Community development: How effective is it as an approach in health promotion? John Raeburn and Tim Corbett University of Auckland Paper prepared for the Second International Symposium on the Effectiveness of Health Promotion University of Toronto May



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Community development:

How effective is it as an approach in health promotion?


John Raeburn

and

Tim Corbett

University of Auckland
Paper prepared for the

Second International Symposium

on the Effectiveness of Health Promotion
University of Toronto

May 28-30, 2001

Note: This version of this paper was submitted in time to go on the symposium website before the symposium itself. It is still in process, and a more finished version will be available later. But the basic arguments and conclusions are here.

The aim of this paper is to look at how effective a community development approach is in health promotion. We hesitate to call community development (CD) a ‘strategy’ – rather, it is a whole distinctive way of thinking about health promotion (HP). Calling it a ‘strategy’ makes it seem very instrumental and calculated. We argue here that CD is a good in its own right – that it is a way of looking at the world which can be valued independently of its effectiveness. It embodies many of the dearest held values and worldviews of those of us who are passionate about HP as an endeavour, and coupled with the concepts of ‘empowerment’ and ‘equity’, probably represents the ideal heartland of HP. Indeed, to take this supposedly ‘cool’ look at CD within an ‘evidence-based’ framework is a paradox – CD is a matter of passion, whereas the modern fashion for evidence-based medicine and evidence-based HP has a gloss about it which is very much a part of modern, corporatised, accountable new right thinking which is exactly what HP represents an antidote to. However, we also realize that HP is in competition with other sectors of the health domain for resources, and of course, we do want to know whether what we do is effective – that is not the issue – but it is how we go about the process of determining its effectiveness that counts, and what is currently meant by an ‘evidence-based’ approach may not be it.


As we understand it, the brief for this paper is the following:


  • To summarise the evidence for the effectiveness of a community development approach to health promotion (CDHP)

  • To discuss conceptual issues around health promotion and the assessment of its effectiveness, in this case with regard to CDHP

  • To discuss ways in which the assessment of the effectiveness of CDHP is currently done, and how it can be done better in the future

These topics could take a whole book to cover, and an army of reviewers. Indeed, in one of the only significant reviews we found in the area (Hancock, Sanson-Fisher et al. 1997) there were 14 authors, and they covered only a fragment of the field. Since both of us were hugely busy, and there was only a limited time to do this in, this review does not pretend to be comprehensive. Instead, we will try to go to the core of the issues, with examples.


We gathered, from afar (and New Zealand, we have decided, is the farthest away country from anywhere in the world!), that the context for this discussion was the current fashion for ‘evidence-based’ health promotion. This is curious, because the whole concept of ‘evidence-based’ seems to come from medicine (as in the Cochrane Collaboration), and once again, we health promoters seem hell bent on aping the ‘culture’ of medicine to justify our place in the world. No doubt we want to be respectable, scientific and to get our share of scarce health resources to do our stuff. But are we jeopardising the true spirit of HP in the process?
We are not arguing against having evidence to support and investigate HP endeavours. Of course not. But it is the rigid formalism of the evidence based approach, with the randomised control trial (RCT) as its explicit or implicit gold standard (Nutbeam, 1999), that we want to question. Again, this is not to say that RCTs, or the big quasi-experimental trials (BQETs), do not have a place in the scheme of things, including some aspects of HP, but there are other ways too. This point has been strongly made in Canada, by a variety of qualitative and post-modernist researchers (e.g. Eakin et al., 1996; Labonte and Robertson ,1996; Poland, 1996). But we also think this goes beyond the quantitative/positivist vs qualitative/constructionist debate. To us, HP is pre-eminently an approach to health, to life, and it is first and foremost a set of values in action. Naturally, we want to see whether HP efforts using this set of values actually work, but that is not the main issue. In short, the wonderfulness that HP represents as an antidote to a modern fractured world almost solely driven by new right, corporatised, high technology, media driven values and imperatives should not be lost in the effort to emulate the tools of that world and its rigidly scientific, squeaky clean evaluative methodologies. We need to preserve the true spirit of health promotion, come what may!
Nowhere are these issues more dramatically represented than in the domain of community development as applied to HP. For us, and for many, community development and its cousin empowerment, represent the true heartland of HP. And at the heart of CD, and HP, certainly as understood by Irv Rootman and John Raeburn, is the concept of ‘people-centredness’ (Raeburn and Rootman, 1998). Here in Toronto in 1991, at an international conference on HP research, we made an impassioned plea that the thirst for good science, especially of a population, numbers driven nature, should not be allowed to eclipse the ‘true’ purpose of HP, and we do so again now (Raeburn, 1992). The true purpose of HP, we believe, is to enhance the lives of real, palpable people, to honour those people, and to make the ‘people-control’ aspect of the Ottawa Charter definition of HP the most central matter, with research methods having to array themselves around that centre, rather than the other way round, which so often seems to be the case. Exactly a decade later, the need to hold fast to this perspective has not lessened one iota - indeed, with the concept of population health becoming a new hegemony (thankfully, not so much in New Zealand as in Canada), it becomes even more important to hold to the true values of HP, and its people-first perspective.
Community development and health promotion
Having said that, let us now address the issue of community development, and how this relates to HP. This, we came to realise as we prepared for this review, and looked at dozens of papers and abstracts, is in itself a thorny issue. Our brief, from the symposium organizers, was to look at community development, and as you are no doubt aware, the community dimension of HP goes well beyond what is normally understood by the term CD. So, we asked, since no-one else at the symposium seemed to be addressing the rest of the community sector, were we meant to be doing this as well? This may seem like splitting hairs, but it is absolutely not so. When we asked Irv Rootman about this, we understood that we should err on the side of CD as such, but also take into account that sector of HP that had at least some degree of community participation in its approach.
Which brings us to the definitional domain. The one major review referred to before,, undertaken by the Australian team of Hancock, Sanson-Fisher et al. (1997), used the term ‘community action’, which is of course the Ottawa Charter term for its community stream. They say the key component of community action is ‘community participation’, and that this falls along a continuum, on which CD is one pole. They also say there are international differences in usage here.
One end of the continuum, where community involvement and active participation occur at all stages of the intervention process, is commonly called “community development” in Australia, Canada, and the United Kingdom, or more often “community organizing” in the United States. [New Zealand does not rate a mention with the Australians!]. Programs at the other end of the continuum, where the community participation is token, and may be consultative only, are often called “community-based”.
They then say that their use of the term ‘community action’ is ‘defined as a health promotion program that involves the community in, at least, implementation and control of the process of the program’. We could unpack this and ask does it need to be a formal ‘program’ as such, or more organic? Is control of the process the same as control of the whole endeavour and agenda, and so on? For us, these are the essential features of CD - where the community owns the programme, intervention, change process or however one might construe this, including setting the agenda (maybe in partnership with outsiders), defining the needs, wishes, and priorities for action, controlling the action, and owning the data and evaluation processes, if those are being undertaken.
Which brings us to two key questions here. The first is, what is ‘the community’ in this context? The second is, what is any evaluation or assessment of outcomes/effectiveness for?
We won’t waste too much time on the former, as many have spent that time before us, although perhaps we should, since Marie Boutilier, Shelley Cleverly and Ron Labonte tell us that misconceptualisations of ‘community’ are a fundamental flaw in much CDHP (Boutilier et al., 2000). According to sociologists, there are over 100 definitions of community). What we mean here is that ‘the community’ is a significant group of people seen in their everyday, ordinary living context, who share either a common locality and actual or potential social bonds and/or goals in that locality, or who have some other binding factor (other than locality) which gives them a sense of commonality and relatedness. Our view is that locality is proto-community, and that other concepts are variations on this. From this perspective, the Hancock et al. (1997) view that Americans equate the term ‘community organization’ (CO) with CD is not correct, if we take the conventional Rothman and Tropman (1987) breakdown of community organization as the gospel - only one of their three types of CO, locality development, would qualify.
The second issue, that of why assess effectiveness in the first place, deserves a bit more attention. The guidelines and indeed the whole thrust of this symposium is that the assessment of the effectiveness of HP is a ‘good thing’. But by whom and for whom?
Now, we the writers of this are academics, and our livelihood depends on our producing scientific papers full of quantitative and qualitative data fit for publication in the appropriate journals. But we also equally work at the coal face in communities, and know the imperatives that pertain to them. And the two can often clash (Allison and Rootman, 1996). For us, the art of assessing effectiveness is not to what extent it can approximate an RCT or some other conventional yardstick, whatever that may be in the qualitative realm, but whether it serves the ‘true’ purpose of HP, which in our view is to enhance the health, wellbeing and quality of life of the people of interest (POI), and to do this in a way that is empowering and strength-building.
So why do academics and experts want to know the effectiveness of HP endeavours? Well, it depends on who is talking. If we assume that we all have the wellbeing of society and people at heart, then there are several reasons, for example:


  • producing a scientific result that can be published in a reputable journal, and hence enhance the careers of the academics involved

  • to give credibility to a ‘soft’ and amorphous area (viz. HP), currently under siege by ‘true’ scientists and decision makers, such as the proponents of population health

  • to get or retain resources for HP, in a climate of ever shrinking resource - that is, a political purpose, or getting funds for research

  • to validate, and be accountable to, community or people processes, particularly to enable community people to justify their work, and to know it is of value, and to ensure the benefit or outcome of what is done is having a desired impact, rather than having no impact or even doing harm - which much community work has the potential to do (e.g. by falsely raising community expectations)

As far as we are concerned, all are justifiable ends, but the last one is far and away the most important, and the others should be secondary.


So, where have we got to?


  • First, the brief of this paper concerns CD, which falls at the community ownership and control end of the community participation continuum

  • Second, we need to retain the vision of ‘true’ HP, and of keeping people at the centre of our preoccupations, rather than ‘science’ as such

  • Third, the definition of community is primarily to do with location, though other concepts are okay too

  • Fourth, the aim of assessing the effectiveness of CDHP is first and foremost to aid in the process of community empowerment and ownership, and only secondarily to serve the purposes of academics and professionals

One could say a lot more about what a CDHP approach should be at this stage. For example our belief is that it should primarily be about building community assets, capacities, strength, resilience, etc rather than dealing to risk factors or deficits, which is often the case (e.g. Rappaport (1992), Raeburn and Rootman (1998), Kretzmann and McKnight (1993)). It should be, to use the new right terminology, about building social cohesion and social capital (Coburn, 1999), and the building of social support and a supportive environment (Sarafino, 1998). It should be about community control and ownership (Raeburn, 1992b; Steptoe and Appels, 1989), and about unifying fragmented or oppressed communities, as we see in the third world (Durning, 1989). It should be about equity, the single biggest social issue we face in today’s world, which impinges directly on health (Wilkinson, 1996). It should be about respecting culture, diversity and the essential humanity of everyone. CDHP, we submit, in its truest form, is a kind of inspirational or ‘spiritual’ enterprise, one of the noblest human enterprises. We know this puts us at the receiving end of those who would label such an approach in HP as one of sentimentalising community (e.g. Labonte, ), but nevertheless, it is a very moving and powerful enterprise for all concerned, one which could change the world (Durning, 1989). We don’t want to see this lost in the ‘coolness’ of rigorous scientific appraisal to meet some high standards of academic excellence. On the other hand, if we can succeed in doing both - keeping the vision and doing good science - then that would be optimal.



Theory and practice

The first thing one does for a paper such as this is a literature search. Given limited time and resources, we largely (not entirely) kept this to the last five or six years, to cover the period since the last symposium (where Marie Boutilier and John Raeburn covered the same territory), and to the sources reasonably accessible to us. We cannot claim to have been exhaustive, but we did get over 90 articles, monographs and references that looked promising. On sorting these, we were astonished to find that the actual number of completed evaluated studies in the whole of community related HP was actually very small. And most of these did not fit the category of CDHP as outlined here. Below, we discuss what we did find in more detail. Here, we say that of the 91 articles and documents we used, 67 were written about evaluation, measurement and effectiveness issues relating to community health promotion (the general term we will use), and only 24 were of evaluated studies. Of these, only one met the criterion of CDHP as such. The rest were more of the community programme or community intervention variety, to use the terminology of Dixon and Sindall (1994).

There were, however, another two sets of literature that did not automatically come up under conventional HP searches, which actually did have significant numbers of evaluated community studies. One was that of mental health promotion (e.g. the Welsh publication called Mental Health Promotion: Forty Examples of Effective Intervention (Health Promotion Wales, 1996), and the other was that of injury prevention research, including violence and suicide prevention (e.g. Klassen et al., 2000; Dejong, 1994). However, few of these studies meet the criteria for CDHP either, although there is significant community involvement in many of them.

What is the theory literature saying?

It is beyond the scope of this article on the effectiveness of CDHP to cover the gamut of theoretical literature in any detail. All we can do is bullet point our summary of what it mainly seems to be to do with.



  • The RCT trial is the gold standard for evidence based evaluation of HP, including community health promotion. But it and its clones show little benefit for using community approaches in the HP projects included in the reviews of these trials, and many feel other forms of research are more appropriate, given the nature of community (e.g. Nutbeam, 1999)

  • The RCT culture, and the cry for ‘evidence based data’, is the product of our current rationalist/new right economic era, with its orientation to accountability, scarce resources for health, lack of feeling for community and social issues, the rise of biomedicine with gene and other discoveries, the dismantling of the welfare state, and hard science as its touchstones (e.g. Dixon and Sindall, 1994)

  • Community research is diffuse, complex and hard. Its protagonists tend to opt for post-modernist methodologies, which often do not get as far as producing effectiveness data, or if they do, these tend to take the form of ‘community stories’ or interviews with participants, which does not necessarily carry much political clout (e.g. Labonte and Feather, 1996)

  • Most community health promotion does not have a good handle on ‘community’, and tends to ignore the very heart of what is implied in the term ‘community development’ - that is, that the building of community as such is a goal, and is beneficial to health - and instead, uses community as a tool or instrument for outsiders’ agendas, with little regard for the people or community-building dimension, or for issues beyond the health problem being addressed (e.g. Hancock and Minkler, 1997; Dixon and Sindall, 1994; Peterson, 1994; Nilsen, 1996; )

  • The voice of the community is not often being heard, and a community led enterprise, which is what CD is about, would have to lead to a whole new paradigm of action and of training professionals (Cheadle et al., 1997; Rosenau, 1994; Guldan, 1996)

  • Most so-called community ‘health promotion’ projects and programmes are actually prevention programmes (Higgins and Green, 1994; DeFriese and Crossland, 1995) and there are still too few which break free from an old lifestyle, individualistic model. However, to be sure, there are many theorists (rather than practitioners!) who think they should break free from these old shackles!

  • There are many different approaches to conceptualising and doing effectiveness measurement for community work, including controlled studies, quasi-experimental studies, programme evaluation, demonstration projects, case studies, interviewing of participants, surveys, psychometric measures, self-report measures, epidemiological studies, story telling, satisfaction measures, using social indicators, doing a critical analysis, focus groups, key informant studies, participant observational studies, ethnographic methods, action research, and so on. Each has its place. Probably the most common methods are surveys and interviews of various kinds, incorporated into controlled studies or standing in their own right. Triangulation seems to be the recommended approach. Obviously, the selection of the appropriate methods and measures depends a lot on one’s research orientation, especially on the quantitative/positivist vs qualitative/constructionist dimension. Hard countable data still seem to rule supreme in the effectiveness studies that are published, although the theoreticians often do not like this kind of data much.
The effectiveness of community development health promotion

Now we move to the more formal appraisal of what studies show the effectiveness of CD to be as a way of ‘doing’ HP. This instantly brings us into tricky territory, because although there is quite a lot of ‘community health promotion’ outcome research, very little of it fits what we would call ‘community development’ research.

For the purposes of this discussion, we make a tripartite distinction among the studies that have been done which impinge on this area, and in an area of multiple usages of language and definition, assert our own, at least for this paper.



There appear to be three main levels of HP activity involving community, which we categorise as A, B and C:

Category A This is the ‘lowest’ level. It is one that places the HP action in the community (e.g. a school, a community health centre, a neighbourhood, or even just a large population), and makes explicit mention of ‘community’, but does little more. The action is something that is ‘done to’ this community, with little attempt to engage them other than to cooperate with or ‘consume’ the action. We use the term community-based HP to describe this level.

Category B This is a middle level, and probably includes a lot of what is referred to by some as ‘community development’. It actually involves at least four subcategories, each of which represents varying degrees of effort to have active community input into the HP process, but where the agendas are still primarily under the control of the professionals or researchers. In each case, ‘community participation’ seems to be used in an instrumental way to help bring about the ends desired by the professionals, for example, to reduce injury rates in a community. The four subcategories are: (1) consultation, discussion, needs assessment and action involving community based service agencies (e.g. police, youth workers, social workers, community workers, teachers, NGO spokespeople, voluntary agency representatives, etc); (2) consultation, discussion ,needs assessment and action involving the people of the community directly (e.g. representative members of the residential or interest community being worked with) ; (3) agencies and/or community people having a degree of decisional and organisational control over the nature of, and implementation of, the intervention activities by community agencies/people; (4) partnership, where the balance of control for decision-making, control and actions is divided equally between professionals and the community, and also where (hopefully) there is an honouring of the culture and uniqueness of the community concerned. This last category comes close to CD as we understand it. But where it falls short of that is that the overall direction, control and priorities still remain in the hands of professionals, and there is no explicit agenda of capacity or community building as such by professionals. This overall category we call community action.

Category C This is the ‘highest’ level, and is the one we call community development. This has three criterion dimensions. One is that the balance of power between professional and community people (not just service agencies) is clearly with the community – that is, the enterprise is community-controlled. Indeed, in its purest form, there may be no professionals involved at all (e.g. Boyte, 1989), or the professionals will simply be used by the community in a consultative way, such as getting advice on how to do surveys or evaluation (Raeburn, 1992). Various forms of ‘facilitation’ rather than ‘control’ by professionals also qualify here. This process of having and exercising power over one’s life and community process is one crucial aspect of an empowerment process. The second criterion is that of community building, based on an agenda of developing social cohesion, mutual support, networks, friendships, cooperativeness, and overall quality of life and liking of the community. This participatory and positive aspect of the CD process is also empowering, since participation is seen to be at the heart of community empowerment (Rappaport, 1987). The third criterion is the development of community capacity and strengths, through people learning skills, confidence, ways of doing things, influencing policy, making a difference, seeing the results of their efforts, etc. Here, community controlled evaluation is a useful too, but it is more what is felt than what can be measured. Such capacity building is probably closest to what most people understand by the concept of empowerment. We call the three criteria here the 3 Cs – community control, community building and capacity building.

This category of CD comes closest, we assert, to the ideal of CD as an enterprise based on the core HP concept of empowerment. However, we do not claim that activities in the other two categories cannot be empowering to some extent. In particular, any sense of control engendered by a community activity is likely to lead to a sense of empowerment, particularly as skills develop and participation increases. These categories are not pure, and there will be overlaps. Nevertheless, we think the distinctions are useful, and that Category 3 is what we should all be aspiring to when we talk about community development with regard to health promotion.

This brings us to the issue of what do we mean by health promotion in this context? This is no place to discuss this in detail, but HP seems a variable feast here. In spite of protestations to the contrary, much HP seems locked pretty firmly into a risk model, which is the hallmark of ‘prevention’ rather than HP. In our view, HP refers primarily to efforts to enhance health, wellbeing and quality of life in a global sense, rather than just attempting to reduce specific disease or problem related risks. Most of the big RCT type trials, such as MRFIT, are concerned primarily with disease related specific risks, and are therefore, in our view, prevention trials rather than HP trials as such. There is, of course, much overlap between concepts of prevention and HP. But we feel that it is better to be honest, and call a spade a spade – that is, if something is a prevention activity, then to call it that, even if it is a modern one that takes HP principles into account. Similarly, treatment can involve HP processes too, such as getting people along to be screened for illnesses, encouraging people to use health services, or using HP principles in recovery. But we feel it is better to call this for what it is as well – it is treatment with some HP aspects.

To make this clearer, and based on the articles we sorted, we have devised a category system here to, designated as Type A, B and C.



Type A. This is where HP and community activities are involved, but where the preoccupation is primarily to do with treatment and recovery. We label these processes and outcomes as to do with treatment/recovery

Type B. This is where a single or several risk factors or behaviours associated with illness or injury categories are targeted by a campaign or intervention with the intention of reducing the risk of contracting an illness, or avoiding injury or disability, or to deal with the risks associated with some mental health or social problem such as youth suicide. Many social marketing campaigns fits into this type, as do most of the big RCT cardiovascular, smoking, destigmatisation, anti-abuse and similar campaigns. A number of school campaigns, and those emanating from health centres would also fit in here. We label these processes and outcomes as to do with prevention.

Type C. These are where the goal is enhanced generic health, wellbeing, quality of life, strength, fitness, resilience, empowerment, justice, equity, community cohesion, and so on. These we regard as the ‘true’ aims of HP, as distinct from prevention or treatment. A Type C HP activity may be stimulated by a specific or ‘negative’ trigger like a concern with heart disease, obesity or youth suicide. But the methods and outcomes are general and geared to positive goals. These processes and outcomes we label as having to do with health and wellbeing.
Note that in this discussion, we are not considering the actual HP methods used, and these can be various across all the categories and types, including media, education, life skills training, policy development, advocacy, creating supportive environments and so on. However, to qualify as a community development method, it would need to exist in a community context where the activity is consonant with the 3 Cs.

From all this, then, it should be clear that the proto CDHP, by our estimate, is that which is Category 3 and Type 3. The farther the deviation from this ‘ideal’, the farther it is from ‘true’ CD. This can be represented by the following chart:



Categories of community HP




Types

Of

HP

Domain

Do-main








Community-based

Community action

Community development

Treatment











Risk









Wellbeing








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