Beruflich Dokumente
Kultur Dokumente
10.1093/heapro/
Issues of participation, ownership
dap054 and empowerment
in a community development programme: tackling
smoking in a low-income area in Scotland
SUMMARY
Founded on community development principles and held by those implementing the intervention. The paper
practice, the ‘Breathing Space’ initiative aimed to produce examines the principles that underpin health promotion
a significant shift in community norms towards non- in the community setting, particularly the concepts of
toleration and non-practice of smoking in a low-income ownership, empowerment and participation, and their
area in Edinburgh, Scotland. The effectiveness of differential interpretation and employment by participants.
Breathing Space was evaluated using a quasi-experimental The data illustrate how these varied understandings had
design, which incorporated a process evaluation in order implications for the joint planning and implementation
to provide a description of the development and imple- of Breathing Space objectives. In addition, the different
mentation of the intervention. Drawing on qualitative data understandings raise questions about the appropriateness
from the process evaluation, this paper explores the varied and viability of utilizing community development approaches
and sometimes competing understandings of the endeavour in this context.
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52 D. Ritchie et al.
Smith et al., 2001), two of which are participation et al., 1994; Labonte, 1994; Robertson and
and empowerment. These principles can and are, Minkler, 1994; Laverack, 2001; Smith et al.,
however, operationalized differentially in 2001). For example, empowerment may be at
different types of community development work. either or both the individual and community
The concept of community participation has level (Bracht and Tsouros, 1990; Bernstein et al.,
proved to be more complex than was originally 1994; Israel et al., 1994; Labonte, 1994; Robertson
envisaged by the early World Health Organization and Minkler, 1994; Robinson and Elliott, 2000;
(WHO) health promotion strategies (WHO, Smith et al., 2001), and tension may exist within
1978; Rifkin, 1986; WHO, 1986; Rifkin et al., community development practice between the
1988; Rifkin, 1995; Labonte, 1998; Zakus and two levels (Robertson and Minkler, 1994;
Lysack, 1998; Laverack and Wallerstein, 2001). Wallerstein and Bernstein, 1994). Whereas
Despite consensus that community participation individual empowerment might be concerned
should engender active processes involving with individuals gaining mastery over their lives,
was set up to oversee planning and imple- what she was talking about were health visitors:
mentation. This alliance formed a steering com- the pharmacists, the local shops—that is not a
mittee, which supported settings-based subgroups community. (I8)
(level two), whose remit it was to take project
objectives forward. Subgroup membership Hence, although Breathing Space was conceived
included the main intervention team and other as a community development project, there was a
community workers with particular expertise or lack of agreement among the partners about
interest in that setting. The third level comprised what community participation meant and who
others who worked or lived in the community, and should be involved.
who were involved in the implementation of Participation and ownership were not only
specific intervention activities. issues at an organizational/agency level, but also
at the level of their membership. Commitment
held by managers did not necessarily reflect the
Similarly, YS2, a youth agency worker, felt that going down the different channels with people who are
smoking was not high on the agenda of young identified as smoking if they are wanting to either stop
people: smoking or to reduce their smoking habits. (PS4)
I think in a lot of ways it’s an adult issue. You know Targeting individual smoking behaviour was not
what I mean? It’s coming from adults it’s not coming necessarily seen as incompatible with the aims of
from young people … I don’t think they see it as a community development work. Some, for
huge issue. (YS2) example, felt that increasing access to cessation
materials and support would lead ultimately to a
Some respondents felt that the focus on smoking change in ‘perceptions on smoking in [the area]’
was ethically problematic. For example, I13 (an (PS3) and help ‘overall to reduce the number of
intervention team member and health board people that smoke’ (I13).
worker) felt that targeting smoking contributed The programme was also affected by
further to people’s already disadvantaged lives. institutional constraints experienced by those
She described smokers as ‘people who maybe have working within the different partner organi-
lots of needs, have complex needs’ and smoking as zations. Some implementers felt they were
‘their little bit of pleasure’ (I13). expected to demonstrate the type of tangible
Some respondents reported difficulties in selling outcomes associated with direct action about
the programme to community gatekeepers. I16, smoking targeted at the individual level. For
when describing the problems she encountered example, the Breathing Space coordinator said:
when trying to get general practitioners on board,
said: As time has gone on there’s been a certain amount of
pressure to do things—practical things. And they tended
… it’s not a particularly nice feeling to be having to to be about smoking, directly about smoking. (R14)
work so hard to sell something … You get home and
say to yourself ‘I’m not peddling drugs here, I’m trying Given the types of outcomes traditionally
to do something good’. (I6) expected of health promotion, the community
56 D. Ritchie et al.
development approach presented some and we are very much on the practical … side
difficulties for respondents. Some, for example, here’ (I9).
were uncomfortable with, and resistant to, the Secondly, even where workers were knowl-
idea of project objectives that were shaped by the edgeable about, or gained familiarity with these
community agenda and that could evolve over precepts, they did not find it easy to translate this
time. A health board worker involved in the con- knowledge into practice. Ways of working asso-
ception of the programme described the dilemma ciated with the different partner organizations/
this posed for some workers: agencies were understood by respondents to be
fundamentally incompatible:
People are probably more used to working in a way
that’s erm—you know—you do this and then you do … there are tensions in doing community
this and then you do this. Whereas what we are trying development if you are a statutory organization … it
to do is to allow a process to emerge … and what doesn’t quite fit, because on one level it’s home grown,
operationalizing the programme necessary for its of community members, because of the very
success. In particular, a narrow focus of the health minimal presence of this group in the Breathing
board on the health of individuals and on smoking Space programme.
behaviour per se was, given the community In conclusion, although current policy may
development aims, felt to place inappropriate celebrate rhetoric of community development and
expectations and constraints upon programme partnership, the data illustrate how the reality may
outcomes. be difficult to deliver, especially for those working
The different approaches, which appeared to in the statutory sector. This is a finding supported
index the respective positions of the community in the literature (Robertson and Minkler, 1994).
organizations and the health board, reflected two Our findings also illustrate the importance of
separate discourses operating within the clarifying the respective roles and inputs of
programme simultaneously. The first favoured organizations/agencies involved in partnership
the concept of community development and working. In particular, it is crucial to recognize