1
Community development:
How effective is it as an approach in health
promotion?
John Raeburn
and
Tim Corbett
University of Auckland
Paper prepared for the
Second International Symposium
on the Effectiveness of Health Promotion
University of Toronto
May 28-30, 2001
Note: This version of this paper was submitted in time to go on the symposium website
before the symposium itself. It is still in process, and a more finished version will be
available later. But the basic arguments and conclusions are here.
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The aim of this paper is to look at how effective a community development approach
is in health promotion. We hesitate to call community development (CD) a ‘strategy’
– rather, it is a whole distinctive way of thinking about health promotion (HP). Calling
it a ‘strategy’ makes it seem very instrumental and calculated. We argue here that CD
is a good in its own right – that it is a way of looking at the world which can be valued
independently of its effectiveness. It embodies many of the dearest held values and
worldviews of those of us who are passionate about HP as an endeavour, and coupled
with the concepts of ‘empowerment’ and ‘equity’, probably represents the ideal
heartland of HP. Indeed, to take this supposedly ‘cool’ look at CD within an
‘evidence-based’ framework is a paradox – CD is a matter of passion, whereas the
modern fashion for evidence-based medicine and evidence-based HP has a gloss about
it which is very much a part of modern, corporatised, accountable new right thinking
which is exactly what HP represents an antidote to. However, we also realize that HP
is in competition with other sectors of the health domain for resources, and of course,
we do want to know whether what we do is effective – that is not the issue – but it is
how we go about the process of determining its effectiveness that counts, and what is
currently meant by an ‘evidence-based’ approach may not be it.
As we understand it, the brief for this paper is the following:



To summarise the evidence for the effectiveness of a community development
approach to health promotion (CDHP)
To discuss conceptual issues around health promotion and the assessment of
its effectiveness, in this case with regard to CDHP
To discuss ways in which the assessment of the effectiveness of CDHP is
currently done, and how it can be done better in the future
These topics could take a whole book to cover, and an army of reviewers. Indeed, in
one of the only significant reviews we found in the area (Hancock, Sanson-Fisher et
al. 1997) there were 14 authors, and they covered only a fragment of the field. Since
both of us were hugely busy, and there was only a limited time to do this in, this
review does not pretend to be comprehensive. Instead, we will try to go to the core of
the issues, with examples.
We gathered, from afar (and New Zealand, we have decided, is the farthest away
country from anywhere in the world!), that the context for this discussion was the
current fashion for ‘evidence-based’ health promotion. This is curious, because the
whole concept of ‘evidence-based’ seems to come from medicine (as in the Cochrane
Collaboration), and once again, we health promoters seem hell bent on aping the
‘culture’ of medicine to justify our place in the world. No doubt we want to be
respectable, scientific and to get our share of scarce health resources to do our stuff.
But are we jeopardising the true spirit of HP in the process?
We are not arguing against having evidence to support and investigate HP endeavours.
Of course not. But it is the rigid formalism of the evidence based approach, with the
randomised control trial (RCT) as its explicit or implicit gold standard (Nutbeam,
1999), that we want to question. Again, this is not to say that RCTs, or the big quasi-
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experimental trials (BQETs), do not have a place in the scheme of things, including
some aspects of HP, but there are other ways too. This point has been strongly made
in Canada, by a variety of qualitative and post-modernist researchers (e.g. Eakin et al.,
1996; Labonte and Robertson ,1996; Poland, 1996). But we also think this goes
beyond the quantitative/positivist vs qualitative/constructionist debate. To us, HP is
pre-eminently an approach to health, to life, and it is first and foremost a set of values
in action. Naturally, we want to see whether HP efforts using this set of values
actually work, but that is not the main issue. In short, the wonderfulness that HP
represents as an antidote to a modern fractured world almost solely driven by new
right, corporatised, high technology, media driven values and imperatives should not
be lost in the effort to emulate the tools of that world and its rigidly scientific, squeaky
clean evaluative methodologies. We need to preserve the true spirit of health
promotion, come what may!
Nowhere are these issues more dramatically represented than in the domain of
community development as applied to HP. For us, and for many, community
development and its cousin empowerment, represent the true heartland of HP. And at
the heart of CD, and HP, certainly as understood by Irv Rootman and John Raeburn, is
the concept of ‘people-centredness’ (Raeburn and Rootman, 1998). Here in Toronto
in 1991, at an international conference on HP research, we made an impassioned plea
that the thirst for good science, especially of a population, numbers driven nature,
should not be allowed to eclipse the ‘true’ purpose of HP, and we do so again now
(Raeburn, 1992). The true purpose of HP, we believe, is to enhance the lives of real,
palpable people, to honour those people, and to make the ‘people-control’ aspect of
the Ottawa Charter definition of HP the most central matter, with research methods
having to array themselves around that centre, rather than the other way round, which
so often seems to be the case. Exactly a decade later, the need to hold fast to this
perspective has not lessened one iota - indeed, with the concept of population health
becoming a new hegemony (thankfully, not so much in New Zealand as in Canada), it
becomes even more important to hold to the true values of HP, and its people-first
perspective.
Community development and health promotion
Having said that, let us now address the issue of community development, and how
this relates to HP. This, we came to realise as we prepared for this review, and looked
at dozens of papers and abstracts, is in itself a thorny issue. Our brief, from the
symposium organizers, was to look at community development, and as you are no
doubt aware, the community dimension of HP goes well beyond what is normally
understood by the term CD. So, we asked, since no-one else at the symposium
seemed to be addressing the rest of the community sector, were we meant to be doing
this as well? This may seem like splitting hairs, but it is absolutely not so. When we
asked Irv Rootman about this, we understood that we should err on the side of CD as
such, but also take into account that sector of HP that had at least some degree of
community participation in its approach.
Which brings us to the definitional domain. The one major review referred to before,,
undertaken by the Australian team of Hancock, Sanson-Fisher et al. (1997), used the
term ‘community action’, which is of course the Ottawa Charter term for its
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community stream. They say the key component of community action is ‘community
participation’, and that this falls along a continuum, on which CD is one pole. They
also say there are international differences in usage here.
One end of the continuum, where community involvement and active
participation occur at all stages of the intervention process, is commonly called
“community development” in Australia, Canada, and the United Kingdom, or
more often “community organizing” in the United States. [New Zealand does not
rate a mention with the Australians!]. Programs at the other end of the
continuum, where the community participation is token, and may be consultative
only, are often called “community-based”.
They then say that their use of the term ‘community action’ is ‘defined as a health
promotion program that involves the community in, at least, implementation and
control of the process of the program’. We could unpack this and ask does it need to
be a formal ‘program’ as such, or more organic? Is control of the process the same as
control of the whole endeavour and agenda, and so on? For us, these are the essential
features of CD - where the community owns the programme, intervention, change
process or however one might construe this, including setting the agenda (maybe in
partnership with outsiders), defining the needs, wishes, and priorities for action,
controlling the action, and owning the data and evaluation processes, if those are
being undertaken.
Which brings us to two key questions here. The first is, what is ‘the community’ in
this context?
The second is, what is any evaluation or assessment of
outcomes/effectiveness for?
We won’t waste too much time on the former, as many have spent that time before us,
although perhaps we should, since Marie Boutilier, Shelley Cleverly and Ron Labonte
tell us that misconceptualisations of ‘community’ are a fundamental flaw in much
CDHP (Boutilier et al., 2000). According to sociologists, there are over 100
definitions of community). What we mean here is that ‘the community’ is a
significant group of people seen in their everyday, ordinary living context, who share
either a common locality and actual or potential social bonds and/or goals in that
locality, or who have some other binding factor (other than locality) which gives them
a sense of commonality and relatedness. Our view is that locality is proto-community,
and that other concepts are variations on this. From this perspective, the Hancock et
al. (1997) view that Americans equate the term ‘community organization’ (CO) with
CD is not correct, if we take the conventional Rothman and Tropman (1987)
breakdown of community organization as the gospel - only one of their three types of
CO, locality development, would qualify.
The second issue, that of why assess effectiveness in the first place, deserves a bit
more attention. The guidelines and indeed the whole thrust of this symposium is that
the assessment of the effectiveness of HP is a ‘good thing’. But by whom and for
whom?
Now, we the writers of this are academics, and our livelihood depends on our
producing scientific papers full of quantitative and qualitative data fit for publication
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in the appropriate journals. But we also equally work at the coal face in communities,
and know the imperatives that pertain to them. And the two can often clash (Allison
and Rootman, 1996). For us, the art of assessing effectiveness is not to what extent it
can approximate an RCT or some other conventional yardstick, whatever that may be
in the qualitative realm, but whether it serves the ‘true’ purpose of HP, which in our
view is to enhance the health, wellbeing and quality of life of the people of interest
(POI), and to do this in a way that is empowering and strength-building.
So why do academics and experts want to know the effectiveness of HP endeavours?
Well, it depends on who is talking. If we assume that we all have the wellbeing of
society and people at heart, then there are several reasons, for example:




producing a scientific result that can be published in a reputable journal, and
hence enhance the careers of the academics involved
to give credibility to a ‘soft’ and amorphous area (viz. HP), currently under
siege by ‘true’ scientists and decision makers, such as the proponents of
population health
to get or retain resources for HP, in a climate of ever shrinking resource - that
is, a political purpose, or getting funds for research
to validate, and be accountable to, community or people processes, particularly
to enable community people to justify their work, and to know it is of value,
and to ensure the benefit or outcome of what is done is having a desired
impact, rather than having no impact or even doing harm - which much
community work has the potential to do (e.g. by falsely raising community
expectations)
As far as we are concerned, all are justifiable ends, but the last one is far and away the
most important, and the others should be secondary.
So, where have we got to?
 First, the brief of this paper concerns CD, which falls at the community ownership
and control end of the community participation continuum
 Second, we need to retain the vision of ‘true’ HP, and of keeping people at the
centre of our preoccupations, rather than ‘science’ as such
 Third, the definition of community is primarily to do with location, though other
concepts are okay too
 Fourth, the aim of assessing the effectiveness of CDHP is first and foremost to aid
in the process of community empowerment and ownership, and only secondarily to
serve the purposes of academics and professionals
One could say a lot more about what a CDHP approach should be at this stage. For
example our belief is that it should primarily be about building community assets,
capacities, strength, resilience, etc rather than dealing to risk factors or deficits, which
is often the case (e.g. Rappaport (1992), Raeburn and Rootman (1998), Kretzmann
and McKnight (1993)). It should be, to use the new right terminology, about building
social cohesion and social capital (Coburn, 1999), and the building of social support
and a supportive environment (Sarafino, 1998). It should be about community control
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and ownership (Raeburn, 1992b; Steptoe and Appels, 1989), and about unifying
fragmented or oppressed communities, as we see in the third world (Durning, 1989).
It should be about equity, the single biggest social issue we face in today’s world,
which impinges directly on health (Wilkinson, 1996). It should be about respecting
culture, diversity and the essential humanity of everyone. CDHP, we submit, in its
truest form, is a kind of inspirational or ‘spiritual’ enterprise, one of the noblest
human enterprises. We know this puts us at the receiving end of those who would
label such an approach in HP as one of sentimentalising community (e.g. Labonte,
), but nevertheless, it is a very moving and powerful enterprise for all concerned, one
which could change the world (Durning, 1989). We don’t want to see this lost in the
‘coolness’ of rigorous scientific appraisal to meet some high standards of academic
excellence. On the other hand, if we can succeed in doing both - keeping the vision
and doing good science - then that would be optimal.
Theory and practice
The first thing one does for a paper such as this is a literature search. Given limited
time and resources, we largely (not entirely) kept this to the last five or six years, to
cover the period since the last symposium (where Marie Boutilier and John Raeburn
covered the same territory), and to the sources reasonably accessible to us. We cannot
claim to have been exhaustive, but we did get over 90 articles, monographs and
references that looked promising. On sorting these, we were astonished to find that
the actual number of completed evaluated studies in the whole of community related
HP was actually very small. And most of these did not fit the category of CDHP as
outlined here. Below, we discuss what we did find in more detail. Here, we say that
of the 91 articles and documents we used, 67 were written about evaluation,
measurement and effectiveness issues relating to community health promotion (the
general term we will use), and only 24 were of evaluated studies. Of these, only one
met the criterion of CDHP as such. The rest were more of the community programme
or community intervention variety, to use the terminology of Dixon and Sindall
(1994).
There were, however, another two sets of literature that did not automatically come up
under conventional HP searches, which actually did have significant numbers of
evaluated community studies. One was that of mental health promotion (e.g. the
Welsh publication called Mental Health Promotion: Forty Examples of Effective
Intervention (Health Promotion Wales, 1996), and the other was that of injury
prevention research, including violence and suicide prevention (e.g. Klassen et al.,
2000; Dejong, 1994). However, few of these studies meet the criteria for CDHP
either, although there is significant community involvement in many of them.
What is the theory literature saying?
It is beyond the scope of this article on the effectiveness of CDHP to cover the gamut
of theoretical literature in any detail. All we can do is bullet point our summary of
what it mainly seems to be to do with.
 The RCT trial is the gold standard for evidence based evaluation of HP, including
community health promotion. But it and its clones show little benefit for using
community approaches in the HP projects included in the reviews of these trials,
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and many feel other forms of research are more appropriate, given the nature of
community (e.g. Nutbeam, 1999)
 The RCT culture, and the cry for ‘evidence based data’, is the product of our
current rationalist/new right economic era, with its orientation to accountability,
scarce resources for health, lack of feeling for community and social issues, the rise of
biomedicine with gene and other discoveries, the dismantling of the welfare state, and
hard science as its touchstones (e.g. Dixon and Sindall, 1994)
 Community research is diffuse, complex and hard. Its protagonists tend to opt for
post-modernist methodologies, which often do not get as far as producing
effectiveness data, or if they do, these tend to take the form of ‘community stories’ or
interviews with participants, which does not necessarily carry much political clout
(e.g. Labonte and Feather, 1996)
 Most community health promotion does not have a good handle on ‘community’,
and tends to ignore the very heart of what is implied in the term ‘community
development’ - that is, that the building of community as such is a goal, and is
beneficial to health - and instead, uses community as a tool or instrument for
outsiders’ agendas, with little regard for the people or community-building dimension,
or for issues beyond the health problem being addressed (e.g. Hancock and Minkler,
1997; Dixon and Sindall, 1994; Peterson, 1994; Nilsen, 1996; )
 The voice of the community is not often being heard, and a community led
enterprise, which is what CD is about, would have to lead to a whole new paradigm of
action and of training professionals (Cheadle et al., 1997; Rosenau, 1994; Guldan,
1996)
 Most so-called community ‘health promotion’ projects and programmes are
actually prevention programmes (Higgins and Green, 1994; DeFriese and Crossland,
1995) and there are still too few which break free from an old lifestyle, individualistic
model. However, to be sure, there are many theorists (rather than practitioners!) who
think they should break free from these old shackles!
 There are many different approaches to conceptualising and doing effectiveness
measurement for community work, including controlled studies, quasi-experimental
studies, programme evaluation, demonstration projects, case studies, interviewing of
participants, surveys, psychometric measures, self-report measures, epidemiological
studies, story telling, satisfaction measures, using social indicators, doing a critical
analysis, focus groups, key informant studies, participant observational studies,
ethnographic methods, action research, and so on. Each has its place. Probably the
most common methods are surveys and interviews of various kinds, incorporated into
controlled studies or standing in their own right. Triangulation seems to be the
recommended approach. Obviously, the selection of the appropriate methods and
measures depends a lot on one’s research orientation, especially on the
quantitative/positivist vs qualitative/constructionist dimension. Hard countable data
still seem to rule supreme in the effectiveness studies that are published, although the
theoreticians often do not like this kind of data much.
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The effectiveness of community development health promotion
Now we move to the more formal appraisal of what studies show the effectiveness of
CD to be as a way of ‘doing’ HP. This instantly brings us into tricky territory,
because although there is quite a lot of ‘community health promotion’ outcome
research, very little of it fits what we would call ‘community development’ research.
For the purposes of this discussion, we make a tripartite distinction among the studies
that have been done which impinge on this area, and in an area of multiple usages of
language and definition, assert our own, at least for this paper.
There appear to be three main levels of HP activity involving community, which
we categorise as A, B and C:
Category A This is the ‘lowest’ level. It is one that places the HP action in the
community (e.g. a school, a community health centre, a neighbourhood, or even just a
large population), and makes explicit mention of ‘community’, but does little more.
The action is something that is ‘done to’ this community, with little attempt to engage
them other than to cooperate with or ‘consume’ the action. We use the term
community-based HP to describe this level.
Category B This is a middle level, and probably includes a lot of what is referred to
by some as ‘community development’. It actually involves at least four subcategories,
each of which represents varying degrees of effort to have active community input
into the HP process, but where the agendas are still primarily under the control of the
professionals or researchers. In each case, ‘community participation’ seems to be
used in an instrumental way to help bring about the ends desired by the professionals,
for example, to reduce injury rates in a community. The four subcategories are: (1)
consultation, discussion, needs assessment and action involving community based
service agencies (e.g. police, youth workers, social workers, community workers,
teachers, NGO spokespeople, voluntary agency representatives, etc); (2) consultation,
discussion ,needs assessment and action involving the people of the community
directly (e.g. representative members of the residential or interest community being
worked with) ; (3) agencies and/or community people having a degree of decisional
and organisational control over the nature of, and implementation of, the intervention
activities by community agencies/people; (4) partnership, where the balance of
control for decision-making, control and actions is divided equally between
professionals and the community, and also where (hopefully) there is an honouring of
the culture and uniqueness of the community concerned. This last category comes
close to CD as we understand it. But where it falls short of that is that the overall
direction, control and priorities still remain in the hands of professionals, and there is
no explicit agenda of capacity or community building as such by professionals. This
overall category we call community action.
Category C
This is the ‘highest’ level, and is the one we call community
development. This has three criterion dimensions. One is that the balance of power
between professional and community people (not just service agencies) is clearly with
the community – that is, the enterprise is community-controlled. Indeed, in its purest
form, there may be no professionals involved at all (e.g. Boyte, 1989), or the
professionals will simply be used by the community in a consultative way, such as
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getting advice on how to do surveys or evaluation (Raeburn, 1992). Various forms of
‘facilitation’ rather than ‘control’ by professionals also qualify here. This process of
having and exercising power over one’s life and community process is one crucial
aspect of an empowerment process. The second criterion is that of community
building, based on an agenda of developing social cohesion, mutual support,
networks, friendships, cooperativeness, and overall quality of life and liking of the
community. This participatory and positive aspect of the CD process is also
empowering, since participation is seen to be at the heart of community empowerment
(Rappaport, 1987). The third criterion is the development of community capacity and
strengths, through people learning skills, confidence, ways of doing things,
influencing policy, making a difference, seeing the results of their efforts, etc. Here,
community controlled evaluation is a useful too, but it is more what is felt than what
can be measured. Such capacity building is probably closest to what most people
understand by the concept of empowerment. We call the three criteria here the 3 Cs –
community control, community building and capacity building.
This category of CD comes closest, we assert, to the ideal of CD as an enterprise
based on the core HP concept of empowerment. However, we do not claim that
activities in the other two categories cannot be empowering to some extent. In
particular, any sense of control engendered by a community activity is likely to lead
to a sense of empowerment, particularly as skills develop and participation increases.
These categories are not pure, and there will be overlaps. Nevertheless, we think the
distinctions are useful, and that Category 3 is what we should all be aspiring to when
we talk about community development with regard to health promotion.
This brings us to the issue of what do we mean by health promotion in this
context? This is no place to discuss this in detail, but HP seems a variable feast here.
In spite of protestations to the contrary, much HP seems locked pretty firmly into a
risk model, which is the hallmark of ‘prevention’ rather than HP. In our view, HP
refers primarily to efforts to enhance health, wellbeing and quality of life in a global
sense, rather than just attempting to reduce specific disease or problem related risks.
Most of the big RCT type trials, such as MRFIT, are concerned primarily with disease
related specific risks, and are therefore, in our view, prevention trials rather than HP
trials as such. There is, of course, much overlap between concepts of prevention and
HP. But we feel that it is better to be honest, and call a spade a spade – that is, if
something is a prevention activity, then to call it that, even if it is a modern one that
takes HP principles into account. Similarly, treatment can involve HP processes too,
such as getting people along to be screened for illnesses, encouraging people to use
health services, or using HP principles in recovery. But we feel it is better to call this
for what it is as well – it is treatment with some HP aspects.
To make this clearer, and based on the articles we sorted, we have devised a category
system here to, designated as Type A, B and C.
Type A. This is where HP and community activities are involved, but where the
preoccupation is primarily to do with treatment and recovery. We label these
processes and outcomes as to do with treatment/recovery
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Type B. This is where a single or several risk factors or behaviours associated with
illness or injury categories are targeted by a campaign or intervention with the
intention of reducing the risk of contracting an illness, or avoiding injury or disability,
or to deal with the risks associated with some mental health or social problem such as
youth suicide. Many social marketing campaigns fits into this type, as do most of the
big RCT cardiovascular, smoking, destigmatisation, anti-abuse and similar campaigns.
A number of school campaigns, and those emanating from health centres would also
fit in here. We label these processes and outcomes as to do with prevention.
Type C. These are where the goal is enhanced generic health, wellbeing, quality of
life, strength, fitness, resilience, empowerment, justice, equity, community cohesion,
and so on. These we regard as the ‘true’ aims of HP, as distinct from prevention or
treatment. A Type C HP activity may be stimulated by a specific or ‘negative’ trigger
like a concern with heart disease, obesity or youth suicide. But the methods and
outcomes are general and geared to positive goals. These processes and outcomes we
label as having to do with health and wellbeing.
Note that in this discussion, we are not considering the actual HP methods used, and
these can be various across all the categories and types, including media, education,
life skills training, policy development, advocacy, creating supportive environments
and so on. However, to qualify as a community development method, it would need to
exist in a community context where the activity is consonant with the 3 Cs.
From all this, then, it should be clear that the proto CDHP, by our estimate, is that
which is Category 3 and Type 3. The farther the deviation from this ‘ideal’, the
farther it is from ‘true’ CD. This can be represented by the following chart:
Categories of community HP
Communitybased
Types
Treatment
Of
Community
action
Community
development





Risk


Wellbeing

 

HP
Domain
Do-main

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Table 1 Degree of approximation to ‘true’ community development
Here, the hearts represent not the prevention of CHD, but our ‘feeling’ towards the
different grades of community oriented HP, in terms of their closeness to ‘true’
CDHP. It will be noted that we have divided the Community Action category into
two subtypes. The right hand column is for those projects that have many elements of
CD in them, but fall short of true CD with its 3C’s criteria of community control,
community building and capacity building. The left hand community action column
would be for community action which has some community participation, but is only
token or at a very low level, with little control or partnership happening. (We could
further subdivide the community action column by saying whether the ‘community’
was defined in terms of the people themselves or community agencies and services,
with the former being judged by us as superior. However, this would make the table
very complex, so we have left that out.
The next step, then, was to do a count of how many of the papers we tracked down
over the past five years or so fitted these categories. To do this, in a very rough and
ready way, we might say, we took those papers which actually included data or
qualitative information from research relating to the outcomes of community oriented
HP endeavours. We could have done a whole thesis on this alone. For example, what
is HP in this context? We excluded some potential categories, simply because they do
not seem conventionally to be classified in the HP domain. In particular, these were
injury prevention, alcohol and drug prevention, and mental health promotion here,
each of which has a significant research literature associated with it. It should also be
noted that this count takes no account of methodology, nor does it set any criteria
about the quality of research, such as whether it had controls or not.. (Note: we
included reviews of outcome studies which might have been done earlier). We also
have not divided the Community Action column into two – it would have taken a
while to sort the studies by the degree of community involvement, and we did not
have a chance to do this before sending this draft in.
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Categories of community HP
Communitybased
Types
Community
action
Community
development
Treatment
2
0
0
Risk
8
5
0
Wellbeing
3
5
1
13
10
1
Of
HP
Domain
Do-main
TOTALS (N=24):
Table 2 Number of researched HP effectiveness articles fitting community
categories from past five years or so (excluding injury/violence prevention, A&D
prevention, and mental health promotion)
Before we proceed, and as an aside, when we came to do this sort (by putting piles of
reprints into rows on the floor), we also had a pile for theory papers related to
community oriented health promotion evaluation. It is of interest to see how the size
of this compared with all the actual research that had been done, and that we could
find, over the same time period. This is illustrated in Table 3.
THEORY
ACTUAL RESEARCH
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67
24
Table 3 Theory vs practice papers relating to the effectiveness of community HP
We feel this table is a telling statement about the activities of academics!
Anyway, to return to Table 2, it can be seen that there is a nicely inverse relationship
between the degree of ‘true’ CD and the studies done. And note that most of the
community action ones fall into the risk or prevention category. Our impression is
that if were to factor two of the other categories related to HP, like injury prevention
and A&D prevention, plus many of the MHP articles, that they too would fall into this
category, although quite a few of the MHP ones also fall into Community –
based/wellbeing and Community action/wellbeing.
As we said before, it is possible to think of subdividing some of the columns in Table
2, as we did in Table 1. The numbers barely justify this, of course! But since there is
such a poor showing in Column 3 – the one we believe in most, and the one we feel
that most health promoters like to think of as their heartland (more fantasyland than
heartland, by the look of it!) – maybe we are being too idealistic to think that
something called ‘community development’ should actually exist at all! Rather,
maybe it is more realistic to think in terms of ‘community participation’ in HP
endeavours, and that this can vary
At this stage, we intended to use this classification to present summaries of our
judgments of how effective programmes seem to have been. At the time of writing
this draft, we have not yet done this, but may have it done by the time the paper is
presented at the symposium! This requires first a rough classification for the judged
effectiveness of studies, taking all matters into account, including the presence or
absence of controls. You will just have to trust our judgment on this – or better, you
could do it yourself, to see if our judgments are reliable. (This would make a nice
study!) This classification is suggested to be as follows with regard to the health
promoting properties or effects of a given approach or study:
A Seems very beneficial
B Has some benefit, but not very great
C Has little or no effect
D Seems to have made things worse
X Impossible to say
14
This would then be used to fill in the cells of the following table:
Categories of community HP
Communitybased
Community
action
Community
development
A
A
A
B
B
B
C
C
C
D
D
D
X
X
X
A
A
A
Types
B
B
B
Of
C
C
C
HP
D
D
D
Domain
X
X
X
A
A
A
B
B
B
C
C
C
D
D
D
X
X
X
Treatment
Risk
Do-main
Wellbeing
15
Table 4: Ratings of benefit of different types of community oriented health
promotion
Obviously, such an approach does not have the rigour of a meta-analysis, or strict
evidence based approach acceptable to, say, the Cochrane Collaboration people. But
there is no reason it could not be reliable – to ascertain this, it simply requires the
application of simple psychometric reliability type measures as one finds in everyday
psychology testing using ratings. And it has the advantage of being universally
applicable. It does not just select those studies which fulfil rigid control or ‘positivist’
criteria. Any study is eligible, quantitative or qualitative, controlled or uncontrolled,
or anywhere in between any of these. It also makes intuitive sense to anyone, whether
scientist, community member, bureaucrat or the ultimate test of low-level
understanding – politicians.
Regardless of these findings, the fact of the matter is there are very few studies that fit
the category of community development as we define it. We don’t think this is
because our definition is faulty – we feel it actually reflects the reality. But given that
it is the reality, should we maybe be taking another approach to the CD-type area? one which emphasises participation rather than the criteria of community control,
community building and capacity building.
If we did this, then our impression the more the active and whole hearted the
participation of a community in a HP project, the greater it is likely to be successful.
The injury prevention literature certainly seems to indicate this (Coggan et al., 2000).
If this is so, then we can perhaps construct an hypothesis that looks like this, and
which is eminently testable, so long as we can have good criteria for degree of
participation:
The community participation hypothesis
Community as
location/target only
Active participation in
planning and execution
Full community control
and self-determination
16
In short, the further the research falls to the right on this continuum, the more
successful it is likely to be, other things being equal. It is only an hypothesis, but we
bet it is borne out!
Anyway, let us now return to the issue of the effectiveness of community approaches
to HP, as shown by existing studies. On the whole, this has not been the best,
resulting in papers with lugubrious titles like: ‘Community health improvement
approaches: Accounting for the relative lack of impact’ (Shortell, 2000); ‘Obstacles
to community health promotion’ (Guldan, 1996); ‘Community development in health
promotion: empowerment or regulation?’(Peterson, 1994); ‘Do local inhabitants want
to participate in community injury prevention?…’ (Nilsen and Kraft, 1997). We also
find statements from reviews such as the following:
[Based on a review of 34 child injury prevention studies] ‘Although
community-based interventions hold promise, there is a paucity of
evidence examining the impact of these approaches on safety
behaviours or injury rates among children’ (Klassen it al., 2000. p84)
[Based a review of seven major lifestyle (heart and cancer) prevention
programmes using community action]: While the advantages of
community action are potentially high, [none of the studies reviewed]
meet all of the criteria for rigorous evaluation….The most
methodogically adequate cancer study, the COMMIT intervention,
had only a moderate degree of success in reducing community
smoking rates. Similarly, none of the six studies (25 articles) on
cardiovascular disease fulfilled all the [scientific] criteria. The results
for the most methodologically adequate study, the Minnesota Heart
Health Program, were disappointing, with strong secular trends
preventing adequate assessment of the intervention … [Overall, there
is a] failure of methodologically superior projects… to show major
gains in reducing health risk behaviours’. (Hancock et al., 1997,
pp235, 229)
The failure of these sorts of studies to show much in the way of results is attributed
primarily by the reviewers as having primarily to do with the methodology of
evaluation. The issue of scientific rigour vs the imperatives of community
considerations are a constant problem, as Ken Allison and Irv Rootman have pointed
out (Allison and Rootman, 1996). Although we have no doubt the research may not
be as good is it could be, we could equally argue that these studies are also not up to
scratch on the community side. For instance, given our previous analysis, we can say
with certainty that they do not use true CD.
Overall, then, what does our overview of the literature of the past five or six years
show us about the effectiveness of community-whatever-it-might-be in health
promotion? (i.e. not just CDHP as such).
17
First, as indicated, the big RCT and QETs which look at lifestyle, risks and usually
heart disease or cancer, do not have impressive results, although they all feel that they
can learn more about how to do the community side better.
Second, while results are generally disappointing, there are a number of studies that
are an exception, and are impressive in what they accomplish. These, however, tend
to be in non-standard HP areas, notably injury prevention and mental health
promotion (MHP).
For example, a well-researched Safe Communities study in New Zealand showed very
impressive results on many measures in a relatively poor community, which among
other things had, in one year, a 7% increase in seat belt wearing, which made it the
best rate in the whole country. Many other safety behaviours changed too, in all
sectors of society, and in three years, there were significant declines in rates of child
injury requiring hospitalisation, whereas in a control community, these rates went up.
Here, very intensive and enlightened community participation was involved, giving a
good deal of ownership to local people, and respecting culture and local identity –
very important issues from a CD perspective – and the results bear testimony to this.
The MHP domain has numerous success stories involving community oriented
programmes and positive wellbeing outcomes, especially relating to resilience and life
skills approaches with children, often in combination with parents, peers and
community organisations. A good set of studies is given in a 1996 Welsh publication
called Mental health promotion: Forty examples of effective intervention (Health
Promotion Wales, 1996) bears testimony to this. And earlier, the classic treatise by
Jack Pransky called Prevention: the critical need demonstrated the same for hundreds
of programmes in the United States, in the area called ‘primary prevention’
(Pransky,1991). Indeed, we in my department at the University of Auckland are so
impressed with what is happening in MHP, and how it often can truly capture the
essence of CD, empowerment, wellbeing, quality of life, and all those things we have
believed in over the years, that we have moved away somewhat from classical HP,
and have developed, and are teaching and researching, a whole new area called
‘Mental Health Development’(MHD) – which we would tell you about if we had time.
Suffice it to say that MHD incorporates many of the things that we feel are missing in
CDHP today – though of course we have yet to evaluate its effectiveness too.
However, we have started, and it looks very promising (e.g. Rix-Trott, 2000).
Just as an aside, but related, is that we believe that the most successful studies are
those that do not emphasise risk or prevention so much (which most of the community
action studies do),but which emphasise positive outcomes – wellbeing, resilience,
capacity, empowerment, etc. The MHP studies that are effective almost all do this. It
has been an ideal for HP too, and is represented in the kind of approach we find here
in the Toronto quality of life research (e.g. Raphael et al., 1999).
The third main conclusion is that there are hardly any effectiveness evaluation articles
in the area of ‘’true’ CD. Indeed, in the last five years, the only one (well, actually
two – the Other Way Project and the Empowering Resource Centre) we could find
was our own in New Zealand, and those were a bit marginal, although an earlier
evaluated project cited in the same source is still going today, and it fits the criteria
fully (cited in Raeburn and Rootman, 1998). We have on several occasions
18
undertaken evaluated Category 3 Type 3 projects, and have had only one failure. But
we don’t always get the evaluations published – which could be the fate of many such
evaluation projects!
Fourth, in spite of the lack of CDHP effectiveness research as such, there is other
evidence that such an approach works, and works really well. This evidence comes
from two sources.
One are case histories, direct observation or other sources. These can be totally
convincing that they are effective, even if the evidence is only anecdotal, or
qualitative, or case study in nature. One in the literature that stands out for us is the
Modello Gardens project using the ‘health realization’ approach (Pransky, 1991),
which comes out of the community psychology literature. Another is the Alkali Lake
work in BC, an even purer example (no professionals were involved), which we have
only seen on a CBC video. Community psychology has many examples also of block
organizations, etc who organize to improve their quality of life, and there are the cases
cited by Saul Alinsky, Nancy Milio, and others over the years that show clearly that
CDHP works. There are also journalistic stories like that of Bertha Gilkey (Boyte,
1989), whose work in Cochrane Gardens in St Louis is a model of a nonprofessional,
community self-determination project which changed the face of a whole low income
housing area.
Another source of convincing but unresearched material comes from development
projects in the third world. A favourite article of ours over the years is that called
‘Grass roots groups are our best chance for global prosperity and ecology’(Durning,
1989), a summary of a report by Worldwatch in 1989. Here, we read stories of a type
with which we are sure you are familiar, of grass roots community groups standing
strong against exploitative corporations, oppressive governments and even armies, to
save their environments, to build schools and health services, to upgrade their
communities, and so on. To give just one example:
In Lima’s El Salvador district, Peruvians have planted a half-million trees; built 26
schools, 150 day-care centres, and 300 community kitchens; and trained hundreds of
door-to-door health workers. Despite the extreme poverty of the district’s inhabitants
and a population that has shot up to 300,000, illiteracy has fallen to 3 percent, one of
the lowest rates in South America – and infant mortality is 40 percent below the
national average. The ingredients of success have been a vast network of women’s
groups, and the neighbourhood association’s democratic administrative structure,
which extends down to representatives in each block. (p42)
Durning says about this and hundreds of other such examples: ‘In the face of seemingly
insurmountable problems, community groups around the planet have been able to accomplish
phenomenal things.’ (p42).
Such projects may not be labelled health promotion by their participants, or even
especially seen as having a health dimension, but they clearly do have positive health
impacts, physical, mental, social and spiritual. The Lima example shows this clearly.
They are perhaps the purest form of CDHP, and they unquestionably work
In short, then, CDHP works, and works splendidly. But we can only draw this
conclusion if we widen the concept of what we customarily call health promotion.
It needs to include injury prevention and mental health promotion. It needs to
19
include examples that may not be labelled health promotion by their
protagonists, such as the community psychology examples, or the third world
ones.
In the meantime, we need more formal effectiveness research to back this up. One can
only regret that some of that energy that is going into theorising about this and related
areas does not go in actually doing the evaluative work. There are so many good
projects, but the people involved in them, including professionals and academics, are
not producing the effectiveness data to show that they do indeed work. These data do
not need to be RCTs and QETs. They can be from quite simple goal-oriented
evaluations, collection of local data, percentage changes in important indicators (like
the literacy rate quoted about for Lima), and qualitative data which has an
effectiveness assessment objectives. . (See below for further suggestions as to the kind
of evaluation we can do here). What we need are data that not only stand up to
scientific scrutiny (and this does not required RCTs), but which can also be used for
political persuasion purposes, and to convince funding bodies for the need to support
these projects. Instead, what do we see? No discernible research projects in this area.
Further, neoliberal governments around the world are defunding and talking down a
community development approach (even while engaging in empty talk about
‘community cohesion’), and even HP itself, which has CDHP at its heart, is under
threat as a concept, notably in Canada, it seems, but also elsewhere, including New
Zealand.
Recommendations for evaluation of effectiveness for CDHP
It is clear to us that CDHP (properly defined) evaluative research is quite rare, and
RCTs or their equivalent for assessing the effectiveness of CDHP are nonexistent. So
we are unlikely to have a meta-analysis in the CDHP field for a long time yet! Yet
CDHP clearly works! So what is the optimal way to evaluate it, to demonstrate its
effectiveness, both to the communities that control it, and to outsiders, including
scientists and politicians?
We do not have the time or space here to do this justice. However, we believe that the
optimal way to go here is by the use not of the RCT or QET, but of that old favourite
in HP planning and evaluation – the planning model. This is the approach we
ourselves take in our ‘true’ CDHP work, and it is a powerful tool which meets many
purposes, and provides convincing outcome data for the different those audiences.
The planning model is based on goals, which go in and out of favour over the years,
but we are reactionary enough to have favoured them constantly, and still do. Written
down, consensual goals are wonderful things – they enable one to set directions
clearly, to have buy-in by everyone, to pick up exactly what needs and wishes
assessments are saying and to translate these into do-able and prioritised outcomes,
and they permit good organization (as in management by objectives) around
20
subprojects. Goals permit easy reviews of progress, and (most important for us here)
they provide the basis for convincing outcome statements. That is, if goals well
represent the aspirations of a community (and it is easy to check that out since they are
so explicit and public), then the attainment of those goals is clearly a success by
anyone’s judgment. This is not to say that goals are the only measure of outcome..
They need to be triangulated with any and every other possible type of data source,
quantitative and qualitative – surveys, focus groups, interviews, objective indicators,
satisfaction measures, health outcomes, and so on. But when these are all organized
around the concept of goals – which are simply statements of what one wants to
achieve by when and by whom – they make coherent and convincing sense, including
to people in the community who have set them in the first place.
The planning model that we use is illustrated by our particular version, called the
People System (Raeburn, 1992). It consists of eight steps, with feedback loops, as
follows:
Outline
aims,
philosophy
& domain
Do needs
and
wishes
assessment
Set goals
Clarify
the
organisational
structure
Develop the
action
components
Proceed with
full
implementation
Do periodic
outcome
evaluations
Of most relevance here is the final element of this system – the outcome evaluation
step. This is where the effectiveness of the project is summed up, both in terms of
goals, and any other measures. The advantage of this model is that outcome
evaluation can be seen as an integral part of the whole enterprise. It is also under the
ownership of the community, who may need some assistance in knowing how to set
goal and collect outcome measures, but that is usually pretty straight forward. Also,
it can be made to fit into any research design, including a RCT or QET. Our own
preference is for informal QETs – as mentioned, there are many QET designs. But
even without a control condition, or comparison community, you can still get very
convincing results with just a demonstration project, since the measures are so
triangulated, and you can get the community to judge how much impact the project
has had on their lives, which can to some extent bypass the need for a control group.
A smart critical analysis, which takes into account ‘secular trends’ in society, may be
just as valuable as a formal RCT or similar.
21
Conclusion
Community development health promotion (CDHP) is only one kind of community
oriented HP, which in turn is only one sector of the HP enterprise, but it represents,
we believe, the true heart of HP. In the context of this ‘effectiveness’ symposium,
there is little to offer in the conventional sense of the ‘gold standard’ of randomised
control trials (RCTs), or even big quasi-experimental trials (QETs), in this area.
Indeed, there seems to be virtually no effectiveness research to speak of in the ‘true’
CDHP area – yet this is the area many health promoters probably feel HP is really
about. There is a large amount of theorising and rhetoric about appropriate paradigms
and epistemology, but very little substantive work using any of these approaches, from
whichever camp!
As a result, we have to extend our search for ‘community’ in HP to a wider sector
than CDHP narrowly defined. There is certainly more outcome research in the
community action sector, and more again in the community-based sector, and it is a
matter of judgment the extent to which the term ‘community development’ can be
used to include these. Our view is that some of the community action studies do start
to approximate ‘true’ CD, especially if we include injury prevention and mental health
promotion studies, and some of these give outstandingly positive results. But at the
same time, in terms of meeting the criteria of CD given here (community control,
community building, and capacity building), the control still remains with the
professionals and researchers. Nevertheless, in good community action studies, a
degree of community building and capacity building may take place, even if this is
seldom explicit or measured in its own right. Most of the major evaluative studies in
the community action area tend to be disappointing too, although there are some
notable exceptions. The failure to find positive results for community action is usually
ascribed in the literature to poor research methodology. While this is probably so, we
also argue that another reason is that the ‘community’ dimension is not CD enough,
and to the extent that it is, then results may reflect this positively. We developed a
participation continuum to try to capture this as an hypothesis. Notwithstanding, such
a continuum should not deflect us from the reality – that in spite of the rhetoric,
virtually no-one is doing outcome evaluated HP work which meets the basic criteria of
CD.
But even if the amount of formal CDHP outcome research is very small, there is other
more informal evidence to indicate convincingly that it works. We hear many
accounts and stories anecdotally and qualitatively that such projects work. In
particular, the developing world has many superb examples of this
In terms of how to go about evaluating CDHP projects, there are many legitimate
approaches beyond the RCT or the QET. We have suggested further that the planning
model approach is an optimal one here. Regardless, we need a rapprochement
between the differing theoretical factions around the topic of HP research and
evaluation, and indeed, we need some of the academic horsepower currently taken up
in theorising to be out there actually doing some evaluative research in the field – in
an empowering and community-controlled way, of course!
We would like to end by suggesting that it would be good if we as health promoters
were to give more attention to actually attempting to assist in the processes of setting
22
up ‘true’ CDHP projects, and to attempting to evaluate them. These projects work –
but we need to have the evidence to show they do. It is time for ‘epistemological’
debates to quieten, and to produce the goods! The survival of the HP we believe in
may depend on it. With HP and indeed society under threat from dislocation and
continuing new threats to our wellbeing – including new and major issues like
gambling – there has never been a greater need for CDHP. Communities can use us
and our expertise – on their terms, of course. But they may get tired of waiting for us
as we argue over theories, and go ahead without us!
CDHP remains the ultimate and most precious jewel of HP. Let us not let it die from
inattention.
23
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