Participation and democracy in health promotion

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Participation and democracy in health promotion

• 9 June 2007, Vancouver
• Goof Buijs, the Netherlands
• gbuijs_at_nigz.nl
• based on the work of Bjarne Bruun Jensen,
  Denmark
• bjbj_at_dou.dk

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contents

• 2 paradigms?!
• key concepts participation and action
• the IVAC approach
• conclusion and challenges

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Different paradigms?

• PREVENTION HEALTH PROMOTION
• Totalitarian Democratic
• Moralize Participate
• Top-down Bottom-up
• Monologue Dialogue
• Individual Collective
• Privation Commitment
• Driven by experts Driven by participants
• Behaviour change Action competence
• Health Information Health Pedagogy
• Disease Quality of life
• Lifestyle Living conditions
• Closed health concept Open health concept

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Two different paradigms?

• Health promotion versus prevention and treatment?
• No- a false contrast
• Instead retrieves a dialogue-oriented versus a
  top down approach to
• Health promotion,prevention and treatment

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Meaning..

• .. That even the surgeon has to be aware of
  supporting the patients own participation and
  actions

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Two paradigms?

• The work (with health promotion), is in short,
  based on visions and possibilities, driven by
  hope, dominated by a bottom up perspective.
• The work (with prevention), is in short, based on
  risk-thinking, driven by fear, dominated by
  experts and by a top down perspective (Jensen
  Johnsen, 2000, s.7)

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Two paradigms?

• Health Promotion efforts are participatory,
  based on dialogue and can be targeted towards
  individuals as well as sections of populations
  (Danish National Board of Health 2005, p. 49).
• In description of prevention nothing is
  mentioned about participation, dialogue,
  user-involvement ect.

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Barriers for changing paradigms

• Basic training
• Professional terminology and language
• Historical background
• Afraid of loosing professionalism
• Expectations from target groups and collaborating
  partner
• Lack of time for dialogue with target groups
• Lack of tools for working in another paradigm
• Demand on documentation and evaluation

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Therefore..

• Health promotion/prevention have different goals,
  but are complementary therefore they do not
  belong to different paradigms
• Starting point for sharing values is in the
  operationalisation of the key concepts (such as
  participation, action competence) in relation to
  the context/ setting

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The concept of participation

• Participation what is it about?
• Students need to be involved in decisions about
  content, process and outcome
• Participation why is it important?
• ethical reasons
• learning efficiency
• creating ownership
• educating for democracy

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Participation - in relation to what and how?
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Different forms of actions
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Components of action competence

• Knowledge/Insight
• Commitment
• Visions
• Action experiences
• Critical thinking

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Four dimensions of knowledge
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traditional knowledge landscape
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Action-oriented knowledge landscape
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experts versus target groups

• Top down approach dominated by experts
• Bottom up approach dominated by the target
  groups
• Dialogue approach the content and the
  professional has an important role to play

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Health conceptdevelopments in health promoting
schools

• From disease-oriented health concept
• healthy food correct nutritional balance
• To wellbeing-dominated health concept
• e.g. healthy food food which tastes good
• Or health concept which includes quality of
  life, disease elements as well as its mutual
  links
• e.g. healthy food nutritional, aesthetical,
  social and sustainable dimensions

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The participation concept

• Criticism of top-down and bottom-up approach (top
  down, moralising, expert-dominated)
• Many projects had to begin with target-group
  dominated (professional was put on the sideline)
• Gradually self-determination became
  targetgroup-professional dialogue with
  professionalism back in the centre

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Three principal lines

• 1. Towards a health concept that contains both
  disease and healthy life
• 2. Towards a participation concept, where the
  professional is placed centrally
• 3. Towards a setting perspective, where the
  framework and education are connected and related
  to education and health competence development

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Pupils Visions (1800, 13 y.o.)

• I have many ideas about how we can improve
• - my daily life (a)
• - my school (b)
• the World (c)
• ANSWERS a b c
• Fully agree/Agree 49 47 58
• Does not agree or disagree 38 39 32
• Totally disagree/Disagree 12 14 10

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Pupils Commitment (1.800, 13 y.o)

• I would like to fight for improving
• my daily life (a)
• my school (b)
• the World (c)
• ANSWERS a b c
•  
• Fully agree/Agree 73 63 78
•   
• Does not agree or disagree 21 30 19
•  
• Totally disagree/Disagree 6 7 3

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Achieving influence is very easy (3.660, 13-15
y.o)

• The students were asked about
• four different settings
• Leisure activities 36
• Family 44
• School 14
• Society 6

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The IVAC approach

• Investigation
• why is it important to us
• do lifestyle and living conditions make an
  influence
• how was it in former times and how has it changed
• Visions
• what alternatives can we imagine?
• how are the conditions in other countries and
  cultures?
• what do we prefer and why?
• Actions Change
• what changes will bring us closer to the visions?
• changes in our own life, in the class, in the
  society?
• what action possibilities exist in order to reach
  the changes?
• which actions will we carry out?

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A case from Denmark - I

• Students actions
• Applications sent to the local government's
  departments 18
• Cleaning (gathering of litter from streets,
  beaches etc.) 12
• Articles in the local newspaper 10
• Written petitions to private companies 6
• Embellishments (painting lamp-posts, stones
  etc.) 6
• Written petitions to local village boards 5
• Establishment of compost containers 5
• Hanging up of posters regarding environmental
  issues 5
• Demonstration concerning traffic conditions (150
  pupils) 1

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A case from Denmark - II

• Changes due to students actions
• City council set aside 130.000 for reorganising
  traffic in Lyngerup local area (roundabout etc.)
• Establishing Toronto-flash and zebra crossing
  near the school
• Reducing speed limit to 50 Km/h near the school
• Planting trees along cycle paths between two
  neighbourhoods
• Intensifying local media debate on traffic
• Extending playground and establishing basketball
  court
• Creating a meeting and activity place for adults
  and children
• Establishing children's village board as part of
  village board
• Establishing compost containers

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What helps to build ownership and action
competence

• Genuine participation (but in a dialogue with a
  professional)
• Own actions (but as integrated elements)
• Barriers might help to increase motivation (but
  the role of the professional is crucial)
• All ages and all socio-economic groups benefit
  from an participatory and action-oriented
  approach

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Challenges for Schools

• Actions often defined by external actors
• Economy used as external motivating factor
• Skills needed by teachers to integrate authentic
  actions and collaboration in education?
• How to prepare the community for acting
  pupils?
• Supporting structure needed?

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Professional competence

• Clarification related to the health concept
• Action-oriented insight about health related
  conditions
• Feeling for - and insight in dialogue with
  target group
• Insight in the targetgroups health
  understandings
• Insight in the active concept facets

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Conclusions and future challenges

• Dialogue, instead of top-down bottom-up
• Towards genuine participation and action
• Focus on competence development
• Potential for schools needs more research and
  development (measure impact and effectiveness)