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Monday 26 May 2008

Community health development: what is it?

International Nursing Review
Community health development: what is it?
Author(s):

Huang, C.-L. RN, MPH1; Wang, H.-H. RN, PhD2

Issue:
Volume 52(1), March 2005, p 13–17
Publication Type:
[Original Article]
Publisher:
Copyright © 2005 Blackwell Publishing Ltd.
Institution(s):
1Lecturer, Department of Nursing, Chang Jung University, Tainan
2Professor, College of Nursing, Kaohsiung Medical University, Kaohsiung, Taiwan
Correspondence address: Chih-Ling Huang, Department of Nursing, Chang Jung Christian University, 396 Cheng Jung Road. Sec. 1, Guei-Ren, Tainan 711, Taiwan; Tel: 886 6 278 5123 ext. 3164; Fax: 886 6 278 5581; E-mail: chhuang@mail.cju.edu.tw.
Keywords: Appropriateness, Community Health Development, Health Promotion, Participatory Action Research, Primary Health Care
Abstract

The Department of Health in Taiwan initiated community health development (CHD), a new approach to national community health care. Community-based research and evaluation approaches have recently been shifting from ‘traditional’ research to ‘participatory’ research. However, there is vagueness about the theoretical foundation of CHD and the appropriateness of using participatory action research (PAR) to evaluate CHD. This article explores theoretical concepts of CHD and discusses the compatibility of PAR and CHD in the theoretical and philosophical foundations. Community health development is a developing and changing process that involves both the social and the health contexts. It operates on the basis of three approaches to care: primary care, health promotion and community development. Partnership and empowerment between community health nurses and the community are concurrently involved in the entire process of CHD practice. The fundamental tenet of PAR focuses on the development of knowledge through partnership and empowerment between the researcher and the community, and the creation of critical consciousness leading to necessary action and effective change. Unlike empirical community-based research, PAR is flexible enough to capture an understanding of the complex social and health phenomena in the CHD framework. Furthermore, utilizing the PAR approach is appropriate not only for the methodological framework of the CHD evaluation, but also for the enhancement of the CHD actualization.



Introduction

Public health services (such as health education and primary care) in community-based settings traditionally focus on the deficiencies of individuals, treatment of sick individuals and problem solving by outside experts. These emphases undermine the clients' sense of capacity and self-worth, decrease their involvement in decision-making about health, limit use of resources from the community and weaken community ties (McKnight 1989). Therefore, alternative approaches to public health care using strategies of community development, participation, partnership and empowerment have been outlined to improve community health (Courtney 1995; Minkler 1990). The Department of Health (DoH) in Taiwan initiated community health development (CHD), a new approach to national community health care.

The CHD programme began in 1999 with a three-year grant from the DoH. The world health movement provides the background for the CHD programme: primary health care to achieve the World Health Organization's (WHO) goal of ‘Health for All’ by the year 2000, the global conference on health promotion, and the WHO healthy cities project (WHO 1986, 1991a; Tsouros 1990). The CHD programme set out a process to break traditional boundaries between government and non-governmental organizations, consolidate community resources and enhance the active participation of community residents for promoting community health (DoH 2000). The CHD programme is currently becoming a means to deal with local concerns. By the end of the year 2001, the granted CHD programmes had set up 213 health building centres in 212 townships. The DoH suggested that the field of CHD lacked an appropriate infrastructure to develop an evaluation programme (DoH 2002). Although the literature describes the theoretical approaches of CHD (Chen et al. 2001) and the appropriateness of participatory action research (PAR) for the evaluation of health promotion (Springett 2001), there is much vagueness about the theoretical foundation of CHD and the appropriateness of using PAR to evaluate the CHD programme. Compared to the traditional, scientific research paradigm advocated by most nursing research texts, PAR is based on very different assumptions. These fundamental perspectives that underpin PAR are the most appropriate way to evaluate the CHD programme. In order to clarify these issues, this article explores the theoretical concepts of CHD and then discusses the theoretical and philosophical compatibility of PAR and CHD.

Theoretical concepts of community health development

In community health development, primary health care health promotion, and community development have been integrated into community health practice. All three approaches to health care involve strengthening community competence and creating community change. Additionally, the two central concepts of partnership and empowerment simultaneously permeate the entire CHD framework. Five concepts are interrelated and non-mutually exclusive in this conceptual framework (Fig. 1). Each concept is discussed below.



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Fig. 1 Community health development (CHD) framework. The CHD framework merges three approaches to care: primary health care, health promotion and community development. Additionally, partnership and empowerment processes synchronously permeate the entire framework. The five concepts are interrelated and non-mutually exclusive in this framework.

Partnership and empowerment

Partnership and empowerment are interrelated and cannot be considered two dichotomous concepts. Four common characteristics emerge from the systemic review to highlight the interrelationship of partnership and empowerment within the nurse–client relationship (Huang et al. 2004). We define the nurse as a community health nurse and the client as a community. These characteristics are described as follows:

1. Equality is defined as the state of being equal in terms of the same value in the perspectives of both the nurse and the client.
2. Interpersonal transaction is a process that involves a relationship between individuals. Some skills influence this process and are important antecedents to the progress of both partnership and empowerment, such as trust, respect, flexibility, open communication and self-awareness.
3. Mutuality is defined as based on a reciprocal relationship between individuals. This mutual process includes sharing, learning, exchange, joint accountability and development of roles.
4. Power sharing and transferring is the process of involving nurses and clients in decision making, sharing control, and developing an awareness of their responsibility and accountability for their actions.

The ultimate goal of partnership and empowerment concepts simultaneously permeating the CHD programme is to make the community change and to motivate the community to take actions to improve well-being.

Primary health care

The Alma-Ata conference defined primary health care as the provision of basic health care to individuals and families in a community-based setting by means acceptable to them, through their full participation and at a cost that the community and country can afford in order to maintain every stage of their development in the spirit of self-reliance and self-determination (WHO 1978). People have the right and responsibility to participate individually and collectively in planning and implementing their health care. Primary health care forms an integral part of both the country's health system and overall social and economic development of the community. Other essential elements of primary health care encompass an intersectoral government approach at all levels; the recruitment and training of primary health care workers; recognition of community felt needs; use of local resources including manpower, material and funds; and the mobilization of the country's resources (WHO 1975). Primary health care is seen as an approach to emphasize people and their needs, thus, reinforcing and strengthening their capacity to shape their own lives (Gottschalk 1996). Effective collaboration of community partners from various disciplines and sectors can contribute to ensuring primary health care for all people (Farley 1993). Moreover, partnership is viewed as a fundamental principle of the provision of primary health care (Leonard 1998).

Health promotion

In the Ottawa Charter, health promotion is defined as the process of enabling people to increase control over, and to improve their health (WHO 1986). Health promotion involves engaging people in this process (Wallerstein & Freudenberg 1998) by focusing on people rather than on risk factors (Raeburn & Rootman 1998).

Health promotion as a process does not involve a single act and a clear outcome. This process is not static in space and time (Nutbeam 1998). The health promotion action embraces understanding changes among all participants and initial concerns from the community, not the health agency. This is, in essence, a decision-making process shaped by a broader context established by all relevant sectors and all levels in order to create supportive environments for health (WHO 1991b). Health promotion practice is adapted to the local needs and takes into account social, cultural and economic contexts. Health promotion works through strengthening community actions. At the heart of this process is the empowerment of communities, their ownership and control of the factors that create health. Another strategy of effective community action is community development that draws on existing community resources to increase self-help and social support and to develop flexible systems for strengthening public participation in health matters (WHO 1986). Community empowerment and participation are seen as essential factors in a democratic health promotion approach and the driving force for self-reliance and development (WHO 1991b). In health promotion, partnerships for health and social development are consolidated and expanded among different sectors at all community levels. Partners must mutually understand and respect each other. Through the sharing of expertise, skills, and resources, partnerships can offer mutual benefits for health (WHO 1997).

Community development

The historical origins of community development are exemplified by the rural development and planning efforts in France in the 1870s. Community development work in the USA was established early on for enhancing farming methods and home-making practices, and for agricultural research in rural areas in 1916 (Mitchell-Weaver 1990). The earlier stage of Taiwan's community development in the 1960s was dedicated to carrying out propaganda on various governmental policies (Ju 1999). Today, community development initiatives focus on identifying issues and problems affecting community life; developing and implementing plans for change; enhancing community strength and self-sufficiency; and establishing and maintaining cooperative and harmonious relationships (Labonte 1987). As such, community development is not a ‘health intervention’, neither is it a community-based programme, although all approaches may contribute to improving the community's health. Community development is viewed as a democratic process and a social process (Minkler 1990) and a means by which the community can become actively involved in the process of improving its well-being historically and currently.

(Minkler 1990) further described four key processes associated with community development that include facilitating community empowerment, increasing community competence, initiating as the people collectively recognize local needs and generating critical consciousness. Critical consciousness is essential to collectively recognize local needs and to assist the community in identifying attainable goals. Community development seeks to recognize the community's ability to solve its own problems and to support the further development of community health through partnership and empowerment processes. In this sense, CHD is health service that is not given to the community, but is created by it.

In summary, CHD is a developing and changing process that involves both the social and the health contexts. Community health development is also an integrated approach to community health care. It operates on the basis of three approaches to care, including primary care, health promotion and community development. Partnership and empowerment between community health nurses and the community are concurrently involved in the entire process of CHD practice to make the community change and to motivate the community to improve the community's well-being. Community health development not only provides basic health care services and health promotion practices, but it is also committed to promoting community development through sharing power, critically reflecting, and collectively participating in health action.

Appropriateness of using participatory action research for the evaluation of community health development

In recent years, PAR has been increasingly used in the field of community health (Koch et al. 2002). Nonetheless, little attention has been paid to examining its appropriateness. Throughout the process of discussing the theoretical and philosophical compatibility of CHD and PAR, justification for using PAR for the evaluation of CHD can be articulated clearly.

The nature of participatory action research

In recent years, community-based research and evaluation approaches have been shifting from ‘traditional’ research (e.g. the classical experiment) to ‘participatory’ research. This shift has occurred, partly because of community coalitions and participation (Connell et al. 1995) and also because of increasing academic research links to public health initiatives (Bruce 1995).

Since the 1970s, participatory research has transformed the concepts of action and participation so that community members become the driving force in the research process (Fals-Borda & Rahman 1991). There are ideological and methodological differences between participatory research and action research (Yeich & Levine 1992). Nonetheless, these approaches espouse many similar values and employ common methods so that some researchers have begun to use the term ‘participatory action research’ (McTaggart 1991; Reason 1994). The core principles of the PAR approach are:

1. Community participants and researchers cooperatively engage in issues of local concern and address the question of research relevance; Moreover, they contribute equally to the research process.
2. The process is democratic collaborative research and a bottom-up approach that focuses on locally defined priorities and perspectives.
3. Researchers and community members establish a partnership that involves a co-learning process.
4. The translation of research findings benefit the community to make informed decisions on collective actions.
5. Community members participate in the generation of local and useful knowledge that leads to effective change.
6. The researchers and participants join together to explore power inequities for an emancipatory educative process that leads to increased consciousness so that community participants can articulate their problems and initiate the solutions to them.
7. There is a way to balance research and community action (Cornwall & Jewkes 1995; Freire 1982; Wallerstein 1999).

Participatory action research methodology addresses a theory and analysis of how research should proceed, rather than dictates a particular research method. It may use different forms of qualitative and quantitative research. It is a process based on inclusive, participatory, and egalitarian attitudes (Cornwall & Jewkes 1995). This research is not conducted on or for, but with or by the community (Wallerstein 1999). Participatory action research is consistent with the epistemology of critical theory that considers the development of knowledge as a consciousness-raising, liberating act. Consciousness raising is a method involving the recognition of change that is achieved (Henderson 1995). Moreover, the philosophy of PAR is the valuing of experience and popular knowledge of people (Fals-Borda & Rahman 1991). Hence, the fundamental tenet of PAR focuses on the development of knowledge through the creation of critical consciousness leading to necessary action and effective change. This action and change process leads to the facilitation of community empowerment and the enhancement of community competence.

Compatibility in the theoretical and philosophical foundation of community health development and participatory action research

Aligning PAR with CHD is a critical step to enhance the rigor of the development of an evaluation study. Community health development and PAR differ in their basic ethos and intent. Although both are developmental processes, CHD is for the development of community health, whereas PAR is for the development of knowledge. The intent of CHD is to create collective participation in social and health actions using a grassroots approach. In contrast, PAR focuses on creating local knowledge using a bottom-up approach and collective concern. However, the common ultimate goal of CHD and PAR is to generate necessary action to create effective change. Furthermore, the research activities in PAR and the programme interventions in CHD are carried out ‘with’ or ‘by’ the community, instead of ‘on’ or ‘for’ the community. In CHD and PAR, community health nurses (researchers or outsiders) and the community participants (respondents or insiders) should employ partnership and empowerment strategies in the developmental process.

In CHD practice, the notion of health is socially constructed. Community health development focuses on community participation and community change, which are dynamic situations. The context of CHD is not fixed. Participatory action research is also a dynamic process involving a collaborative interaction between the community and the researcher rather than following a restricted and rigid research methodology. The process of inquiry is social and flexible (Kelly 1990). To summarize, the paradigm underpinning CHD is one that focuses on subjective measurement, understanding ‘lay’ experience through a holistic and ecological approach. The participatory paradigm is based on the notion that reality is a subjective truth to be discovered and a holistic construct (Reason 1993).

In empirical, community-based evaluation research, there is a linear causal mechanism underpinning the relationship between intervention input and outcome. It is not flexible enough to capture an understanding of the complex social and health phenomena in the CHD framework. Participatory action research is the synthesis of community participation, research and action that supports consciousness-raising on local issues of relevance and community strength for the problem solutions (Rains & Ray 1995). Upon examination, CHD and PAR share a similar theoretical and philosophical foundation. Participatory action research not only supports the evaluation of CHD, but also simultaneously enhances the development of CHD practice.

Conclusion

Community health development, an innovative and comprehensive framework for community health, demonstrates how incorporating the concepts of primary health care, health promotion, and community development and the concepts of partnership and empowerment synchronously permeate the entire framework. This process can lead to motivating the community to change and improve the community's well-being.

Based on the examination of theoretical and philosophical principles, PAR is compatible with CHD. Therefore, utilizing the PAR approach is appropriate for the methodological framework of CHD evaluation. Furthermore, using the PAR approach enhances the actualization of CHD.

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Keywords: Appropriateness; Community Health Development; Health Promotion; Participatory Action Research; Primary Health Care

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