Participation and democracy in health promotion

9 June 2007, Vancouver

Goof Buijs, the Netherlandsgbuijs@nigz.nl

based on the work of Bjarne Bruun Jensen, Denmark bjbj@dou.dk

contents

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

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

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

Meaning…..

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

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)

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.

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

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

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

Participation - in relation to what and how?

Selecting the topic

Analysing, exploring

Vision/ aim

Action and evaluation

Students suggest Common decisions

Students suggest Students decide

Teacher suggests Common decisions

Teacher/ external decisions

Different forms of actions

Direct actions

Individual

Collective

Indirect actions

1

43

2

Components of action competence

• Knowledge/Insight

• Commitment

• Visions

• Action experiences

• Critical thinking

• …

Four dimensions of knowledge

HEALTH

AND ENV. ISSUES

Effects ”what?”

Change strategies ”how?”

Causes ”why?”

Visions ”where?”

traditional ”knowledge landscape”

HEALTH

AND ENV. ISSUES

Effects ”what?”

Change strategies ”how?”

Causes ”why?”

Visions ”where?”

Action-oriented knowledge landscape

HEALTH

AND ENV. ISSUES

Effects ”what?”

Change strategies ”how?”

Causes ”why?”

Visions ”where?”

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

Health concept:developments 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

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

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

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

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

”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%

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?

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

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• Painting lamp posts, putting up bird houses, planting shrubs

and cleaning roadsides.

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

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?

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 targetgroup’s health understandings

• Insight in the active concept facets

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)