Case Studies On Health Promotion Initiatives From The Nordic Countries

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Contents
	Introduction
1	Promoting healthy school meals for Norwegian children
2	From control policy to comprehensive family planning: success stories from Finland
3	Everybody is needed - Södra Skaraborg, Sweden
4	The promotion of oral health among Danes
5	Interventions for smoke-free schools. From information deficit to social influence
6	The prevention of night blindness in Bangladesh
7	Health policy development in Costa Rica

Case study #4: Everybody is needed - Södra Skaraborg, Sweden

Name of the person reporting:	Charli C-G Eriksson
Address:	National Institute of Public Health S - 10 352 Stockholm Sweden
Telephone:	+ 46 - 8 - 5661 3511
Fax No	+ 46 - 8 - 5661 3505
E-mail:	charli.eriksson@fhinst.se

Rationale for Initiative

The Swedish society has changed dramatically during the recent years. The policy of employment for all has not been maintained due to the economic recession. Moreover, a number of structural reforms as part of the emerging post-industrial society have also contributed to eliminating more than 500,000 jobs in Sweden. Therefore, many persons in their adult productive years are unemployed. These people usually are regarded as a burden for society. However, all men and women can contribute to the development of the society and in the creation of beneficial conditions for health and quality of life.

The present development process started in four municipalities in Southern Skaraborg county in Sweden; Falköping, Habo, Mullsjö and Tidaholm. In 1993 more than 10,000 persons of the 38,000 inhabitants 16-64 years old were outside working-life, i.e. neither active in the private nor governmental sectors. These people belong to the so-called third-sector due to a variety of reasons. Each year more than 1,000 million SEK are paid to these people as part of the safety net within the Swedish welfare system. In order to receive money from these funds, the unemployed have to abstain from paid work. Consequently more than 90% of the money are spent in such a way that they contribute to keep the receivers in a passive position. Moreover, these money come from several different agencies which do not cooperate or coordinate their support to the people in need. The prevailing attitude among the professionals was paternalistic, which also contributed to the neglect of the human resources among the persons in the third sector of the society. At the same time many important tasks in the municipalities are not taken care of because the lack of financial resources or the low profitability.

Objectives of Initiative

The overall goal or vision is to improve the health of the people by 50%. The process started when the economic recession was very deep. The unemployment rate was high and the immediate public health challenge was to prevent the health impact of unemployment. The objectives of the development process are based on certain fundaments and a process-oriented approach in contrast to project initiatives.

Fundaments	instead of		Objective
Shared values, goals and approaches	process	project	work
	work/activity	passivity	increased health
	salary/employment	assistance	personal development
Clear definitions	mobilization of resources	prescribed measures	sense of coherence
Participation for all	cooperation	territoriality	quality of life
	opportunities	threat / barriers	social network
Solidarity	future plans	hopelessness	decreased need for passive assistance
Involvement	new work	marginalisation
Alliances	empowerment	alienation	real citizenship

Description of Initiative

The initiative was taken by three persons of which one was a politician and two were retired administrators from the county council. A number of meetings and seminars that discussed health and social issues were held. A coalition building process was started aiming at involving all political parties and all relevant governmental agencies active in the four municipalities. A NGO was created with these different institutions as members. The main objective of the organization is to support the development approach among the people in the third sector. This has included alternative usage of funds within different parts of the welfare system, the application for funds from external sources, taking political initiatives and proposing changes in the welfare system in relation to assistance to unemployed people.

Persons were invited to become part of the development process. These persons were interviewed individually by two of the persons that started the process. The overall approach was explained and the role of a process leader was outlined. The participation in the process was wholly voluntary. These volunteers participated in a 10 weeks training program, which was tailored to the need of the participants. After the training the persons were supposed to become process leaders, i.e. to start a work which did not compete with already available jobs and which could involve other healthy or disabled persons. All participants in the training process developed ideas and many new activities started. The processes included many activities that contributed to the quality of life in the different communities in the four municipalities. Two groups have been trained as process leaders and more than 700 persons have participated in these new work-processes. At the end of 1996 about 200 persons participated and 27 process leaders were active. A second organization was created by the participants in the processes. Individuals are members and it functions as a union for the workers in the process. The new organization "Opportunity Sector - Everybody is needed" (Möjligheternas sektor/Bruk för alla) is a key actor in the further development of the process locally as well as in relation to other interested persons in Sweden.

The process leaders are employed by the municipalities. However, at present the economic constraints for the municipalities make it difficult to extend the activities. The central government is looking into possibilities to change the legislation with the aim of removing the barriers for local community development processes like the on-going restructuring in Southern Skaraborg county. The participants have their economic support through sickness benefits, assistance from the unemployment insurance or other parts of the welfare system. However, yet it has not been possible to overcome a six-months restriction in the duration of support from the Labour Market Board.

Evidence of Success

It was possible to create a broad political and inter-agency coalition in support of a health promoting development process in the four municipalities. An organisation was created which has been advocating changes in the welfare system in Sweden. The activities have received considerable media coverage.

It has been possible to change the vicious circle of passivity into active participation among a range of different situations. Persons with long-term sick leave have become involved in activities of value not just for the persons themselves but also for the local communities. Persons with high risk of becoming permanently marginalized in the society have found new opportunities and new friends through participation in the local processes. The self-reported health as measured by questionnaires improved among the participants.

Due to the slow process of change in the national legislation, participants have not been allowed to continue their participation with the economic support from the Labour Market Board. However, some participants still visit their earlier processes. Follow-up studies have shown that to leave the process has a negative impact on the health of the participants.

Evaluation

A field research unit was opened in Falköping with the aim of analysing the development process from a multi- and interdisciplinary perspective. Two main issues were the impact on health and economy. A research program has been developed and several different projects have started. A longitudinal approach has been taken to analyse the health of process leaders and participants. The research activities have received funds from the National Institute of Public Health for the first year. The unit is a part of the National Institute for Psychosocial Factors and Health and it receives financial support from the Ministry of Health and Social Affairs, various research financing agencies and the county council.

Reflections

A main reason for the success is the shared vision and the empowerment strategies put into practice. The development of a new type of leadership giving room for bottom-up approaches within a humanistic framework. Essential for the development process is the emphasis of participatory democracy. The development process is also based on learning from experience and involving resource persons as consultant but not as experts taking power from the people.

A major concern at present is the reluctance at the national level to review and consolidate the welfare system in order to strengthen the capacity of supporting local initiatives and giving flexibility and fairness as key elements in a combined work and social welfare policy.

Dissemination

During 1995 the National Institute of Public Health collaborated with the two NGOs in Skaraborg in a series of five 3-days seminars to present the development process for interested persons. The short presentations that have been given in many different contexts by participants in the process needed to be complemented by a more detailed presentation and discussion. The ideas was that some of the participants in the seminars would be interested in becoming parts of a national network that was created 1 October 1996. A second network meeting was arranged in march 1997. The further development of the visions and strategies for the network will be undertaken by a working group with a majority of persons from the third sector of the society.

Three other places in Sweden have completed or are presently undertaking training of process leaders. Organisations have been created in seven places. The network meetings have been attended by about 50 participants.

Lessons learned

It is possible to achieve successful initiatives where partnership and alliances among different political parties, different local agencies and groups are used to support bottom-up community development processes. Moreover, as part of the empowerment process the participants organized themselves into a union, which has taken over responsibility for the further development of the process.

Many initiatives have been taken in Sweden to support unemployed people. The lessons learned from Skaraborg is the need for changing from a paternalistic to a participatory approach giving the persons more power and a real influence over their situation, i.e. health promotion in its basic appearance.

References

Konarski,K. & Eriksson,C. (1996). Jordmån för ett gott liv: Processen "Det finns bruk för alla". Samhällsutvecklingen och forskningsstrategin. I C.Eriksson (Ed.). Att överbygga hälsogapen i Sverige genom hälsofrämjande och sjukdomsförebyggande arbete. Stockholm: Folkhälsoinstitutet.

Konarski,K. (1992). Jordmån för ett gott liv. Stockholm: Allmänna Förlaget (Folkhälso-gruppens rapport nr. 16).