A Comparative Appraisal of Four Community Health Development Organisations
De Montfort University Leicester
MA Health & Community Development
Module1
Assignment1
21.12.98
Steven McCluskey
A Comparative Appraisal of Four Community Health Development Organisations
(Word Count: 3989)
A Comparative Appraisal of Four Community Health Development Organisations
Introduction
The following paper is concerned with an analysis of four health development organisations which operate on behalf of communities to improve the health status of the population within the City of Glasgow. It sets out to explore the particular role, approach and contribution of each of these organisations to community development. Each organisation has been selected to demonstrate four strategic levels of operation from it's particular position within the public health field in Scotland.
These are:
. Health Education Board for Scotland (HEBS), the national agency for health education in Scotland
2. Glasgow Healthy City Partnership, Glasgow City inter-agency initiative on health
3. Greater Glasgow Health Board Health Promotion Department
4. East End Health Action Project
Community: an exploratory analysis
In order to gain an understanding of the sphere of practice of the above organisations in terms of community health development it is helpful to firstly explore what constitutes the definition of 'community'. Although many definitions of community have been constructed (Bell and Newby 1971), the dominant view traditionally focuses on community as a locality or neighborhood (Wellman and Leighton 1979). A broader concept is offered by the Community Development Foundation (1992) where it refers to community development as taking place within 'communities of interest' and neighborhoods. Although this is considered to offer a more expansive conceptual framework in which organisational practice can operate, it does however ignore, the importance of group 'identity' as part of community. This is best summed up by Toronto's Department of Public Health (1994) which describes a community as:
"a group of individuals with a common interest, and an identity of themselves as a group. We all belong to multiple communities at any given time (and) we cannot really say that a community exists until a group with a shared identity exists" (in Labonte 1998:28).
This definition is particularly useful as it embraces conventional, 'locality' and topical, 'interest' concepts of community. It also acknowledges that shared feelings of 'belonging to' or 'identifying with' individual or sets of groups needs to be defined by group members themselves in order to ensure that a sense of community is experienced.
An exploration of the meaning of community is absent from the theoretical and planning literature of all the four organisations under analysis in this paper. Greater Glasgow Health Board (G.G.H.B) Health Promotion Department and East End Health Action Project are two initiatives with a direct involvement in community activities at 'grass-roots' level within localities. The remaining organisations adopt a more 'distanced' approach in their key role of improving health within communities through the promotion of the principles and practice of community development and the provision of support systems and structures to organisations and projects which have a more direct 'hands on' role. The exact nature of how these objectives are achieved will be discussed later on in this report.
The Glasgow Healthy City Partnership describes it's community development role in terms of 'facilitation' and 'support'. This facilitation and support is long term, strategic and aims to secure a sustained improvement of health within local communities. The Health Education Board for Scotland is similar in its strategic approach (HEBS 1997). HEBS describes it's function in terms of 'stimulating' and 'supporting' action at community level.
The theoretical base of all four organisations suggests an involvement in the development of communities from a traditional conception of community as locality (Labonte 1998). However, this does not necessarily preclude organisational practice with 'communities of interest', as individuals can identify themselves with 'multiple communitiess' that exist within and across the boundaries of localities, as previously highlighted by the Toronto Department of Public Health.
Examples of this approach can be found in the practice of G.G.H.B. Health Promotion Department and the East End Health Action Project, who are both involved in supporting social groups which cut across geographic boundaries such as the G.G.H.B. Health Promotion Departments 'Priority Needs' team focus on black and ethnic minorities and the homeless population.
This model aligns itself to the 'systems perspective of social structure, whereby a community is viewed as a system which includes interconnecting sets of subsystems. This systems view stems from the theory of functionalist analysis which was the dominant social theory in sociology in the middle of this century (Haralambos and Heald 1980). Thompson and Kinne (1990) consider this concept in relation to community health and propose a useful schematic of 'community as system'. This perspective is made up of interconnecting social levels of community which exist between the individual level and the system level of community. A subsystem level of sectors includes those relating to health, education, communication, religion, recreation, social welfare, politics and economics. An additional two sectors include: "voluntary and civic groups, such as health related agencies, political action groups, and other grass roots groups, and other groups that may be specific to particular communities" (1990:48). Finally, there is the inter-relationship level between community and the sectors within the subsystem; these involve areas such as networks, coalitions and advisory boards.
The relationship between the parts which make up the social system is central to this perspective, as is the glue that binds them together:
"The system is based on some degree of cooperation and consensus on societal goals, norms, and values. The system is made up of various subsystems or sectors, individuals, and the interrelationships among them. The system, however, is not a simple aggregation of it's component parts; rather, it is a unique structure that includes all the parts and the relations that connect them. The system provides the context for all activities, including making choices about behaviors" (Thompson and Kinne 1990:48).
In relation to community health development, this view offers an opportunity to consider where the potential to make change exists, and how interventions may impact change within particular parts of the structure or community. The relationship between the parts implies that change at one level can influence change in other parts of the system and also in the structure as a whole.
This perspective suggests the need for a strategic understanding of how communities can be supported (Hunter 1998) which recognises the integral relationship between individuals and the broader cultural and social levels of communities and ...
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In relation to community health development, this view offers an opportunity to consider where the potential to make change exists, and how interventions may impact change within particular parts of the structure or community. The relationship between the parts implies that change at one level can influence change in other parts of the system and also in the structure as a whole.
This perspective suggests the need for a strategic understanding of how communities can be supported (Hunter 1998) which recognises the integral relationship between individuals and the broader cultural and social levels of communities and society (Thompson 1993).
The theoretical perspectives of how community and society is structured offer a useful framework in which to analyse the processes, methods and activities for achieving change from the particular levels of operation within the four organisations under review. All four of the organisations are concerned with influencing change in various levels and sectors of the community system to a greater or lesser degree. The respective approaches are united in their understanding of the need to target activities for change both from within and outside the community system, although the emphasis on certain components may vary.
It is important to consider how individuals and communities are shaped and influenced by the broader societal structure in order to ensure that community development approaches, efforts and resources are maximised to the full, and that interventions achieve change which is long term and sustainable.
In summary, it is suggested that reflection and clarification of the meaning and understanding attributed to the term community would benefit all of the agencies under review, thus enabling them to develop a more strategic focus to their operational practice in relation to community health development. In effect this would enable agencies to ensure that practice is informed by an awareness of the particular dynamics, complexities and relationships that make up community. This analysis enables a clearer and more precise definition of community development and its relation to health.
Community Development and Health
Contemporary community development theory and practice has its origins in the broader sphere of the community work movement (Taylor 1992), which includes a number of common approaches and models concerned with influencing positive change in communities. The social/community planning model is one such approach which is closely aligned to community development (Popple 1995). This model is introduced here to demonstrate the broad reach of this approach. Many of the community health development approaches of the four agencies are considered to extend into the broader social planning arena of which this approach is concerned. This involves strategies and practices which set out to influence planning priorities and funding, services and policy. This also relates to the systems perspective of social structure previously discussed, where opportunities to influence these areas exist within the subsystem levels of communities, particularly within the political and economic spheres.
This focus is most notable within the Glasgow Health City Partnerships development plan, in commenting on community development, it states that:
"Opportunities for community and individual action on health are, however, encouraged or constrained by people's social and economic circumstances and their physical environment. Community development must therefore also be supported by complementary change at societal and organisational levels to remove barriers to community and individual action and to provide direct support to communities and individuals so that they are more able to take appropriate action" (1998:20).
The Glasgow Health City Partnership inhabits a unique position from which to impact on various spheres of activity at a local and national level. At a local level its impact is made in its capacity as a partnership agency, whereby it creates an opportunity to harness and coordinate the collective resources of a wide range of agencies and communities. At a national level it operates as a WHO Healthy City Project, extending 'partnership status' to city wide organisations. Glasgow Healthy City Partnership also have plans to further extend their remit by establishing a city-wide network of smaller and more localised projects and community groups.
It is interesting to note that the Health Promotion Department of G.G.H.B. does not make any explicit reference to community development as a function within it's current operational plan (1997/98). It does however identify 'Community Liaison as one of it's functions and describes this in terms of supporting community approaches, collating information on local health needs, facilitation and identifying resources and services (G.G.H.B 1997).
Although some of these activities could be considered to constitute aspects of a community development approach, no reference is made to key principles of community development such as participation and empowerment. Indeed, references to community are conspicuous by their absence throughout the departmental planning framework document. It is important to highlight at this stage however that many practitioners within the health promotion department would consider themselves to be active in community health development work within local communities in spite of the absence of any theoretical planning and strategic framework.
An explicit theoretical framework which is linked to practice is necessary to enable practitioners to reflect on their practice in the context of societal influences and changes (Dalyrymple and Burke 1995). It ensures that practice does not take place in a vacuum and that workers within an organisation have a common reference point to guide, support and inform their work.
The East End Health Action Project is the only organisation of the four which describes itself primarily as a community development project. Therefore it comes as no surprise to find that their theoretical framework is amongst the most developed and advanced of all the organisations. There is an explicit recognition by the organisation that the process of community development should involve action not only at individual and group level but also at societal and organisational levels.
An example in practice of this broader approach by the East End Health Action Project focuses on work at individual level to establish a 'Women's Health Group' within a local community. This initiative will link into the development of a city wide health policy for women. This policy is coordinated by the Glasgow Healthy City Partnership organisation, and is featured within their operational plan. In turn, the partnership agency identify the policy as making a link to the development of a Glasgow City Health Action Framework (City Health Plan) which will be used to inform and influence mainstream policy, development plans and action concerned with social, economic and environmental issues, including urban regeneration.
The importance of community initiatives accessing and feeding into mainstream structures is highlighted by Cawley et. al (1995) in their analysis of a womens service in North Manchester. It is interesting to note however, that they consider this to be an advantage from the perspective of a service that is part of the NHS. In comparison, the work of the East End Health Action Project serves as a useful case study of how this can also be achieved from a position outwith the NHS.
The aforementioned area of activity by the East End Health Action project also highlights the relationship between some of the organisations under analysis in this paper, and the opportunities which exist to support each other in the common objective of achieving positive change through a community development approach. Another example of this interconnecting relationship is evident in a current community development initiative by the Health Education Board for Scotland. This has involved the production of a community development learning pack - 'Health Issues in the Community'. The development of this resource has been informed by a range of individuals and community groups involved in community development. It has been designed to offer support and guidance to those involved in the community health field and covers issues such as power, equity, health and participation. The course is accredited and provides participants with an opportunity to acquire an academic qualification. Training courses are currently being delivered throughout Scotland by tutors who have been trained with a specific remit to deliver the learning pack. Tutor training courses run twice a year. Many of the trained tutors operate within the city of Glasgow and are currently running courses for members of community groups across the city. The coordinator of the East End Health Action project has undergone tutor training and plans to run a variety of courses for local people within communities throughout the East End of Glasgow.
Values and Principles
The approaches and activities described so far within the four organisations are underpinned by their value base and principles, whether these are explicit or not. Values are considered to be central to how we conduct ourselves in all aspects of our lives as they form our thinking about right and wrong. Values are universal, all members of society possess them, although the emphasis and importance of particular values may differ within different cultures. Values have the potential to bring people together or drive them apart (Sykes 1998). Common values can act as a powerful force in unifying people from diverse religions, cultures and backgrounds (Baba 1997). The emphasis expressed here on values can be applied to our own work practice, and the partnerships that we form with different organisations.
The East End Health Action project and the Glasgow Healthy City Partnership explicitly recognise the importance of organisational values and the extent to which values shape the delivery of their objectives from a community health development perspective. It is interesting to note however, that the East End Health Action project have directly taken their organisational values from the development plan (1997) of the Glasgow Healthy City Partnership. Whilst the explicit emphasis on values by the East End Health Action project is welcomed, it is not clear whether they have been adopted by a process of reflection and discussion by project workers, or merely imported. Discourse and exploration around personal and professional values is considered to be a necessary prerequisite in defining our attitudes, beliefs, goals and responses to individuals and communities (Waddington 1994). By developing a common understanding and consensus about what is important in our work, there is an increased likelihood of collectively being able to achieve our common goals (Haralambos and Heald 1980).
Glasgow Healthy City Partnership embrace seven core values which have been informed by various national and international health and human rights declarations and strategies.
It is useful at this stage to consider some of these in more detail to gain an insight into the organisations driving principles in relation to community development and health. Empowerment and participation are two key values which are considered to guide their practice. These core values are explicitly linked to their understanding of what constitutes community development in the context of their adopted model of health. The organisation believes that the empowerment of individuals is fundamental to their capacity to participate and take responsibility for their own health and the health of others. From a community development perspective they suggest that community and individual empowerment can be achieved through the provision of: "information, knowledge, skills and practical support which builds trust, confidence and self-esteem" (Glasgow Healthy City Partnership 1997:19). The emphasis on community as well as individual empowerment is to be welcomed. Community empowerment suggests collective identity and control which Wallerstein (1992) equates with the 'social action' model of social change. This model has the same goals as the 'radical-political model' of health promotion (Tones et al. 1990), which is concerned with addressing the broader social and political structures of society, which undermine self- empowerment (Anderson 1986). In my view, this broader social and political model of empowering communities is to be encouraged as it is capable of harnessing the collective power of communities to influence change on health which is longer term and sustainable (Mayo and Craig 1995). This approach is also desirable as it aligns itself to the systems perspective of communities and social structure previously discussed.
The Brazilian educator Paulo Friere was considered to be one of the most influential exponents this century of empowerment and collective action for social change (Wallerstein and Bernstein 1988). Friere's approach has some similarities with the health promotion models of social and political change described above. He recognises the need for individuals to make connections with their lives and the outside world, and the importance of becoming socially aware of the structures which impact on their situations. He suggests that powerlessness can be overcome and liberty achieved through critical consciousness and collective action concerned with changing the broader social structures that impact on people's lives (Heaney 1995). Participation in community health is more often equated with collective participation and the social and economic context of health (Curtice 1990).
A recent community consultation event conducted by Glasgow Health City Partnership offers some insight into the social/political model of collective community participation in practice. This demonstrates how the empowerment of individuals and community groups can influence policy at a political level.
The consultation set out to gather community views on the Governments public health proposals contained in the Green Paper 'Working Together for a Healthier Scotland' (Scottish Office 1998). This community perspective formed the core response of the partnership to the Scottish Office. The success of this event in terms of empowerment and participation can be gleamed by reference to the final document (Glasgow Health City Partnership 1998) and the views contained therein. The consultation event was attended by 120 community delegates from 80 community organisations throughout Glasgow. This level of participation in this event was considered positive. Overall, the consultation exercise was able to collate a valuable body of community views in relation to key areas within the 'Green Paper'. Comments and views focused on significant areas, such as strengthening communities, communities as meaningful partners, funding, resourcing and infrastructure issues, accessing services, understandings and definitions of health, contribution of local authorities, community involvement and participation, community liaison and special needs (Glasgow Health City Partnership 1998).
The real test however, of the success of this exercise will be in the final publication of the Scottish Office white paper next year when it will be clear as to what extent community interests and views have been represented
Empowerment is thought to be a core principal to achieving change as part of health promotion practice (Nutbeam and Smith 1991). It is argued however, that this is dependent upon the particular approach, practice and emphasis adopted by health promotion. Overall, the health promotion approach adopted by G.G.H.B. Health Promotion Department is described in terms of principles alone, which "emphasise equity, empowerment, participation, co-operation, and developing work within a local context" (G.G.H.B. 1997:2). Whilst these principles are welcome and desirable, they are not in any way explicitly linked to a theoretical framework or model of health promotion. Whilst it is recognised that any single theory of health promotion may not adequately describe the diverse range of activities that the department is involved in, it is however, considered desirable to have a framework which enables practioners to locate their practice, and to contest and make determinations about the suitability of particular interventions (Naidoo and Wills 1994).
Health Concepts
The focus of this paper, until now, has been on the relationship between community, community development and health, values and principles and empowerment and participation. These areas have been analysed with consideration to their relationship with the broader social, economic and political context. Discussions on concepts of health have intentionally been left to last, not because these are considered to be of the least importance, but rather as this is the one area where there exists a common and unified perception and understanding by all four organisations. The concepts of health which have been adopted by the organisations are based upon an understanding that health status is strongly related to the broader physical, social, economic and cultural environment. Related factors such as genetic inheritance, gender, (dis) ability/impairment, age, sexuality and ethniticity are also considered to be variables in individual health status.
The World Health Organisations (WHO 1946) holistic definition of health as: "a state of complete physical, mental and social well-being, not merely the absence of disease or infirmity", has been influential within all four organisations as a positive statement which shifts from negative definitions that focus on a narrow 'medical' view of health. The WHO definition has often been criticised for being to idealistic (Naidoo and Wills 1994), I would tend to agree however with the sentiment expressed by Ogunnusi (1998) where he states that: "there is a need to formulate workable objectives around ideals, surely this is the only way to ensure new thinking and progressive movement".
Inequalities in Health
Inequalities in health is identified within all four of the organisations as an area for particular emphasis and priority.
Variations in health status are known to exist amongst population groups throughout the UK.
Nowhere in Scotland are health inequalities more evident than the City of Glasgow which contains up to 80% of Scotland's classified areas of multiple deprivation (Glasgow Healthy City Project 1995). The reasons for these differentials have been explored and debated at great length since the early 1980's which saw the publication of a considered landmark report (Black 1980) which documented the existence of a relationship between inequalities in morbidity and mortality and social class gradients. An increasing body of evidence has since reaffirmed this position and provides evidence of a widening gap in health inequalities between those in socially advantaged and disadvantaged groups (Whitehead 1989). The recent publication of the government commissioned inquiry into inequalities in health (Acheson 1998) provides us with the most up todate and comprehensive review of the evidence on inequalities in health since the Black report.
Summary
In conclusion, the four health development organisations are considered to have a significant and important role to play in community health development in Glasgow from their particular strategic level of operation within the public health field. Strengths and weaknesses have been identified and discussed within all the projects, and there are clearly important areas, within all the organisations, which would benefit from being strengthened. There are however, some examples of good theory and practice across all the projects. The relationships and links between the organisations have been highlighted and discussed and it is suggested that these opportunities should be exploited where appropriate. Indeed, these links are considered to be ideal avenues in which each organisation could benefit from the experience and practice of each other.
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