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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 !ttawa Charter "and its # Principles$ in %&'(. However, the translation of policy into practice has proved problematic, and solutions to these problems are still in development. )he first part of this review attempts to e*tract some definitions which can set the way to understanding this process, and briefly visits the policy environment. )he second part lifts abstracts from the literature in order to address the +uestions of community development approaches to health promotion, the need and barriers, loo,s at the problems of defining effectiveness or success of interventions, suggests re+uisites 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. -ather, the abstracts, sometimes repetitive, have been e*tracted and placed in an order that can begin to ma,e some sense although this process is in no way complete. %. What is Health Promotion? Page % .. /pproaches to Health Promotion Page 0 0. Policy 1nvironment Page ( 2. Community Development /pproaches to Health Promotion Page 3 2.% What is Community? Page ' 2.. What is Community Development? Page ' 2.0 What are Community Development /pproaches to Health Promotion? "4iterature /bstracts$ Page & 2.2 4ac, of 1vidence re Community Development Intervention !utcomes Page %2 2.# Difficulties in defining success or effectiveness Page %( 2.( 5ome e*amples of Community Development /pproaches to Health Promotion Page %3 #. /ny Community Development /pproaches to Health Promotion must have the following elements 6 Page .& (. 7uestions of Community 1mpowerment 8 Partnership Page 29 1. What is Health Promotion? :;c<inlay 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 ta,en in a fair bit of water so re+uired resuscitation, which he duly performed. >ust as that person was o,, he heard another shout and lo and behold another person was in trouble. !f course he dived in and rescued that person too. >ust as they were coming around, another shout? / third person had to be rescued. )his went on for some time until he became e*hausted and started to thin, about what was going on upstream that was causing all these people to end up in the river in such distress. 5o he headed up for a loo,. )his is, in essence, what health promotion is. !f course people need to be rescued and brought bac, to full health @A) someone also needs to go upstream and figure out why there are so many people needing to be rescued.B C0.D 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$, and tertiary prevention and health care "management of established disease e.g. to minimise disability and prevent complications e.g. foot care for people with diabetes$. ;id6stream we have primary prevention

and health care, usually individual, for e*ample attempts to reduce ris, of contracting disease "educating smo,ers, vaccinating$. /nd upstream we have health promotion including social policies and health promotion programmes, such as ta*es on tobacco, smo,e free legislation and advertising bans. )his may include health education, which aims to reduce ill6health and increase positive health influencing peopleEs beliefs, attitudes and behaviour. Health Promotion has a dual role to prevent ill health and promote positive health. C.#, 0.D :Health promotion is the process of enabling people to increase control over, and to improve, their health. )o reach a state of complete physical, mental and social well6being, an individual or group must be able to identify and to realiFe aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the obGective of living. Health is a positive concept emphasiFing social and personal resources, as well as physical capacities. )herefore, health promotion is not Gust the responsibility of the health sector, but goes beyond healthy life6styles to well6being.B C!ttawa Charter for Health Promotion, Hirst International Conference on Health Promotion, !ttawa, .% Iovember %&'( 6 WH!JHP-JH1PJ&#.%D C(&D / refined definition might be, Khealth promotion is the process of enabling individuals and communities to increase control over the determinants of health and thereby to improve their health.K /mong other things, this definition suggests that in our efforts to evaluate 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 Kdeterminants of healthK 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. C20D /nother 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 s,ills, creating supportive environments, strengthening communities, influencing governments to enact healthy public policies, and reorientating and improving health services.B C%0D Common Themes:

Health promotion involves the whole population in the conte*t of everyday life 1nabling Control or 1mpowerment Promoting Wellbeing "rather than dealing with :illnessB$ @uilding capacity ItEs a process not Gust an outcome Directed towards action on determinants or causes of healthJdisease. Wide definition of determinants of health. Community Development

Put another way= Health Promotion L aims to gain effective public participation 1L aims to= 0 L create a supportive environment 1 L build healthy public policy 2 L strengthen community action 3 L develop personal s,ills 4 L empower local people 5 L improve e+uity and ine+uality 6 L re6orientate health service

7 L advocate for health C.#D

)hree words describe the role of practitioners involved in integrated health promotion programs= L Enable= Integrated health promotion focuses on achieving e+uity in health. / maGor aspect of the wor, of integrated health promotion is to provide the opportunities and resources that enable people to increase control over and improve their health. )his includes developing appropriate health resources in the community and helping people to increase their health ,nowledge and s,ills, 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. L Advocate= /ction for health often re+uires health wor,ers to spea, out publicly or write on behalf of others, calling for changes in resources, policies and procedures. )he Cancer Council lobbying for a ban on smo,ing in all enclosed spaces is an e*ample, as is a local community health wor,er writing letters to the local paper calling on the council to improve facilities for physical activity for older people. L ediate= ;any sectors of the community, such as government departments, industry, non6 government organisations, volunteer organisations, local government and the media ta,e action that has an impact on peopleEs health, sometimes acting to support one another, sometimes disagreeing about what should be done. Health wor,ers play a role in mediating between these different groups in the pursuit of health outcomes for the community, or in mediating between the health re+uests of different sectors of the community. C..D !. Approaches to Health Promotion How can one go about KdoingK health promotion? )he following strategies, which are often combined, are commonly used=

Creating supportive environments= /ctivities aimed at establishing policies that support healthy physical, social and economic environments "WH!, %&&'$. Health education= Consciously constructed opportunities for learning designed to facilitate changes in behavior towards a predetermined goal, and involving some form of communication designed to improve health literacy, ,nowledge, and life s,ills conducive to individual and community health "P/H!, %&&(M WH!, %&&'$. Health communication= / strategy to inform the public about health concerns and place important health issues on the public agenda achieved through the use of 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 "WH!, %&&'$. 5elf6help= /ctions ta,en by lay persons to mobiliFe the necessary resources to promote, maintain or restore the health of individuals or communities through self6 care activities such as self6medication, self6treatment and first aid in the normal social conte*t of peopleNs everyday lives "WH!, %&&'$. !rganisational development= / process typically used in industry although applicable to other settings such as communities, to improve performance, productivity and morale issues, and attain an optimally functioning organiFation, with a high level of cohesion, well6being and satisfaction on the part of all those involved "-aeburn 8 -ootman, %&&'$. Community development J action= / process of collective community efforts directed towards increasing community control over the determinants of health, improving health and becoming empowered to apply individual and collective s,ills to address health priorities and meet respective health needs "WH!, %&&'$. Healthy public policy= Hormal statements that demonstrate concern for heath and e+uity and which ma,e healthy choices possible or easier for citiFens, through

creating supportive social and physical environments that enable people to lead healthy lives "P/H!, %&&(M WH!, %&&'$. /dvocacy= / combination of individual and social actions designed to gain political commitment, policy support, social acceptance and systems support for a particular health goal or program "P/H!, %&&(M WH!, %&&'$. -esearch= Information which lin,s 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, as,s meaningful +uestions and is systematic and rigorous "Iaidoo 8 Wills, %&&'$. 1valuation research is formal or systematic activity, where assessment is lin,ed to original intentions and is fed bac, into the planning process "Iaidoo 8 Wills, .999$.K ;edical approach= Hocused on disease and biomedical e*planations of health. Iarrow concept of disease "ignore socialJenvironmental dimensions$ e.g. immunisation, screening C##, .#D

E"amples o# approaches to health promotion $E%les & 'imnet( 1))*+ C.#D Aim 1. Health a%areness .oal -aising awareness, or consciousness, of health issues !. attitudes and behaviour Changing the lifestyles of individuals Appropriate ethod E"ample , 'mo-in. 1ncourage people to see, early detection and treatment of smo,ing6related disorders

tal,s group wor, mass media displays and e*hibitions campaigns group wor, s,ills training self help groups one6to6one instruction group or individual therapy written material advice one6to6one teaching displays and e*hibitions written materials mass media campaigns group teaching

Persuasive education to prevent non6smo,ers from starting and persuade smo,ers to stop

/. 0mprovin. -no%led.e Providing information

Oiving information to clients about the effects of smo,ing. Helping them to e*plore their own values and attitudes and come to a decision. Helping them to learn how to stop smo,ing if they want to Clients identify what, if anything, they want to ,now about it

2. 'el# empo%erin. Improving self6 awareness, self6esteem, decision6ma,ing

group wor, practising decision6ma,ing values clarification social s,ills training stimulation, gaming and role play assertiveness training counselling

#. 'ocietal1environmental chan.e Changing the physical or social environment

positive action for under6served groups lobbying pressure groups community development community6based wor, advocacy schemes environmental measures planning and policy ma,ing organisational change enforcement of laws and regulations

Io smo,ing policy in public places. Cigarette sales less accessible, especially to childrenM promotion of non6 smo,ing as social norm. @anning tobacco advertising and sports sponsorship

Integrated health promotion service delivery can be organised from one or more different angles, depending on the ,ey priorities identified and the problem definition, including= health or disease priorities, for e*ample, mental health, heart disease, diabetes, oral health lifestyle factors, such as physical activity and nutrition, tobacco use, safe se* population groups, for e*ample, culturally and linguistically diverse groups, same6se* attracted youth, adolescents, older people living alone settings, for e*ample, health promoting schools, health promoting wor,places, health promoting hospitals, council estates.

)he ,ey re+uirement for +uality practice is how programs are planned, delivered and evaluated. @y definition, +uality practice is= enabling it is done by, with and for people, not on themM it encourages participation involves the population in the conte*t of their everyday lives, rather than focusing Gust on the obvious lifestyle ris, factors of specific diseases directed to improving peopleEs control over the determinants of their health a process 6 it leads to something, it is a means to an end. C..D

/. Policy Environment In %&3&, the thirty6second World Health /ssembly launched the Olobal 5trategy for health for all the year .999 thereby endorsing the -eport and Declaration of the International Conference on Primary Health care, held in /lma6/ta, A55- in %&3'. )he commitment to the achievement of KHealth for /ll by the Pear .999K was accepted by the %#9 member states and became the basis of all the WH! 6 related new developments in the field of health care in the world. / modern movement termed Health Promotion emerged out of the historical need for a fundamental change in strategy to achieve and maintain health. )he Health Promotion Programme at the regional office for 1urope of World Health !rganisation "WH!$ was established in %&'2 bringing to fruition the obGectives outlined in the policy documents that the -egional !ffice for 1urope had developed over the previous five years. )he first International Conference on Health Promotion met in %&'( in !ttawa to present a charter for action in order to wor, towards the achievement of Health for /ll by the Pear .999 and beyond. )he action plan of the %&'( 2tta%a Charter advises that health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to ta,e account of differing social, cultural, political and economic systems. )he declaration and programme for action is predicated upon the fundamental prere+uisites for health i.e. peace, shelter, education, food, income, sustainable resources, a stable ecosystem, social Gustice and e+uity. /t the heart of this health promotion action programme lies the ,ey concerns with advocacy, enablement and mediation.

Identification of priority issues is only one dimension of the !ttawa /ction plan. )he role 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$ 1ndeavouring to build a healthy public policy ii$ Wor,ing to create supportive environments iii$ Helpin. to stren.then community action in various settin.s iv$ 5triving to develop personal s,ills v$ Wor,ing together to re6orientate Health 5ervices C((D 2tta%a Charters 3ive strate.ies )he %&&3 World Health !rganisation "WH!$ >a,arta Declaration on Health Promotion into the .%st Century e*plicitly ac,nowledges the demonstrated effectiveness of health promotion in the following statement= Health promotion ma,es a difference. -esearch and case studies from around the world provide convincing evidence that health promotion wor,s. 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 e+uity in health. )here is now clear evidence that= Comprehensive approaches to health development are the most effective 6 those which use combinations of the !ttawa CharterNs five strategies are more effective than single trac, approaches. Settings offer practical opportunities for the implementation of comprehensive strategies 6 these include mega6cities, islands, cities, municipalities, and local communities, their mar,ets, schools, wor,places, and health care facilities. Participation is essential to sustain efforts - people have to be at the centre of health promotion action and decision6 ma,ing processes for it to be effective. Health learning fosters participation 6 access to education and information is essential to achieving effective participation and the empowerment of people and communities. )hese strategies are core elements of health promotion and are relevant for all countries "WH!, %&&3$. C%#D )he theoretical drive for WH!Ns action programme is based upon a shift in emphasis from issues to settings. )he shift has been from infectious diseases to behavioural diseases and ris, factors followed by an increasing emphasis on the environmental factors that create and maintain health. )he aim now is to influence the conte*t of health actions and ma,e the social and physical environment supportive to health and to provide individuals with strategies of health improvement and maintenance that can be integrated with meaning into a personNs overall life pattern. C((D Improving health and reducing health ine+ualities are now cross6cutting A< Oovernment priorities, with national targets agreed by various departments "public service agreements$, as part of the Oovernment Intervention in Deprived /reas "OID/$. )here are now unprecedented national policy drivers to involve communities in local decision6ma,ing across sectors. C.%D %&&& 5aving 4ives= !ur Healthier Iation is a comprehensive government6wide public health strategy for 1ngland. Its goals are to improve health and to reduce the health gap "health ine+ualities$. )he strategy aims to prevent up to 099,999 untimely and unnecessary deaths by the year .9%9. )argets, including health ine+ualities, will be tailored to local needs through needs assessments in association with local authorities. .992 Choosing Health= ;a,ing healthy choices easier is a government white paper, which sets out the ,ey principles for supporting the public to ma,e healthier and more informed choices in relation to their health. C.(D 4. Community Development Approaches to Health Promotion De#initions 4.1 What is Community?

)he A5 Oovernment .9%9 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 !rganiFation, %&&'M A5 Department of Health and Human 5ervices, .999$. ;embers of a community gain their personal and social identity by sharing common beliefs, values and norms which have been developed by the community in the past and may be modified in the future. )hey e*hibit some awareness of their identity as a group, and share common needs and a commitment to meeting them. C%, .'D 4.! What is Community Development? Community development see,s to empower individuals and groups of people, with the s,ills they need to advocate on their own behalf, improve their lives, and provide communities with access to resources. C((D !r put another wayQ. Community development, in very simple terms, is the process of developing social capital. It is a process that emphasises the importance of wor,ing with people as they define their own goals, mobilise resources, and develop action plans for addressing problems they have collectively identified. C..D Definition of social capital "Putnam %&&0$= )he community cohesion resulting from high levels of civic identity and the associated phenomenon of trust, reciprocity and civic engagement. Hour characteristics= the e*istence of community networ,s, formal or informal, civic engagement "particularly in networ,s$, local identity and a sense of solidarity and e+uality with other community networ,s, and norms of trust and reciprocal help and support. C.#D 5ocial capital and community development= Participating in social and civic activities, such as community group meetings, child care arrangements with neighbours, neighbourhood watch schemes and voting, all wor, to produce a resource called social capital. 5ocial capital is critical to the health, wealth and wellbeing of populations.00 It is a ,ey indicator of the building of healthy communities through collective and mutually beneficial interaction and accomplishments. 02 -ecent research has lin,ed these types of activities to improved health outcomes. 0#, 0(, 03, 0' C..D C00. Putnam, -. "%&&0$, ;a,ing Democracy Wor,, Princeton Aniversity Press, Princeton, Iew >ersey. 02. @aum, H., Palmer, C., ;odra, C., ;urray, C. and @ush, -. ".999$, RHamilies, social capital and healthE, in Winter, I. "ed.$, 5ocial Capital and Public Policy in /ustralia, /ustralian Institute of Hamily 5tudies, ;elbourne. 0#. @er,man, 4. and 5yme, 5. "%&3&$, R5ocial networ,s, host resistance, and mortality= / nine6year follow6up study of /lameda County residentsE, /merican >ournal of 1pidemiology, vol. %9&, no. ., pp. %'( .90. 0(. <awachi, I., <ennedy, @., 4ochner, <. and Prothrow65mith, D. "%&&3$, R5ocial capital, income ine+uality, and mortalityE, /merican >ournal of Public Health, vol. '3, no. &, pp. %2&% '. 03. @aum, Palmer, ;odra, ;urray and @ush, op. cit. 0'. <awachi, I., ColditF, O., /scherio, /., -imm, 1., Oiovannucci, 1., 5tampfer, ;. and Willet "%&&($, R/ prospective study of social networ,s in relation to total mortality and cardiovascular disease in men in the A5/E, >ournal of 1pidemiology and Community Health, vol. #9, pp. .2# #%.D )he notion of social capital represents a way of thin,ing about the broader determinants of health and about how to influence them through community6based approaches to reduce ine+ualities in health and wellbeing.0& / focus on social capital supports a balance of strategies that address behaviour and those that focus on the settings in which people live,

wor, and play. )he 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, ta,e action to promote health. 5imple measures, such as providing space for people to meet, may be as health promoting as providing health information in an effort to change behaviour. C..D C0&. Oillies, P. "%&&'$, R1ffectiveness of alliances and partnership for health promotionE, Health Promotion International, vol. %0, no. ..D 5ervice providers can also enhance the social capital within a community by supporting community proGects 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 wor,ing with the local sporting club to encourage all parts of the community to participate in sporting activities. C..D 4./ What are Community Development Approaches to Health Promotion? $5iterature Abstracts+ The evidence su..ests that there has been a shi#t to loo-in. at the social( economic( political( and environmental determinants o# health because other methods o# ill,health reduction have #ailed. There#ore( the ar.ument .oes( it is necessary to develop communities themselves to ta-e control o# their o%n health a.enda to tac-le these health issues #rom the source. Ho%ever( developin. communities brin.s its o%n problems6 problems o# de#inition6 and tensions bet%een the various a.enda setters and resource holders. The su..estion is( in much o# the literature( althou.h not clearly proven( that the only %ay le#t to .o #or%ard is community development( and some %riters su..est that partnerships can be and need to be #or.ed bet%een communities( health service providers( and academics. 7elo% are some abstracts #rom the literature revie%( theorisin. about community development approaches and its barriers. This is #ollo%ed by a discussion on the laco# comparable evidence and the di##iculty in de#inin. e##ectiveness or success in loo-in. at interventions6 some e"amples o# speci#ic interventions6 a discussion o# %hat community development approaches should or must include6 and #inally some notes on empo%erment and partnership. /gain there is a problem of definition= Community Development= the process by which a community identifies its needs, develops an agenda with goals and obGectives, then builds the capacity to plan and ta,e action to address these needs and enhance community well6being. Community Organisation= the process of involving and mobilising maGor agencies, institutions and groups in a community to wor, 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 needsJcircumstances. C%.D / Community Development approach to health Q is a process by which a community defines its own health needs to bring about change. )he emphasis is on collective action to redress ine+ualities in health and enhance access to health care. "Community Development and Health Ietwor,, Iorthern Ireland$ C.3D CNorthern Ireland is one area where Community Development pproaches have been adopted stronglyD 'ocial( political( economic and environmental determinants o# health :-ecent epidemiological analysis of health, disease and disability in the populations of most developed countries confirms the role of social, economic and environmental factors in determining increased ris, of disease and adverse outcomes from disease. C2.D

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. C2.D )hrough the Charter, health promotion has come to be understood as public health action which is directed towards improving peopleNs control over all modifiable determinants of health. )his includes not only personal behaviours, but also the public policy, and living and wor,ing conditions which influence behaviour indirectly, and have an independent influence on health. C2.D ")his more sophisticated approach to public health action is reinforced by accumulated evidence concerning the inade+uacy of overly simplistic interventions of the past. )o ta,e a concrete e*ample, efforts to communicate to people the benefits of not smo,ing, in the absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are doomed to failure. / more comprehensive approach is re+uired which e*plicitly ac,nowledges social and environmental influences on lifestyle choices and addresses such influences alongside efforts to communicate with people. )hus, more comprehensive approaches to tobacco control are now adopted around the world. /longside efforts to communicate the ris,s 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$, and to reflect social unacceptability through environmental bans. )his more comprehensive approach is not only addressing the individual behaviour, but also some of the underlying social and environmental determinants of that behaviour.$ C2.D 0nsu##iciency o# education alone It is now well understood from e*periences in addressing specific public health problems of tobacco control, inGury prevention and prevention of illicit drug use, and the more general challenge of achieving greater e+uity in health, that education alone is generally insufficient to achieve maGor public health goals. C2.D :;ore 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. C%'D 5uch an approach corresponds with increased interest in understanding the comple* issues that compromise the health of people living in marginaliFed communities. 1mphasis has also been placed on the need for e*panded use of both +ualitative and +uantitative research methods "e.g. Israel et al$M greater focus on health and +uality of lifeM and more translation and integration of basic, intervention, and applied research. C%'D Oreater community involvement in processes that shape research and intervention approaches, e.g., through partnerships between academic, health services and community6 based organisations is one means towards these ends. C%'D "%'$ Community development and health :1ssentially, community development wor, ac,nowledges that health is as affected by the social conditions of peopleEs lives such as damp housing, unemployment, or poor access to facilities, as it was by lifestyle choices. ;aGor policy documents including )owards a Healthier 5cotland "%&&&$ and !ur Iational Health ".999$ highlight the importance of considering life circumstances alongside lifestyle choices and disease in promoting health and wellbeing. C0%D / World Health !rganisation "WH!$ position paper "%&&%$ directly lin,ed community participation to empowerment as a means in itself of promoting healthier individuals and environments. Hurthermore, research has recognised the significance of powerlessness and empowerment to the health of individuals and communities "Wallerstein %&&0$. )he concept of healthy communities as developed by the WH! regards active community participation as essential to creating healthy communities=

:)he formation of local social capital can thus lead to the promotion of shared values and a common vision, integrated planning and resource utiliFation, and ultimately to systemic change.B ";urray, .999, p%9%$ C0%D )here is a growing body of literature showing that being part of a social networ, of contacts is protective for health "Hisher .99%$. )he effects derive from improved self6esteem, trust and increased feelings of being in control. C0%D Community Development 0ssues :Current health promotion policy and practice places a high value on community development wor, because it aims to enable communities to identify problems, develop solutions and facilitate change. C09D )he overt ideological agenda of community development is to remedy ine+ualities and to achieve better and fairer distribution of resources for communities. )his is achieved ideally through participatory processes and bottom6up planning. 1mpowering communities to have more say in the shaping of policies influencing health represents a brea, with earlier traditions of public health associated with top6down social engineering. C09D However, community development means different things to different people and can operate on different levels "5ee /rnsteinEs ladder, %&3%$. Community development has, for e*ample, been lin,ed to community organisation, community6based initiatives, community mobilisation, community capacity building and citiFen participation. C09D )here is, however, a common understanding of core principles, which inform community development wor,, two of which are participation and empowerment. )hese principles can and are, however, operationalised differentially in different types of community development wor,. C09D Despite consensus that community participation should engender active processes involving choice, and the potential for implementing that choice, implementation has proven difficult. Hor e*ample, when formal health services adopt an empowerment framewor,, their formal structures are not necessarily conducive to participation. C09D /lthough it is commonly agreed that appropriate leadership and effective organisational structures are crucial to successful community participation, this re+uires a political climate that nurtures and facilitates the approach. C09D :Community development uses a variety of methods and activities such as self help wor,, outreach, local action groups, lobbying, peer wor,, festivals and events, information, advocacy, group wor,, networ, building and pump priming community initiatives with small grants. C0%D )he ,ey characteristic of community development is that it starts from the e*periences 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 decision6ma,ing and evaluation. C0%D 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 ,nowledge and e*pertise of individuals and communities living through an e*perience and the centrality of drawing on this source of e*pertise to define problems and solutions and ultimately to design more effective services. )he main benefits of community development approaches have been summarised as= L Improving networ,s in a community, which has been shown to have a protective effect on health.

L Identifying health needs from usersE point of view, in particular disadvantaged and socially e*cluded groups. L Change and influence, as it enhances local planning and delivery of services. L Developing local services and structures that act as a resource. L Improving self6esteem and learning new s,ills that can aid employment. L Widening the boundaries of the health care debate by involving people in defining their views on health and local services. L )ac,ling underlying causes of ill health and disadvantage. C0%D Health 0ne8ualities( C7P9 & Community )here is increasing empirical evidence that a comple* set of conte*tual factors "including social, economic and physical environmental factors, such as poverty, air pollution, racism, inade+uate housing, and income ine+ualities$ play a significant role in determining health status. )hese factors contribute to the disproportionate burden of disease e*perienced by marginalised communities. )here is also considerable evidence suggesting that numerous resources, strengths and s,ills e*ist within communities "e.g. supportive interpersonal relationships, community6based organisations$ that can be engaged in addressing problems and promoting health and well6being. )his 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 SSparticipatory action researchE E, SSparticipatory researchE E, SSaction researchE E, and SScommunity6based researchE E. Policy changes at the organiFational, community and national levels are needed to help address barriers and challenges to the adoption of such approaches and to support their increasing use. C%(D o# community development )he community development approach encounters particular challenges in the conte*t of health care. While support for the idea of e*tending community development approaches 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 maGor changes within the organisation or into areas that the organisation had not previously considered. )he conclusion of a DH55 "Iorthern Ireland$ "%&&&$ document was that community development is still at a relatively early stage of development within mainstream agencies. It found most IH5 )rusts and @oards did not have a stated policy for a community development approach, and there was a lac, of focus for this wor, and few instances of training for staff in this area. C0%D )he way of wor,ing with and not Gust on behalf of individuals and communities that is central to the community development approach, sits uneasily with traditional western medicine and the Rmedical modelE in which professionals ,now what the problem is as well as the solution. )he challenge is not to the value of medical e*pertise per se, but rather to its dominance in respect of health ,nowledge and the allocation of resources. C0%D Hew health service professionals are fluent with community development approaches and ways of wor,ing with, rather than on behalf of, people. In describing a public health programme set up to lin, new mothers with e*perienced mothers and Public Health Iurses in Ireland during the %&'9s, >ohnstone "%&&0$ concluded= :Hamiliarisation of all health care wor,ers with changes in policy and the bac,ground of research and development and aims of policy would eliminate some of the frustrations and create a more supportive environment...)he community based approach has proved more effective in achieving change where this is indicated and is li,ely to be a more useful model for empowerment and self6care then the traditional type of health care approach.B "p.##$ 5ubse+uently, >ohnstone "%&&0$ advocated that the education and training of health care wor,ers should include the possibility of wor,ing 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. ;c<night ".99%$ 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. 5ervice systems on the other hand, had hierarchical structures designed to ensure :a few people could control a lot of peopleB to produce goods or services. 5uch

structures ensured uniformity and that goods and services met the same standards. 1ach ,ind of structure has its own "very different$ rationale, ways of wor,ing and communicating, and the two ,inds of system therefore often find it very difficult to engage constructively together. )he central concern identified by ;c<night ".99%$ was that of ensuring people were at the centre and influencing what happens. C0%D K/lthough there is general agreement about the comple* interplay among individual6, family6, organiFational6, and community6level factors as they influence health outcomes, there is still a gap between health promotion research and practice. )he authors suggest that a disGuncture e*ists between the multiple theories and models of health promotion and the practitionerNs need for a more unified set of guidelines for comprehensive planning of programs. C2'D 4.4 5ac- o# Evidence re Community Development 0ntervention 2utcomes KHor the purposes of this review, researchers defined an intervention as an organiFed and planned effort to change individual behavior, community norms or practices, organiFational structure or policies, or environmental conditions.K C03D :Despite the fact that community development approaches have been used by several of the maGor community6based heart health initiatives, evidence of their use and usefulness remains sparse.B C%.D :)he health effects of social interventions have rarely been assessed and are poorly understood. 5tudies are re+uired to identify the possible positive or negative health impacts and the mechanisms for these health impacts. )he assessment of indirect health effects of social interventions draws attention to competing values of health and social GusticeB C#'D :)he Wor,ing Oroup also debated what is meant by KevidenceK in the conte*t of health promotion, with several members arguing that the concept of KevidenceK may in fact be an inappropriate one in this conte*t. !ne of the ,ey arguments for this position is that the concept of Krules of evidenceK in science tends to be related to particular disciplines, and since health promotion is by nature Kmulti6disciplinary,K it is not clear whose rules of evidence it should follow. However, most members of the group felt that it was impractical to ta,e this stance given the fact that relevant policyma,ers, including members of the World Health /ssembly, were demanding Kevidence6basedK health promotion. 5everal members suggested that it would be prudent if, at least for the time being, we accept the use of the term KevidenceK within health promotion. /s suggested by <eith )ones, perhaps the best way to thin, of it is within a Gudicial paradigm= KWe should assemble evidence of success using a ,ind of NGudicial principleN 6 by which I mean providing evidence which leads to a Gury committing CitselfD to ta,e action even when %99T proof is not available.K )his approach has several advantages= it is a concept of KevidenceK 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 +uality and it implies that one must ta,e the Kweight of evidenceK into account. However, this approach does not give us any guidance regarding what evidence is needed in the conte*t of health promotion.K C20D :Health outcomes in populations are the product of three factors= "%$ the siFe of effect of the interventionM ".$ the reach or penetration of an intervention into a population and "0$ the sustainability of the effect."2$. )here are few written accounts of the adoption of community development approaches within the fields of statutory health care, while there is a thriving literature about the community development approach to health ">ones, %&&'$. )his picture is bound to change as the emphasis on adopting community development approaches increases.B C0%D :)here is a well recognised gap between research findings and the implementation of evidence based prevention strategies in community settings ";cOinnis and Hoege, .999$. -esearch should inform community leaders or facilitate using proven intervention strategies in community environments. However, community leaders and health promotion e*perts suggest that a barrier to the adoption of research6based, efficacious interventions is that

these strategies may not meet community needs "Oreen and ;ercer, .99%$. Interventions may be too comple*, difficult or costly to integrate with e*isting activities. Part of the problem may be researchersE attempts to find the most efficacious program rather than a program that could be implemented and delivered with limited resources to many people.B C%D :)he low level of individual participation rates in studies that recruited from a representative targeted population raises +uestions about generalisability.B C%D 0ntervention : 'port , evidence :Despite a comprehensive search for literature relating to the effectiveness of policy interventions implemented through sporting organisations for promoting healthy behaviour change, no evidence in the form of well6designed and evaluated interventions was found. )he ability to provide clear directions or strategies for future health promotion interventions is therefore limited. It is li,ely that these types of interventions are rarely evaluated or published, or that such evaluations are only available through contacting each sporting club, sporting association, health promotion agency or other agencies with a remit for sport "e.g. local councils$. /n internet search identified a number of case studies in this area. )hese included post6data 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. )his will enable practitioners to more readily and the available evidence, and conse+uently, to implement effective interventions. In future, funding for evaluation should be built into sporting programs. However, as noted in the review by Payne "Payne .990$ there is a limited capacity to carry out evaluation in sporting organisations. Payne suggests that academic6based researchers should wor, in partnership with the sport and recreation industry to ensure that sporting programs are evaluated in a useful way. )his may simply involve the introduction of data collection toolsJdatabases in order to evaluate programs in a +uasi6e*perimental manner. Practitioners therefore need to form relationships with the tertiary education sector.B C'D :It is important to recognise that these conclusions are drawn from a wide range of research across many different issues. 1stablishing 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 comple* and multifactorial etiologies and which re+uire long time frames for measurable changes to occur. )his must be ta,en into account in considering the material provided in this report.B C%#D Evidence mental health( healthy eatin.( and physical activity in schools Hindings= )his synthesis identified good +uality systematic reviews that covered mental health, aggressive behaviour, healthy eating, physical activity, substance use and misuse, driver education, and peer approaches. -eviews of programmes that promoted mental health in schools "including preventing violence and aggression$ show these programmes to be among the most effective ones in promoting health. !f these programmes, the ones that were most effective were of long duration and high intensity, and involved the whole school. Iew 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. Hour new reviews of programmes that focused on promoting the prevention of substance use confirmed previous findings that these programmes are relatively ineffective. /lso, 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, peer6delivered health promotion was found to be effective, compared with teacher6led interventions, and this approach was highly valued by the young people involved. )he systematic review, which evaluated health outcomes of programmes that used elements of the health promoting schools approach, included small studies of variable +uality. It found apparent benefits to the social and physical environment of the school, and some studies found the programmes benefited health6related behaviour "dietary inta,e and physical fitness$. Io reviews evaluated the cost effectiveness of the programmes or interventions.B C%&D There is a clear lac- o# comparative data in measurin. e##ectiveness o# di##erent approaches to health promotion.

4.* Di##iculties in de#inin. success or e##ectiveness De#inition o# .oals o# intervention $%hat to measure+ :-each is defined as the percent of potentially eligible individuals who participate in the intervention study, and how representative they are of the target population from which they are drawn. 1fficacyJeffectiveness is the intended positive impact of the intervention and its possible unintended conse+uences on +uality of life and related factors. -each and efficacyJeffectiveness operate at the individual level. /doption is the percent of potential settings and intervention agents that participate in a study and how representative they are of targeted settingsJagents. Implementation refers to the +uantity and +uality of delivery of the interventionEs various components. /doption and implementation are setting6level dimensions. Hinally, the maintenance dimension includes individual6 and setting6level indices. /t the individual level, maintenance is defined as the longer6term efficacyJeffectiveness of an intervention. !utcomes at ( months post6intervention contact reflect longer6term individual maintenance. )he setting level definition of maintenance refers to the institutionalisation of a program and is assessed according to the percent of settings that continue the intervention program, in part or in whole, beyond the study duration "Olasgow et al., %&&&M Olasgow et al., .99%$.B C%D K)here is increasing evidence emerging regarding the effectiveness of community6based inGury prevention programmes. )he use of multiple interventions implemented over a period of time can allow inGury prevention messages to be repeated in different forms and conte*ts and can begin to develop a culture of safety within a community. Important elements of community6based programmes are a long6term strategy, effective and focused leadership, multi6agency collaboration, the use of local surveillance to develop locally appropriate interventions and tailoring interventions to the needs of the community. )ime is also needed to coordinate e*isting networ,s, and to develop new ones. However, a positive and sustained impact of community6based programmes on inGury rates has not yet been demonstrated conclusively. )here is a need to develop valid and reliable indicators of impact and outcome appropriate to community studies. Where pro*y measures are used for inGury outcomes, it is important that there is clear evidence of the association between the pro*y "e.g. haFard removal, ,nowledge gain or behaviour change$ and inGury ris, ")owner et al., %&&(Oo$. )here is also an urgent need to develop and monitor indicators to assess and monitor a culture of safety, programme sustainability and long6term community involvement. Community6based inGury prevention programmes have been hampered by the lac, of resources allocated to both their programme development, and appropriate and rigorous evaluation.K C0(D :Health promoting schools and health promotion in schools= two systematic reviews U 1nsure that process evaluation which describes the way in which programmes have been implemented is underta,en and reported in all studies of health promotion in schools. U Develop valid and reliable measures for evaluating the outcome of the health promoting school initiatives, particularly those measuring mental and social well6being for children and adults. Incorporate these in all studies of health promotion in schools.K C(3D 4.; 'ome e"amples o# 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 lin,s user involvement and commissioning to improve health and reduce ine+ualities. Communities can be geographicalVsuch as particular housing estatesVor communities of interest, such as user groups. )rained community development wor,ers bring local people together to= W identify and support e*isting community networ,s, thus improving healthM W identify health needs, in particular those of marginalised groups and those suffering ine+ualityM W wor, with other relevant agencies, including community groups, to tac,le identified needsM W encourage dialogue with commissioners to develop more accessible and appropriate services.

;any e*amples of these activities e*ist. 5tudies show that community support through social networ,s is protective of peopleEs health. High levels of trust and density of group membership are associated with reduced mortality. Conversely, lac, of control, lac, of self esteem, and poor social support contribute to increased morbidity. Ieeds assessment that is focused on communities can identify solutions as well as problems. -esults of such initiatives include a new post of youth health adviser to support youth centred health activities across practices in 4ewisham, which has led to improved learning about contraception and se*ual health, improved liaison with practices, and changes in practice provision to ma,e services more appropriate for the young people they serve. In 5t PeterEs Ward, a deprived area of Plymouth, a community development approach has resulted in free pregnancy testing in a local community proGect, the setting up of a :parentwiseB proGect that draws on resources within the community, changes in health visitorsE wor,ing, and the provision of more acceptable antenatal classes. )he more involved the community is in needs assessment, the more li,ely changes are to ensue. )hese assessments can provide representative views, particularly if +uantitative approaches are used to triangulate these views, and there is little evidence that patients ma,e unreasonable demands. Community development can also lessen the impact of poverty on health. In )or+uay concern about nutrition has led to the setting up of a food cooperative managed by local people that ma,es available cheap, healthy food. Community development can reduce social e*clusion by ensuring that marginalised groups influence health services. In @radford such an approach increased the upta,e of cervical and breast screening among women from ethnic minorities. ;inority ethnic communities, disabled people, adolescents, and elderly people have all been involved in the commissioning process in Iewcastle, where a community development wor,er, accountable to the community, brings together community groups with purchasers and providers to implement change. 1*amples of community development interagency activity include the wor, of a safety group in )or+uay 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 4ewisham, a community development solution was found through a new bus service. @y 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 e*ercise tolerance.K C(%D !. 2utcomes o# Community,based Participatory 9esearch 0mproved 9esearch <uality 2utcomes When the 1PC researchers loo,ed at the influence of community involvement on the +uality of interventional studies, they discovered %% of the %. completed intervention studies had reported enhanced intervention +uality. >ust two studies reported improved outcomes, while eight noted enhanced recruitment efforts, four reported improved research methods and dissemination, and three described improved descriptive measures. Xery little evidence of diminished research +uality resulting from C@P- was reported. Community and 9esearch Capacity !f the (9 studies reviewed, 23 reported improved community involvement, including additional grant funding and Gob creation, as an outcome associated with the study. )he authorsVtypically academicsVgenerally focused on the increased capacity of the participant community, rather than that of the research community. Health 2utcomes /mong the %. 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, immuniFation rates, and safer se* behavior$. Hinally, three studies measured the impact of the intervention on emotional support, empowerment, and employee well6being.

Oiven the highly varied health outcomes, measurement strategies, and intervention approaches used, the 1PC researchers were unable to perform a direct comparison of studies and their relative impact on health outcomes. ;oreover, an absence of cost6 effectiveness data precluded any comparison of outcomes from C@P- studies and those of more traditional research studies. 5evel o# Community 0nvolvement Community involvement varied in different stages of the research. )here was strong involvement in recruiting study participants, designing and implementing the intervention, and interpreting findings. ;any authors argued that community involvement "especially in theses areas$ leads to= Oreater participation rates. Increased e*ternal validity. Decreased loss of follow up. Increased individual and community capacity. )he disadvantages of community involvement were not fre+uently reported, but they may include= )he introduction of selection bias "bias in recruitment$. Decreased "and sometimes an absence of$ randomiFation. )he potential selection of highly motivated intervention groups not representative of the broader population. C03D

/. =ood Practice : ental Health Hrom mid >uly %&&' to the end of ;ay %&&&, /useinet 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. )he aim was to give the agencies the opportunity to build their capacity by developing a range of tailored, potentially sustainable strategies. /ll agencies made %or-#orce development the foundation of their reorientation process. /s most of the agencies were not primarily mental health focused, enhancing the mental health literacy of staff was a vital first step in reorientation. )hey informed staff about the mental health issues faced by the young people who used their service, gave them the s,ills to recognise ris, factors and early warning signs, and established procedures for appropriate referral. )he training programs were documented to guide future training needs and to provide resources for staff. /ll of the proGects showed evidence of or.anisational development. ;anagement support was demonstrated by the formation of steering committees, reference groups and umbrella groups. Policy development occurred within as well as between agencies. !ne proGect developed an early intervention policy outlining referral and support mechanisms and others developed recommendations for incorporating early intervention into new policies. )wo proGects developed formal interagency agreements and policies. )he development of partnerships was one of the most successful aspects of the reorientation proGects. ;ost of the agencies established new networ,s or strengthened e*isting ones by including guest spea,ers and staff from other agencies in their training programs. 5everal of the proGects developed successful formal partnerships. )wo of the larger proGects were collaborations between influential agencies and had the resources to allow the proGects to e*pand beyond their original scope. /ll of the agencies allocated resources to the proGects and several of the larger agencies contributed additional funds to employ the reorientation officer full6time. /fter /useinet funding had ceased, most of the agencies had allocated funds to sustain or e*pand the reorientation process or to ta,e it in a new direction. C.D ;ost agencies had sustained or e*panded their early intervention activities two and a half years after the reorientation proGect. )he e*tent of reorientation ranged from conceptual shifts in staff ,nowledge and increased awareness and identification of mental health problems,

through to e*tensive 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 proGects were conducted, the agencies were better able to detect mental health problems and target referrals, there was an increase in mental health awareness and literacy within the organisation and in the community, and increased support from the community. !ne agency noted that while the strategies developed in the reorientation proGect had not been sustained, the proGect had led to different ways of implementing early intervention activities and subse+uent success with other proGects. )he remaining two proGects noted a mar,ed change in early intervention ways of thin,ing and referrals although they did not have the resources to continue concrete proGects. 5everal of the agencies reported that the reorientation proGect had given them the confidence to underta,e other proGects or apply for further funding. ;ost of the agencies considered that the reorientation proGects served as a useful platform from which to either begin or e*pand early intervention activities. C.D 7arriers 'ta## over%or-ed> :;ost of the reorientation officers thought that the resources allocated to the proGect were insufficient and that they had insufficient time in which to achieve the obGectives of the proGect. 5everal of the reorientation officers in the non6government agencies especially found their wor,load demanding because they were employed on a half6time basis. 5ome of the staff were initially reluctant to be involved in the reorientation proGects because of their already heavy wor,loads. Oenerally, as staff became involved in the training they became more enthusiastic about the proGect and prioritised their time to enable greater involvement. C.D 'ustainable 3undin. :;any of the barriers identified in the original reorientation proGects are still evident. High staff turnover rates are a reality in many agenciesM therefore time and resources need to be devoted to training new staff in early intervention. )he heavy wor,loads of staff remained an issue, although some of the agencies developed strategies to reframe rather than add to e*isting wor,loads. ;ost of the agencies felt that the sustainability of the proGects was largely dependent on funding. 5eed funding was perceived as being useful for platform activities, but all identified the mar,ed need for more funding to sustain and e*pand early intervention activities. ;any of the agencies reported that their involvement in the /useinet proGect had helped them to secure funding from other sources. C.D Iew barriers were identified at follow6up, when many of the agencies were applying early intervention approaches directly with clients. They o#ten #ound it di##icult to re#er clients %ith early si.ns o# mental health problems to mental health services because the latter typically #unction #rom a crisis intervention model . In addition, mental health services already have high demands on their services and are often not able to ta,e on new referrals. C.D 4. Wor-place E"ample @eyond the organisation participating in the present study, it is hoped that individuals and groups involved in wor,place health promotion can use the findings to help overcome two of the ,ey barriers to adopting the health promoting settings approach. )hese barriers are= "i$ a lac, of information on the relationship between wor, characteristics and employee healthM and "ii$ not having the confidence or ,nowledge to identify and address organiFational6level issues. @oth +ualitative and +uantitative methods were employed in the audit, and the results revealed that there was a close relationship between several wor, characteristics and employee well6being. Wor,based support, Gob control and time6related pressures were identified as three wor, characteristics that offer valuable opportunities for boosting the health6promoting value of the organiFation participating in the present study. C0D *. Plenty o# e"amples o# lar.e company %or-place health promotion %orld %ide ;odel of good practice= )he 5hanghai ProGect 5hanghai is the largest industrial city in China, with a population of over %0.# million people. In collaboration with WH!, and supported by the Oovernment of the PeopleEs -epublic of China, the 5hanghai ;unicipal Health @ureau and

the 5hanghai Health 1ducation Institute conducted a pilot wor,place health6promotion proGect from %&&0 to %&&#. )he proGect involved .% (%0 wor,ers in four wor,places= WuGing Chemical Comple*, 5hanghai Hudong 5hipyard, 5hanghai Io. 02 Cotton ;ill and 5hanghai @aoshan 5teel Company. @ased on data gathered through a baseline survey conducted in early %&&0, and guided by members of the 5hanghai Health 1ducation Institute and an occupational health e*pert advisory reference group, each wor,place developed, implemented and evaluated wor,place health6promotion programs. )he proGect adopted an integrative model of wor,place health promotion and sought to address identified organisational, environmental and behavioural factors that were negatively impacting upon the health of the wor,ers. Health6promotion programs employed multiple strategies in line with the !ttawa Charter and sought to develop healthy policies and regulations, create safe and supportive environments, strengthen preventive health services, facilitate wor,ersE participation and educate wor,ers to promote healthy behaviour. Initiatives underta,en included the establishment of health education and health6promotion committees, drafting and implementing wor,place standards for identified occupational haFards, improved management of wor,place sanitation and hygiene, and improved occupational health haFard monitoring and control "e.g. noise, dust and chemical lea,age$. !ther initiatives included the supply of nutritious foodstuffs and the reduction of salt in food in wor,place canteens, planting trees and flowers, cigarette smo,ing and alcohol cessation programs, cervical screening and thorough follow6up treatments, improved preventive health services for wor,ers, and greater wor,er participation in the identification and control of occupational haFards. During the proGect, particular attention was given to such issues as staff mobiliFation and training, establishing co6ordinating and networ,ing mechanisms, and regular consultation with wor,ers, management and e*pert reference groups. )hese measures ensured that all interested parties were involved in the planning of the proGect and that they were given opportunities to participate in its implementation. Hurthermore, there was an emphasis on multi6sectoral involvement and the integration of health promotion into management practices. )he proGect was closely monitored, and an evaluation carried out in %&&# showed e*cellent measurable outcomes, e.g.= L reduced incidence of wor,6related inGuries by %9 .9TM L reduced diseases and related health care costs "e.g. pharyngitis, from %(T to %9T$M L improved health and safety ,nowledge and practices "the use of safety devices or protective e+uipment increased from .9 09T to 39 &9T$M L reduced ris, behaviour "reduction of salt consumption, cigarette smo,ing$M L reduced levels of sic, leave by #9T. !ther notable proGect achievements included= improved company image and management practices, a cleaner and safer wor,place environment and wor, conditions, increased housing provision, recreation facilities and even transport in the case of the Hudong shipyard. 4earning from this pilot proGect, the proGect team has since developed what they have proudly called the R5hanghai ;odelE of wor,place health promotion. )he modelEs four distinctive features are= comprehensive, integrative, a system of management and multi6sectoral networ,s, and a multiplicity of intervention strategies. 5ince then, the 5hanghai ProGect team has developed draft Chinese language guidelines for wor,place health promotion, and has been funded by the World @an, to wor, with %9 more wor,places. 5uccessful factors for wor,place health promotion= /ction and criteria models currently available point uniformly to the following factors as ,ey indicators of a successful wor,place healthpromotion initiative. Participation: all sta## must be involved in all phases . C.&D ;. 5ee Iote %#. Public Health Division, Department of Human 5ervices, ;elbourne, Xictoria, /ustralia

Health Promotion 5trategies for Community Health 5ervices. /n 1vidence6@ased Planning Hramewor, for Iutrition, Physical /ctivity, and Healthy Weight ebpfYnutrition.pdf 4ots of e*amples of ?utrition( Physical Activity( and Healthy Pro@ects A. ?utrition: E##ective Components #or ?utrition 0nterventions , 'ummary In December of %&&&, the Prevention Anit within the Division of Preventive !ncology at Cancer Care !ntario commissioned a review of international literature on nutrition interventions, in the areas of policy, programs and media. )he purpose of the review, which included literature from >anuary %&&#6>anuary .999, was to consolidate e*isting ,nowledge of nutrition intervention effectiveness in order to inform the development of a nutrition and healthy body weight strategy for cancer prevention for the province. Hifteen interventions studies were included in the review, %9 of which reported positive outcomes, and # reporting negative outcomes, in well6designed studies "i.e. controlled trials with or without randomiFation$. /mong those reporting positive outcomes, five components were common= %L theoretically based "5orenson, OlanF, Perry, 4i+uori, Iic,las, Horester$ .L Involvement of the family as a source of supportM "5orenson, OlanF, 4i+uori, Perry, Coates, Havas$ 0L Ase of participatory models for planning and implementing interventionsM "Perry, 4i+uori, Havas, Iic,las, 5orenson, OlanF$ 2L Provision of clear messages for media campaignsM "!wen, -eger, Iorum$ #L Provision of ade+uate training and support to intervenors "@eresford, Perry, 4i+uori, Havas, Horester$ / number of lessons were learned by those reporting negative study outcomes including= %L 1nsuring sufficient intensity and duration of the intervention to bring about change and behaviour maintenance. -epeated and on6going contact is necessary throughout the intervention including post follow6up "Olasgow, -esnicow, <ristal, >effrey$ .L ;a,ing environments conducive to support behaviour change, in particular modification of food service policies for wor,sites and schools "Olasgow, -esnicow$ 0L Ensurin. particpatory mechanisms for planning, such as steering committees and, "Olasgow, -esnicow$ 2L Delivering school6based interventions either before the school day begins or during school hoursM afterhours results in lower attendance "-esnicow$ Intervention settings, such as schools, wor,places "5orenson, OlanF$ and health care institutions, offered prime channels to employ these principles, especially when developing and implementing interventions for large groups of people. Community settings wor, well for women whose learning is enhanced by a family friendly atmosphere. )he review suggests that these settings should be regarded as ideal places to focus a nutrition intervention strategy within !ntario. )he principles derived from this review e+uipped Cancer Care !ntario with the information necessary to develop a nutrition and healthy body weight strategy for the province of !ntario. )his included establishing a reference group ",nown as the !ntario Collaborative Oroup on Diet and Cancer$ with a mandate to lin, practitioners in the areas of policy, community and public health programs and research and use them as a reference group. )he Anit too, the lead in developing a program logic model for the overall strategy "with guidance from the Collaborative Oroup$ and invested in developing a behavioural change pilot proGect K)a,e #K to increase vegetable and fruit consumption among women with children under the age of %2, based on sta,eholder feedbac,, and is currently being piloted. C%3D B. 'ee ?ote !/ C'tories that can chan.e your li#e: communities health ine8ualitiesD $HealthE0ne8ualities.pd#+ 5ots o# =ood Practice E"amples and =reat <uotes #rom 5outhampton City PC) AGala Health ProGect, ;iddlesbrough PC) Hootball Community ProGect, @lyth Xalley Hood Cooperative 4imited, )he Hoyer Hederation and health proGects, -otherham PC) Healthy

Hearts ProGect, 1asington PC) transport initiative, Iorthamptonshire Heartlands PC) !lder Persons Health Horum, )hurroc, PC) Community ;others, 5lough PC) Health /ctivists ). Community development at strate.ic level In the ne*t few paragraphs, actual e*amples of the adoption of a community development approach in relation to health are documented. Crai.avon and 7anbrid.e Community Health and 'ocial 'ervices Trust /t 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 re6arrangements are slower to gain ground. )he Craigavon and @anbridge Community Health and 5ocial 5ervices )rust in Iorthern Ireland is an e*ceptional e*ample of a Health 5ervice )rust which has accepted that community development has to inform its whole approach. "5HH, .99%cM ;c5hane and !EIeill, %&&&$ )he )rust accepted the contribution of community development to the core business of Health and 5ocial 5ervices by mainstreaming this approach across all its programmes of care. )he importance of increasing community development awareness and s,ills for other managers and staff was also recognised and the )rust was actively committed to a training strategy. It viewed this as a core feature of implementing the OovernmentEs strategy on social inclusion, social Gustice and partnerships for health and wellbeing. )he )rustEs Community Development Anit has actively wor,ed with different community groups, ensuring that broader aspects of health are highlighted. Hor instance, a -apid Participatory /ppraisal was conducted bringing together various parties such as nursing, community wor,, social wor, staff and local people. )his enabled issues to do with housing, the local economy and community infrastructure to be included and wor,ed at to improve the wellbeing of the community. The Addie%ell Pro@ect !ne e*ample of local communities becoming involved in setting the agenda around health was that of the /ddiewell )as, Oroup "/ddiewell -esearch ProGect, .999$. In a Goint initiative between local residents, West 4othian Council and the Aniversity of 1dinburgh, the /ddiewell )as, Oroup developed indicators and measures to do with health and wellbeing that were seen as important by the community. )he Health Anit based within the local Council wor,ed alongside local people to ensure their participation in the identification, definition and proposals for measuring health indicators. )he wor, was founded on the principle that the best people to decide what issues and indicators were important were local people themselves. Wor-in. to.ether: 5earnin. to.ether / two year training programme, Wor,ing )ogether= 4earning )ogether, was set up as part of the 5cottish 1*ecutiveEs R4istening to CommunitiesE programme, to provide training in understanding social e*clusion, partnerships and Wor,ing for Communities Pathfinders in 5cotland. )he programme aims to ensure that communities are involved in :genuine, meaningful partnership where they can e*ert real influenceB "Wor,ing )ogether= 4earning )ogether website 6,$. )here are (9 partnerships and &99 people participating in training from agencies and communities led by a consortium of organisations including the 5cottish Community Development Centre, Community 4earning 5cotland, the 5cottish Council for Xoluntary !rganisations, the Poverty /lliance, and the Aniversity of Dundee. C0%D 1F. ?utrition: Database o# 0nternational ?utrition 0nterventions Includes Intervention ;ethodology, 1valuation ;ethod, 8 Impact /chieved K%9. Iutrition education 5eptember, .990 %9.% Oeneral community nutrition programmes %9.. ;ass media nutrition education %9.0 5chool6based nutrition educationK,J%nutrition.htm C02D 11. Database o# 'chool,based interventions Includes Intervention ;ethodology, 1valuation ;ethod, 8 Impact /chieved KInterventions using schools 5eptember .990K,J%schools.htm 1!. 0llicit dru.s: e##ective prevention re8uires a health promotion approach K)here is an emerging evidence base for interventions that tac,le particular ris, and protective factors. In the A5/, for e*ample, the ;idwestern Prevention ProGect, conducted by PentF and co6wor,ers, e*amined the effectiveness and replicability of a multi6component, community6 based drug misuse prevention programme. )he study loo,ed at the effectiveness of school interventions in the conte*t of broader community mobiliFation strategies. 5ignificant reductions in tobacco and cannabis use occurred amongst students followed up at Pears & and %9. However, training for community leaders and the use of mass media was less effective when not teamed with school6based and parenting programmes. /nother A5 study, ProGect Iorthland, led by Perry and colleagues, used similar school6 and community6based approaches to reduce alcohol and other drug use in Iorth West ;innesota. )he research found statistically significant reductions in drug use, changed peer norms and improved parent child communication. )he case can be made from both of these studies for whole6community approaches that complement individual6focused interventions. )he Oatehouse proGect in /ustralia aims to reduce the rates of depression and self6harm amongst young people. )his school6based 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 trustM "ii$ enhancing s,ills and opportunities for good communicationM and "iii$ building a sense of positive regard through valued participation in aspects of school life. Drawing on the !ttawa Charter framewor,, the proGect aims to create a healthy environment rather than concentrating on individuals. /lthough still at an early stage, the proGect has already demonstrated a reduction in the rate of smo,ing in intervention schools compared with non6intervention schools. When people become socially disconnected they may see, comfort and a sense of security through drug use, and find support and ready acceptance from other drug users. In the A<, particular emphasis has been placed on structural issues that e*acerbate this problem, such as poor housing, low income, unemployment, poor education and high crime environments. Prime ;inister )ony @lair has set up a 5ocial 1*clusion Anit within the Cabinet !ffice to focus on ,ey points of transition when young people are at greatest ris, of becoming e*cluded and marginaliFed. /ction is centred on truancy, homelessness, neighbourhood renewal, teenage pregnancy, and opportunities for young people not in education, employment or training. 5uch RGoined up solutions to Goined up problemsE are very much at the centre of the !ttawa CharterNs healthy public policy domain. In /ustralia, the Centre for /dolescent Health has recently completed a report on evidence6 based approaches to promoting adolescent health. )he wor, reviewed %3' research articles and assigned weightings to signify the confidence with which programmes can be implemented. )he Rbest buysE comprise a broad set of health promotion approaches, including health promoting schools, social mar,eting, peer intervention, parent support and community strengthening. )he Xictorian government, upon the advice of its Drug Policy 1*pert Committee, has endorsed these approaches and has announced that substantial funding, representing at least %9T of the total drug budget, will be allocated to prevention. 5trategies are li,ely to include the following elements.K C0'D 1/. Community,based research: creatin. evidence,based practice #or health and social chan.e KIn the following section, three e*amples of community6based research are provided to demonstrate how community6based research generates evidence from practice. Games 7ay idli#e Pro@ect $Hills( ullett and 7ur.ess( in pro.ress $. )his proGect was generated by a local community health centre in order to create a program for women that would ma*imiFe their participation in and control of ma,ing health decision in their midlife. )he in+uiry group consists of two university researchers from the Community Health Promotion Coalition, Aniversity of Xictoria "the authors of this paper$, program

planners and staff from the >ames Community Health ProGect, and women of the community, including a physician, a homeopath, a naturopathic physician, an editor, teachers, counsellors and social wor,ers. )his group is in the process of generating evidence about ways of being that are Kwomen6centredK. )he group is e*ploring women6centred care in several different conte*ts such as education programs, support groups, physicianJclient interactions and informal groups. )o date it has used a critical incident method to collect accounts from group membersE own e*periences about what constitutes women centred care in midlife. ;embers subse+uently conducted interviews, held focus groups or collected narrative accounts of their practice. )he data is being analyFed, considered in light of former ,nowledge and new methods are being chosen to generate further evidence about how to practice in a way that is women6centred. a-in. Connections: ?urturin. Adolescent =irlsH 'tren.ths $7annister( in process+ )his community based research proGect, funded by the @ritish Columbia Health -esearch Houndation "@CH-H$, 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. 1ffective relationships were viewed as the focal point for building self6esteem and enhancing health. / participatory action research "P/-$ framewor, is being used to understand adolescent girlsN "ages %26%&$ e*periences of relationships and to facilitate action. Hour groups of girls, each of which has direct lin,s to an advisory committee, have been meeting wee,ly for %' wee,s. )he advisory committee serves as a forum for the girls to present their health related concerns and to generate further action. )he adolescent girls are involved in analyFing the data. )he girls report that they are learning new ways of interacting, thereby enhancing their ability to handle relationships. In year two of the proGect, it is intended that the girls will use their learning and reflections to create action to influence policy6ma,ers and practitioners who are wor,ing with adolescent girls. 'harin. 9esources To Alleviate 'carce 9esources 5everal non profit organisations as,ed a researcher to wor, with them because of their concern about current funding structures that have created a competitive situation for non6 profit agencies in the community 6 agencies that previously had wor,ed together to resolve issues in order to sustain a healthy community. )he methodology of co6operative in+uiry "Heron, %&&(M -eason, %&''$ is being used to develop a model of inter6agency collaboration, a transformative model for practice that will afford community agencies the ability to evolve together within new funding conte*ts. / critical incident techni+ue was the initial method by which the current successful and unsuccessful collaborative relationships were e*amined. @y reflecting on their current practice, the members of the in+uiry 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. )heir emergent model, which is based on the e*periential, representational, propositional and practical ,nowledge of those engaged in living the model, is significantly different from theoretical models, which tend to be reduced to administrative models.K C0&D 14. Health Education 7oard #or 'cotland: Health promotion pro@ects: mental health KHealth promotion proGects listK,JtopicsJmentalhealthJmentproGect.cfm C22D 1*. ental Health Promotion K)he Iational 5ervice Hramewor, 5tandard !ne= ;ental Health Promotion Ouidance Hor Oood PracticeK,JlibraryJregionalpapersJdeliveryofstandardonecontinuation(.ht m C2#D 1;. Health Education 7oard #or 'cotland publication section: Community development approaches in primary care: options #or obesity mana.ement KCommunity development approaches in primary care= options for obesity managementK,JtopicsJtopicsection.cfm? topicZdiet8)*t)CodeZ09.8)*t5IoZ%#8)/ZtopictitlesT(9 C23D

1A. The 3ood Trust: 0mprovin. health( promotin. .ood nutrition( increasin. access to nutritious #ood and advocatin. better public policy K@uilding 5trong Communities )hrough Healthy Hood )he Hood )rustNs mission is to ensure that everyone has access to affordable, nutritious food. Hounded in %&&., the )rust wor,s to improve the health of children and adults, promote good nutrition, increase access to nutritious foods, and advocate for better public policy.K In ,eeping with its organiFational mission, )he Hood )rust evaluates the success of its programs and initiatives by its effectiveness in= Improving communitiesN access to affordable and healthy fresh foodsM Increasing awareness among at6ris, consumers of the value of proper nutrition and its relation to individual healthM and 1ffecting positive behavioral change among children and adults, as relates to healthy eating habits.

http=JJwww.thefoodtrust.orgJ C2&D 1B. Healthy livin. : The Department o# Health: Health topics: Healthy livin. KHealthy living= Promoting healthy lifestyles for people in 1ngland and Wales is an important governmental responsibility. DH runs initiatives to help people +uit smo,ing, eat better and e*ercise more, as well as health screening proGects and training and s,ills programmes.K,JPolicy/ndOuidanceJHealth/nd5ocialCare)opicsJHealthy4ivingJfsJen C#(D 1). Community development and its impact on health: 'outh Asian e"perience ,, Hossain et al. /!B $A44/+: B/F ,, 7 G KCommunity development and its impact on health= 5outh /sian e*perienceK http=JJbmG.bmGGournals.comJcgiJcontentJfullJ0.'J3220J'09 C(0D !F. Welcome to ?atPaCT KWhere PC)s grow by sharing information, e*periences, and achievements.K http=JJwww.natpact.nhs.u,J C(#D *. Any Community Development Approaches to Health Promotion must have the #ollo%in. elements Process( Community,based Participatory 9esearch( Capacity 7uildin. The Community =uide , A 9esource #or Public Health Pro#essionals 'tep 1: Assess the primary health issues in your community <evin 5heridan "<5$= How do you do this? "%$ Collect Data. ".$ Carry out +ualitative and +uantitative research as, community members what the primary health issues are? /lso as, health service providers what they are? Do these coincide or not? How do you collect this research in an increasingly cynical or over6consulted environment? @y forming a partnership with community organisations in the research area who can reach target groups. /ny partnership should be e+ual all partners to consensually set agenda for research. )rain community members to carry out fieldwor,. "0$ !n basis of this research, partners "which could include health service providers$ can decide on interventions. 7uestions to be as,ed should include :how would it be easier for you to change your lifestyle or get involved in changing your lifestyle?B, :how would it be easier for you to receive communications on the issues?B Community feedbac, should be built into any research process. "2$ 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 ,nowledge, and to address any gaps in capacity at the earliest stage. "#$ /nother point to consider is who initiates all this obviously the focus of the wor, has been set in the first instance by the funders, and then perhaps by the recipients of the funds. / general call out to community organisations to suggest research and intervention proGects would be useful, and if this does not produce, a more proactive engagement with community organisations will be needed. !r else, either the academic researchers, fund6recipients, or health service providers, or a combination in partnership, will need to identify geographical andJor focus groups to be approached to ta,e the proGect forward. "($ / funding pool for interventions will need to be established early, allocating a notional amount for each possible interventions, to include research, implementation, training 8 capacity building, evaluation, and costs of administering any partnership. "3$ Hunding for interventions should be sustainable not short6term. 'tep !: Develop measurable ob@ectives to assess pro.ress in addressin. these health issues <5= It is essential from the beginning to have an understanding about how success or effectiveness of any chosen interventions will be measured or evaluated. 1valuation should be built into the process and funding from the outset. 'tep /: 'elect e##ective interventions to help achieve these ob@ectives 'tep 4: 0mplement the selected interventions 'tep *: Evaluate the selected interventions <5= It would be useful to develop a cross6referenced internet resource of good practice. Clear headings and navigation will have to be established. C#3D Community,based research I any o# the .uidelines #or Community,based 9esearch can also be applied to Community Development itsel#. Community,based research: creatin. evidence,based practice #or health and social chan.e Definition and Principles of Community6@ased -esearch Community6based research is becoming increasingly important in the health care field as communities are being re+uired to ta,e greater ownership and control over decisions affecting the health of the people in the communities. Community6based research is first and foremost about people. C29D Community6based research is a collaboration between community groups and researchers for the purpose of creating new ,nowledge or understanding about a practical community issue in order to bring about change. )he issue is generated by the community and community members participate in all aspects of the research process. Community6based research therefore is collaborative, participatory, empowering, systematic and transformative. C29D Community,based research is .uided and de#ined by the #ollo%in. set o# principles =

Community-!ased "esearch is a Planned Systematic Process = Community6based research is a systematic process re+uiring careful planning of each stage. ;ost community wor,ers begin researching by as,ing +uestions about their programs, the needs of their clients, the effectiveness of their wor,, whether new ideas are feasible, possible solutions to e*isting community problems, and so on. )hese issues become community6based research by formaliFing the community issue into a researchable +uestion and systematically planning for KdataK collection and analysis. )his formaliFed research process creates new ,nowledge upon which to base practice. It is the focus on ,nowledge development that distinguishes community6based research from community development.

Community-!ased "esearch is "elevant to the Community = Community6based research must have a high degree of relevance to the community. Community6based research focuses the research endeavour in the conte*t of daily wor, activities in order to solve problems and help ma,e those activities more effective and ultimately more satisfying. )he research should result in decision6ma,ing 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 as#ing $uestions such as = What are the practical problems we are facing in our wor, in the community? What are some +uestions and concerns regarding the community and health6related activities within that community? What issues are the focus of community attention? 7uestions such as these guide the selection of meaningful research topics and provide for the development of appropriate research +uestions for community6based research. Community-!ased "esearch "e$uires Community Involvement = In community6based research, the community is actively involved in and understands the research process. )he research is driven by a partnership between the community and researchers, and tends to be multi6disciplinary in nature. It is a collaborative effort involving the community at all stages of the research process. )he level of community andJor researcher involvement may vary at each stage of the research, but community6based research involves Goint responsibility and decision6ma,ing during every step. It re+uires the researcher"s$ and the community sta,eholders to share power and control of decision6ma,ing throughout the process. In a community6based research process, the distinction between the researcher and the researched may be minimiFed or eliminated. -ather than viewing participants as ma,ing Ke+ualK contributions, in the sense of doing the same thing, community6based research emphasiFes the uni+ue strengths and contributions of the participants. It goes beyond respect and trust for the person and includes valuing the wor, and perspectives of each participant. It is a synergistic alliance that ma*imiFes the contributions of each participant and it focuses on shared responsibility for the research and research process. Community-!ased "esearch Has a Problem-Solving %ocus = 1ffective community6 based research is usually designed to illuminate and solve practical problems. )his problem6solving focus means that the research deals with a problem or practical issue which has been identified by the community as being important to the lifeJhealth of that community. )he primary obGective is fre+uently to guide decision6ma,ing, so effective community6based research focuses on gains to the community through both the results and the research process itself. It focuses on change by creating solutions for e*isting problems and identifying future actions and policies that will most li,ely contribute to the health of the community. Community-!ased "esearch %ocuses on Societal Change = Anli,e conventional orthodo* research which focuses on prediction or understanding alone, community6 based research see,s to bring about change. It is premised on the fact that engaging in a participatory, collaborative research process, and being involved the decision6 ma,ing about that process is empowering and transforming. 1ngagement in the process allows people to develop new ways of thin,ing, behaving and practising. Community-!ased "esearch is bout Sustainability = With orthodo* research and many forms of +ualitative research, as the research ends, so too does the proGect. Community based research ma,es a lasting contribution to the community. )his may be in the form of a new program that is ongoing, or a new service that is delivered. /t times products such as manuals or wor,boo,s may be created. !ne of the most significant contributions is the enhanced capacity of the community to continue to engage in future research or evaluation. )he ac+uisition of new s,ills and ,nowledge related to research and evaluation is an essential component of community6based research.

)hese principles distinguish community6based research from other more orthodo* forms of research including other forms of community research that are done in or for communities. In

addition, these ,ey principles situate community6based research in a different paradigm than orthodo* research and determine, to a large e*tent, what methodologies and methods are used. C29D ;ore <ey points J=oodK user and public involvement has the #ollo%in. -ey elements = L Involvement becomes a core activity, not an add on or a Rtop downE approach. L / strategic approach is adopted across the whole organisation with strong leadership from senior management. L )here is community and organisational development 6 citiFens need to become more informed and e*perienced, but organisational systems and practices also need to change. L Partnerships are formed with other local agencies, for e*ample, 5ocial Inclusion Partnerships and 4ocal /uthorities, to ensure coordination and cost efficiency. L Io single approach or techni+ue constitutes involvement of users and public. L Xarious techni+ues can be used, which must be chosen according to the purpose of the initiative. L )he resource implications of involvement are ac,nowledged 6 for e*ample, training, venues, cr[che facilities etc. L )angible gains from participating can be identified and these can be demonstrated and communicated. L Communication mechanisms are set up to ensure regular feedbac, in accessible formats. L Involvement strategies need to be evaluated and constantly reviewed as part of a dynamic process of continuous learning. C0%D Health 5ervice providers also need capacity building= KWe recogniFed that CC@ could only be effective if our own organiFation, D)H-, 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 wor,. We were obliged, to use ;adine vanderPlaatEs insightful phrase, to :turn the evaluative gaFe inwardB.K C00D Participatory research approaches :With many of the methods discussed in the previous 5ection, control of the process is still invested in the authority or organisation. RParticipatory researchE approaches grew out of dissatisfaction with traditional power relationships between RresearcherE and RresearchedE and a demand from disabled people in particular, for more empowering models "!liver %&&($. C0%D Community development wor,ers in countries in 5outh /merica, /frica and /sia pioneered participatory approaches in the early %&'9s ">ones and >ones, .99.$. In contrast to traditional research, Rparticipatory researchE 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. )he philosophy underlying such approaches is that in order to provide anti6oppressive research fulfilling a social Gustice agenda, it is fundamental that the views, perceptions, direct e*periences and definitions of ,nowledge held by people on the receiving end of services are ta,en account of, valued and acted upon "@randon, .99%$. C0%D )he main purpose of participatory approaches was to raise awareness and ensure that those affected by the research retained control over the whole process from the start. /s !liver "%&&.$ argued in relation to disability research, research should not be understood as a set of technical obGective procedures carried out by professionals but :part of the struggle by disabled people to challenge the oppression they currently e*perience in their livesB. )he research +uestion 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. )he degree of user involvement could be affected by a number of barriers including discriminatory attitudes, access barriers, issues around resources and representativeness "@randon, .99%$. Ievertheless, there is now evidence of research and evaluation being carried out by users and user organisations "@eresford, .999$. People with learning disabilities for e*ample, have been involved as originators of research ideas, advisers and consultants to research proGects as well as

interviewers and analysers of research findings. 1*amples such as the e*perience of the Pilton Health ProGect serve to confirm that the way issues are defined, articulated and tac,led have a direct bearing upon the levels and +uality of participation and the importance of this approach ">ones, %&&'$. C0%D 7uilds on stren.ths and resources %ithin the community. Community based participatory research see,s to identify and build on strengths, resources, and relationships that e*ist within communities of identity to address their shared health concerns. )hese may include individual s,ills and assets 6 sometimes called human capitalM networ,s of relationships characterised by trust, cooperation and mutual commitment 6 sometimes called social capitalM and mediating structures within the community such as churches and other organisations where community members come together. Community6 based participatory research e*plicitly recognises and see,s to support or e*pand social structures and social processes that contribute to the ability of community members to wor, together to improve health, and to build on the resources available to community members within those social structures. 3acilitates collaborative( e8uitable involvement o# all partners in all phases o# the research. Community6based participatory research involves a collaborative partnership in which all parties participate as e+ual 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 s,ills and resources available from outside the immediate community of identity. )hus, C@P- efforts often involve individuals and groups who are not members of the community of identity, including representatives from health and human service organiFations, academia, community6based organiFations, and the community6at6large. )hese partnerships focus on issues and concerns identified by community members, and wor, to create processes that enable all parties to participate and share influence in the research and associated change efforts. 0nte.rates -no%led.e and action #or mutual bene#it o# all partners. Community6based participatory research see,s to build a broad body of ,nowledge related to health and well6being while also integrating that ,nowledge 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 ta,en. C@P- 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,learnin. and empo%erin. process that attends to social ine8ualities . Community6based participatory research is a co6learning and empowering process that facilitates the reciprocal transfer of ,nowledge, s,ills, capacity, and power. Hor e*ample, researchers learn from the ,nowledge and :local theoriesB of community members, and community members ac+uire further s,ills in how to conduct research. Hurthermore, recognising that socially and economically marginalised communities often have not had the power to name or define their own e*perience, researchers involved with C@P- ac,nowledge the ine+ualities between themselves and community participants, and the ways that ine+ualities among community members may shape their participation and influence in collective research and action. /ttempts to address these ine+ualities involve e*plicit attention to the ,nowledge of community members, and an emphasis on sharing information, decision6 ma,ing power, resources, and support among members of the partnership. 0nvolves a cyclical and iterative process. Community6based 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 ta,ing "as appropriate$, specification of learnings, and establishment of mechanisms for sustainability.

Addresses health #rom both positive and ecolo.ical perspectives . Community6based participatory research addresses the concept of health from a positive model that emphasises physical, mental, and social well6being "WH! %&2($. 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 #indin.s and -no%led.e .ained to all partners . Community based participatory research see,s to disseminate findings and ,nowledge gained to all partners involved, in language that is understandable and respectful, and :where ownership of ,nowledge is ac,nowledgedB. )he ongoing feedbac, of data and use of results to inform action are integral to this approach. )his dissemination principle also includes researchers consulting with participants prior to submission of any materials for publication, ac,nowledging the contributions of participants and, as appropriate, developing co6authored publications. 0nvolves a lon.,term commitment by all partners. Oiven the emphasis in community6based 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, C@P- re+uires a long6term commitment by all the partners involved. 1stablishing trust and the s,ills and infrastructure needed for conducting research and creating comprehensive approaches to community change necessitates a long time frame. Hurthermore, communities need to be assured that outside researchers are committed to the community for the long haul, after initial funding is over. 0n summary( community6based 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 resourcesM selecting priority issues to addressM collecting, interpreting, and translating research findings in ways that will benefit the communityM and emphasiFing the reciprocal transfer of ,nowledge, s,ills, capacity and power. /s appropriate, such partnerships may involve individuals and groups who are not members of the community of identity, for e*ample, 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. C%' 6 Paper includes policy recommendations for increasing community6based participatory research see headings below Hunding -esearch Partnerships Planning grants. 4ong6range funding. Initial and ongoing funding for infrastructure. Hunding directly to community6based organiFations as well as universities. Hunding for comprehensive approaches that e*tend beyond categorical perspectives and traditional research designs. Orant application and review process. Capacity @uilding and )raining for C@P- Partners Pre and post doctoral training and continuing education. )raining programs for community members. Institutional support for continuing education and community service. 1ducational opportunities for members of traditionally marginalised communities. @enefits and -eward 5tructures for C@P- Partners )enure and promotion process. -oles, responsibilities and recognition of community partners involved in C@P-. D

Public Health Division, Department of Human 5ervices, ;elbourne, Xictoria, /ustralia= Health Promotion 'trate.ies #or Community Health 'ervices. An Evidence,7ased Plannin. 3rame%or- #or ?utrition( Physical Activity( and Healthy "ebpfYnutrition.pdf$

Higure 2. contains -oles and -esponsibilities in a -egional Health Promotion 5ystem. P.3 C%#D 7ene#its o# C7P9 Overall !enefits of C!P"& 1nhances data +uality and +uantity, by establishing trust. ;oves beyond categorical approaches. Improves research definition and direction. 1nhances translation and sustainability of research findings. Improves the communityNs health, education and economics, by sharing ,nowledge obtained from proGects.

!enefits to Schools of Public Health Hulfills missions of schools of public health. @rings together disciplines that have historically operated in their own research silo. Increases student interest and participation in research.

!enefits to State and local Health Departments Increases patient contact, primary care, and self6management. Hacilitates development and implementation of more effective public health interventions. 1nhances behavioural change and decreases costs to health departments.

!enefits to Public and Private %unding Institutions Cost effectiveness of C@P-. Increased trust from communities. Ion6categorical nature allows for greater fle*ibility in support.

In addition to outlining benefits of C@P-, the Conclusions and -ecommendations section highlights challenges facing C@P- and offers possible solutions to overcome them. )hree principal challenges identified by participants included= development o# university, community partnerships, institutional commitment, and trainin.. C(D De#inition o# C7P9 Community6based participatory research "C@P-$ is committed to social change and strives to enhance health and +uality of life in urban communities. C@P- is methodologically sound, rigorous research that respects and encourages varied research methods and adheres to standard ethical review processes. C@P- proGects are driven by community needs and priorities to answer relevant +uestions, build programs, and affect public policy. -ather than a specific research method, C@P- is a widely respected RprocessE for conducting research that values the lived e*perience 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 action6oriented recommendations$. -ecognising that there are barriers to both community and academic involvement in C@P-, e+uitable partnerships between sta,eholders are established "with clear terms of reference$ to guide C@P- proGects. Data generated through these proGects are Gointly owned and accessible to all partners. /ttention to trust6building, decision6ma,ing, power and resource6 sharing, and reciprocal capacity6building "where the ,nowledge bases and s,ill sets of all research partners are enhanced as a result of the research process$ are e*pected outcomes in all C@P- proGects. C%2D Community,partnered approaches to research Community6partnered approaches to research promise to deepen our scientific base of ,nowledge in the areas of health promotion, disease prevention, and health disparities.

Community6partnered research processes offer the potential to generate better6informed hypotheses, develop more effective interventions, and enhance the translation of the research results into practice. 5pecifically, involving community and academic partners as research collaborators may improve the +uality and impact of research by= W ;ore effectively focusing the research +uestions on health issues of greatest relevance to the communities at highest ris,M W 1nhancing recruitment and retention efforts by increasing community buy6in and trustM W 1nhancing the reliability and validity of measurement instruments "particularly survey$ through in6depth and honest feedbac, during pre6testingM W Improving data collection through increased response rates and decreased social desirability response patternsM W Increasing relevance of intervention approaches and thus li,elihood for successM W )argeting interventions to the identified needs of community members W Developing intervention strategies that incorporate community norms and values into scientifically valid approachesM W Increasing accurate and culturally sensitive interpretation of findingsM W Hacilitating more effective dissemination of research findings to impact public health and policyM W Increasing the potential for translation of evidence6based research into sustainable community change that can be disseminated more broadly. Hor the purpose of this P/-, community refers to populations that may be defined by= geographyM raceM ethnicityM genderM se*ual orientationM disability, illness, or other health conditionM 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 ma,ers, or lay public groups with public health concerns. Community6based organisations refer to organisations that may be involved in the research process as members or representatives of the community. While not an e*haustive list, organiFations as varied as )ribal governments and colleges, state or local governments, independent living centers, other educational institutions such as Gunior colleges, advocacy organisations, health delivery organisations "e.g., hospitals$, health professional associations, non6governmental organiFations, and federally +ualified health centers are possible community partners.K C#9D Community empo%erment is a community development strate.y Community development initiatives see, to increase the capacity and resources of communities. )he classic typology, formulated by -othman and )ropman, includes social planning by outside e*perts, locality development or participatory development of goals and programs, and social action or advocacy. 5trategies used include grassroots organising, professional organiFers, coalitions, census development, problem solving, political and legislative action, and nonviolent confrontation. / more recent typology e*cludes social planning and promotes the value of community building from peopleEs strengths and assets, in addition to community organising methods. Community empowerment is a community development strategy that derives from the wor, of the @raFilian educator Paulo Hreire. )his approach uses nontraditional educational methods to enable individuals to understand their goals independent of the prevailing social order and to develop capacities to realiFe these goals. /pplications to health focus on enhancing awareness of needs, promoting effective problem solving, and developing capacities for implementing solutions in high6ris, communities. / related strategy is media advocacy, which see,s to create leverage for broader policy change by influencing public opinion. @ecause the goals and approaches used in participatory community interventions cannot be fully specified in advance, evaluations rely on action research methods and +ualitative or mi*ed methods. 5ome evaluations also use e*perimental strategies, such as group6level randomiFed trials. Charles and De;aio established a framewor, to Gudge the degree of community participation. ;ore recent reviews suggest that greater community involvement may promote intervention adoption and sustainability. In participatory research, s,ills are re+uired in developing trust with community members and leaders and dealing with differences in authority. Conflicts may arise over priorities for

sustaining interventions versus identifying e*perimental 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 re+uire substantial developmental time, and the evaluation phase may be of long duration. )he feasibility of achieving change in communities may be affected by political and social factors. Hence, community research re+uires long6term commitment to particular communities. 5trategies that can help mitigate these problems include agreeing on goals and e*pectations at the outset, maintaining a structured, e+ual partnership, using an independent community organiFer, sharing e*pertise and resources across community organiFations and researchers, educating the community about research goals and purposes, and developing financial support for community programs. 1ven though community intervention research poses uni+ue challenges, many of the conceptual, practical, and methods challenges are similar to those of practice6based +uality improvement research, in which e*act goals are not easily specified in advance and long6term commitment is re+uired, and to policy research, where randomiFation options and availability of suitable databases for evaluation are limited. Hurthermore, the conceptual and measurement framewor,s underlying both policy and +uality improvement research are similar= both suggest that health interventions should be embedded within local conte*ts and address and involve multiple sta,eholders. /s in community intervention research, evaluations of practice6based +uality improvement interventions and public policies have revealed mi*ed resultsM however, health services research has not retreated from designing and evaluating +uality improvement interventions or evaluating policy. Hurthermore, with recent advances in methods, health services research has yielded a new generation of policy and +uality improvement studies that are interpretable and useful to health care systems. Hor e*ample, research on +uality improvement interventions for depression in primary care progressed from the development of effective models within well6organiFed practices to effective models being implemented by community6based practices under minimal research supervision.K C#%D Capacity buildin. : 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 s,ills, 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. <ey actions areas for building capacity=

!rganisational development Partnerships Wor,force development 4eadership -esources /gencies, 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 systemsM program sustainabilityM increased problem solving abilities Oreater capacity of people, organisations and communities to promote health

Implementing strategies from each of the ,ey 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 re+uirements in structures and s,ills "strengthening agencyJsystem infrastructure$.

2. Continue to deliver, transfer and adapt a particular program through a 3.

networ, of agencies, or to sustain the benefits achieved "program maintenance and sustainability$. 5trengthen the generic problem6solving capability of organisations and communities to be able to develop innovative solutions, learn through e*perience and apply these lessons. C..D

Capacity 7uildin. de#inition Capacity building has been defined as being "at least$ three activities= "%$ building infrastructure to deliver health promotion programs, ".$ building partnerships and organisational environments so that programs are sustained and health gains are sustainedM and "0$ building problem6solving capability. )he last element is crucial. )here is little value in building a system that cements in todayEs solution to todayEs problems. We need to create a more innovative capability so that in the future the system or community we are wor,ing with can respond appropriately to new problems in unfamiliar conte*ts. C2D Capacity 7uildin. evidence :Qthe effort that health promotion wor,ers put into capacity6building or ma,ing their colleagues and partner organisations more interested in and more capable of engaging in effective health promotion practice. )he rationale for capacity6building is simple. @y building sustainable s,ills, resources and commitments to health promotion in health care settings, community settings and in other sectors, health promotion wor,ers prolong and multiply health gains many times over. C2DB Capacity 7uildin. de#inition Different uses of the term of capacity6building appearing in the health promotion literature %. Health infrastructure or service development Capacity to deliver particular program responses to particular health problems. Asually refers to the establishment of minimum re+uirements in structures, organisation, s,ills and resources in the health sector. .. Program maintenance and sustainability Capacity to continue to deliver a particular program through a networ, of agencies, in addition to or instead of, the agency which initiated the program. 0. Problem6solving capability of organisations and communities Capacity of a more generic ,ind to identify health issues and develop appropriate mechanisms to address them, either building on the e*perience of a particular program, or as an activity in its own right. C2D ;. <uestions o# Community Empo%erment & Partnership /lthough Community Development and Community @ased Participatory -esearch emphasise empowerment, it seems unli,ely that full empowerment of any particular community or focus group is li,ely to be achieved within our e*isting democratic and institutional framewor,. 1*isting structures donEt 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. )his will need to involve strong leadership or facilitation, and strong pre6partnership agreements. Xery good on the tensions between traditional health promotion providers 8 community empowerment methodology 8 how to incorporate the two. C%9D Community empo%erment: LM Policy Environment Community empowerment through their involvement in planning is central to the development of the community strategy. It is also an opportunity for communitiesE perceptions of the relationship between health, health services and local authority functions to be e*plored. /ll community strategies reviewed include details of the mechanisms used to involve local communities. Hor many authorities new approaches are currently being developed to reach groups in neighbourhoods or populations who have been Rhard to reachE by traditional methods of consultation. ;any authorities are also mapping other consultation and

involvement activities, such as those underta,en through the IH5, to identify other sources of information. C.%D 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. HI;P and H/\ partnerships and IH5 representatives have therefore been able to participate in or influence multi6sectoral wor,shops, events, surveys and panels. In the better e*amples, local authorities combine community needs assessment data "gathered from and with ,ey partners$, with other information to set out the health and wellbeing issues for the community. C.%D However some of the needs assessment e*ercises appear to be predominantly the wor, of the local authority. In these cases, there is little reference to IH5 consultation e*ercises "such as those underta,en through the HI;P or H/\$ and apparently few attempts to understand communitiesE health issues in the conte*t of other concerns or local authority functions. )his tends to result in RhealthE being variously interpreted in consultations as health services, health and social care, health behaviour and education, individual or community health. In some authorities, communities are offered a list of issues from which to select their priorities. RHealthE is included but not usually e*plained. C.%D Health data and national health concerns can mas, other community concerns which are in fact related to health. 5ome authorities have found that health may appear relatively low down a list of priorities for a particular community, yet wider determinants and factors affecting immediate +uality of life come first. In some authorities health is ran,ed very differently throughout their geographic area ma,ing it difficult to reconcile national and local priorities in the community strategy. )his highlights the importance of local area plans that can articulate these differences and provide a basis for different types of support and action. C.%D A common duty to consult and involve communities Central to the development of integrated local planning is the re+uirement to involve local communities. Councils are under a statutory duty to consult as part of the process of preparing their community strategy. However the e*pectation is that communities will have much more involvement than simply via consultation. R)he involvement of local people is central to the effective development and implementation of community strategies, and ,ey to change in the longer termE "D1)-, .999= #9$ 4ocal strategic partnerships need to decide how community views will influence and inform their decision ma,ing process, how differences of views will be aired and resolved and how decisions will be e*plained to communities "D1)-, .999= #9$. C.%D R45Ps should agree protocols to ensure that local people are involved in the design and delivery of relevant programmes which affect their communitiesE "D1)-, .99%= %..%$ )he IH5 is also re+uired to involve local people in planning its services and in the development and delivery of the HI;P, and to lin, this to broader community development processes within the 45P "as set out in the Health and 5ocial Care /ct .99%$ to= R1nsure that the views of patients and the public are built into local planning decisions that affect peopleEs health e.g. through the HI;P, 45P and social servicesE "DH, .99%d= /nne* /$. IH5 activity to involve patients and the public is e*pected to build on local authoritiesE own mechanisms for engaging local communities and support the role and function of overview and scrutiny committees "DH, .99%d$. A @oint #ocus on -ey population .roups 45Ps are e*pected to improve the involvement of Rhard6to6reachE communities who have traditionally been underrepresented in consultation and community development programmes across the public sector. )here is a duty on all public sector bodies to avoid discrimination between people of different racial groups and similar duties are li,ely in respect of gender and disabled people "D1)-, .999= #0$.

HI;Ps are e*pected to prioritise action which will support greater access and use of IH5 services and care among vulnerable groups. )hey are also to develop Goint action to improve the health of children and young people, older people, people with disabilities, blac, and minority ethnic groups and those in deprived communities. 45Ps are similarly e*pected to identify ways to build capacity and training to increase the involvement of communities including disabled people, older people, youth groups, people from faith, blac, and minority ethnic communities, and to wor, with community and voluntary sectors to develop relationships within the 45P "D1)-, .99%$. /ctions agreed in the community strategy and the HI;P will need to be trac,ed to identify C.%D Tension bet%een Jbottom,upK and Jtop,do%nK pro.rammin. Health promotion often comprises a tension between Rbottom6upE and Rtop6downE programming. )he 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. )he latter, more associated with disease prevention efforts, begins by see,ing 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. )he tension between these two approaches is not unresolvable, but this re+uires a different orientation on the part of those responsible for planning more conventional, top6down programmes. )his article presents a framewor, intended to assist planners, implementers and evaluators to systematically consider community empowerment goals within top6down health promotion programming. )he framewor, Runpac,sE the tensions in health promotion at each stage of the more conventional, top6down programme cycle, by presenting a parallel RempowermentE trac,. C%%D Characteristics o# 'uccess#ul Partnerships )rusting relationships 1+uitable processes and procedures Diverse membership )angible benefits to all partners @alance between partnership process, activities and outcomes 5ignificant community involvement in scientifically sound research 5upportive partner organiFation policies and reward structures 4eadership Culturally competent and appropriately s,illed staff and researchers Collaborative dissemination !ngoing partnership assessment, improvement and celebration 5ustainable impact 7arriers to 'uccess#ul Partnerships When characteristics above are absent Hunding mechanisms, policies and procedures o 4imited funding sources o Hunding agency re+uirements, definitions, timelines and reviews o 4ac, of funding and funding mechanisms that specifically support community as research partner 9ecommendations at the level o# 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 @e strategic about dissemination

Invest in ongoing assessment, improvement and celebration C.%D

Empo%erment( Health 5iteracy and Health promotion , puttin. it all to.ether KHealth 4iteracy can only be achieved through a process of health education which see,s to develop understanding of health issues and how to apply these to ma,e decisions. However, many traditional Rtop6downE didactic health education methods, while providing ,nowledge, have a negative effect of disempowering people by creating dependency on professionals and. )he challenge is to provide this cognitive input through educational processes which reinforce and not undermine community confidence and power. 5elf efficacy can be achieved in a variety of ways that promote self esteem and develop individual or community power over their lives and surroundings. )his can be on any aspect of their lives for e*ample action on housing, income generating, and the process of community participation or democratisation at a national level. However it can even ta,e place at a simple level of learning new s,ills in farming, ma,ing ones own clothes, coo,ing, creative e*pression 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 data6base of evaluated health promotion interventions in developing countries. / disappointing feature of this database has been the lac, of published evaluations using either +ualitative or +uantitative research methodologies that demonstrate that empowerment has ta,en placed. !ne approach to the lac, of evaluation studies has been the criticism of methods of evaluation that wor, within positivist framewor,s and therefore fail to ade+uately encompass the aims of empowerment approaches which might re+uire alternative paradigms. However, I suggest that the difficulty in evaluation has been the problematic and ill6defined nature of empowerment. )he model proposed in this paper should ma,e the evaluation of health empowerment a simpler process by ma,ing more e*plicit and hence measurable the two component parts.K C2%D Partnerships are strengthened by Goint development of research agreements for the design, implementation, analysis, and dissemination of results C(.D A partnership approach to health promotion: a case study #rom ?orthern 0reland. 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 Iorthern Ireland. )he general thrust of these approaches is that local communities can be organised to address health and social needs and to wor, with government agencies, voluntary bodies and local authorities in delivering services and local solutions to problems. 5ince the !ttawa Charter was launched in %&'(, government in Iorthern Ireland has stressed that community development should no longer simply be added on to ,ey aspects of Health and 5ocial 5ervices, but should instead be at the core of their wor,. )here is increasing consensus that traditional approaches to improving health and well6being, which have focused on the individual, are paternalistic and have failed to tac,le ine+ualities effectively. Partnerships within a community development setting have been heralded as a means to facilitate participation and empowerment. )his paper outlines the policy bac,ground to community development approaches in health promotion and delivery in Iorthern Ireland. Drawing on evidence from a case study of a community health proGect it highlights the benefits and difficulties with this approach. )he findings suggest that partnerships can positively influence a communityNs health status, but in order to be effective they re+uire effective planning and long6term commitment from both the state and the local community. C(2D