Appropriate settings for health promotion (e.g. Schools, the workplace)

Principles and Practice of Health Promotion: Health Promotion Planning and Implementation in Settings and Communities

This section covers:

• Methods of development and implementation of health promotion programmes
• Appropriate settings for health promotion (eg schools, the workplace)
• Community development methods
• Involvement of the general public in health programs and their effects on health care
• The benefits and means of community development, including the roles and cultures of partner organisations such as local authorities (see also Health Promotion and Intersectoral working)

Introduction

This section considers the types of methods that are used in health promotion practice. This includes an overview of health promotion planning models to develop and quality assure effective interventions; settings-based health promotion and community participation and community development approaches. (Working in collaboration with other sectors is covered in Section 4 - Health Promotion and Intersectoral working)

3.1 Health Promotion Planning Models

A considerable body of knowledge has accumulated about the most effective ways of developing, implementing and evaluating health promotion programmes.  Often referred to as 'best practice', the term is usually associated with health promotion planning or logic models. Health promotion planning models describe a process of problem definition or needs assessment, that allow for collection of information about need from a range of sources. These planning models also enable solution definition, identifying the type of intervention that will bring about the desired effect. Information to design and plan interventions is sourced from evidence;  the experiences of practitioners or service providers, and includes the community or target group of the population that are involved. Usually it would be advised to pilot test such interventions and modify them in the light of formative evaluation of their impact. Best practice would include the consideration of national and local political context, socio-cultural factors and the resources (financial and human) available to implement an intervention. Design of evaluation procedures is also incorporated, including process measures of indicators of impact, and where feasible, longer term outcomes.

The principles of effective practice, gleaned from experience and characteristics of interventions judged to be effective by research standards, are well known and should be incorporated in the design. These include for example, community involvement and partnership working in the delivery of the intervention. Over time these have been consolidated into quality assurance mechanisms, and standards of good practice; either disseminated in guidance or protocols for effective interventions, or through expert systems and quality monitoring tools. Another dimension of best practice is being aware of the capacity and capability of those delivering the intervention, and/or of the structures and systems in place to deliver it. Thus not only is it necessary to consider whether there are perhaps enough staff to deliver it, it is important to consider whether they have the knowledge and skills, whether the organisational context is supportive and necessary resources are available for example. So part of best practice in health promotion is building the capacity of the operating systems to deliver the changes indicated as necessary, and the awareness of fit with the wider policy context.

This section will review key steps in planning and implementing a health promotion programme and describe a small number of well known models that illustrate the principles and are in current use. Davies & Kepford (2006; 152-154) summarise the essential stages in planning a health promotion intervention as follows:

• Assess need - using epidemiological data, demographic and socio-economic information, felt needs of target audience, perceived needs of professionals, and assets of target group

• Interrogate the evidence base for effective interventions - assess international review level literature and other learning from comparable cultural settings

• Identify resources - equipment, financial, human

• Aims - identify what you hope intervention will achieve in terms of behavioural or health change for example

• Targets - set a numerical target if appropriate and if baseline data and evaluation methodology are robust enough to measure progress

• Objectives - the specific actions to achieve the aim

• Methodology - techniques to be employed

• Evaluation - to assess achievement of desired outcome and to add to evidence base

• Resource allocation and budget setting

A selection of planning tools are listed in Table 3.1 with a brief note of their particular strengths. (A fuller list including web addresses is available in Davies & Kepford, 2006). Two models, Precede-Proceed and the European Quality Instrument for Health Promotion, are then described in more detail to illustrate different approaches.

Table 3.1 Selected health promotion planning tools (adapted from Davies & Kepford, 2006)

Precede-Proceed Model

Figure 3.1 illustrates the Precede-Proceed planning model, which is one of the earliest and well-known (Green & Kreuter, 1991, 1999). This model is clearly based on the recognition of the multiple determinants of health and starts with an assessment of the quality of life and social problems, as ultimate goals, of which health is a contributory factor. It proposes a sequence of diagnostic phases that emphasise the environmental and organisational factors that influence health behaviour. It considers the predisposing factors, those personal factors such as motivation, knowledge attitudes and beliefs; reinforcing factors, the attitudes and behaviours of role models, peers etc; and enabling factors, resources and skills etc that either support or hinder change in behaviour or environment. The fifth phase also pays attention to the capacity for implementation of the programme of the delivery agent and its context.  An interesting aspect of this model is its incorporation of evaluation steps and clear association of evaluative phases with the diagnostic phases, demonstrating the appropriate distinctions between process, impact and outcome evaluation.  This is similar to the more recent 'theory of change approach', which aims to clarify to those planning and evaluating community-based interventions, how the proposed actions will lead to the anticipated outcomes by making explicit the links between programme components and outcomes, that is articulating their theory of change (Weiss, 1999 - see section 5 on evaluation for further information).

Figure 3.1 The PRECEDE-PROCEED planning model

European Quality Instrument for Health Promotion (EQUIHP)

Box 3.1 outlines the criteria in the European Quality Instrument for Health Promotion (EQUIHP) for supporting development of interventions, benchmarking  and evaluation, drawn from a thorough review of existing frameworks and tools and consensus testing to facilitate cross-national comparisons and collaboration in enhancing quality (Bollars et al, 2005).  The tool was derived as part of the Getting Evidence into Practice Project funded by the European Commission, the full tool includes detailed indicators and a user manual.

 

References

Davies M & Kepford J (2006) Planning a health promotion intervention. In Davies M & Macdowall W (Eds.) Health promotion theory. Understanding Public Health Series. Maidenhead: OUP, McGrawHill

Green LW & Kreuter MW (1991,1999) Health promotion planning: an educational and ecological approach. 2nd/3rd Edn. California, Mayfield

Bollars C, Kok H, Van den Broucke S & Molleman G (2005) European Quality Instrument for Health Promotion with User Manual Woerden: NIGZ www.nigz.nl/gettingevidence

Weiss CH (1999) Nothing as practical as good theory: exploring theory-based evaluation for comprehensive community initiatives for children and families. In: Connell JP et al (eds.) New approaches to evaluating community-wide initiatives Vol. 1. (See also: Theory of Change: a practical tool for action, results and learning. www.aecf.org/initiatives/ accessed6/10/06)

3.2 Appropriate settings for health promotion

This section will look at definitions of the 'settings' approach to health promotion, and some theoretical issues and practical steps to achieving health promoting settings.

The introduction of the term 'health promotion setting', or 'settings-based health promotion', is usually attributed to the WHO, which has supported its implementation through networks, such as Health Promoting Hospitals and Healthy Schools networks, since its first mention in the Ottawa Charter.  It is defined as, 'the place or social context in which people engage in daily activities in which environmental, organisational, and personal factors interact to affect health and well-being…A setting is also where people actively use and shape the environment and thus create or solve problems relating to health. Settings can normally be identified as having physical boundaries, a range of people with defined roles, and an organisational structure' (WHO, 1998 p19, cited in Dooris, 2004))

The settings concept has enabled the potential demonstration of all the Ottawa Charter's five arenas for action. However much of the discourse and the practice of settings-based health promotion, falls short of the full realisation of the concept in addressing comprehensive action.  There can also be confusion in the way the terminology is applied between inter-sectoral health promotion and settings-based health promotion. Whitelaw et al (2001) caution that there are significant differences in the breadth of work labelled as settings-based. They comment that problems have been created in understanding the relative benefits of a wide range of diverse activities which may conceal differences in effectiveness and appropriateness of different elements for different contexts by: 'thesheer scale of the work (ranging from, for example, broad national approaches to highly localized work); the subsequent location of such work ('settings' ranging from, for example, nation states, cities, communities, schools, colleges, universities, health services/hospitals, workplaces and prisons); and as is suggested by the diversity of the outcomes claimed in the name of settings activity, the respective emphasis of each of the components of activity (ranging from broad policy and environmentally oriented work through to activity of a more individualistic and participative nature).'  (Whitelaw et al, 2001 p341)

The difference in scale and application may also lead some practitioners to feel that their efforts fall widely short of the ideal.  Others have proposed that there are hierarchies of settings, with some eg cities containing others eg schools. Galea et al (2000) consider that within such a frame of reference it is important to describe an 'elemental setting, that is one which is indivisible for the purpose of organising meaningful health promotion and health protection programmes.'  (Galea et al, 2000) They consider an elemental setting to have three characteristics:

• it is small enough for its members to self-identify as belonging to that setting and to engender a sense of one identity;

• it has distinguishing social, cultural, economic and psychological peculiarities; and

• it has a recognisable, formal or informal administrative structure to which health promotion or health protection activities can link.

Table 3.2 describes five types of settings based health promotion, drawn from a review of activities in different settings (Whitelaw et al, 2001). These consider different perspectives of problems (the way in which the health 'concern' is perceived) and solutions, broadly whether the solution lies with the individual, or with the system or structure represented by the setting.

• The 'passive' model  - where the problems and solutions rest within the voluntary control of the individual, and the setting is simply a neutral communications channel offering access to defined population groups. An example of this would be health education within schools, where the school provides the opportunity to regularly reach cohorts of young people to teach them about keeping healthy.
   

• The 'active' model - a variation of this theme where aspects of the setting are used to support the changes required in the target group. So health education about smoking in schools might be supported by action on smoking policies; hand washing in nurses would include not only leaflets but action on the environment through improved washing facilities, introduction of policies and staff training. Thus the problem and some of the solution are with the individual but changes to the setting contribute to achieving it.
   

• The 'vehicle' model - an understanding that the problem and the solution lie within the setting but that the route to achieving change is through incremental steps on specific topics. Thus 'health promotion projects are used as a secondary vehicle towards the primary aim of wider development within the setting' (Whitelaw et al, 2001, p343). An example here might be health promoting hospitals' projects where action on specific topics is used to develop a wider understanding in the organisation of the benefits of development towards being an health-promoting organisation.
   

• The 'organic' model - places more emphasis on the role of individuals within the organisation in changing the system in the longer term. This model is based on assumptions that within an organisational setting the processes of the system are built up from the multitude of actions of individuals and groups within it. The solution therefore lies with developing individuals and changing processes embedded within the system. Actions here might include improving staff communications, and more generic (ie not topic focussed) staff training programmes. This approach has similarities with community development methods, and continuous quality improvement approaches.
   

• The 'comprehensive' model also aims to make structural and process changes within the organisation, but considers that largely these are not within the control of individual staff to influence, as in the organic model. The solutions here lie with the levers of overarching settings strategies and policies, and the actions of senior management.

In reality much settings-based work combines these approaches, and indeed the distinction may also be to do with the developmental stage of the work. Thus tangible health promotion projects may be a precursor to engaging staff involvement and senior management commitment to more significant organisational development and changes in systems and structures.

Table 3.2  Five types of settings-based health promotion (adapted from Whitelaw et al, 2001)

Health promoting hospitals

In the 1990's the WHO developed the Health Promoting Hospitals (HPH) Network to support a growing number of hospitals that were beginning to attempt to put the Ottawa Charter 'reorient health services' principle into practice. Implementation of this strategy means paying attention to the other four strategies of: developing healthy public policy, creating environments that are supportive of health, involving the community and developing personal skills of staff, patients, families and the wider community - within the hospital setting. The HPH network endorsed the fundamental principles of the Vienna Recommendations on Health Promoting Hospitals as shown in Box 3.2.

However health promoting hospital practice has ranged from 'doing a health promotion project', to delegating the role to a specific department or member of staff, being a health promoting setting, and also playing a part in promoting the health of the community (Johnson & Baum, 2001). In order to stimulate self-assessment and reflection on the extent to which health promotion activities are incorporated into the organisational culture of the hospital, promoting the health of patients and staff, supporting healthy environments and actively co-operating with the community, the WHO have produced Standards for Health Promotion in Hospitals (WHO, 2004) as in Box 3.3. The production of standards and a quality assessment process is seen to be valuable in the hospital setting as it parallels similar quality assurance approaches for clinical and other hospital services.

These standards are focussed on effective health promotion activities in hospitals, and hence are called standards for health promotion in hospitals. They do not cover the issues to do with the wider impact of the hospital on the local environment, on employment or sourcing services and products for example, in a way that is health-enhancing and sustainable. The connections with the community are primarily related to the improved health promotion work within the hospital ensuring that it is joined-up with and draws upon community support and services, rather than being an active player in promoting wider community health. However given the limitations of some responses to HPH and the dangers of marginalized 'projectism', adoption of and adherence to these standards would be a great improvement in many hospital settings.

Each year in the EU public authorities spend 16% of the EU GDP on goods, services and works, around 1500 billion euros. This includes schools, hospitals and national and local administrations. The potential to harness this purchasing power positively to invest in health, the environment and in economic development, is enormous (EC, 2001). The health sector in particular is a huge consumer of goods and services. In the UK, the NHS is the largest single employer with over 1 million staff, spends over £11billion on goods and services and is the single largest buyer of food.

The King's Fund explored the connections between health improvement and sustainable development in Claiming the Health Dividend (King's Fund, 2002) demonstrating how investment in promoting health, addressing the determinants of ill-health, employment, poverty, environmental pollution and social exclusion through sustainable deployment of NHS resources, could contribute to reducing demand on health services. The connections between sustainable development and health improvement are synergistic. This basically means that where actions to promote economic, social and environmental sustainability do improve health; improving the health (e.g. of the working age population) and reducing health inequalities also contributes to sustainable development. They describe how a 'virtuous circle' can be achieved of interaction between the sectors by focussing on health spend in the areas of: employment; purchasing policy and the procurement of goods and services; the management of waste, travel and energy, and the design and construction of new buildings.

The power of purchasing extends across the whole range of goods and services, but just to take food as an example, the Sustainable Development Commission (2004) states the argument succinctly; 'How food is served, prepared, purchased and produced can have a huge impact on the health of individuals, communities and the environment. Through nutritional standards, catering and procurement, the NHS has the power to speed patient recovery, build a healthy workforce, strengthen local communities, bring jobs to poor neighbourhoods, cut road traffic, and promote sustainable farming.' The NHS spends £300 million on food each year, this can 'buy' more investment in the economy if sourced locally - every £10 spent on organic local food generates £25 for the local economy, but only £14if spent in a supermarket. Local procurement would also reduce the need for spending on transport and packaging waste.

Claiming the Health Dividend also outlines ways in which savings can be made in waste management policies, on 'green travel plans', on energy consumption and sustainable building design and construction which can have a significant impact on health inequalities. The concept of 'environmental exclusion', describes the relationship between poor environmental quality and deprivation: those living in the 10% most deprived wards suffer more nitrogen dioxide pollution; 50% of carcinogenic emissions occur in 20% of the most deprived wards; and in quality of life issues fear of crime is much higher in the most deprived areas (ODPM, 2004). The report highlights the potential synergy between government departments on the public health impacts of liveability and environmental protection, civil renewal and social enterprise; and emphasises the mutually reinforcing relationships between local environment issues and community engagement. Residents' prioritisation of local environment issues can provide a way in to engagement on the wider health improvement agenda.

Health Promoting Schools

Following on from the Ottawa Charter endorsement of the school as a setting for health promotion, the development of whole-school approaches to health promotion and the WHO Health Promoting Schools Network, health promoting schools have become widely supported in many countries.

The whole-school approach recognises that both the explicit (or formal) curriculum, and the hidden curriculum (what is learnt at school from norms, values and school life) are important in promoting health. The health-promoting school takes this a stage further to develop the 'hidden' curriculum into openly stated health-enhancing policy. Much has been written about health-promoting schools, and many national schemes and international networks exist to support their development. For example in England following the success of the National Healthy School Standard with the involvement of over ten thousand schools in the programme, in 2004 the intention to make every school a healthy school was announced in the Healthy Living Blueprint for Schools (DfES, 2004). This built on the solid foundations of accredited local partnerships between education and health services, and joint working at national policy level between the education and health departments in government. A more specific guide to healthy school status was issued in 2005 www.wiredforhealth.gov.uk.

The aims of the National Healthy Schools Programme (NHSP) are to:

• support children and young people in developing healthy behaviours

• help to raise pupil achievement

• help to reduce health inequalities

• help promote social inclusion

There is evidence that the health-promoting school is effective (Lister-Sharp et al, 1999; www.wiredforhealth.gov.uk/evidenceofimpact). Schools with healthy school status have better results for all Key Stage 1 assessments and Key Stage 2 Science compared with other schools. Schools involved in the NHSP are more inclusive and pupils report a range of positive behaviours such as diminished fear of bullying and a reduced likelihood of using illegal drugs. Personal, Social and Health Education (PSHE) provision is enhanced and there is more effective liaison between home and school, and school and external support agencies in healthy schools.

Workplaces, universities and prisons

Health promoting workplaces have grown out of relatively well established programmes to improve employee health, but now increasingly recognise their importance to the wider consideration of sustainable social and economic development. Chu and colleagues (2000) reviewing progress note the following familiar distinctions between different types of activity:

• 'as a strategy of behaviour prevention in the workplace (lifestyle approach)

• as a part of extended occupational safety and health

• as a strategy to influence important health determinants at work

• as a strategy to reduce absenteeism

• as a part of organisational development' (p157)

Success factors for workplace health promotion include: participation of all staff; project management including needs assessment, priority setting, monitoring and evaluation; integration into companies' regular management practices: and comprehensively covering activities that are directed at both individuals and the environment.

Other, but relatively less well-developed settings include prisons and universities. Both of these fit the definition of having defined boundaries and organisational structures and a clear population group. Health-promoting universities were described in Tsouros et al (1998) and signalled as an important setting because of their scale in terms of staff numbers, throughput of students and impact on the local community.

A strategy for health-promoting prisons was published in 2002 in England, to tackle the significant levels of physical and mental ill-health in the prison population (DH, 2002). This is implemented through the 'Prison Service Order for Health Promotion (PSO 3200)' which requires attention to issues such as: mental health promotion and well-being; smoking; healthy eating and nutrition; healthy lifestyles including sex and relationships, and drug and other substance misuse. Working in partnership with the local health service this enables a focus on, and access to some of the most vulnerable and socially excluded in society. The Health in Prisons Project (www.hipp-europe.org) is another WHO network of similar initiatives in countries across Europe.

This overview has considered the definition of settings approach, some theoretical issues and practical steps to achieving health promoting settings in the context of hospitals and schools; and briefly with reference to prisons, workplaces and universities. The differences and similarities between intersectoral work and settings based work have been considered, and different models of settings based work discussed. Although health promotion projects taking place within a setting may well be a useful step towards developing the setting to become health promoting, they do not constitute what we think of as settings-based health promotion. This needs to encompass organisational development and have an impact on all the policies and practices within the organisation, and on the wider community it serves or is located within. There are now recognised standards of practice for different settings, guidelines and extensive examples from different countries that all point to the transferability and value of this approach in delivering health promotion.

References

• Chu C, Breucker G, Harris N et al (2000) Health-promoting workplaces - international settings development. Health Promotion International, 15:2, 155-167

• Coote A (Ed.) (2002) Claiming the Health Dividend: unlocking the benefits of NHS spending. London, King's Fund. www.kingsfund.org.uk

• Department for Education & Skills (2004) Healthy Living Blueprint for Schools, DfES/0781/2004

• Department of Health/Prison Service (2002) Health Promoting Prisons: a shared approach. London: The Stationery Office. www.doh.gov.uk/prisonhealth

• Dooris M (2004) Joining up settings for health: a valuable investment for strategic partnerships? Critical Public Health 14:1 49-61

• European Commission (2001) Guidelines for environment-friendly procurement http://europe.eu.int/comm/environment/gpp

• Galea G, Powis B & Tamplin S (2000) Healthy Islands in the Western Pacific - international settings development. Health Promotion International, 15:2 169-178

• Johnson A & Baum F (2001) Health promoting hospitals: a typology of different organisational approaches to health promotion. Health Promotion International, 16:3, 281-287

• Lister-Sharp D, Chapman S, Stewart-Brown S & Sowden A (1999) Health promoting schools and health promotion in schools: two systematic reviews. Health Technology Assessment 3: 22

• Office of the Deputy Prime Minster (2004) Environmental Exclusion Review for Neighbourhood Renewal Unit, ODPM - Summary Report

• Sustainable Development Commission (2004) Healthy Futures: food and sustainable development www.sd-commission.gov.uk/healthyfutures

• Whitelaw S, Baxendale A, Bryce C et al (2001) 'Settings' based health promotion: a review. Health Promotion International, 16:4 339-353

• WHO Health Promoting Hospitals Network (1997) The Vienna Recommendations on Health Promoting Hospitals. Copenhagen: WHO Europe

• World Health Organization (1998) Health Promotion Glossary, Geneva: WHO

• World Health Organization (2004) Standards for health promotion in hospitals: self-assessment tool. Copenhagen: WHO Europe

See also:

• Speller, V (2006) Developing healthy settings. In: Macdowall, W, Bonell, C & Davies, M (Eds.) Health Promotion Practice. Understanding Public Health Series. Maidenhead: OUP, McGraw-Hill

• Various publications from the Healthy Settings Development Unit at the University of Central Lancashire. www.uclan.ac.uk/facs/health/hsdu

• Tones K & Tilford G (2004) Health promotion: Planning and Strategies. London, Sage Publications

3.3 Health promotion and community development

Community participation is a central tenet of the Health for All strategy and the Ottawa Charter, and a defining principle of health promotion practice. While health promotion can and does act on individuals, what distinguishes it from preventive clinical practice is a focus of creating the conditions for change in individuals and groups at community level. This section looks at some of the ways in which health promoters work with communities to improve their health. It will briefly cover concepts of community, community development, empowerment and community participation.

Community

Although the meaning of 'community' may seem to be self evident in fact it is a concept that has defied simple definition. The most obvious type of community is one defined by geography, a district in a town, an estate or neighbourhood, or a school - but such a community is not homogenous. It consists of people of different ages, ethnic origins, interests and aspirations. So, communities can be defined in relation to their interest groups, health and social need, and political views. Laverack (2004) identifies four key characteristics of community:

• A spatial dimension, that is, a place or locale

• Non-spatial dimensions (interests, issues, identities) that involve people who otherwise make up heterogeneous and disparate groups

• Social interactions that are dynamic and bind people into relationships with one another

• Identification of shared needs and concerns that can be achieved through a process of collective action

Some of the key issues of working with communities relate to notions of power and control in the relationship between community members and the professionals from health and other services. Thus in working with communities an understanding of who the community comprises and why they have a common or shared need is essential; so too is the recognition that communities can only define themselves from within.

Community development

Henderson et al (2004) defined community development as:

'Community development seeks to bring about change locally, regionally and nationally. People differ on the definition of community development and the term is constantly under review. There are, however, some essential baselines. Community development is not just about what happens in neighbourhoods and interest groups: it is also concerned with how organisations and agencies respond to community issues and how they support local initiatives. One way of defining community development is to set out its goals. These are: to combat social exclusion; to promote participation; and to encourage people to acquire new skills. '

The authors point out the importance of understanding the key events and turning points in the history of community development and what can be learned from them. The earliest supporter of community development was the education sector with the development of community-based adult education, from the 1960s to late 1970s social work was the main sponsor of community development (Seebohm, 1968), but since then economic development and regeneration have been the main drivers. There are tensions within community development about whether it is seen as a specialist profession in its own right with a core body of values, knowledge and skills, or whether it is seen as a generalist concept that can be applied in varying contexts. Prior to publication of the Seebohm report on community work in social services departments, funding came mainly from the voluntary sector, however most resource now comes from the statutory sectors. Given the emphasis on radical analysis of the causes of poverty in communities and transfer of power to communities this also has the potential to create tension. As Henderson et al (2003) say, 'Some organisations want to use community development as a tool for putting particular policies and programmes into practice; others want to use it to challenge assumptions, policies and resource allocations.'

The debate whether community development is a bottom-up social movement, or a professional tool to direct communities towards organisational or policy goals, in however inclusive or participative manner, is also an important one. Quoting Henderson et al (2003) again, 'It would be wrong, in our view, to see the social movement and professional elements of community development as necessarily in conflict. Both have driven community development forward, and arguably they need each other. The energies and commitment of local people are the lifeblood of professional community development, and most social movements need, at some point, to develop more formal organisations. There has been a growing awareness that community development must avoid becoming trapped - literally and metaphorically- at the neighbourhood level. If change is to occur, work has to be done within key organisations and agencies. '

(For more information about community development methods see:

Henderson P, Summer S & Raj T (2003) Developing Healthier Communities, An introductory course for people using community development approaches to improve health and tackle health inequalities. London, Health Development Agency)

Empowerment

The concept of empowerment is embodied in the Ottawa Charter in the phrase 'enabling people to take control over and to improve their health' (WHO, 1986). There are (at least) two rather differing perspectives on empowerment that influence health promotion practice today; the critical consciousness raising perspective of Freire (1972), and the psychological construct of self-efficacy (Bandura, 1977). Freire, working in Brazil in the 1950's and 60's sought through education to liberate people from the oppression of poverty and their associated helplessness to change the circumstances of their lives. The process of critical consciousness raising 'refers to learning to perceive social, political, and economic contradictions, and to take action against the oppressive elements of reality' (Freire, 1972). According to Freire, empowerment is inextricably related to notions of sharing power through carrying out transformations with the oppressed rather than for them. Freire's work has been influential in health education theory as it is centred around the acquisition of information and knowledge to bring about change, and emphasizes the power of collective social action.

Self-efficacy relates to individual's self-perceptions of their competence at performing particular activities (Bandura, 1977). It differs from self-esteem, which is a rather more global concept of feelings of self worth, in that self-efficacy is situation specific. Individuals can feel control or mastery over certain behaviours, while avoiding activities that they feel exceed their coping capacities. Community development approaches have the potential to both empower through raising individual's beliefs in their own capabilities, either to make personal behaviour changes or to participate more fully in collective activities such as having the confidence to speak up at meetings for example; and through working with groups to achieve social change by advocacy, and facilitating engagement with decision-makers.

Community participation

The term 'community participation' is used sometimes interchangeably with community development. In fact it is a more general term and can be used to describe different forms and degrees of involvement, which are usually considered to relate to different levels of sharing power between communities and decision-makers. Arnstein's ladder of participation (Arnstein, 1971) is the classic description of these different levels (Figure 3.2):

Figure 3.2 Arnstein's ladder of participation (1971)

Degree of actual power	Control
	Delegated power
	Partnership
Degree of tokenism	Placation
	Consultation
	Informing
Non-participation	Therapy
	Manipulation

Whilst climbing up the ladder has been considered to represent the goal of increasing degrees of empowerment and control, it must be remembered that not all communities, or individuals within a community, wish to have total control, or even significant responsibility. For some aspects of working with communities simple provision of information may be appropriate, or working in mutually respectful partnerships of community members and professionals. At all times the key issues are: what is the purpose of the work, to what extent do the community want to be involved, are those who are engaged in activities actually representing the community, or engaging in their own personal desire for increased power, perhaps resulting in the further exclusion of marginalized groups? What are the goals of the health and social workers and is their style of working empowering? Principles for involving the public in community development in the context of primary care have been summarized by Crowley et al (2000) in Box 3.4.

References

Arnstein S R (1971) Eight rungs on the ladder of citizen participation. In: Citizen Participation: effecting community change. (Eds S E Cahn & B A Passett), New York, Praeger Publications

Bandura A (1977) Self-efficacy: towards a unifying theory of behavioural change. Psychological Review, 64: (2), 191-215

Crowley P (2000) Community development and primary care groups. In: Communities developing for health. Liverpool, UK Health for All Network

Freire P (1972) Pedagogy of the oppressed. Harmondsworth, Penguin

Henderson P, Summer S & Raj T (2004) Developing healthier communities. An introductory course for people using community development approaches to improve health and tackle health inequalities. London, Health Development Agency

Laverack G (2004) Health promotion practice. Power and Empowerment. London, Sage

See also;

Speller V (2006) Working with communities. Chapter 10 in Davies M & MacDowall W (Eds.) Health Promotion Theory: Understanding Public Health Series, Open University Press/McGrawHill

Tones K & Tilford G (2004) Health promotion: Planning and Strategies. London, Sage Publications

© V Speller 2007