REAT LAKES UNIVERSITY OF KISUMU TICH FACULTY DEPARTMENT OF COMMUNITY NUTRITION BACHELORS OF SCIENCE IN COMMUNITY NUTRITION YEAR 3/4 DISTANCE LEARNING MODE: MAY-AUG 2014 NUT 423: HEALTH PROMOTION COURSE MODULE Course Coordinator: Damaris Nelima Email:damarisnelima@yahoo.com Course facilitator:Dr. Rose Olayo Email:rose_olayo@yahoo.com 1 . What is Health Promotion? 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). Mid-stream we have primary prevention and health care, usually individual, for example attempts to reduce risk of contracting disease (educating smokers, vaccinating). And upstream we have health promotion including social policies and health promotion programmes, such as taxes on tobacco, smoke free legislation and advertising bans. This may include health education, which aims to reduce ill-health and increase positive health influencing people’s beliefs, attitudes and behaviour. Health Promotion has a dual role to prevent ill health and promote positive health.

“Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.” [Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986 WHO/HPR/HEP/95.1] [69]

A refined definition might be, "health promotion is the process of enabling individuals and communities to increase control over the determinants of health and thereby to improve their

health." Among 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 "determinants of health" 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.

Another 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 skills, creating supportive environments, strengthening communities, influencing governments to enact healthy public policies, and reorientating and improving health services.”

Definitions

4.1 What is Community?

The US Government 2010 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 Organization, 1998; US Department of Health and Human Services, 2000). Members 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. They exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them.

4.2 What is Community Development?

Community development seeks to empower individuals and groups of people, with the skills they need to advocate on their own behalf, improve their lives, and provide communities with access to resources.

Or put another way…. Community development, in very simple terms, is the process of developing social capital. It is a process that emphasises the importance of working with people as they define their own goals, mobilise resources, and develop action plans for addressing problems they have collectively identified. [22]

Definition of social capital (Putnam 1993): The community cohesion resulting from high levels of civic identity and the associated phenomenon of trust, reciprocity and civic engagement. Four characteristics: the existence of community networks, formal or informal, civic engagement (particularly in networks), local identity and a sense of solidarity and equality with other community networks, and norms of trust and reciprocal help and support.

Social 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 work to produce a resource called social capital. Social capital is critical to the health, wealth and wellbeing of populations. It is a key indicator of the building of healthy communities through collective and mutually beneficial interaction and accomplishments. Recent research has linked these types of activities to improved health outcomes.

What is 'health' There are several definitions of health (see 'Glossary'). The one we quote here comes from the World Health Organization Constitution written in 1948. Health is a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity. The health of an individual needs to be considered in the context of the family, group and community environment. Individual and community health are also affected by what is happening in the wider community such as changes in public policies and legislation, and technical developments (also see 'Introduction' and the section on 'Changing the Wider Environment'). Health promotion strategies can be broad, focusing on changing the

environment around the individual. They can also be specific, focusing on the individual and the groups to which the person belongs. What is a 'community' The word 'community' can have several different meanings. The definition we are using is from the World Health Organisation. Community A specific group of people, often living in a defined geographical area, who share a common culture, values and norms, are arranged in a social structure according to relationships which the community has developed over a period of time. Members 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. They exhibit some awareness of their identity as a group, and share common needs and a commitment to meeting them WHO 1998:5

What is 'community development' Community development is based on the idea that local people already know what the issues and problems are and how to solve them. The community development approach can assist communities to undertake projects in planned and structured ways, recognising the strengths and knowledge of local people. Community development refers to the process of facilitating the community's awareness of the factors and forces which affect their health and quality of life, and ultimately helping to empower them with the skills needed for taking control over and improving those conditions in their community which affect their health and way of life. It often involves helping them to identify issues of concern and facilitating their efforts to bring about change in these areas. Hawe et al 1990:203

HEALTH PROMOTION Health promotion is the process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or

cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being.

Importance of communication in health promotion at individual level

1. Effective health communication can help raise awareness of health risks and solutions, provide the motivation and skills needed to reduce these risks 2. Health communication can help individuals find support from other people in similar situations, and affect or reinforce attitudes (PLWHA) 3. Health communication also can increase demand for appropriate health services and decrease demand for inappropriate health services (access to family planning among the adolescents). 4. It can make available information to assist in making complex choices, such as selecting health plans, care providers, and treatments.

1 . Ottawa Charter for Health Promotion The first International Conference on Health Promotion, meeting in Ottawa this 21st day of November 1986, hereby presents this CHARTER for action to achieve Health for All by the year 2000 and beyond. The fundamental conditions and resources for health are:
• • • • • • • •

peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.

Advocate Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioural and biological factors can all favour health or be harmful to it. Health promotion action aims at making these conditions favourable through advocacy for health. Enable Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. This must apply equally to women and men.

mediate The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action through multisectoral approach all concerned: by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media. People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health. Health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take into account differing social, cultural and economic systems.

Health Promotion Action Means: Build Healthy Public Policy Health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health. Health promotion policy combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change. It is coordinated action that leads to health, income and social policies that foster greater equity. Joint action contributes to

ensuring safer and healthier goods and services, healthier public services, and cleaner, more enjoyable environments. Health promotion policy requires the identification of obstacles to the adoption of healthy public policies in non-health sectors, and ways of removing them. The aim must be to make the healthier choice the easier choice for policy makers as well. Create Supportive Environments Our societies are complex and interrelated. Health cannot be separated from other goals. The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. The overall guiding principle for the world, nations, regions and communities alike, is the need to encourage reciprocal maintenance - to take care of each other, our communities and our natural environment. The conservation of natural resources throughout the world should be emphasized as a global responsibility.

Changing patterns of life, work and leisure have a significant impact on health. Work and leisure should be a source of health for people. The way society organizes work should help create a healthy society. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable.

Systematic assessment of the health impact of a rapidly changing environment - particularly in areas of technology, work, energy production and urbanization - is essential and must be followed by action to ensure positive benefit to the health of the public. The protection of the natural and built environments and the conservation of natural resources must be addressed in any health promotion strategy.

Strengthen Community Actions Health promotion works through concrete and effective community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health. At the heart of this process is the empowerment of communities - their ownership and control of their own endeavours and destinies. Community development draws on existing human and material resources in the community to enhance self-help and social support, and to develop flexible systems for strengthening public

participation in and direction of health matters. This requires full and continuous access to information, learning opportunities for health, as well as funding support. Develop Personal Skills Health promotion supports personal and social development through providing information, education for health, and enhancing life skills. By so doing, it increases the options available to people to exercise more control over their own health and over their environments, and to make choices conducive to health. Enabling people to learn, throughout life, to prepare themselves for all of its stages and to cope with chronic illness and injuries is essential. This has to be facilitated in school, home, work and community settings. Action is required through educational, professional, commercial and voluntary bodies, and within the institutions themselves.

Reorient Health Services The responsibility for health promotion in health services is shared among individuals, community groups, health professionals, health service institutions and governments. They must work together towards a health care system which contributes to the pursuit of health. The role of the health sector must move increasingly in a health promotion direction, beyond its responsibility for providing clinical and curative services. Health services need to embrace an expanded mandate which is sensitive and respects cultural needs. This mandate should support the needs of individuals and communities for a healthier life, and open channels between the health sector and broader social, political, economic and physical environmental components.

Reorienting health services also requires stronger attention to health research as well as changes in professional education and training. This must lead to a change of attitude and organization of health services which refocuses on the total needs of the individual as a whole person.

Moving into the Future Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love. Health is created by caring for oneself and others, by being able to take decisions and have control over one's life circumstances, and by ensuring that the society one lives in creates conditions that allow the attainment of health by all its members.

Caring, holism and ecology are essential issues in developing strategies for health promotion. Therefore, those involved should take as a guiding principle that, in each phase of planning, implementation and evaluation of health promotion activities, women and men should become equal partners.

Commitment to Health Promotion The participants in this Conference pledge:
1.

To move into the arena of healthy public policy, and to advocate a clear political commitment to health and equity in all sectors;

2.

To counteract the pressures towards harmful products, resource depletion, unhealthy living conditions and environments, and bad nutrition; and to focus attention on public health issues such as pollution, occupational hazards, housing and settlements;

3.

To respond to the health gap within and between societies, and to tackle the inequities in health produced by the rules and practices of these societies;

4.

To acknowledge people as the main health resource; to support and enable them to keep themselves, their families and friends healthy through financial and other means, and to accept the community as the essential voice in matters of its health, living conditions and well-being;

5.

To reorient health services and their resources towards the promotion of health; and to share power with other sectors, other disciplines and, most importantly, with people themselves;

6.

To recognize health and its maintenance as a major social investment and challenge; and to address the overall ecological issue of our ways of living.

The Conference urges all concerned to join them in their commitment to a strong public health alliance.

Call for International Action

The Conference calls on the World Health Organization and other international organizations to advocate the promotion of health in all appropriate forums and to support countries in setting up strategies and programmes for health promotion. The Conference is firmly convinced that if people in all walks of life, nongovernmental and voluntary organizations, governments, the World Health Organization and all other bodies

concerned join forces in introducing strategies for health promotion, in line with the moral and social values that form the basis of this CHARTER, Health For All by the year 2000 will become a reality. The Bangkok Charter for Health Promotion

The Bangkok Charter identifies actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion. The Bangkok Charter affirms that policies and partnerships to empower communities, and to improve health and health equality, should be at the centre of global and national development.

The Bangkok Charter complements and builds upon the values, principles and action strategies of health promotion established by the Ottawa Charter for Health Promotion and the recommendations of the subsequent global health promotion conferences which have been confirmed by Member States through the World Health Assembly.

Audience The Bangkok Charter reaches out to people, groups and organizations that are critical to the achievement of health, including: • governments and politicians at all levels • civil society • the private sector • international organizations, and • the public health community.

CORE THEORIES OF HEALTH PROMOTION

Why Is Theory Important to Health Promotion and Health Behavior Practice? Effective public health, health promotion, and chronic disease management programs help people maintain and improve health, reduce disease risks, and manage chronic illness. They can improve the well-being and self-sufficiency of individuals, families, organizations, and communities. Usually, such successes require behavior change at many levels, (e.g., individual, organizational, and community).

Not all health programs and initiatives are equally successful, however. Those most likely to achieve desired outcomes are based on a clear understanding of targeted health behaviors, and the environmental context in which they occur. Practitioners use strategic planning models to develop and manage these programs, and continually improve them through meaningful evaluation. Health behavior theory can play a critical role throughout the program planning process. What Is Theory? A theory presents a systematic way of understanding events or situations. It is a set of concepts, definitions, and propositions that explain or predict these events or situations by illustrating the relationships between variables. Theories must be applicable to a broad variety of situations. They are, by nature, abstract, and don’t have a specified content or topic area. Like empty coffee cups, theories have shapes and boundaries, but nothing inside. They become useful when filled with practical topics, goals, and problems.

1. Concepts are the building blocks—the primary elements—of a theory. 2. Constructs are concepts developed or adopted for use in a particular theory. The key concepts of a given theory are its constructs. 3. Variables are the operational forms of constructs. They define the way a construct is to be measured in a specific situation. Match variables to constructs when identifying what needs to be assessed during evaluation of a theory-driven program. 4. Models may draw on a number of theories to help understand a particular problem in a certain setting or context. They are not always as specified as theory.

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Most health behavior and health promotion theories were adapted from the social and behavioral sciences, but applying them to health issues often requires that one be familiar with epidemiology and the biological sciences. Health behavior and health promotion theories draw upon various disciplines, such as psychology, sociology, anthropology, consumer behavior, and marketing. Many are not highly developed or have not been rigorously tested. Because of this, they often are called conceptual frameworks or theoretical frameworks; here the terms are used interchangeably.

How Can Theory Help Plan Effective Programs? Theory gives planners tools for moving beyond intuition to design and evaluate health behavior and health promotion interventions based on understanding of behavior. It helps them to step back and consider the larger picture. Like an artist, a program planner who grounds health

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Interventions in theory creates innovative ways to address specific circumstances. He or she does not depend on a “paint-bynumbers” approach, re-hashing stale ideas, but uses a palette of behavior theories, skillfully applying them to develop unique, tailored solutions to problems. Using theory as a foundation for program planning and development is consistent with the current emphasis on using evidence-based interventions in public health, behavioral medicine, and medicine. Theory provides a road map for studying problems, developing appropriate interventions, and evaluating their successes. It can inform the planner’s thinking during all of these stages, offering insights that translate into stronger programs. Theory can also help to explain the dynamics of health behaviors, including processes for changing them, and the influences of the many forces that affect health behaviors, including social and physical environments. Theory can also help planners identify the most suitable target audiences, methods for fostering change, and outcomes for evaluation. Researchers and practitioners use theory to investigate answers to the questions of “why,” “what,” and “how” health problems should be addressed. By seeking answers to these questions, they clarify the nature of targeted health behaviors. That is, theory guides the search for reasons why people do or do not engage in certain health behaviors; it helps pinpoint what planners need to know before they develop public health programs; and it suggests how to devise program strategies that reach target audiences and have an impact. Theory also helps to identify which indicators should be monitored and measured during program evaluation. For these reasons, program planning, implementation, and monitoring processes based in theory are more likely to succeed than those developed without the benefit of a theoretical perspective.

Explanatory Theory and Change Theory Explanatory theory describes the reasons why a problem exists. It guides the search for factors that contribute to a problem (e.g., a lack of knowledge, self-efficacy, social support, or resources), and can be changed. Examples of explanatory theories include the Health Belief Model, the Theory of Planned Behavior, and the Precaution Adoption Process Model.

Change theory guides the development of health interventions. It spells out concepts that can be translated into program messages and strategies, and offers a basis for program evaluation. Change theory helps program planners to be explicit about their assumptions for why a 13

program will work. Examples of change theories include Community Organization and Diffusion of Innovations. Figure 1. illustrates how explanatory theory and change theory can be used to plan and evaluate programs.

Fitting Theory to the Field of Practice This monograph includes descriptions and applications of some theories that are central to health behavior and health promotion practice today. No single theory dominates health education and promotion, nor should it; the problems, behaviors, populations, cultures, and contexts of public health practice are broad and varied. Some theories focus on individuals as the unit of change. Others examine change within families, institutions, communities, or cultures. Adequately addressing an issue may require more than one theory, and no one theory is suitable for all cases.

Because the social context in which behavior occurs is always evolving, theories that were important in public health education a generation ago may be of limited use today. At the same time, new social science research allows theorists to refine and adapt existing theories. A recent Institute of Medicine report2 observed that several theorists have converged in their

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views, identifying several variables as central to behavior change. As a result, some constructs, such as self-efficacy, are central to multiple theories. Effective practice depends on using theories and strategies that are appropriate to a situation. One of the greatest challenges for those concerned with behavior change is learning to analyze how well a theory or model “fits” a particular issue. A working knowledge of specific theories, and familiarity with how they have been applied in the past, improves skills in this area. Selecting an appropriate theory or combination of theories helps take into account the multiple factors that influence health behaviors. The practitioner who uses theory develops a nuanced understanding of realistic program outcomes that drives the planning process.

Choosing a theory that will bring a useful perspective to the problem at hand does not begin with a theory (e.g., the most familiar theory, the theory mentioned in a recent journal article, etc.). Instead, this process starts with a thorough assessment of the situation: the units of analysis or change, the topic, and the type of behavior to be addressed. Because different theoretical frameworks are appropriate and practical for different situations, selecting a theory that “fits” should be a careful, deliberate process.

HEALTH PROMOTION INTERVENTIONS

A health intervention is an effort to promote behaviors that optimize mental and physical health or discourage or reframe behaviors considered potentially health-averse. To the former category belong the alignment of one or more forms of authority, influence, or evidence— familial relations, scientific studies, health education, mass media opinions, dominant social norms, organized religion, legal enforcements, cultural myths, among many others—with behaviors intended to regulate the mind and body into a state of productivity conducive to, or at least harmlessness not subtractive from, the prevailing norms of a given society. It is perhaps not surprising that in an era when the resources for health promotion are limited and the expectations as to what can be achieved are high, that ‘sustainability’ has become a familiar catch-cry. Yet all too often enthusiasm has overshadowed critical reflection on whether aiming for sustainability is warranted, let alone feasible.

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There has been a lack of consensus about conceptual and operational definitions of sustainability in respect to health programmes (Shediac-Rizkallah and Bone, 1998). For health promotion, sustainability may refer to intervention effects or the means by which these are produced—the programmes and agencies that implement interventions. The aim of health promotion is to produce intervention effects that may be sustained over time.

In the health promotion literature, there has been considerable concern about the need to maintain and retain health promotion programmes long term [e.g. (Schwartz et al., 1993;Bracht et al., 1994)]. While there is no doubt that such efforts are often warranted to ensure desirable effects, there are situations in which the retention of a health promotion agency may be more important than maintaining particular programmes in order to ensure an ongoing capacity for health promotion (Stern and Gibelman, 1990;Rosenberg and Weissman, 1995).

Furthermore, in some circumstances health promotion effects will be sustained without the need for ongoing intervention. When this occurs, efforts to sustain programmes are not warranted (Green, 1989). We have explored more fully the issues surrounding these differing targets for sustainability (programmes, agencies or effects) elsewhere (Crisp and Swerissen, 2002).

Knowing what it is that one seeks to sustain is a useful start, but whether such aspirations are realistic is another question. Unfortunately, to date the not insubstantial body of literature on sustainability in health promotion is not particularly helpful to decision makers. Definitions are confused, there are relatively few empirical studies, and explanatory models tend to be relatively simplistic and descriptive, often failing to consider the substantial literature on learning theory, community action and social policy that has addressed non-health-related issues. Here we draw on this literature to provide some guidance for the development of a policy on sustainability for health promotion. Previous SectionNext Section

SUSTAINABILITY AND LEVELS OF SOCIAL ORGANIZATION

In developing a policy on sustainability for health promotion, it is necessary to be able to differentiate between (i) levels of social organization which are the focus of change, (ii) the 16

programmes and agencies which are the means employed to achieve change, and (iii) the outcomes or effects that are achieved. Having previously discussed the sustainability of programmes, agencies and effects, we now turn to the complex relationship between the means of intervention (programmes and agencies), the outcomes or effects that are achieved and levels of social organization.

Levels of organization A number of social intervention theorists have proposed that the social order of society is made up of increasingly complex levels of organization [e.g. (Rappaport, 1977)]. In this respect we would argue that health promotion interventions may be focussed on individual action, the physical and social organization of settings, and broader societal and institutional processes (Swerissen et al., 2001). Although these levels of social organization are nested within one another, they involve different social processes.

Individual change Interestingly, a good deal is known about the effectiveness and sustainability of health promotion interventions that are aimed at individual behaviour change. There is now a significant body of evidence on principles that underpin the most effective interventions to address behavioural risk factors [e.g. (Glanz and Rimmer, 1990)]. Most of these interventions are aimed at changing individual behaviour through provision of information through education and social marketing to change knowledge, attitudes and beliefs that are the precursors of behaviour change. However, in the absence of other measures, even well designed educational and social marketing interventions have a relatively low success rate in producing changes in behavioural intention for most common behavioural health risks [e.g. (Mittlemark et al., 1993;Winkleby, 1994;Fortmann et al., 1995;Tudor-Smith et al., 1998)]. Moreover, even when individuals modify behavioural health risks, there is a high probability that they will not maintain the change they make (Quigley and Marlatt, 1999).

Interactive and individually tailored intervention programmes for behavioural health risks lead to higher levels of sustained behaviour change than social marketing. These programmes have adapted social learning theory and often introduce strategies to promote the maintenance and generalization of intervention effects. But it is difficult to recruit

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participants for them. It is also clear that behavioural risk factor interventions are more likely to succeed with more affluent, well educated groups with greater control over the social and material resources that affect their lives (Jarvis and Wardle, 1999). Behavioural programmes tend to atomize health promotion. Because the environmental and social consequences for health-related action are not directly addressed by working with individuals and small groups, sustainable behaviour change is difficult to achieve. Neither do skills learnt to modify behaviour in relation to one form of health risk readily generalize to address others, and nor do skills learnt by one person necessarily transfer to another [e.g. (King and Remenyi, 1986)].

Consequently, behaviour change programmes targeted at individuals often require ongoing funding and resources if they are to have a sustained impact on populations. Fundamentally, behaviour change programmes targeted at individuals do not alter the social and environmental conditions that promote and maintain the behavioural risks that are the focus of intervention.

Organizational change It is clear that health risks and outcomes are strongly associated with social and environmental circumstance [e.g. (Wilkinson and Marmot, 1998)]. In part, health promotion interventions have sought to address social and environmental determinants of health by organizational interventions in a range of settings, including schools, work places, community, sporting and recreational organizations.

There is a significant body of evidence on the factors that affect the sustainability of settinglevel interventions (Kickbusch, 1996;Leeder, 1997;Nutbeam, 1997). The principles and strategies for social intervention in organizations and communities are well developed [e.g. (Rappaport, 1977)]. In relation to physical settings, for example, there is a long history of effective and sustained public health intervention to prevent the spread of infectious disease and to reduce the impact of environmental toxins, primarily through the design and regulation of the physical environment and production processes. These interventions reduce risk by redesigning the physical environment and individual behaviour alters accordingly.

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More recently, there has been greater emphasis on the modification of organizational practices that impact on chronic disease and injury. These include the availability of smokefree settings, alcohol serving practices, food choices and sun protection measures (Corti etal., 1995;Corti et al., 1997). There is considerable evidence that once organizational policies and practices are adopted and put in place, they are maintained over time without the need for ongoing intervention programmes (Rothman, 1974;Jackson, 1985;Rappaport, 1995). Organizational interventions draw heavily on the literature on organizational change and consultation. The sustainability of setting-level change within organizations has more to do with the changes to an organization's rules and practices rather than the behaviour of particular individuals. The intervention model assumes that changes to organizational rules and practices have a direct impact on the behaviour of individuals. But because settings are adaptive and dynamic, it is often difficult to get the ‘rules of the game’ to change. When the basic equilibrium of a social system is threatened there is often a ‘backlash’, and it is important that interventions take this likelihood into account. Organizations also vary in the extent to which their pre-existing structures and processes are able to facilitate organizational change to promote health. Considerable organizational development may be required where these do not exist. Although organizational change has greater potential to produce sustainable health promotion effects, there is a trade off between the effort required to change organizational practices and the potential for long-term sustainable change.

Social research on organizational change suggests that intervention programmes that achieve setting-level change need longer time frames and different skills and resources than individual-level change strategies in order to produce sustainable changes in practice (Rappaport, 1977). It is also worth noting that contractual relationships between funding organizations and organizations that provide programmes represent a unique form of organizational intervention insofar as the funding organization is effectively in a position where it can purchase organizational or structural change. The disadvantage of purchasing structural change is that organizations will resist withdrawal of funds once structural change has been effectively implemented, even when no further resources are actually required for implementation. One possible strategy to overcome this problem is to differentiate between the costs of implementing structural change and the incentives for maintaining it.

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Community action Setting-level interventions also include rela-tionships between organizations, and between organizations and individuals (Crisp et al., 2000). Social intervention strategies and tactics for community organization and development emphasize the use of social planning and social action models. There is now a significant literature on the use of social planning and social action models for community development and the creation of new settings. These strategies often require more intensive resources over much longer time frames than those required for organizational- or individual-level change (Goodman et al., 1993;Wickizer et al., 1998). Potentially, community action strategies may have a significant impact on the physical and social determinants of health across the organizations and communities involved. However, there is usually significant resistance to the resource redistribution and the changes to the existing social relationships and practices concerned. Intervention programmes therefore require long-term support if they are to be sustained, and if they are withdrawn too early programme effects may disappear quickly.

Institutional change Institutional change is usually focused on key societal decision makers and those who have direct influence upon them. Its focus is on achieving major policy change, redistribution of resources, and the establishment or reform of legislation and regulation. The intervention strategies that are employed are largely those of social advocacy, which usually includes the provision of information, lobbying, and the demonstration of community support. These interventions may involve the creation of new organizations and networks for this purpose, which require substantial ongoing resources over an extended period of time to achieve success. Moreover, it is likely that significant counter pressure and resistance to change will occur. It is unlikely that institutional change strategies can be sustained without ongoing support. However, institutional change, once achieved, has a pervasive effects on communities, organizations and individuals. Moreover, that change is usually sustained over time, although the capacity for its reversal should not be underestimated when it remains contested in the community.

Interventions and levels of social organization It is important to note, as Watzlawick and coworkers have pointed out, that attempts to deal with one level of social organization in terms of another are doomed to confusion: For 20

example, the economic behaviour of the population of a large city cannot be understood in terms of the behaviour of one inhabitant multiplied by, say 4 million … a population of 4 million is not just quantitatively but qualitatively different from an individual, because it involves systems of interaction among individuals. [(Watzlawick et al., 1974), p. 6.] They distinguish between two types of change that social (and health) interventions may produce: first and second order change. For them, first order change is change within a system that itself does not change. Interventions seek to change individuals (or their immediate environment) so that they are better able to adapt to the existing settings and institutions. In contrast, second order change produces change in the fundamental rules and processes of social systems. Often this requires change to the rules for the allocation and distribution of access, information and resources (Watzlawick et al., 1974).

According to Watzlawick and coworkers (Watzlawick et al., 1974), confusion of first and second order change leads to errors of ‘logical typing’. As a result, inappropriate interventions are implemented. This may include attempts to change organizational and community processes when individual change strategies are warranted, but typically it involves the use of individual change strategies when problems are a function of underlying social determinants. For example, this might include a focus on ‘lifestyle’ issues for a high incidence of chronic and systemic disease associated with discrimination and exclusion of indigenous groups.

Often errors of logical typing attribute health problems to the deficits of the individuals who manifest them, whether those deficits are seen as environmental disadvantage (e.g. poor living conditions of aboriginal Australians) or an inherent characteristic of the individual (genetic characteristics of people with disabilities). Either way, the institutional and organizational factors that lead to the disadvantage are not in question. Instead interventions seek to change individuals (or their immediate environment) so that they are better able to adapt to the existing settings and institutions, when it is in fact the response of the social system to the characteristics of the individual (e.g. aboriginality) that underpins the problem. This leads to ‘victim blaming’ (Ryan, 1971).

In contrast, second order change, which produces change in the fundamental rules and processes of social systems, values the strengths of those who are seen to have problems. It 21

requires the promotion of self determination and partnerships, rather than seeking to impose well meaning, but nevertheless victim blaming solutions. However it also means the redistribution of power and control over important resources; as a result, second order change is usually much more difficult to achieve.

It is also important to note that most models of health promotion intervention now recognize the interactive nature of the relationships between biological, individual, setting and institutional determinants. Sociological and ecological models of human behaviour emphasize that social systems are dynamic, interdependent and adaptive (Hawe, 1994). What is viewed from the outside as unhealthy or maladaptive practice or behaviour needs to be seen in a social and historical context [e.g. (Trickett et al., 1972)].

Interventions that are pitched at the wrong level of the social system are unlikely to be effective, let alone sustainable. For health promotion, this has been characterized as the shift from risk factor interventions to interventions aimed at risk conditions. Risk factor interventions are conceptualized at the individual level of social organization. Typically they focus on behaviours such as smoking, eating and physical activity.

On the other hand, risk conditions such as social cohesion and support, income security and access to social, educational and health services, are more usually thought of as a function of organizational, community and institutional levels of social organization. For example, there is now strong interest in findings that communities with high levels of income inequality tend to have less social cohesion, more violent crime and higher death rates. There is also evidence that friendship, good social relations and strong supportive networks improve health at home, at work and in the community, whereas low social support has been linked to increased rates of premature death, poorer chances of survival after heart attack, lesser feelings of well-being, more depression, greater risk of pregnancy complications and higher levels of disability from chronic diseases [e.g. (Wilkinson and Marmot, 1998)].

Individual action occurs within, and is maintained by a social context. Interventions that isolate individual action from its social context are unlikely to produce sustainable health gain in the absence of change to the organizational, community and institutional conditions that make up the social context. 22

Health promotion programmes are more likely to produce sustainable effects if they address appropriate levels of social organization in seeking to achieve health promotion outcomes. Programme design and implementation should take into account the evidence linking intervention strategies, levels of social organization and the sustainability of programme effects. Furthermore, programmes should differentiate between intervention strategies to promote: (i) capacity building to develop and maintain the infrastructure required for health promotion; (ii) changes in individual, organizational, community and institutional levels of social organization that will lead to health gain; and (iii) the likely sustainability of these changes and the ongoing need for programme resources over time. Judgements about the sustainability of health outcomes that result from health promotion should also take into account the need to maintain strategic support for health promotion interventions, the importance of retaining an ongoing capacity for health promotion interventions and the difficulty in demonstrating the health gain in the short term. Notwithstanding the benefits which can accrue to individuals, organizations or communities as a result of sustainable health promotion efforts, financial considerations often underpin the desires of funding agencies for sustainability. However, while long-term savings may eventuate, effecting sustainable change may require substantial financial resources and support over a long period of time. In fact many health promotion efforts fail to become sustainable because insufficient resources are provided in the short to medium time frame (Goodman et al., 1993). Indeed, funding bodies that are serious about facilitating sustainable health promotion efforts should be asking themselves whether they are providing sufficient funds to projects.

Some resistance to funding programme or effect sustainability should be anticipated, especially from those whose income stream is threatened by changes such as moving away from programmes that focus on changing individual behaviour towards programmes that seek to improve health by changing social environments. It may be that such changes need to be phased in, while at the same time working with current grant recipients to encourage them to explore new avenues in health promotion for which there is greater potential for sustainability. Arguably, to some degree, funding bodies must take responsibility for socializing recurrent grant recipients' expectations of what are appropriate and effective health promotion interventions. Consequently changes in funding policy and practices should be accompanied by providing information, if not training, about newly preferred funding priorities. 23

Strategies for health promotion in a globalized world

Effective interventions Progress towards a healthier world requires strong political action, broad participation and sustained advocacy. Health promotion has an established repertoire of proven effective strategies which need to be fully utilized. Required actions To make further advances in implementing these strategies, all sectors and settings must act to:

• advocate for health based on human rights and solidarity • invest in sustainable policies, actions and infrastructure to address the determinants of health • build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and health literacy • regulate and legislate to ensure a high level of protection from harm and enable equal opportunity for health and well-being for all people • partner and build alliances with public, private, nongovernmental and international organizations and civil society to create sustainable actions.

Commitments to Health for All

Rationale The health sector has a key leadership role in the building of policies and partnerships for health promotion. An integrated policy approach within government and international organizations, as well as a commitment to working with civil society and the private sector and across settings, are essential if progress is to be made in addressing the determinants of health.

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1 . Make the promotion of health central to the global development agenda

Strong intergovernmental agreements that increase health and collective health security are needed. Government and international bodies must act to close the health gap between rich and poor. Health promotion must become an integral part of domestic and foreign policy and international relations, including in situations of war and conflict. This requires actions to promote dialogue and cooperation among nation states, civil society, and the private sector. These efforts can build on the example of existing treaties such as the World Health Organization Framework Convention for Tobacco Control.

2 . Make the promotion of health a core responsibility for all of government

All governments at all levels must tackle poor health and inequalities as a matter of urgency because health is a major determinant of socioeconomic and political development. Local, regional and national governments must: • give priority to investments in health, within and outside the health sector • provide sustainable financing for health promotion.

To ensure this, all levels of government should make the health consequences of policies and legislation explicit, using tools such as equity-focused health impact assessment.

3. Make the promotion of health a key focus of communities and civil society

Communities and civil society often lead in initiating, shaping and undertaking health promotion. They need to have the rights, resources and opportunities to enable their contributions to be amplified and sustained. In less developed communities, support for capacity building is particularly important. Well organized and empowered communities are highly effective in determining their own health, and are capable of making governments and the private sector accountable for the health consequences of their policies and practices.

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Civil society needs to exercise its power in the marketplace by giving preference to the goods, services and shares of companies that exemplify corporate social responsibility. Grass-roots community projects, civil society groups and women’s organizations have demonstrated their effectiveness in health promotion, and provide models of practice for others to follow. Health professional associations have a special contribution to make.

4 . Make the promotion of health a requirement for good corporate practice

The corporate sector has a direct impact on the health of people and on the determinants of health through its influence on: • local settings • national cultures • environments, and • wealth distribution.

The private sector, like other employers and the informal sector, has a responsibility to ensure health and safety in the workplace, and to promote the health and well-being of their employees, their families and communities. The private sector can also contribute to lessening wider global health impacts, such as those associated with global environmental change by complying with local national and international regulations and agreements that promote and protect health. Ethical and responsible business practices and fair trade exemplify the type of business practice that should be supported by consumers and civil society, and by government incentives and regulations.

A global pledge to make it happen

All for health Meeting these commitments requires better application of proven strategies, as well as the use of new entry points and innovative responses. Partnerships, alliances, networks and collaborations provide exciting and rewarding ways of bringing people and organizations together around common goals and joint actions to improve the health of populations. 26

Each sector – intergovernmental, government, civil society and private – has a unique role and responsibility.

Closing the implementation gap Since the adoption of the Ottawa Charter, a significant number of resolutions at national and global level have been signed in support of health promotion, but these have not always been followed by action. The participants of this Bangkok Conference forcefully call on Member States of the World Health Organization to close this implementation gap and move to policies and partnerships for action.

Call for action Conference participants request the World Health Organization and its Member States, in collaboration with others, to allocate resources for health promotion, initiate plans of action and monitor performance through appropriate indicators and targets, and to report on progress at regular intervals. United Nations organizations are asked to explore the benefits of developing a Global Treaty for Health.

Worldwide partnership This Bangkok Charter urges all stakeholders to join in a worldwide partnership to promote health, with both global and local engagement and action.

Commitment to improve health We, the participants of the 6th Global Conference on Health Promotion in Bangkok, Thailand, pledge to advance these actions and commitments to improve health.

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Importance of Communication in Health Promotion at Community Level

1. Effective health communication can be used to influence the public agenda, advocate for policies and programs, promote positive changes in the socioeconomic and physical environment 2. Improve the delivery of public health and health care services, and encourage social norms that benefit health and quality of life. 3. A development strategy that uses communication approaches can reveal people ’s underlying attitudes and traditional wisdom 4. Help people to adapt their views and to acquire new knowledge and skills and spread new social messages to large audiences.

Successful health promotion efforts increasingly rely on multidimensional interventions to reach diverse audiences about complex health concerns, and communication is integrated from the beginning with other components, such as community-based programs, policy changes, and improvements in services and the health delivery system.

How can one go about "doing" health promotion?

The following strategies, which are often combined, are commonly used:

•

Creating supportive environments: Activities aimed at establishing policies that support healthy physical, social and economic environments (WHO, 1998).

•

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, knowledge, and life skills conducive to individual and community health (PAHO, 1996; WHO, 1998).

•

Health communication: A 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 28

collective health, as well as increase awareness of the importance of health in development (WHO, 1998). • Self-help: Actions taken by lay persons to mobilize the necessary resources to promote, maintain or restore the health of individuals or communities through self-care activities such as self-medication, self-treatment and first aid in the normal social context of people's everyday lives (WHO, 1998). • Organisational development: A 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 organization, with a high level of cohesion, well-being and satisfaction on the part of all those involved (Raeburn & Rootman, 1998). • Community development / action: A 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 skills to address health priorities and meet respective health needs (WHO, 1998). • Healthy public policy: Formal statements that demonstrate concern for heath and equity and which make healthy choices possible or easier for citizens, through creating supportive social and physical environments that enable people to lead healthy lives ( PAHO, 1996; WHO, 1998). • Advocacy: A 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 (PAHO, 1996; WHO, 1998). • Research: Information which links 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, asks meaningful questions and is systematic and rigorous (Naidoo & Wills, 1998). Evaluation research is formal or systematic activity, where assessment is linked to original intentions and is fed back into the planning process (Naidoo & Wills, 2000)." • Medical approach: Focused on disease and biomedical explanations of health. Narrow concept of disease (ignore social/environmental dimensions) e.g. immunisation, screening

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The notion of social capital represents a way of thinking about the broader determinants of health and about how to influence them through community-based approaches to reduce inequalities in health and wellbeing. 39 A focus on social capital supports a balance of strategies that address behaviour and those that focus on the settings in which people live, work and play. The 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, take action to promote health. Simple measures, such as providing space for people to meet, may be as health promoting as providing health information in an effort to change behaviour.

Service providers can also enhance the social capital within a community by supporting community projects 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 working with the local sporting club to encourage all parts of the community to participate in sporting activities.

4.3 What are Community Development Approaches to Health Promotion? (Literature Abstracts) The evidence suggests that there has been a shift to looking at the social, economic, political, and environmental determinants of health because other methods of ill-health reduction have failed. Therefore, the argument goes, it is necessary to develop communities themselves to take control of their own health agenda to tackle these health issues from the source. However, developing communities brings its own problems; problems of definition; and tensions between the various agenda setters and resource holders.

The suggestion is, in much of the literature, although not clearly proven, that the only way left to go forward is community development, and some writers suggest that partnerships can be and need to be forged between communities, health service providers, and academics.

Below are some abstracts from the literature review, theorising about community development approaches and its barriers. This is followed by a discussion on the lack of

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comparable evidence and the difficulty in defining effectiveness or success in looking at interventions; some examples of specific interventions; a discussion of what community development approaches should or must include; and finally some notes on empowerment and partnership.

Social, political, economic and environmental determinants of health

“Recent 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 risk of disease and adverse outcomes from disease.

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.

Through the Charter, health promotion has come to be understood as public health action which is directed towards improving people's control over all modifiable determinants of health. This includes not only personal behaviours, but also the public policy, and living and working conditions which influence behaviour indirectly, and have an independent influence on health.

(This more sophisticated approach to public health action is reinforced by accumulated evidence concerning the inadequacy of overly simplistic interventions of the past. To take a concrete example, efforts to communicate to people the benefits of not smoking, in the absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are doomed to failure. A more comprehensive approach is required which explicitly acknowledges social and environmental influences on lifestyle choices and addresses such influences alongside efforts to communicate with people. Thus, more comprehensive approaches to tobacco control are now adopted around the world. Alongside efforts to communicate the risks 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

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environmental bans. This more comprehensive approach is not only addressing the individual behaviour, but also some of the underlying social and environmental determinants of that behaviour.)

Insufficiency of education alone It is now well understood from experiences in addressing specific public health problems of tobacco control, injury prevention and prevention of illicit drug use, and the more general challenge of achieving greater equity in health, that education alone is generally insufficient to achieve major public health goals.

“More 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. Such an approach corresponds with increased interest in understanding the complex issues that compromise the health of people living in marginalized communities. Emphasis has also been placed on the need for expanded use of both qualitative and quantitative research methods (e.g. Israel et al); greater focus on health and quality of life; and more translation and integration of basic, intervention, and applied research. Greater community involvement in processes that shape research and intervention approaches, e.g., through partnerships between academic, health services and communitybased organisations is one means towards these ends.

Community development and health

“Essentially, community development work acknowledges that health is as affected by the social conditions of people’s lives such as damp housinog, unemployment, or poor access to facilities, as it was by lifestyle choices. Major policy documents including Towards a Healthier Scotland (1999) and Our National Health (2000) highlight the importance of considering life circumstances alongside lifestyle choices and disease in promoting health and wellbeing.

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A World Health Organisation (WHO) position paper (1991) directly linked community participation to empowerment as a means in itself of promoting healthier individuals and environments. Furthermore, research has recognised the significance of powerlessness and empowerment to the health of individuals and communities (Wallerstein 1993). The concept of healthy communities as developed by the WHO regards active community participation as essential to creating healthy communities: “The formation of local social capital can thus lead to the promotion of shared values and a common vision, integrated planning and resource utilization, and ultimately to systemic change.” (Murray, 2000, p101)

There is a growing body of literature showing that being part of a social network of contacts is protective for health (Fisher 2001). The effects derive from improved self-esteem, trust and increased feelings of being in control.

Community Development Issues “Current health promotion policy and practice places a high value on community development work because it aims to enable communities to identify problems, develop solutions and facilitate change.

The overt ideological agenda of community development is to remedy inequalities and to achieve better and fairer distribution of resources for communities. This is achieved ideally through participatory processes and bottom-up planning. Empowering communities to have more say in the shaping of policies influencing health represents a break with earlier traditions of public health associated with top-down social engineering.

However, community development means different things to different people and can operate on different levels (See Arnstein’s ladder, 1971). Community development has, for example, been linked to community organisation, community-based initiatives, community mobilisation, community capacity building and citizen participation

There is, however, a common understanding of core principles, which inform community development work, two of which are participation and empowerment. These principles can 33

and are, however, operationalised differentially in different types of community development work.

Despite consensus that community participation should engender active processes involving choice, and the potential for implementing that choice, implementation has proven difficult. For example, when formal health services adopt an empowerment framework, their formal structures are not necessarily conducive to participation.

Although it is commonly agreed that appropriate leadership and effective organisational structures are crucial to successful community participation, this requires a political climate that nurtures and facilitates the approach.

“Community development uses a variety of methods and activities such as self help work, outreach, local action groups, lobbying, peer work, festivals and events, information, advocacy, group work, network building and pump priming community initiatives with small grants.

The key characteristic of community development is that it starts from the experiences 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 decision-making and evaluation. 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 knowledge and expertise of individuals and communities living through an experience and the centrality of drawing on this source of expertise to define problems and solutions and ultimately to design more effective services. The main benefits of community development approaches have been summarised as:

•

Improving networks in a community, which has been shown to have a protective effect on health.

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•

Identifying health needs from users’ point of view, in particular disadvantaged and socially excluded groups.

• • • •

Change and influence, as it enhances local planning and delivery of services. Developing local services and structures that act as a resource. Improving self-esteem and learning new skills that can aid employment. Widening the boundaries of the health care debate by involving people in defining their views on health and local services.

• Tackling underlying causes of ill health and disadvantage. REFERENCES Bracht, N., Finnegan, J. R., Rissel, C., Weisbrod, R., Gleason, J., Corbett, J. et al. (1994) Community ownership and program continuation following a health demonstration project. Health Education Research, 9, 243–255. Abstract / FREE Full Text

Corti, B., Holman, C. D. J., Donovan, R. J., Frizzell, S. K. and Carroll, A. M. (1995) Using sponsorship to create healthy environments for sport, racing and arts venues in Western Australia. Health Promotion International, 10, 185–197. Abstract / FREE Full Text

Corti, B., Holman, C. D. J., Donovan, R. J., Frizzell, S. K. and Carroll, A. M. (1997) Warning: Attending a sport, racing or arts venue may be beneficial to your health. Australian and New Zealand Journal of Public Health, 21, 371–376. MedlineWeb of Science

Crisp, B. R. and Swerissen, H. (2002) Program, agency and effect sustainability in health promotion, Health Promotion Journal of Australia, 13, 40–42.

Crisp, B. R., Swerissen, H. and Duckett, S. J. (2000) Four approaches to capacity building in health: Consequences for management and accountability. Health Promotion International, 15, 99–107. Abstract / FREE Full Text 35

Fortmann, S. P., Flora, J. A., Winkleby, M. A., Schooler, C., Taylor, C. B. and Farquhar, J. W. (1995) Community intervention trials: reflections on the Stanford five-city project experience. American Journal of Epidemiology, 142, 576–586. Abstract / FREE Full Text

Glanz, F. L. and Rimmer, B. (eds) (1990) Health Behaviour and Health Education: Theory, Research and Practice. Josey-Bass, San Francisco, CA. Goodman, R. M., Steckler, A., Hoover, S. and Schwartz, R. (1993) A critique of contemporary health promotion approaches: based on a qualitative review of six programs in Maine. American Journal of Health Promotion, 7, 208–220. Medline

Green, L. (1989) Is institutionalization the proper goal for grant-making? American Journal of Health Promotion, 3, 44. Medline

Hawe, P. (1994) Capturing the meaning of ‘community’ in community psychology. Health Promotion International, 9, 199–210.

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