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Centrally initiated health promotion: Getting on the agenda of a community and transforming a project to local ownership

Maurice B. Mittelmark
Department of Psychosocial Sciences and Research Center for Health Promotion
School of Psychology, University of Bergen
Bergen, Norway

Introduction

A growing number of public and private agencies world wide are developing health promotion initiatives intended for implementation in local communities. This paper reviews briefly the rationale for community-based health promotion, and proposes several strategies to foster successful implementation and maintenance of programs that are centrally initiated. These ideas are developed from American experience, but with a focus on strategies that appear to be meaningful to health promotion initiatives in most societies.

Much of the American experience with the community-based health promotion model comes from cardiovascular disease (CVD) prevention research and demonstration projects. Several of the largest were conducted in California, Minnesota, Rhode Island, and Pennsylvania (Farquhar, 1978; Blackburn, Luepker, Kline, et al, 1984; Mittelmark, Luepker, and Jacobs, et al, 1986; Farquhar, Fortmann, Maccoby, et al, 1985; Lasater, Abrams, Artz, et al, 1984; Stunkard, Felix, and Cohen, 1985). They were founded on the premise that a population-based prevention strategy, in which entire communities would be assisted to reduce their levels of risk factors for heart and blood vessel diseases, would result ultimately in a reduction of illness and early death from these highly prevalent diseases (Rose, 1992).

The successes of these research projects in launching and maintaining community-based education programs helped inspire the development of practical planning models for community-based health promotion that are in widespread use today (Kreuter, 1992). These projects have also played some modest role in stimulating a health promotion ideology in which community-level action is viewed as an indispensable element in a co-ordinated, multi-level strategy that includes individuals, families, neighbourhoods, schools, work places, communities, regions, states, and international arenas (First International Conference on Health Promotion, 1986; Bracht, 1990; Green and Kreuter, 1991).

This multi-level strategy recognises explicitly that health, however defined, is shaped in part by forces beyond an individual's control. It recognises also that effective large scale action, such as national policy making, requires complementary action in communities, to address the proximal social, economic, and environmental factors that influence health (First International Conference on Health Promotion, 1986).

In most societies today, community-based health promotion is also highly consistent with modern values of democratisation. The community-centred approach ideally places decision-making authority and responsibility for health improvement as close to the citizenry as possible, while avoiding the 'victim-blaming' potential of programs that target only the individual citizen (Green and Keuter, 1991; Bracht, 1990).

There are additional, seemingly universal, practical reasons to focus on the local community and its settings for health promotion. Many communities are organised as formal administrative units such as towns, cities, and municipalities. In most of the world, these local political and administrative units have the responsibility, structures, and resources to implement and maintain a wide variety of services for the local population. People tend to identify closely with the district they live in, stimulating citizen involvement in many arenas of community life, including promoting better health in the population.

An emerging reality for public and private economies is the struggle to adjust to a rapidly changing political and economic world. Two favoured coping strategies are 'privatisation' and 'decentralisation', with local communities asked to take on more and more of the administrative and financial responsibility for providing health and human services.

The local community plays a significant role in public health practice. Data on population health provide feedback to authorities and the citizenry-at-large about progress in dealing with important health issues. For many health surveillance systems, the local municipality is a practical level at which to aggregate and report health and vital statistics. Problems thus identified at the municipality level naturally invite solutions at the same level if at all possible.

Also, communities and their settings (schools, worksites, churches) are convenient, accessible organisational units within which health promotion researchers can develop, test, and implement new programs.

Despite the many reasons to favour community-based health promotion action and research, this approach has its challenges and difficulties. Communities may not be organised in ways that favour an emphasis on health promotion action. Many communities have formal public health and health protection units, but these do not often include health promotion among their priorities, nor may these units have the expertise needed for health promotion.

Also, a typical community is a busy community, with many formal and informal organisations dedicated to a wide range of local issues including public safety, education, leisure activity, the arts, and health and human services for the needy, as but examples. Many of these activities compete for a shrinking resource base of facilities, people, and money. Effective volunteers and professionals may be difficult to recruit to yet another cause, however worthy it may be. Even when a new program competes successfully for a community's relatively scarce resources, there may be unexpected and untoward consequences. The number of skilled and effective volunteers available in any community is limited, and there is often competition among various 'causes ' for the best volunteers. A new health promotion initiative that is successful in attracting community involvement may inadvertently drain resources from other existing and worthy causes.

For these same reasons, community-based health promotion action and research programs that depend on citizen involvement seem always in danger of fading away once the peak of community interest begins to wane. New programs often are launched with an infusion of external resources, money from a government grant for example, and a high level of community enthusiasm naturally follows. But just as grants start, they also end. Sustaining grant-initiated programs over the long term on indigenous resources can be as or more difficult than introducing the program in the first place. All of this is further complicated by the problem of knowing which programs are worthy of sustenance and which are not. Self-evidently, some programs should fade away, or at least be seriously reorganised, such as those whose mission is accomplished, and those whose mission has failed (Green and Kreuter, 1991).

As well, there can be confusion about what, exactly, can and should be sustained. Program maintenance is but one possibility, in which a health promotion demonstration program becomes eventually an integral part of a community's infrastructure (Altman, 1995; Goodman, McLeroy, Steckler, and Hoyle, 1993). But there are other important possibilities, such as building the capacity and competence of the community to solve new problems and building professionals' skills for health promotion (McKnight, 1985; Jackson, Fortmann, Flora, et al, 1994; Eng and Young, 1992; Green, 1989; Altman, 1995).

Models for Community-based Health Promotion

Traditionally, medical services, the media and health education were the main channels of communication for health initiatives. Today, it is recognised that many other channels are potentially available, if local community government, schools, businesses, arts and entertainment, churches, civic organisations, and self-help groups can be enlisted as partners for health promotion action. It is also recognised that is difficult work. A number of planning models have been developed to guide health promoters and communities on a path to successful program implementation and maintenance (Bracht, 1990; Bracht and Tsouros, 1991; Green and Kreuter, 1991; Butterfoss, et al, 1993; Sanderson, et al; Dluhy, 1990; Creighton, 1992; Kreuter, 1992; U.S. Department of Health and Human Services; Goodman and Steckler, 1989; Altman, 1995).

These differ in their terminology, complexity, focus, and theoretical roots, but all have essentially the following characteristics. The processes of health promotion are emphasised, rather than the materials and products. A key feature is partnership with a broad range of community leadership, professionals, and ordinary citizens, not merely with the health care sector. Many models have as a central element the building of a broad-based coalition to support the project, and emphasise that potential coalition members should ideally be partners not only in the action phase, but also in planning stage. In one way or another, most health promotion planning models are framed as staged guides for long term planning and action, exemplified by Bracht and Kingsbury's (1990) five stage model: 1) community analysis, 2) design initiation, 3) implementation, 4) maintenance and consolidation, and 5) dissemination and assessment. Below, this model is used as a convenient framework for a discussion of principles and suggested practices for centrally-initiated health promotion programs.

Community analysis --

Most planning models emphasise that much time and energy is required at the start of a project for community analysis, that this must precede action, and that action should be founded on the results of community analysis. The rationale for community analysis receives much attention in these models. Because it is time and resource consuming, there is fear that health promotors and communities will tend to run through it quickly if at all, and move too soon into action. Among the questions of community analysis are these: What boundaries should be used to define the community? What is its social structure, formal and informal leadership, style(s) of problem solving, and history of collaborative undertakings? What are the community's health and behaviour patterns, environmental conditions, and economic climate? What are the community's capacities and assets, and how ready is it to accept the project? What are the barriers to implementation?

Capacity and Determination of the Initiator -- There is one critical, preliminary analysis that is usually not addressed in planning models: An agency that intends to initiate a community-based health promotion project should first critically examine its own capacity and determination not only to introduce, but also to support, its community initiatives. What should this capacity and determination be? Based on experience with a wide range of state health agency-initiated projects, the following might be the most vital: commitment from the initiating organization's leadership to support staff and keep community-based health promotion in the organizational agenda, building of linkages between the organization and the community projects it supports, program evaluation and dissemination of results, means and ways to obtain advise and participation of outside experts, and attention to the issue of program maintenance from the outset (Schwartz, Smith, Speers, et al, 1993; Elder, Schmid, Dower, et al, 1993; Goodman, Steckler, Hoover, et al, 1993).

However, no matter the contents of such a list of initiator capacities, the vital lesson, it is suggested, is that initiating agencies should evaluate early not only a community's capacity to adopt a program, but its own capacity and determination to support the community. The implications are clear: if such a self assessment points out weaknesses, these should be corrected, or the project should be discontinued. An initiating agency that is neither prepared nor willing to provide serious support should withdraw from the arena of community-based health promotion.

Design initiation --

Design initiation is the stage during which community coalitions and project initiators work together to identify, select, and recruit citizens for membership on task forces and work groups; establish a core planning group; choose an organisational structure; define the organisation s mission and goals; clarify roles and responsibilities of coalition members, volunteers, and professional staff; determine what specific strategies and methods will be employed during the action phase; provide training for health promotion action; provide recognition, reinforcement, and reward for volunteers, participants, and staff.

Selecting, training, and supporting the project coordinator -- Among the roles a community-based project coordinator must fill, perhaps the most critical in that of 'community organizer.' Community organization is the process of mobilizing community leaders and citizens to contribute their time, resources, and talent to attaining the goals of the program, consistent with local values (Bracht, 91) and ommunity organization is the foundation of a community-based program. Relatively inexpensive efforts in organization can potentially leverage large community contributions. Stimulated by community organization efforts, the local health agencies may provide technical expertise, schools may alter curricula, corporate leaders may introduce health promotion at the workplace, and businesses may donate time, contest prizes, space, and other resources (Mittelmark, Hunt, Heath, et al, 1993).

The most effective project coordinators are perceived as leaders in the community. They have a history of community involvement, they are seriously motivated by the goals of the project, and they possess substantial administrative ability. Many excellent health promotion project coordinators do not have formal training or experience in public health or health promotion, or in the specific health promotion subject at hand. The initiating agency should be prepared to provide needed training to an excellent candidate, rather than select a properly trained, but otherwise mediocre health professional (Goodman, Wheeler, and Lee, 1995; Goodman, Steckler, Hoover, et al, 1993).

Given the critical role of the community-based project coordinator, it is only a slight exaggeration to assert that the most critical decision in the genesis of a community-based health promotion program is the selection of a local project coordinator, the most critical intervention is the training of that person, and the most critical resource is the technical support provided to that person (Mittelmark, Hunt, Heath, et al, 1993).

Goals and Goal Conflict -- Self-evidently, setting clear goals at the start of a program that the initiator and the community can agree to greatly assists program implementation. But this can be much harder to do in practice than in theory. The hard-earned experience of the Florence, South Carolina, 'Heart to Heart' Project is a classic case study of disruptive goal conflict that could have perhaps been avoided (Goodman, Wheeler, and Lee, 1995). 'Heart to Heart' was implemented under conditions of bureaucracy quite typical in many countries: it was a central government initiative (Centers for Disease Control and Prevention) to implement a local health promotion program (the town of Florence) through a regional health authority intermediary (the state health department).

The project recorded some important successes, including increased community awareness of CVD, increased linkages among service providers, and reduced turfism, among other benefits (Goodman, Wheeler, and Lee, 1995). However, a serious impediment to fuller success was chronic confusion and conflict about the goals of the project. The initiators, the intermediary, and community members all had different ideas about what the goals were, each tending quite naturally to define goals in line with their divergent interests. Because goals were not agreed to early and explicitly, deficiencies in project implementation occurred, including failure to effectively reach needy community groups such as the poor, and failure to use the skills and resources of community volunteers on the project co-ordinating council (Goodman, Wheeler, and Lee, 1995).

Implementation --

Implementation is that stage during which prior planning comes to fruition via effectively operating programs and broad citizen participation, supported by a practical plan of work to determine priorities for intervention activities, identify specific project objectives, obtain resource support, design and conduct evaluation, and provide feedback to community and to implementing agency on progress, problems, and advisable course corrections.

Partnership with the community -- Community participation at the earliest stages of project planning and implementation helps significantly to promote adoption of the project by the community (Bracht, 1990; Bracht, Finnegan, Rissel, et al, 1994; Lefebvre, 1990; Mittelmark, Hunt, Heath, et al, 1993; Goodman, Steckler, Hoover, et al, 1993). This implies an evolving partnership between the initiating agency and community, one in which the initiator is the senior partner at the beginning of the project, but the community is senior partner when the project matures (Mittelmark, 1990; Goodman, Wheeler, and Lee, 1995).

Community partnership models are various: partnership with a single lead agency, with an agency consortium, with multiple independent agencies, or with an independent foundation, such as a citizen board (Lefebvre, 1990). In practice, an initiating agency may need and want to establish multiple community partnerships using several or all of these models (Lefebvre, 1990), establishing in effect a community health promotion network (Jackson, Fortmann, Flora, et al, 1994).

Whatever the model or the numbers of partnerships, a lesson learned in several of the CVD prevention projects was that a relatively formal agreement on partnership, reached very early in the genesis of the project, promoted better program implementation and better program maintenance (Bracht, Finnegan, Rissel, et al, 1994; Rissel, Finnegan, and Bracht, 1995). These agreements also set the stage formally for program maintenance by including maintenance as a partnership issue.

The Community Advisory Board (CAB) partnership model has been used in virtually all the American community-based CVD prevention projects, and is almost a defining feature of the American approach. A systematic approach to selection and recruitment will produce a CAB whose members are tied into a broad array of community's organizations and structures at the highest levels. These are formal and informal leaders, who can provide direct access to existing community organizations and resources, including volunteers and supporting health professionals (Carlaw, Mittelmark, Bracht, et al, 1984; Bracht, Finnegan, Rissel, et al, 1994). From among the informal and formal community influentials that agree to volunteer on behalf of a project, astute planners are advised to select, nurture, and support at least one person who will be a champion for the project, an individual with bargaining, negotiation, and leadership skills (Steckler and Goodman, 1989; Goodman and Steckler, 1989). Such a champion can not only help coalitions run smoothly and assist implementation in other ways, but may be a critical player in the long term goal of program maintenance.

Maintenance and Consolidation –

Maintenance and consolidation is that stage during which project participants gain experience and expertise with the project; integrate successful intervention programs into existing community structures and networks for eventual adoption and maintenance of key programs; establish a co-operative atmosphere that bridges the vested, and sometimes conflicting, interests of diverse community groups; attract new volunteers and staff to counter inevitable turnover; disseminate evaluation results in the community to increase program visibility, community-wide acceptance, and involvement.

Program Maintenance and Capacity-building -- As already stated, a well-founded CAB helps tie a project into a broad array of community's organizations and structures at the highest levels. An very important 'extender' effect is also a benefit of this strategy, because others in a Board member's home organization (a bank, a health department, a school) will themselves be more likely to work actively and enthusiastically for the new project if the boss is excited about it. In the Minnesota program, the connections of CAB members to existing community organizations was given much of the credit for the fact that 60 percent of intervention activities continued to function well, several years after central funding for the community program ended (Rissel, Finnegan, and Bracht, 1995).

However, CAB's, task forces, and work groups that work well in the implementation phase of a project may not be feasible to maintain over the very long term. In the California CVD prevention project, for example, CAB's and associated networks were very effective during the most active, centrally-funded phase of the project, but during the maintenance phase, when resources were much more meager, keeping these networks and their programs up and running in their original form was judged not feasible (Jackson, Fortmann, Flora, et al, 1994; Altman, 1995). So, instead of a program maintenance strategy, the community and the original sponsors agreed to focus on community capacity-building, assisting health educators in existing organizations to acquire health promotion knowledge and skills. Taking a long range view, building community capacity, rather than program maintenance, may be the preferred strategy in many communities. But for this approach to be acceptable to program initiators, ground work must be carefully laid so that capacity-building is recognized from the beginning as a acceptable and valued outcome.

Dissemination and Reassessment --

Dissemination and reassessment is a continuous process during which the community analysis is updated; the effectiveness of intervention programs is assessed; future directions are charted regarding program funding, management, and long term sustenance; results are summarised and disseminated to the community and its neighbours, to the sponsors, and to the health promotion 'community' at large.

Institutionalisation -- What is sometimes meant by 'program maintenance' is the transition of a program from dependence on outside support to indefinite continuance supported solely by local resources. This attainment of independence and longevity is often referred to as 'institutionalisation' (Goodman and Steckler, 1989). While this may be the dream of program initiators, as the ultimate in leveraging, this kind of transition is not always feasible. For many programs, a more realistic scenario is this -- there is an initial surge of activity by the initiating, external agency, replaced over time by increasing collaboration and initiative from the community, accompanied by a fading of the exogenous contribution, which nevertheless is long present, perhaps for many, many years (Farquhar, Maccoby, and Wood, 1985; Mittelmark, Hunt, Heath, et al, 1993).

Indeed, the notion of long term, perhaps permanent external support for a health promotion initiative seems quite defensible for certain types of programs, namely those that are complex, expensive, technologically challenging, and ever changing as new knowledge is gained (Kreuter, 1992). In these characteristics health promotion is not unlike public health or medicine. Such undertakings may long flourish if supported by a multi-level infrastructure, including long term commitment from an initiating agency, but may flounder if left to their own devices.

To illustrate this by way of analogy, consider how the infrastructure of medicine outside a community is vital to the delivery of quality care in the community. Regional medical schools draw students from many communities and return them to communities to practice medicine. These local providers serve local patients' needs. Difficult cases can be referred to regional speciality centres and consultation is available locally, regionally, nationally, and even internationally. Continuing education occurs at the regional and national levels. Through conferences and journals, new information is widely shared. It is virtually impossible to visualise quality community medical care independent of these permanent, external supports (Mittelmark, Hunt, Heath, et al, 1993)

Leveraging and Dumping -- Leveraging is a financial term that refers to the use of an initial investment to draw larger investment. The term can also be used to describe a common strategy used by public and private funders, in which they require a grant-receiving community to contribute resources for program implementation (matching), and assist the community to make plans for program maintenance when the external funding has run out (Green and Krueter, 1991).

However, many demonstration programs intended for dissemination to other communities make no specific provisions for program maintenance in the original demonstration communities. Goodman and Steckler (1988-89) have introduced the term 'dumping', referring to a tendency of outside funders get programs started in local communities, and then leave it up to the local community to carry on over the long term. There are good reasons for local communities to be wary of both leveragers and dumpers. With leveraging, local budget decisions can be viewed as dictated by outsiders, and with dumping, local officials can inherit long term responsibility for programs that were not really local initiatives. Local communities that have either been 'leveraged' or 'dumped' in the past, and felt manipulated in the process, may be very reluctant to enter a health promotion partnership in which the experience may be repeated.

Final Thoughts - More on Infrastructure

Several principles and suggested practices for community-based health promotion have been described here. It has been suggested here and elsewhere that activity at all these stages could be greatly enabled and enhanced if supported by a health promotion infrastructure with linkages at national, regional, and local levels (Mittelmark, Hunt, Heath, et al, 1993; Kreuter, 1992). The example of organised medicine was put forth here to make the case that quality care at the local level demands such infrastructure, and if so for medicine, why not for health promotion?

But medicine is medicine, and health promotion is something quite different. Is such an infrastructure realistic for health promotion? How might it be organised? Who would the key players be? Who would pay for it?

One model for such an infrastructure is emerging in the United States, called PATCH -- Planned Approach to Community Health (U.S. Department of Health and Human Services; Kreuter, 1992). The PATCH approach has been demonstrated in a wide range of settings and with a broad array of public health issues -- examples include chronic disease risk factor reduction in public housing in Washington, D.C. (Rivo, Gray, Whitaker, et al, 1992), health needs assessment in an Hispanic-American community in Texas (Ugarte, Duarte, and Wilson, 1992), health promotion in African-American communities in Illinois (Bogan, Omar, Knobloch, et al, 1992) and in Florida (Coward, Sutherland, and Harris, 1995), health promotion organised from an inner city health centre and from a rural primary care practice in Massachusetts (Fulmer, Cashman, Hattis, et al, 1992), and community-, hospital-, health clinic-, and neighbourhood centre-based chronic disease prevention programs in Maine (Goodman, Steckler, Hoover, et al, 1993).

These and other community-based public health projects that have used the PATCH model have been linked, at least theoretically, to the kind of infrastructure called for in this paper. The nerve centre is the federal Centers for Disease Control and Prevention. PATCH is intended to be applied at the local community level, but operating within an interdependent system that connects local, state, and federal public health agencies (Kreuter, 1992). As a result, PATCH recognises the need, and has taken the challenge, to provide practical guidance to local communities and to strengthen communications among the many federal, state, and local agencies that have something to contribute to a health promotion network.

PATCH is a promising start, but it is essentially a public health infrastructure, not a health promotion infrastructure. The difference is not trivial. The PATCH collaboration is squarely in the health sector and it relates primarily to health units at various levels of government. But there is rapidly emerging understanding that most of the main determinants of health are almost totally outside the control of the health care sector: income and social status, social relations, education, employment and working conditions, and the physical environment (Green and Kreuter, 1991; World Bank, 1993; Advisory Board of the Second International Heart Health Conference, 1995; Federal, Provincial and Territorial Advisory Committee on Population Health, 1994).

The Canadians, who have played perhaps the central role world-wide in stimulating modern health promotion ideology and action, have articulated the present challenge: collaboration across many sectors is urgently required, including the economic, education, environmental, employment, and social services sectors, with active participation not only of government, but of voluntary, professional, business, consumer, and labour organisations (Federal, Provincial and Territorial Advisory Committee on Population Health, 1994).

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Ugarte CA, Duarte P, Wilson KM: PATCH as a model for development of a Hispanic health needs assessment: The El Paso experience. Journal of Health Education 23:153-156, 1992.

U.S. Department of Health and Human Services. Planned Approach to Community Health: Guide for the local Coordinator. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion (undated).

World Bank: World Development Report 1993: Investing in Health. Oxford University Press, Oxford, 1993.

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