment to
particular communities.
Strategies that can help mitigate these problems include agreeing on goals and expectations
at the outset, maintaining a structured, equal partnership, using an independent community
organizer, sharing expertise and resources across community organizations and researchers,
educating the community about research goals and purposes, and developing financial
support for community programs.
Even though community intervention research poses unique challenges, many of the
conceptual, practical, and methods challenges are similar to those of practice-based quality
improvement research, in which exact goals are not easily specified in advance and long-term
commitment is required, and to policy research, where randomization options and availability
of suitable databases for evaluation are limited. Furthermore, the conceptual and
measurement frameworks underlying both policy and quality improvement research are
similar: both suggest that health interventions should be embedded within local contexts and
address and involve multiple stakeholders. As in community intervention research,
evaluations of practice-based quality improvement interventions and public policies have
revealed mixed results; however, health services research has not retreated from designing
and evaluating quality improvement interventions or evaluating policy. Furthermore, with
recent advances in methods, health services research has yielded a new generation of policy
and quality improvement studies that are interpretable and useful to health care systems. For
example, research on quality improvement interventions for depression in primary care
progressed from the development of effective models within well-organized practices to
effective models being implemented by community-based practices under minimal research
supervision." [51]
Capacity building support and resources
When integrating health promotion principles and processes in an organisation, or when
implementing a specific program, it is important to create optimal conditions for success.
Capacity building for integrated health promotion enhances the potential of the system to
prolong and multiply health effects and to address the underlying determinants of health.
Capacity building involves the development of sustainable skills, organisational structures,
resources and commitment to health improvement to prolong and multiply health gains many
time over. It can occur within a specific program and as part of broad agency and system
development.
Key actions areas for building capacity:

Organisational development Partnerships Workforce development Leadership

Resources
Agencies, organisations and communities with the capacity to use a broad range of
interventions and strategies to address health and wellness issues in a collaborative
way through strengthened systems; program sustainability; increased problem solving
abilities
Greater capacity of people, organisations and communities to promote health

Implementing strategies from each of the key action areas should build the combined ability of
the agency or partnership to:
1. Deliver appropriate program responses to particular priority health issues,
including the establishment of minimum requirements in structures and skills
(strengthening agency/system infrastructure).
2. Continue to deliver, transfer and adapt a particular program through a
network of agencies, or to sustain the benefits achieved (program
maintenance and sustainability).
3. Strengthen the generic problem-solving capability of organisations and
communities to be able to develop innovative solutions, learn through
experience and apply these lessons. [22]

Capacity Building definition

Capacity building has been defined as being (at least) three activities: (1) building
infrastructure to deliver health promotion programs, (2) building partnerships and
organisational environments so that programs are sustained and health gains are
sustained; and (3) building problem-solving capability. The last element is crucial. There is
little value in building a system that cements in todays solution to todays problems. We need
to create a more innovative capability so that in the future the system or community we are
working with can respond appropriately to new problems in unfamiliar contexts. [4]
Capacity Building evidence
the effort that health promotion workers put into capacity-building or making their
colleagues and partner organisations more interested in and more capable of engaging in
effective health promotion practice. The rationale for capacity-building is simple. By building
sustainable skills, resources and commitments to health promotion in health care settings,
community settings and in other sectors, health promotion workers prolong and multiply
health gains many times over. [4]
Capacity Building definition
Different uses of the term of capacity-building appearing in the health promotion literature
1. Health infrastructure or service development Capacity to deliver particular program
responses to particular health problems. Usually refers to the establishment of
minimum requirements in structures, organisation, skills and resources in the health
sector.
2. Program maintenance and sustainability Capacity to continue to deliver a particular
program through a network of agencies, in addition to or instead of, the agency which
initiated the program.
3. Problem-solving capability of organisations and communities Capacity of a more
generic kind to identify health issues and develop appropriate mechanisms to address
them, either building on the experience of a particular program, or as an activity in its
own right. [4]
6. Questions of Community Empowerment & Partnership
Although Community Development and Community Based Participatory Research emphasise
empowerment, it seems unlikely that full empowerment of any particular community or focus
group is likely to be achieved within our existing democratic and institutional framework.
Existing structures dont really understand it or are unable to deal with it. However, it may be
possible to move towards a form of empowerment through mutually educating partnerships.
This will need to involve strong leadership or facilitation, and strong pre-partnership
agreements.
Very good on the tensions between traditional health promotion providers & community
empowerment methodology & how to incorporate the two. [10]
Community empowerment: UK Policy Environment
Community empowerment through their involvement in planning is central to the development
of the community strategy. It is also an opportunity for communities perceptions of the
relationship between health, health services and local authority functions to be explored. All
community strategies reviewed include details of the mechanisms used to involve local
communities. For many authorities new approaches are currently being developed to reach
groups in neighbourhoods or populations who have been hard to reach by traditional
methods of consultation. Many authorities are also mapping other consultation and
involvement activities, such as those undertaken through the NHS, to identify other sources of
information. [21]
In many cases, the process of community consultation and involvement has been coordinated
through the main local partnership responsible for the community strategy, which includes
health representation. HIMP and HAZ partnerships and NHS representatives have therefore
been able to participate in or influence multi-sectoral workshops, events, surveys and panels.
In the better examples, local authorities combine community needs assessment data

(gathered from and with key partners), with other information to set out the health and
wellbeing issues for the community. [21]
However some of the needs assessment exercises appear to be predominantly the work of
the local authority. In these cases, there is little reference to NHS consultation exercises (such
as those undertaken through the HIMP or HAZ) and apparently few attempts to understand
communities health issues in the context of other concerns or local authority functions. This
tends to result in health being variously interpreted in consultations as health services, health
and social care, health behaviour and education, individual or community health. In some
authorities, communities are offered a list of issues from which to select their priorities.
Health is included but not usually explained. [21]
Health data and national health concerns can mask other community concerns which are in
fact related to health. Some authorities have found that health may appear relatively low down
a list of priorities for a particular community, yet wider determinants and factors affecting
immediate quality of life come first. In some authorities health is ranked very differently
throughout their geographic area making it difficult to reconcile national and local priorities in
the community strategy. This highlights the importance of local area plans that can articulate
these differences and provide a basis for different types of support and action. [21]
A common duty to consult and involve communities
Central to the development of integrated local planning is the requirement to involve local
communities. Councils are under a statutory duty to consult as part of the process of
preparing their community strategy. However the expectation is that communities will have
much more involvement than simply via consultation. The involvement of local people is
central to the effective development and implementation of community strategies, and key to
change in the longer term (DETR, 2000: 50) Local strategic partnerships need to decide how
community views will influence and inform their decision making process, how differences of
views will be aired and resolved and how decisions will be explained to communities (DETR,
2000: 50). [21]
LSPs should agree protocols to ensure that local people are involved in the design and
delivery of relevant programmes which affect their communities (DETR, 2001: 1.21)
The NHS is also required to involve local people in planning its services and in the
development and delivery of the HIMP, and to link this to broader community development
processes within the LSP (as set out in the Health and Social Care Act 2001) to: Ensure that
the views of patients and the public are built into local planning decisions that affect peoples
health e.g. through the HIMP, LSP and social services (DH, 2001d: Annex A).
NHS activity to involve patients and the public is expected to build on local authorities own
mechanisms for engaging local communities and support the role and function of overview
and scrutiny committees (DH, 2001d).
A joint focus on key population groups
LSPs are expected to improve the involvement of hard-to-reach communities who have
traditionally been underrepresented in consultation and community development programmes
across the public sector. There is a duty on all public sector bodies to avoid discrimination
between people of different racial groups and similar duties are likely in respect of gender and
disabled people (DETR, 2000: 53).
HIMPs are expected to prioritise action which will support greater access and use of NHS
services and care among vulnerable groups. They are also to develop joint action to improve
the health of children and young people, older people, people with disabilities, black and
minority ethnic groups and those in deprived communities. LSPs are similarly expected to
identify ways to build capacity and training to increase the involvement of communities
including disabled people, older people, youth groups, people from faith, black and minority
ethnic communities, and to work with community and voluntary sectors to develop
relationships within the LSP (DETR, 2001). Actions agreed in the community strategy and the
HIMP will need to be tracked to identify [21]

Tension between bottom-up and top-down programming

Health promotion often comprises a tension between bottom-up and top-down
programming. The former, more associated with concepts of community empowerment,
begins on issues of concern to particular groups or individuals, and regards some
improvement in their overall power or capacity as the important health outcome. The latter,
more associated with disease prevention efforts, begins by seeking to involve particular
groups or individuals in issues and activities largely defined by health agencies, and regards
improvement in particular behaviours as the important health outcome. Community
empowerment is viewed more instrumentally as a means to the end of health behaviour
change. The tension between these two approaches is not unresolvable, but this requires a
different orientation on the part of those responsible for planning more conventional, top-down
programmes. This article presents a framework intended to assist planners, implementers and
evaluators to systematically consider community empowerment goals within top-down health
promotion programming. The framework unpacks the tensions in health promotion at each
stage of the more conventional, top-down programme cycle, by presenting a parallel
empowerment track. [11]
Characteristics of Successful Partnerships
Trusting relationships
Equitable processes and procedures
Diverse membership
Tangible benefits to all partners
Balance between partnership process, activities and outcomes
Significant community involvement in scientifically sound research
Supportive partner organization policies and reward structures
Leadership
Culturally competent and appropriately skilled staff and researchers
Collaborative dissemination
Ongoing partnership assessment, improvement and celebration
Sustainable impact
Barriers to Successful Partnerships
When characteristics above are absent
Funding mechanisms, policies and procedures
o Limited funding sources
o Funding agency requirements, definitions, timelines and reviews
o Lack of funding and funding mechanisms that specifically support community
as research partner
Recommendations at the level of the partnership
Pay close attention to membership issues
Develop structures and processes that help develop trust and sharing of influence
and control among partners
Provide training and technical assistance to partners
Plan ahead for sustainability
Pay close attention to the balance of activities within the partnership
Be strategic about dissemination
Invest in ongoing assessment, improvement and celebration [21]
Empowerment, Health Literacy and Health promotion - putting it all together
"Health Literacy can only be achieved through a process of health education which seeks to
develop understanding of health issues and how to apply these to make decisions. However,
many traditional top-down didactic health education methods, while providing knowledge,
have a negative effect of disempowering people by creating dependency on professionals
and. The challenge is to provide this cognitive input through educational processes which
reinforce and not undermine community confidence and power.

Self efficacy can be achieved in a variety of ways that promote self esteem and develop
individual or community power over their lives and surroundings. This can be on any aspect of
their lives for example action on housing, income generating, and the process of community
participation or democratisation at a national level. However it can even take place at a simple
level of learning new skills in farming, making ones own clothes, cooking, creative expression
through music and drama. In situations where self efficacy has already been developed in a
community through action on other issues not involving health, health promoters can build
upon this and use shorter and simpler learning processes.
Health education using participatory learning methods provide a possible way forward through
the promotion of both health literacy and self efficacy.
In recent years I have developed a data-base of evaluated health promotion interventions in
developing countries. A disappointing feature of this database has been the lack of published
evaluations using either qualitative or quantitative research methodologies that demonstrate
that empowerment has taken placed. One approach to the lack of evaluation studies has
been the criticism of methods of evaluation that work within positivist frameworks and
therefore fail to adequately encompass the aims of empowerment approaches which might
require alternative paradigms.
However, I suggest that the difficulty in evaluation has been the problematic and ill-defined
nature of empowerment. The model proposed in this paper should make the evaluation of
health empowerment a simpler process by making more explicit and hence measurable the
two component parts." [41]
Partnerships are strengthened by joint development of research agreements for the design,
implementation, analysis, and dissemination of results [62]
A partnership approach to health promotion: a case study from Northern Ireland.
In recent years there has been a renewal of interest in community development and
partnership approaches in the delivery of health and social services in Northern Ireland. The
general thrust of these approaches is that local communities can be organised to address
health and social needs and to work with government agencies, voluntary bodies and local
authorities in delivering services and local solutions to problems. Since the Ottawa Charter
was launched in 1986, government in Northern Ireland has stressed that community
development should no longer simply be added on to key aspects of Health and Social
Services, but should instead be at the core of their work. There is increasing consensus that
traditional approaches to improving health and well-being, which have focused on the
individual, are paternalistic and have failed to tackle inequalities effectively. Partnerships
within a community development setting have been heralded as a means to facilitate
participation and empowerment. This paper outlines the policy background to community
development approaches in health promotion and delivery in Northern Ireland. Drawing on
evidence from a case study of a community health project it highlights the benefits and
difficulties with this approach. The findings suggest that partnerships can positively influence
a community's health status, but in order to be effective they require effective planning and
long-term commitment from both the state and the local community. [64]