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SUMMARY
Founded on community development principles and held by those implementing the intervention. The paper
practice, the Breathing Space initiative aimed to produce examines the principles that underpin health promotion
a significant shift in community norms towards non- in the community setting, particularly the concepts of
toleration and non-practice of smoking in a low-income ownership, empowerment and participation, and their
area in Edinburgh, Scotland. The effectiveness of differential interpretation and employment by participants.
Breathing Space was evaluated using a quasi-experimental The data illustrate how these varied understandings had
design, which incorporated a process evaluation in order implications for the joint planning and implementation
to provide a description of the development and imple- of Breathing Space objectives. In addition, the different
mentation of the intervention. Drawing on qualitative data understandings raise questions about the appropriateness
from the process evaluation, this paper explores the varied and viability of utilizing community development approaches
and sometimes competing understandings of the endeavour in this context.
51
52 D. Ritchie et al.
Smith et al., 2001), two of which are participation et al., 1994; Labonte, 1994; Robertson and
and empowerment. These principles can and are, Minkler, 1994; Laverack, 2001; Smith et al.,
however, operationalized differentially in 2001). For example, empowerment may be at
different types of community development work. either or both the individual and community
The concept of community participation has level (Bracht and Tsouros, 1990; Bernstein et al.,
proved to be more complex than was originally 1994; Israel et al., 1994; Labonte, 1994; Robertson
envisaged by the early World Health Organization and Minkler, 1994; Robinson and Elliott, 2000;
(WHO) health promotion strategies (WHO, Smith et al., 2001), and tension may exist within
1978; Rifkin, 1986; WHO, 1986; Rifkin et al., community development practice between the
1988; Rifkin, 1995; Labonte, 1998; Zakus and two levels (Robertson and Minkler, 1994;
Lysack, 1998; Laverack and Wallerstein, 2001). Wallerstein and Bernstein, 1994). Whereas
Despite consensus that community participation individual empowerment might be concerned
should engender active processes involving with individuals gaining mastery over their lives,
choice, and the potential for implementing that community empowerment focuses on the social
choice, implementation has proven difficult contexts where empowerment takes place
(Zakus and Lysack, 1998). For example, when [(Wallerstein and Bernstein, 1994), p. 142]. While
formal health services adopt an empowerment it has been suggested that the two levels are
framework, their formal structures are not nec- interdependent, the aims of each may differ
essarily conducive to participation. (Rifkin, (Robertson and Minkler, 1994) and this may
1990; Labonte, 1998; Zakus and Lysack, 1998). impede practice (Laverack and Wallerstein,
Although it is commonly agreed that appropriate 2001).
leadership and effective organizational structures Community development has been used in
are crucial to successful community participation several major UK heart-health initiatives,
(Laverack and Wallerstein, 2001), this requires a reflecting the centrality of the approach within
political climate that nurtures and facilitates the the New Public Health strategy (Robinson and
approach (Labonte, 1998; Zakus and Lysack, Elliott, 2000). There is, however, limited evi-
1998). dence of its overall success (Farquhar et al., 1990;
Tensions can also occur where community Luepker et al., 1994; Carleton et al., 1995;
participation is engaged for disease prevention COMMIT Research Group, 1995; Goodman
purposes rather than following a bottom-up, et al., 1995; Shelley et al., 1995; Brownson et al.,
community-defined agenda (Rifkin, 1990; 1996; Baxter et al., 1997; Secker-Walker et al.,
Asthana and Oostvogels, 1996; Labonte, 1998; 2000; Hancock et al., 2001). A major difficulty
Zakus and Lysack, 1998). It has been argued, in assessing effectiveness of different pro-
however, that these approaches are not neces- grammes arises because communities utilizing
sarily incompatible and that both positions can this approach tend to interpret and implement
be accommodated (Rifkin, 1990). If, it is sug- aspects of community development deemed most
gested, community participation is seen as a appropriate to their specific needs (Buchanan,
process rather than an intervention this will 1994; Robinson and Elliott, 2000). Because
affect the value placed on different types of community development programmes are not
outcomes (Rifkin, 1995; Labonte, 1998; Laverack operationalized in a consistent way it is difficult
and Wallerstein, 2001). to compare like with like.
However, there are many different levels at In order to understand better how these
which the community may participate and at one programmes perform, it is necessary to examine in
extreme this may amount to little more than depth how the community development approach
tokenism (Labonte, 1994; Petersen and Lupton, is rolled out within the local context (Robertson
1996). Moreover, communities do not have the and Minkler, 1994; Wallerstein and Bernstein,
same access as local authority organizations and 1994). To this end we draw on the evaluation of
government agencies to those resources enabling Breathing Space, a community-based smoking
them to define and set the agendas and participate intervention in an area of low income. The paper
on an equal footing (Labonte, 1994; Wallerstein examines the development and execution of the
and Bernstein, 1994; Blackburn, 2000). Breathing Space programme through participants
The concept of empowerment has also understandings about community development
assumed different meanings within the context of and the translation of these understandings into
community-based health promotion work (Israel health promotion practice.
Empowerment issues in community development 53
was set up to oversee planning and imple- what she was talking about were health visitors:
mentation. This alliance formed a steering com- the pharmacists, the local shopsthat is not a
mittee, which supported settings-based subgroups community. (I8)
(level two), whose remit it was to take project
objectives forward. Subgroup membership Hence, although Breathing Space was conceived
included the main intervention team and other as a community development project, there was a
community workers with particular expertise or lack of agreement among the partners about
interest in that setting. The third level comprised what community participation meant and who
others who worked or lived in the community, and should be involved.
who were involved in the implementation of Participation and ownership were not only
specific intervention activities. issues at an organizational/agency level, but also
at the level of their membership. Commitment
held by managers did not necessarily reflect the
DISCUSSION OF FINDINGS commitment of members. The heightened
presence of health board workers did not appear
Participation and ownership to arise from any intention on their behalf to
dominate the Breathing Space programme.
Respondents felt that each of the Breathing
Indeed, a senior manager from the health board
Space partners should have a different yet equal
described the initial ambivalence of some health
role to play in the development and execution of
board workers as a function of their lack of involve-
the programme. The role of Wester Hailes Urban
ment in the early stages of the project:
Regeneration Partnership (WHURP), for
example, was described by a (WHURP) manager To start with there wasnt real ownership, there was a
as: facilitating and taking forward some of the lot of phew, Ive got to do this nowwhereas now
actual interventions in specific settings where this is a piece of work and its going forward and Im a
theres a health promotion specialist (health bit concerned about how Im going to fit it in. (M1)
board employee) working, whereas the role of
the health agency was described as taking Because some programme workers were not
forward the communitys aspects, making sure privy to the initial decision-making processes
that the project is in line with community defined through which the programme evolved, the level
needs (M5). of enthusiasm or perceived ownership associated
In practice, parity of participation was an issue with successful community development work
for many respondents. Hence, the manager was forfeited.
quoted above said It cant just be [us] providing
the support and doing the work (M5). Most
concern about parity of input, however, centred Smoking as a priority
upon Lothian Health Board (LHB), which was Many respondents felt that Breathing Space was
singled out by many respondents as being too not a community venture and, related to this, that
prominent in both the development and the smoking was not a community-defined priority.
implementation of Breathing Space. The pro- Views on this issue differed according to the
portion of health board representatives (nine out organization that respondents represented and
of 12 at one point) on the intervention team and the role they played in the initiation of the
the heightened profile of health board workers programme. Representatives of the community
throughout the project contributed to the view of health agency felt that the community had
some respondents that the programme was identified smoking as a priority because smoking
developed effectively by one organization (I8). had been central to the community-based work
Concern about the over-representation of the from which Breathing Space had evolved:
health board was matched by at least equal, if
not greater concern about a perceived under- We were the core of the project before Breathing
representation of the local community Space came into being. It was built on the work that we
organizations: and the health project did. The whole thing evolved
out of our work. (I8)
I can remember one meeting where a senior member
of health board staff was talking about we need to get Respondents, such as I1 from the Health Board,
the community involved, the community involved, but who were key players in the initiation and early
Empowerment issues in community development 55
Similarly, YS2, a youth agency worker, felt that going down the different channels with people who are
smoking was not high on the agenda of young identified as smoking if they are wanting to either stop
people: smoking or to reduce their smoking habits. (PS4)
I think in a lot of ways its an adult issue. You know Targeting individual smoking behaviour was not
what I mean? Its coming from adults its not coming necessarily seen as incompatible with the aims of
from young people I dont think they see it as a community development work. Some, for
huge issue. (YS2) example, felt that increasing access to cessation
materials and support would lead ultimately to a
Some respondents felt that the focus on smoking change in perceptions on smoking in [the area]
was ethically problematic. For example, I13 (an (PS3) and help overall to reduce the number of
intervention team member and health board people that smoke (I13).
worker) felt that targeting smoking contributed The programme was also affected by
further to peoples already disadvantaged lives. institutional constraints experienced by those
She described smokers as people who maybe have working within the different partner organi-
lots of needs, have complex needs and smoking as zations. Some implementers felt they were
their little bit of pleasure (I13). expected to demonstrate the type of tangible
Some respondents reported difficulties in selling outcomes associated with direct action about
the programme to community gatekeepers. I16, smoking targeted at the individual level. For
when describing the problems she encountered example, the Breathing Space coordinator said:
when trying to get general practitioners on board,
said: As time has gone on theres been a certain amount of
pressure to do thingspractical things. And they tended
its not a particularly nice feeling to be having to to be about smoking, directly about smoking. (R14)
work so hard to sell something You get home and
say to yourself Im not peddling drugs here, Im trying Given the types of outcomes traditionally
to do something good. (I6) expected of health promotion, the community
56 D. Ritchie et al.
development approach presented some and we are very much on the practical side
difficulties for respondents. Some, for example, here (I9).
were uncomfortable with, and resistant to, the Secondly, even where workers were knowl-
idea of project objectives that were shaped by the edgeable about, or gained familiarity with these
community agenda and that could evolve over precepts, they did not find it easy to translate this
time. A health board worker involved in the con- knowledge into practice. Ways of working asso-
ception of the programme described the dilemma ciated with the different partner organizations/
this posed for some workers: agencies were understood by respondents to be
fundamentally incompatible:
People are probably more used to working in a way
thats ermyou knowyou do this and then you do there are tensions in doing community
this and then you do this. Whereas what we are trying development if you are a statutory organization it
to do is to allow a process to emerge and what doesnt quite fit, because on one level its home grown,
people are finding difficult is being diffuse very its grass roots development, its power is located in the
difficult, the anxiety is enormous. (I1) community and then you are there as a totally
different, like well quite a powerful structure with
RI1 felt, however, that workers who persevered certain ways of working. (I1)
despite reservations could reach a better under-
standing of the enterprise, over time: Unsurprisingly, respondents representing the
health agency described themselves as more
You know, its working quite slowly for people , appropriately placed and better qualified to
really its like pennies beginning to drop, and people support a community-based approach:
realising yes thats what it is about. (I1)
we have a lot more facilities and support services to
Others, such as I2, a health board employee, offer Its not saying we are better, weve just got
described her uncertainty about the unfolding more on offer in terms of alternatives and stuff than
nature of the endeavour: say the GPs and the practice nurses. (CS1)
operationalizing the programme necessary for its of community members, because of the very
success. In particular, a narrow focus of the health minimal presence of this group in the Breathing
board on the health of individuals and on smoking Space programme.
behaviour per se was, given the community In conclusion, although current policy may
development aims, felt to place inappropriate celebrate rhetoric of community development and
expectations and constraints upon programme partnership, the data illustrate how the reality may
outcomes. be difficult to deliver, especially for those working
The different approaches, which appeared to in the statutory sector. This is a finding supported
index the respective positions of the community in the literature (Robertson and Minkler, 1994).
organizations and the health board, reflected two Our findings also illustrate the importance of
separate discourses operating within the clarifying the respective roles and inputs of
programme simultaneously. The first favoured organizations/agencies involved in partnership
the concept of community development and working. In particular, it is crucial to recognize
empowerment, while the second favoured that not all partners will have equal input into the
prevention of unhealthy lifestyles (and to a lesser programme and that the nature of that input will
extent the promotion of individual empow- be quite different. For example, community-based
erment). That these discourses were seen as agencies might usefully focus upon their own role
mutually reinforcing rather than incompatible by in engaging with the own local community and
many respondents, reinforces a sense of their then communicating effectively within the actual
reluctance to grasp wholeheartedly the radical structures of decision making. It is very impor-
agenda and modus operandi of community tant for the success of programmes that the
development work. relationships between partnership organizations,
At an even more fundamental level, the and the structures and processes of decision
perceived low level of input from actual making, are explicitly acknowledged. Certainly,
community members, and a lack of consensus this is crucial for ensuring that respective
about what constituted the community, raised a organizations and agencies feel that they have
question mark over whether or not smoking was a ownership of the programme. The study has
community-defined priority in Wester Hailes. highlighted not only the importance of community
Whereas those who were involved in the develop- ownership, but also the importance of ensuring
ment of the programme and/or had experience of that members of organizations signed up to the
community-based no-smoking health promotion programme are involved at an early stage of the
work saw smoking as a community issue, others programmes development.
did not. While White Papers on tobacco and public
health (Secretary of State for Health, 1999;
Secretary of State for Scotland, 1999) demonstrate
government identification of smoking as an ACKNOWLEDGEMENTS
important contributor to social inequalities in
health (Graham, 1998), this may not necessarily be The evaluation research on which this paper
reflected at a community level. Reticence expressed draws was funded by the Department of Health.
by some Breathing Space workers towards the issue The Research Unit in Health, Behaviour and
of smoking reflected their concern that other Change is jointly funded by the Scottish
problems experienced by the community were Executive Health Department and the Health
more pressing. These views resonate with a body of Education Board for Scotland. All opinions
sociological findings, which indicate how the social expressed in the article are those of the authors
circumstances of disadvantaged lives play an and not necessarily those of the funders.
important part in sustaining smoking (Laurier
et al., 2000). That is, smoking is portrayed as one Address for correspondence:
mechanism that smokers use to cope with living Deborah Ritchie
and caring in disadvantaged circumstances Department of Sociology
Queen Margaret University College
(Graham, 1987, 1993; Gaunt-Richardson et al., Clerwood Terrace
1999). However, it is important to note that neither Edinburgh EH12 8TS
the views of the community organizations nor the UK
health board can be seen as reflecting the position E-mail: dritchie@qmuc.ac.uk
58 D. Ritchie et al.