Bush Book - Department of Health

Transcription

VOLUME 1 STRATEGIES & RESOURCES
Acknowledgements
Key contributors’ names appear in bold.
Every effort has been made to ensure correct spelling of names. We
apologise for any error.
Kathy Abbott, Susan Abbott, Patrick
Ah Kit, Cynthia Ah Mat, Ann
Alderslade, Kerry Arabena, David
Ashbridge, Robert Assan, Carol
Atkinson, Olive Aumann, Anne Bates,
Dianne Bates, Jewel Bennett, Marlene
Bennett, Gayle Blennehassett,
Heather Boulden, Dennis Bourke,
Maggie Brady, Jenny Brands, Cherie
Cable, Peg Carmody, Elizabeth
Chalmers, Edna Chong, Louise Clark,
Stephen Clarke, Mary Clements, John
Condon, Margaret-Ann Cook, Gavan
Curry, Joe Daby, Barbara Darmain,
Anne Davies, Dayalan Devanesen,
Barbara Dhamany, Sharon Dixon,
Beryl Mayanini Djakala, Ann
Donaldson, Wendy Dow, Michelle
Dowden, Tim Duggan, Sue Earle,
Karen Edmond, Tim Emerton, Chris
Evans, Lorna Fejo, Penny Fielding,
Graham Franklin, Christine Franks,
Pat Gamananga, Anne Garrow,
Belinda Garvan, Pam Gollow, Gillian
Gorham, Kumanjayi Napanangka
Granites, Billy Gumana, Ganalarritj,
Rhonda Gungarinya, Steve Guthridge,
Terrence Guyula, Gillian Hall, Mike
Hall, Nea Harrison, Margie HayesHampton, Bev Hayhurst,
Raymond Hector, Shirley Hendy,
Linda Hipper, Debbie Hobbs,
Vivienne Hobson,
Brendon Huddleston, Kim
Humpheries, Rowena Ivers, Vicki
James, Gary Janke, Lorraine Johns,
Sally Johnston, Jenni Judd, Monica
Kelly, Lesley Kemmis, Pat Kemp,
Penny Kenchington, Netra Khadka,
Richard King, Sally-Ann King, Jill
Kleiner, Sabina Knight,
George Kruger, Sharon Laver,
Eva Lawler, Alison Laycock,
Rosemary Lee, Annemarie Leutwiler,
Leo Lingwoodock, Betty Little, Mike
Loder, Hugh Lovesy, Glenda Lucas,
Lyn Maloney, Esther Manson,
Gloria Markey, Peter Markey,
Virgina Martin, Lorna Mason, Hellen
Matthews, Justine McCarthy, John
McComb, Valmai McDonald, Stuart
McDonell, Blair McFarland,
Alison McLay, Margie McLean,
Matthias Merzenich, John Morgan,
Anne Mosey, Ngalawur Mununggurr,
Anne Murrungun, Tess Narkle, Tony
Neale, Lyn O’Donoghue,
Irene Ogilvie, Deborah Osborne,
Agnes Palmer, Maria PalmerThompson, Peter Pangquee, Barbara
Paterson, Cheryl Patullo, Mona
Phillips, Cliff Plummer, Jackie Priestly,
Cheryl Rae, Ruth Richards, Jan
Ritchie, Olive Rogers, Libby Ross,
Alan Ruben, Ginny Russell, Barbara
Schmidt, David Scrimgeour, Bubbles
Segall, Barb Shaw, Jill Shaw, Rhonda
Simons, Kerr Simpson, Gary Smith,
Greg Smith, Ray Smith, Sandy
Spears, Michelle Spiers, John Spink,
Frank Spry, Helen Stewart, Robin
Strand, Noelene Swanson,
Kerry Taylor, Jim Thurley, Belinda
Toal, Jude Torzillo, Robert Trenery,
Darrin Trindall, Melanie van Haaren,
Gwen Walley, Fiona Walsh,
Wanamula, Carol Watson, Colin
Watson, Tarun Weeramanthri, Nick
Williams, Nola Wilson, Peter Winsley,
Lee Wood, Jo Wright, Manybunu
Wunungmarra,
Ninikirri Wunungmurra, Yambalpal,
Daisy Yarmirr, Boyan Yunupingu,
Peter Zero
ACKNOWLEDGEMENTS, new 2007 edition
Editor: Alison Laycock
Key contributors:
Cheryl Rae
Di Bates
Nikki Clelland
Louise Clark
Sue Earle
Bev Hayhurst
Jenni Judd
Dorothy Morrison
Helen Nikolas
Nicola Slavin
Toni Thomson
Robyn Tranthem
Gwen Walley
Lynette Windsor
Thanks also to:
Ann Alderslade
Rowena Albert
Margaret Bronham
Sarah Brown
Christopher Cliffe
Julie Cook
Steve Cooper
Patricia Corpus
William Costigan
Cynthia Croft
Bill Craig
Tamie Devine
Jay Easterby-Wood
Michelle Evison-Rose
Natalie Fisher
Vanessa Fleming
Justine Glover
Jenny Hains
Colleen Hayes
Vivienne Hobson
Kathy Long
John Louden
Valmai McDonald
Tina McKinnon
Sue McMullen
Karen Mulligan
Tracey McNee
Mary-Anne Meginess
Lyn Moloney
Lynette O’Donoghue
Barbara Patterson
Ralph Quinney
Catherine Richardson
Barbara Sharp
Kerrie Simpson
Selina Sullivan
Rosemary Tipiloura
Gill Thomson
Robert Whitehead
Alexandra Walker
Carol Watson
Julie Wright
2
Introduction
Foreword to this edition
Since publication of the ‘Public Health Bush Book’ in 1999 many frontline workers
have found it to be a useful resource. Growing local, national and even international
demand has resulted in several reprints of a resource that was designed as a
Department of Health and Community Services guide to help staff do effective
health promotion work in Northern Territory communities.
This new edition builds on the continuing relevance of the first edition and updates
the content to reflect contemporary approaches in public health and health
promotion practice. It also reflects changes in the approach to health services
management in many Northern Territory communities. These changes are in
themselves significant; they come from, and provide evidence of, increased
community capacity and empowerment at the local level. Research for a new edition
found that many of the health promotion strategies and activities documented as
case studies in the first edition have been sustained and strengthened in the
intervening years. These stories provide further evidence that when health
promotion work is done well it can help people to take rightful control of their health.
This edition of the ‘Public Health Bush Book’ will help resource staff to work within
the Northern Territory Government framework for ‘Building Healthier Communities
2004-2009’. The framework emphasises balance between treatment and prevention
and focuses on ‘giving kids a good start in life’, ‘strengthening families and
communities’, ‘getting serious about Aboriginal health’, ‘creating better pathways to
health services’, ‘filling service gaps’ and ‘tackling substance abuse’. It identifies 4
key areas for strengthening and reforming our health and community services
system, most notably the goals of ‘valuing and supporting our workforce’ and
‘creating a health information network.’
It also acknowledges to the 2005 endorsement of ‘Aboriginal Health and Families: A
Five Year Framework for Action’ which emphasises the need for services that are
accessible, balanced and which contribute to sustained health and welfare gains for
Aboriginal Territorians. The framework uses a life-course approach to tackle health
determinants and reduce health inequities. It includes policy goals specific to
‘partnerships and engagement’, ‘cultural security and gender’. This policy framework
and its goals affirm the need for, and relevance of, the information and approaches,
strategies and resources described in the Public Health Bush Book’.
Our thanks are extended to all those people who contributed to this update. It is our
hope that the Public Health Bush Book’ continues to be a best practice guide for
health promotion, supporting the health and community services workforce and the
transfer of public health knowledge into practice.
Jenny Cleary
Assistant Secretary, Health Services
June 2007
3
Introduction
Foreword to First Edition
The ‘Public Health Bush Book’ has been written as a resource for people who work
with remote Aboriginal communities in the Northern Territory. It has been written by
people who have worked in, or with, remote community health care teams over
many years, and relates their accumulated learning to published national and
international evidence.
It is a practical book which takes its name from the ‘Northern Territory Bush Book: A
guide for field staff’, in whose 1979 Foreword, Dr Charles Gurd, Secretary for
Health, wrote
The contents describe the “portfolio of responsibilities” of community health
nurses and other staff in rural areas, as well as the background and
treatment of conditions of special importance in the Northern Territory.
Many of these responsibilities are preventive and special attention needs
to be given to these to ensure they are done well. (emphasis added)
Health is not just an absence of disease, it is a way of life, and our
philosophy as health workers should be to spend more of our time in
teaching healthy living… (emphasis added)
That ‘portfolio of responsibilities’ has grown in extent and complexity over the two
decades since 1979, and the resources that nourish, record and share our
expanding knowledge, practice and capacity, have likewise needed to grow.
Today’s community health care teams have the CARPA Standard Treatment
Manual as a well researched guide to managing conditions that are both common
and of special importance in the Northern Territory. It incorporates certain basic
public health measures such as maternal and infant health, immunisation,
screening, early detection, and in the latest edition, brief interventions for healthy
lifestyles. The current, third edition has been adopted across Territory Health
Services.
This first edition of the ‘Public Health Bush Book’ provides today’s community health
care teams with a well researched guide that gives special attention to doing
preventive work well, and to promoting health as a way of life. Its foundation is
the ‘new public health’ or health promotion approach - to work in ways that
acknowledge and strengthen the capacity of people to take rightful control of their
own health and lives.
This book is particularly timely in relation to studies being published in the
international literature that renew the evidence base for the links that exist between
a sense of personal control, social cohesion and physical health. DHCS has
recognised their fundamental interconnectedness in adopting a comprehensive
definition of health as mental, social and physical wellbeing.
4
Introduction
This book is also particularly timely in relation to ‘Strategy 21’ - THS Corporate Plan
1999-2003, the founding philosophy and design for our health care action for the
next century - most notably, the goal to Strengthen Community Capacity. It is a
practical guide that resources community health care workers to work with
individuals, families, groups and communities in ways that recognise and reinforce
the capacity of people to know what is needed, and how to do it.
The ‘Public Health Bush Book’ is dedicated to all those who have worked for, and
who care about, the health of the citizens of the Northern Territory; to better health
for Aboriginal citizens; and to our collective future.
Shirley Hendy
Chief Health Officer
January 2000
5
Introduction
Preface
This resource was developed to support and strengthen public health practice in
community settings.
Participants in the Health Promotion Principles and Practice Training Program had
identified the lack of knowledge about “what to do” and the skills to “do it” as barriers
to doing more health promotion activities in their everyday work. Producing a
resource to support public health training and provide guidance to staff to achieve
better health outcomes in Aboriginal communities was one response to that need.
Megan Smith was the first Project Officer from February 1996 to June 1997. She
consulted with over 60 managers and key public health professionals in Territory
Health Service about overall content and approach. She facilitated workshops and
meetings involving over 100 operational staff to discuss specific topic areas and
tease out the complexities and realities of doing prevention and health promotion
work in remote areas. Megan did the initial drafting of the chapters.
An Advisory Group provided guidance on content areas and processes for gathering
information. Its members were:
Penny Kenchington, Acting Coordinator, Sexual Health Unit, Alice Springs; Sally
Anne King, Assistant Aboriginal Health Worker Manager, Darwin; Sabina Knight,
Manager, Remote Health Education Program, Alice Springs; Peter Pangquee,
Aboriginal Health Worker Manager, Gove; Melanie van Haaren, Director of Nursing,
Remote Area Services, Alice Springs; Gwen Walley, Training Development
Coordinator, Aboriginal Living with Alcohol Program, Alice Springs; Tarun
Weeramanthri, Community Physician, Darwin; Jo Wright, DMO Darwin.
Allison Adams, project officer from February 1997 to April 1999 continued
researching and drafting the ‘Environmental Health’ chapter. She then took the
resource through the next stage of editing, referencing and updating to incorporate
new directions and approaches that were developing at the time.
Ray Smith compiled the chapter ‘Planning and Evaluating a Health Promotion
Project’, based on materials developed for the Health Promotion Principles and
Practice Training Program and materials drafted by Megan Smith.
The work was completed by a core editorial group, consisting of Nea Harrison,
Alison Laycock and Carol Watson, with further editorial advice provided by Louise
Clark, Sue Earle, Gloria Markey, Joe Martin-Jard, Annie Villesèche and Peter
Zeroni.
The Librarians of Territory Health Service Library Services, Anne Alderslade, Sally
Bailey and staff, in Darwin and Alice Springs provided reference material and
suggested other useful references.
6
Introduction
Dot Morrison finalised the bibliographies.
Public Affairs and Social Services provided invaluable specialist publishing advice
and support to finalise the publication.
Many people, within Territory Health Services and from other organisations,
contributed their ideas at workshops. Many others wrote or told their stories, drafted
material, commented on numerous drafts of the various chapters and provided
unflagging support for this project. Their names appear inside the front cover.
We thank you one and all.
We hope that the Public Health Bush Book will occupy a special place, as a practical
friend, in your ‘toolkit’ of resources for working in community settings in the Northern
Territory.
Health Promotion Strategy Unit
(Previously Public Health Strategy Unit)
The Revised Edition 2007
Alison Laycock undertook the task of updating Volume 1, Strategies and Resources.
She was advised by a group of staff from NT Department of Health and Community
Services program areas who provided guidance on how the chapters should be
updated, helped to gather input from colleagues and commented on drafts. Its
members were Nikki Clelland, Di Bates, Louise Clark, Toni Thomson, Nicola Slavin,
Jenni Judd, Bev Hayhurst, Sue Earle, Robyn Tranthem, Gwen Walley and Lynette
Windsor.
Many other people contributed input and willingly supported the revision process.
Their names also appear inside the front cover. We thank you all.
Health Promotion Strategy Unit 2007
7
Contents
Contents
Acknowledgements ............................................................................................ 1
Foreword to this edition ..................................................................................... 3
Foreword to First Edition.................................................................................... 4
Preface ................................................................................................................. 6
Introduction ....................................................................................................... 12
Aims ................................................................................................................ 12
How to use the Public Heath Bush Book......................................................... 14
Volume 1: Strategies and Resources .............................................................. 14
Volume 2: Facts and Approaches to Three Key Public Health Issues ............. 14
Chapter 1
PUBLIC HEALTH IN CONTEXT......................................................16
About this chapter ............................................................................................ 16
Some key concepts........................................................................................... 16
Public health and health promotion ................................................................. 16
Primary Health Care (PHC) ............................................................................. 19
Considering culture ......................................................................................... 20
Cultural respect and cultural security............................................................... 23
Websites listed in this chapter ......................................................................... 23
More useful websites ........................................................................................ 23
Bibliography ...................................................................................................... 24
Chapter 2
EDUCATION FOR HEALTH ............................................................26
What is education for health? .......................................................................... 27
The aim of education for health ....................................................................... 28
Changing theory and practice: a timeline ....................................................... 29
Stage 1: 1910 - 1960s Education through provision of health information .................. 29
Stage 2: mid 1960s - 1970s Education through varied audio-visual channels ............ 29
Stage 3: 1970s - mid 1980s Education incorporating adult learning principles............. 30
Stage 4: 1986 – mid 1990s Education for health within the Ottawa Charter Framework ........ 30
Stage 5: mid 1990s - 2000s Education with more emphasis on a settings approach and
the social determinants of health .......................................................................... 31
Key theoretical and practice frameworks ........................................................ 32
Primary Health Care ........................................................................................ 32
Adult Learning ................................................................................................. 32
Education for Critical Consciousness .............................................................. 33
Turning the theory into practice ...................................................................... 33
Your education for health role ......................................................................... 33
Working with young people ............................................................................. 34
Education for health in a cross cultural setting................................................. 34
Turning the theory into practice: a case study ................................................. 36
Useful websites ................................................................................................. 37
Bibliography ...................................................................................................... 37
Chapter 3
SHARING HEALTH INFORMATION ...............................................39
Related chapters ............................................................................................... 40
About information sharing ............................................................................... 40
Information Privacy Principles ......................................................................... 41
Where information can be found ..................................................................... 41
Why share health information .......................................................................... 42
What information can be shared ...................................................................... 43
8
Contents
Who information can be shared with ............................................................... 44
When and where to share information ............................................................ 44
How to share health information...................................................................... 45
Ways of sharing health information ................................................................. 46
Using resources that support information sharing ............................................ 54
Using tables and graphs to present data ......................................................... 55
Organising information sharing sessions ....................................................... 58
Bibliography ...................................................................................................... 62
Chapter 4
STRATEGIES FOR HEALTH PROMOTION ...................................64
What is ‘health’ ................................................................................................ 66
Health promotion .............................................................................................. 67
The five action areas for health promotion....................................................... 68
The health promoting way of working .............................................................. 71
Health promotion strategies overview ............................................................. 72
Things to think about when choosing strategies .............................................. 72
Working with individuals .................................................................................. 74
Using individual approaches............................................................................ 74
Models of individual health behaviour change ................................................. 74
Brief interventions ............................................................................................ 76
Working with groups ...................................................................................... 101
Working with groups in health promotion ....................................................... 101
Working with communities............................................................................. 109
What is a ‘community’ ................................................................................... 109
What is ‘community development’ ................................................................. 109
Changing the wider environment ................................................................... 121
Modifications to the environment ................................................................... 121
Policy and Legislation.................................................................................... 122
Technical interventions.................................................................................. 123
Organisational interventions .......................................................................... 125
The use of incentives and disincentives ........................................................ 125
Social advocacy and lobbying ....................................................................... 126
Using media..................................................................................................... 128
About social marketing and media use .......................................................... 128
What media to use? ...................................................................................... 128
Limited reach media ...................................................................................... 129
Mass media ................................................................................................... 134
Using screening .............................................................................................. 136
What is screening .......................................................................................... 136
Types of screening ........................................................................................ 136
Using screening as a health promotion strategy ............................................ 137
Why screen ................................................................................................... 137
Criteria for screening ..................................................................................... 138
Community health surveys ............................................................................ 139
Screening in the Northern Territory ............................................................... 140
Consent......................................................................................................... 141
Screening resources ..................................................................................... 141
Useful websites and on-line resources listed in this chapter ...................... 142
Bibliography .................................................................................................... 143
Chapter 5
PROJECT
PLANNING AND EVALUATING A HEALTH PROMOTION
149
About this chapter .......................................................................................... 151
9
Contents
Getting started: research in planning and evaluation .................................. 151
What is research ........................................................................................... 152
Research tools: ways to collect information ................................................... 152
Literature search ........................................................................................... 154
Ethical matters ................................................................................................ 156
Thinking about planning a health promotion project ................................... 158
Why plan ....................................................................................................... 158
Forming the project team .............................................................................. 159
Reflection-action approach ............................................................................ 159
The planning cycle ........................................................................................ 161
Doing a community profile ............................................................................. 161
Steps for planning a health promotion project ............................................. 163
Major steps in planning, sustaining and evaluating a health promotion project .......... 163
Step 1: identify the issues or health problems in the community .................... 164
Step 2: prioritise the issues or health problems ............................................. 166
Step 3: identify risk factors and set the goal for the project ............................ 169
Step 4: determine contributing factors and state objectives for the project .... 169
Step 5: determine what the strategies will be ................................................ 173
Step 6: develop the action plan ..................................................................... 176
Step 7: sustain the project ............................................................................. 178
Step 8: evaluate the project ........................................................................... 179
Documenting the project ................................................................................ 180
Questions to help plan the documentation..................................................... 180
What needs to be documented ...................................................................... 180
Recording a project plan ............................................................................... 182
Thinking about evaluating the project ........................................................... 185
Why evaluate? .............................................................................................. 185
Who is the evaluation for? ............................................................................. 185
Planning the evaluation .................................................................................. 187
The Eight Stage Model of Evaluation ............................................................ 188
Focus questions for process, impact and outcome evaluations ..................... 189
Collecting information for a process evaluation ............................................. 190
Collecting information for impact and outcome evaluations ........................... 191
How to collect the information ....................................................................... 192
When to collect the information for process, impact and outcome evaluation 193
Information gathering tools for planning and evaluation ............................. 198
Questionnaires .............................................................................................. 198
Tips on writing a questionnaire ...................................................................... 198
Interviews ...................................................................................................... 199
Surveys ......................................................................................................... 201
Analysing the data .......................................................................................... 203
How to analyse qualitative data ..................................................................... 203
How to analyse quantitative data ................................................................... 205
Reporting on the project................................................................................. 206
Useful websites ............................................................................................... 211
Bibliography .................................................................................................... 211
Chapter 6
A HEALTH PROMOTING HEALTH CENTRE ...............................215
What is a healthy workplace? ........................................................................ 216
What is a healthy and health promoting health centre? ................................. 216
Primary Health Care ...................................................................................... 217
Essential primary health care services .......................................................... 218
Accessing resources for best practise in primary health care ........................ 220
Quality improvement processes for primary health care services .................. 220
10
Contents
The health centre: the people......................................................................... 222
The multidisciplinary team ............................................................................. 222
The health centre: the place ........................................................................... 230
A functional, safe and comfortable place to work........................................... 230
The building and grounds .............................................................................. 230
Increasing access to health information......................................................... 236
The health centre: the policies ....................................................................... 237
What is policy ................................................................................................ 237
Local health centre policies ........................................................................... 240
Local health centre operating guides ............................................................. 245
Primary Health Care in action ........................................................................ 247
Websites listed in this chapter ....................................................................... 252
Bibliography .................................................................................................... 252
Chapter 7 Glossary .............................................................................................255
Foreword ......................................................................................................... 255
List of terms .................................................................................................... 255
Useful Glossary Websites .............................................................................. 268
Bibliography .................................................................................................... 269
Appendix of case studies from first edition .................................................. 272
11
Introduction
Introduction
The Public Health Bush Book is a resource for all community health care providers
who want to strengthen their health promotion and disease prevention practice. It
has been written specifically for teams who work with Aboriginal communities in the
Northern Territory. The Public Health Bush Book is one response to the needs of
staff for more support to do public health work and to do it well.
Aims
• To provide a range of strategies and ideas and a variety of tools to assist
staff to work more effectively within a Primary Health Care model
This resource emphasises brief and early interventions, disease and harm
prevention and health promotion strategies. It focuses on strategies to address
direct causative or risk factors for ill health, especially misuse of alcohol, tobacco
and other drugs, inadequate environmental health and hygiene, poor nutrition and
physical activity. It suggests how you can use these strategies, both when people
present for treatment at the health centre and in the course of everyday life and
work in an Aboriginal community. It will help you to work in ways that recognise and
reinforce the capacity of people to know what is needed and how to do something
about these needs.
• To include something for everyone who works with Aboriginal people
For experienced workers, it provides a useful check for evaluating current work
practices and extending them. For the less experienced, it serves as a resource to
guide efforts in developing sound public health practices.
The theory, principles and strategies presented in these two volumes have a strong
basis in research and practice, both nationally and internationally. The principal
approaches are based on the Ottawa Charter for Health Promotion (1986) and are
described under ‘Key Concepts’ in Chapter 1, Public Health in Context.
Working in partnership; community development; participatory research, planning
and evaluation; and education for health are the fundamentals for working in a
health promoting way. These processes involve the transfer of skills and knowledge
to community members. They are essential to strengthen people’s capacity to take
control and improve their own health and well-being and they need to be based on a
two-way learning process.
• To be practical and real
Health sector workers have generously contributed case studies, and this second
edition includes some new stories. Case studies from the first edition which are no
longer in the text can be found at Appendix 1 at the back of this resource – they
continue to be important for informing our current public health practice.
12
Introduction
People’s stories show how they are:
 working in partnership with individuals, groups (especially families) and
communities to plan actions to improve health
 working with communities on their identified needs or raising awareness and
facilitating community action on the underlying determinants of ill health
 looking at the resources within the community and engaging Aboriginal people in
taking control of the process
 sharing their considerable knowledge and skills about health matters
 listening and learning from Aboriginal people as they share their beliefs,
knowledge and skills
 reflecting on their work practices and aiming for continuous improvement
• To reflect the principles of endorsed policies in Aboriginal health
This resource supports the aims of the Northern Territory’s policy and approaches to
improve health outcomes for Aboriginal people.
In 2005 NT Cabinet endorsed the Aboriginal Health and Families: A Five Year
Framework for Action. It follows on from the NT Aboriginal Health Policy of 1996 in
providing a framework for the NT Government to address the unsatisfactory state of
Aboriginal health. The principles of these policies are central to the way we all
approach our work and are underpinned by the National policy and strategies.
Download Aboriginal Health and Families: A Five Year Framework for Action
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/apacttoc.shtml
For a hard copy
Ph: 8999 2660
Download The National Strategic Framework for Aboriginal and Torres Strait
Islander Health 2003
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubshealthstrategy.htm.
For a hard copy
Ph: (02) 6289 5291.
13
Introduction
How to use the Public Heath Bush Book
This resource can be used in a number of ways:
• as information and tools to support public health workforce development
strategies
• as a guide to support the health and community services workforce in their
learning and development
• as a source of information to stimulate individual, group and community action
The Public Health Bush Book is presented in two volumes.
Volume 1: Strategies and Resources
This volume outlines the theory and a range of strategies and resources for practice
in the field. It includes step by step guides to processes and strategies and a range
of checklists and worksheets to help teams to plan and evaluate their work. It also
includes a list of NT contact phone numbers for further information and assistance.
In this volume:
About this resource
Chapter 1:
Public Health in Context
Chapter 2:
Education for Health
Chapter 3:
Sharing Health Information
Chapter 4:
Strategies for Health Promotion
Chapter 5:
Planning and Evaluating a Health Promotion Project
Chapter 5:
A Health Promoting Health Centre
Chapter 7:
Glossary
Volume 2: Facts and Approaches to Three Key Public Health Issues
This volume provides a background to four key, underlying public health issues
facing remote communities: Alcohol and Other Drugs, Environmental Health and
Nutrition and Physical Activity and Mental Health. It includes facts, issues and
approaches in the four areas. It will be useful for gaining an overall understanding of
their impacts on health and what you can do about them. Each chapter includes a
list of contact phone numbers in each of the program areas. In the current edition of
Volume 2 (1999, reprinted 2002):
Chapter 1:
Chapter 2:
Chapter 3:
Alcohol and Other Drugs
Environmental Health
Nutrition and Physical Activity
Some tips
Throughout the volumes there are personal and team activities designed to
stimulate reflection and development. Look for this symbol  It indicates an action
14
Introduction
you can take. There is a lot of interaction between some chapters and readers are
referred to linking chapters or sections where additional reading would be valuable.
Each chapter has a bibliography. It contains references used in the chapter as well
as some recommended readings. The references are available through DHCS
Library Services or through the program areas. Public health and health promotion
are evolving fields. It is recommended that you:
 Visit DHCS libraries in the major centres to read recent journals and to browse
and borrow the latest books. Online resources are available.
 Visit the useful websites listed in each chapter if you have internet access. In
many cases these sites provide further links to sites that can resource and inform
your practice
 Use the internet to do your own searches on particular topics, approaches and
resources
 Take the opportunity to update your knowledge and skills through available public
health training and development opportunities. This resource will add value to
other workforce development activities.
15
Chapter 1 – Public Health in Context
Chapter 1
PUBLIC HEALTH IN CONTEXT
Some key concepts........................................................................................... 16
Public health and health promotion ................................................................. 16
Spectrum of Health Promotion Interventions ............................................... 19
Primary Health Care (PHC) ............................................................................. 19
Considering culture ......................................................................................... 20
Cultural respect and cultural security............................................................... 23
As you use this public health resource… ..................................................... 23
More useful websites ........................................................................................ 23
Bibliography ...................................................................................................... 24
About this chapter
This chapter briefly describes the development and understanding of public health,
health promotion and primary health care. It draws attention to how these disciplines
are related and what they mean for your practice. The key principles of equity,
community participation and social justice underpin public health, health promotion
and primary health care.
Some key concepts
Public health and health promotion
The origins of health promotion are complex and closely related to the development
of public health. A major shift in health thinking happened around the time of the
important global meeting of the World Health Organisation (WHO) at Alma Ata in
1978. The declaration of Alma Ata recognised that improvements in people’s health
depended on more than investment in growth of health services (which had been a
major focus since the second world war), and that other sectors needed to be
developed as well. At the Alma Ata meeting primary health care (PHC) was declared
as the way health services needed to be delivered to improve the health of
populations. This required a shift in focus:
•
from teaching people how to manage their health (top down), to an
approach that makes the most of community members capacity to
establish their own goals, strategies and priorities (bottom up)
•
from medical systems to community based services and resources
•
from the professionals to the consumers of health care (McMurray
2003:76)
The global strategy was called “Health for All by the Year 2000” (WHO 1981). It set
measurable goals and targets, drove health development over the following two
decades and provided an environment in which the idea of health promotion, as
“enabling people to increase control over their health” (WHO 1986) could be
fostered and grow. (adapted from Catford J 2004:1)
16
The principles of health promotion were proposed by WHO in 1984. They were:
• Health promotion involves the population as a whole in the context of their
everyday life, rather than focusing on people at risk for specific diseases
• Health promotion is directed towards action on the determinants or causes of
health
• Health promotion combines diverse, but complementary, methods and
approaches
• Health promotion aims particularly at effective and concrete public action
• Health professionals – particularly in primary health care – have an important
role in nurturing and enabling health promotion. (WHO 1984 in Catford
2004:2)
So in the mid 1980s, a new public health movement emerged which refocused on
the underlying determinants of health. The Ottawa Charter for Health Promotion:
(1986) was the first document to state the five action areas for this ‘new’ public
health: build healthy public policy; create supportive environments; strengthen
community action; develop personal skills and reorient health services.
The Ottawa Charter for Health Promotion was actually subtitled ‘Towards a new
public health’. It was this document that brought the term ‘new public health’ into
use. (Baum 2002:531)
It may be useful to think of the ‘new’ public health as a social model of health that
links ‘traditional’ public health concerns (such as clean water and air, safe food,
work safety) with the behavioural, social and economic factors that affect people’s
health. It emphasises the social determinants of good health and illness, and the
social organization of health care. It emphasises illness prevention, community
participation and primary health care. (Germov 2002:14)
During the 1990’s we learnt the value of reaching people through the settings and
sectors in which they live and meet. This focused health promotion activities on a
‘settings approach’, taking workers and activities into physical and social settings
that serve as supportive environments for health protecting and promoting activities.
These include schools, workplaces, and other community venues and well as health
care settings. Another shift in this decade was moving interventions ‘upstream’, from
defining goals and targets for people and populations, towards goals that aim to
change organizations, systems and the environment.
The National Public Health Partnership defined public health as “the organised
response by society to protect and promote health and to prevent illness, injury and
disability” (National Public Health Partnership 1997), with public health aiming to:
• prevent health problems and strengthen the determinants of good health in the
places where people live, work, meet and play;
• focus on health issues as they affect groups in the community, and on planning
and implementing interventions with the full participation of those groups;
• improve health of those in the community whose health is poor compared with
others, thereby reducing inequalities in health status between groups
From The Solid Facts 1998 ...
“...People’s lifestyles and the conditions in which they live and work strongly influence their
health and longevity. Medical care can prolong survival after some serious diseases, but the
social and economic conditions that affect whether people become ill are more important for
health gains in the population as a whole. Poor conditions lead to poorer health. An
17
unhealthy material environment and unhealthy behaviour have direct harmful effects, but the
worries and insecurities of daily life and the lack of supportive environments also have an
influence.”
Wilkinson and Marmot (eds)1998:6-7
The 2003 edition continues to emphasise the social determinants of health and the role that
public policy can play in shaping the social environment to achieve better health …
“(We) need a more just and caring society – both economically and socially …much
depends on understanding the interaction between material disadvantage and its social
meanings. It is not simply that poor material circumstances are harmful to health; the social
meaning of being poor, unemployed, socially excluded, or otherwise stigmatised also
matters.”
Wilkinson and Marmot (eds)2003:9
In the 2000’s, the new public health is building on this evolution and on proven
effective approaches. There is increasing emphasis on health determinants. It
especially embraces the wider agenda of the social determinants that impact on
health. This is reflected in the 2005 Bangkok Charter for Health Promotion in a
Globalised World. The charter identifies, as critical to health, the need to respond to
increasing inequities, new patterns of consumption and communication,
commercialisation, global environmental change and urbanization. It calls for
integrated policy approaches and commitment to working across sectors and
settings, to address the social determinants of health.
For health service providers, taking a public health approach means recognising that
individual health behaviours (and therefore health outcomes) are influenced by
family systems, knowledge and education, environmental conditions, belief systems
and a whole host of economic, political, historical and cultural forces. The following
diagram illustrates these influences or determinants.
knowledge and
beliefs about
health
choices of things to do
in the community
personal priorities
and willingness to
participate in health
transport
education
cultural
traditions and
practices
money available
what is happening
in the community
responsibilities
and obligations
food
self esteem
family
situation
accommodation
environmental
conditions
So health promotion in the 2000’s, as a “process of enabling people to increase
control over, and to improve, their health” (WHO 1986) uses integrated and
complementary approaches that work across sectors and settings and sensitively
18
take into account a range of health determinants. This spectrum of health promotion
interventions is shown in the diagram below, which presents our health promotion
strategy model in the Northern Territory.
Spectrum of Health Promotion Interventions
Individual
Screening,
individual risk
assessment,
immunisation
Health
education and
skill
development
Population
Social
marketing
Community
Action
Settings and
supportive
environments
Health
information
Ensuring the capacity to deliver quality programs
through capacity building strategies including:
Workforce development
Organisation Development
Resources
Adapted by NT DHCS from Department of Human Services, Victoria 2003
Remember - the new public health is based on a belief that the participation of
communities in activities to promote health is as essential to the success of those
activities as is the participation of experts. (Baum 2002: 531).
Primary Health Care (PHC)
The Declaration of Alma Ata (WHO 1978) provided the blueprint for Primary Health
Care with an aim of achieving an acceptable level of health for all people: Health for
All by the Year 2000 (WHO statement 1981). Australia was a signatory to the
declaration.
WHO definition of 1978 – a critical moment for Primary Health Care
Primary health care is essential health care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to
individuals, and families in the community through their full participation and at a
cost that the community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination ...
WHO 1978:3
See the historic declaration on the WHO website
http://www.euro.who.int/AboutWHO/Policy/20010827_1
The Alma-Ata declaration defined primary health care as both a level of service and
as an approach to health care. It incorporated five principles: equitable distribution of
resources; community involvement; emphasis of prevention; use of appropriate
technology; an approach that involves a range of sectors.
19
Unlike public health and health promotion, primary health care is concerned with
treatment, cure and care of people with illness. (Baum 2002:532, 533). And primary
health care providers are also key people in public health and health promotion, with
a role that includes screening, individual and group health education and
interventions, community development, advocacy, and involvement in public health
planning. (Baum 2002:51, 52)
Primary Health Care has come to mean a number of things:
•
the first level of contact that people have with the health care system and the
first stage of a continuing health care process. It strives to bring health care as
close as possible to where people live and work (Wass 2000:8-10)
•
a strategy [process] for organising comprehensive health care with the aim of
achieving a balance along the continuum of treatment, rehabilitation, disease
prevention, and health promotion
•
a philosophy underpinned by a set of principles to guide health care providers
wherever they work
•
a set of activities including health education, promotion of food supply and
nutrition, safe water and sanitation, maternal and child health care, immunisation,
prevention and control of diseases, treatment of diseases and injuries, provision
of essential drugs, mental health services, and appropriate responses to
community priorities
Considering culture
How effective you are in your work will largely depend on your willingness to learn
from and work in partnership with local Aboriginal people and Aboriginal colleagues.
Aboriginal culture has enabled people to live and thrive in challenging environments
for over 60 000 years. If you are open to recognising, appreciating and
understanding Aboriginal world views and health beliefs, your capacity as a health
service provider will be greatly enhanced.
From experience...
One of the main valuable points for anyone new starting is to listen and learn from the
Aboriginal Health Workers. They are a most valuable resource and certainly prevent a lot of
grief and conflict. They are a great buffer between the community and health centre staff and
can teach so much if they know their advice and opinions are valued.
RAN, East Arnhem, 1996
Communicating well...
I am working alongside a wonderful yolngu person who is teaching me so much. I’m learning
to rely on her so that I can be the best instrument for her work. I can bring to what we do
here, but I am guided by her as to how I bring that in, and what I can bring in. I am very
much reliant on her for how we can bring an understanding about health for the benefit of the
people here - so (that) it’s a clear message, it’s a relevant message and it’s a message that,
20
while I am working as an OT, people are able to make a decision and act on that decision
because they’ve got that understanding clear.
Naomi,“Sharing True Stories: Improving Communication in Indigenous Health Care”
website http://www.sharingtruestories.com
There are written resources you can use to orient yourself to Aboriginal culture:
• DHCS Library Services has an extensive ‘Aboriginal Health Collection’
• Cross cultural orientation guides are available through DHCS Library Services.
You can access guides to particular subjects at:
http://internal.health.nt.gov.au/orgsup/croc/guides.shtml
• Some guides have been produced for people who work in particular regions of
the Northern Territory:
For Central Australia
 Apmer Anwekantherrenh: Our Country An Introduction to the Anmatyerr
and Alyawarr people of the Sandover River Region, Central Australia by
Jeannie Devitt (1994)
 Keeping Company: An Inter-cultural Conversation by Christine Franks and
Barbara Curr (1996).
 CARPA Orientation Manual: An Introduction to Aboriginal Health Care in
Central Australia by CARPA (1996)
For the Top End
 Taking Time for People: An Orientation Manual for People Working in the
East Arnhem District by Jeannie Devitt (1995)
 Communication and Cultural Knowledge in Aboriginal health Care by
Anne Lowell (2001)
 See the “Sharing True Stories: Improving Communication in Indigenous Health
Care” website http://www.sharingtruestories.com
‘Big relationships’
When new Balanda sisters come in to work among the Aboriginal Health Workers,
the first thing that they want to learn is from us - we teach them what’s there and
what’s to be done - we teach them about...[our] relationships to anyone (others). We
teach them about the death of the families and how families could get together for
that ceremony because we Aboriginal people have got big relationships. And that’s
how Balanda sisters usually learn - slowly by slowly until they sometimes
understand Yolngu way of life and culture... So there was no problem between us,
the Aboriginal Health Workers and the Balanda sisters, everything is smooth working together as a team.
Burrayburray Dhurrkay, Senior Health Worker
Milingimbi, November 1992 in Devitt 1995:3
21
Aboriginal cross cultural awareness courses are available. If you have not
participated in a cross cultural course, make inquiries as soon as possible. Some
Government funded training programs are:
Aboriginal Cultural Awareness Program (ACAP) - Top End
Offered as 3 x 1 day modules
Module 1
Introduction to Culture and People
Module 2
Society and Power
Module 3
Empowerment and Governance
Contact DHCS Workforce Development, Darwin
Ph:
8922 8747
Fax: 8922 8010
Aboriginal Cultural Awareness Program (ACAP) – Central Australia
DHCS in partnership with the Institute for Aboriginal Development
Offered as 5 days training in 3 modules –1 day plus 2 x 2 day modules
Contact DHCS Workforce Development, Alice Springs
Ph:
8951 7724
Fax: 8951 7733
One recommended reference book for ACAP is Binan Goonj: Bridging Cultures in
Aboriginal Health by Anne Eckermann, Toni Dowd, Mary Martin, Lynette Nixon, Roy
Gray and Ena Chong (1992).
Another recommended reference book is Why Warriors Lie Down and Die, by
Richard Trudgeon (2000)
Race, Culture, Indigeneity and the Politics of Public Health, NT
Offered as a 3 day short course
Social Determinants of Indigenous Health, NT
Offered as a 4 day short course
Menzies School of Health Research
For short course information: http://www.menzies.edu.au/shortcourses
Ph:
(08) 8922 7873
Fax: (08) 8927 5187
Email: [email protected]
Non-government providers of cultural awareness and language training in the NT
include:
• Aboriginal organizations and groups
• church-based organizations
• education institutions
• private providers
Some will customise presentations and workshops to suit your work team.
 Ask others who they know and recommend
 See listings in the Telephone Directory
 Do internet searches using key words such as ‘NT cross cultural awareness’
22
Cultural respect and cultural security
Principles of cultural respect and cultural security need to guide your work.
Cultural respect: “the recognition, protection and continued advancement of the
inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander
peoples” (AHMAC 2004)
 Download at: http://www.health.vic.gov.au/korri/cultural-respect-framework.pdf
Cultural security: “ a commitment that the construct of effective clinical care,
public health, health systems administration and the provision of services … will not
compromise the legitimate cultural rights, views and values of Aboriginal people.
The crux of the move to cultural security is a shift in emphasis from attitude to
behaviour, ensuring that the delivery of health services is of such a quality that noone is afforded a less favourable outcome simply because they hold a different
cultural outlook …” (Dept of Health WA 2004:2, DHCS 2005:26)
 See handbook Increasing Cultural Competency for Healthier Living - a Handbook
for Policy, Planning and Practice on the NHMRC website.
http://www.nhmrc.gov.au/publications/index.htm
As you use this public health resource…
Remember that each remote community has its own, unique history, peoples and
complexities. This resource will help you understand some of these factors and
provide you with some guidance. The most valuable resource for working with
communities, however, will be your own ears, eyes, and minds.
Websites listed in this chapter
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/apacttoc.shtml
http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-oatsih-pubshealthstrategy.htm.
http://www.euro.who.int/
http://internal.health.nt.gov.au/orgsup/croc/guides.shtml
http://www.sharingtruestories.com
http://www.menzies.edu.au/shortcourses
http://www.health.vic.gov.au/korri/cultural-respect-framework.pdf
http://www.nhmrc.gov.au/
More useful websites
http://www.nt.gov.au/health/healthdev/health_promotion/promotion_main.shtml
http://www.health.nsw.gov.au/public-health/health-promotion/settings/index.hrml
www.healthpromotion.org.au
http://www.who.int/topics/healthpromotion/en
http://www.wpro.who.int/health_topics/healthy_settings/
23
http://www.nphp.gov.au/
http://www.vichealth.vic.gov.au/cochrane/
http://www.health-evidence.ca/
http://www.crcah.org.au
http://www.menzies.edu.au
http://www.ards.com.au
http://www.naru.anu.edu.au
http://www.healthinfonet.ecu.edu.au
http://www.ath.crc.org.au
http://www.health.gov.au/oatsih/cont.htm
http://www.iuhpe.nyu.edu/
Bibliography
Baum F 2002, The New Public Health, 2nd Edition, Oxford University Press, Victoria
Catford J 2004, Health Promotion’s Record Card: How principled are we 20 years
on?, Health Promotion International Vol 19, No1, Oxford University Press
Central Australian Rural Practitioners Association 1996, CARPA Orientation Manual:
An Introduction to Aboriginal Health Care in Central Australia, Central Australian
Rural Practitioners Association, Alice Springs.
Commonwealth of Australia 2003, National Strategic Framework for Aboriginal and
Torres Strait Islander Health, Canberra
Devitt J 1994, Apmer Anwekantherrenh: Our Country: An Introduction to the
Anmatyerr and Alyawarr People of the Sandover River Region, Central Australia,
Urapuntja Health Service Council, Utopia, Northern Territory.
Devitt J 1995, Taking Time for People: An Orientation Manual for People Working in
the East Arnhem District, Territory Health Services, [Darwin].
Eckermann A, Dowd T, Martin M, Nixon L, Gray R & Chong E 1992, Binan Goonj:
Bridging Cultures in Aboriginal Health, University of New England Press, Armidale,
NSW.
Franks C & Curr B 1996, Keeping Company: An Inter-Cultural Conversation, Centre
for Indigenous Development Education and Research, University of Wollongong,
Wollongong, NSW.
Freeman P & Rotem A 1999, Essential Primary Health Care Services for Health
Development in Remote Aboriginal Communities in the Northern Territory, A Report
prepared for Territory Health Services by the WHO Regional Training Centre for
Health Development, University of New South Wales, Sydney.
Germov J 2002, Second Opinion: An Introduction to Health Sociology, Allen &
Unwin, Sydney
King L & Ritchie J 1999, Promoting Health in the Northern Territory: A Review,
Report prepared for the Territory Health Services by the WHO Regional Training
Centre for Health Development, University of New South Wales, Sydney.
24
Lawson JS 2001, Public Health Australia: An Introduction, 2nd Edition, McGraw-Hill,
Sydney
Lowell A, “Sharing True Stories: Improving Communication in Indigenous Health
Care” http://www.sharingtruestories.com, downloaded May 2005
National Aboriginal Health Strategy Working Party 1989, A National Aboriginal
Health Strategy, National Aboriginal Health Strategy Working Party, Canberra.
National Public Health Partnership 1997, Public Health in Australia: The Public
Health Landscape, National Public Health Partnership, Melbourne.
Northern Territory Department of Health and Community Services 2005, Aboriginal
Health and Families: A Five Year Framework for Action, Northern Territory
Department of Health and Community Services, Darwin.
Territory Health Services 1998, The Aboriginal Public Health Strategy and
Implementation Guide 1997-2002, Territory Health Services, Darwin.
Trudgeon R 2000, Why Warriors Lie Down and Die, Aboriginal Resource and
Development Services Inc, Darwin
Wass A 2000, Promoting Health: The Primary Health Care Approach, 2nd Edition
Harcourt Brace, Sydney.
Wilkinson R & Marmot M (eds) 2003, The Solid Facts: Social Determinants of
Health, 2nd Edition World Health Organization Regional Office for Europe, Centre for
Urban Health, WHO, Copenhagen.
Health, World Health Organization Regional Office for Europe, Centre for Urban
Health, WHO, Copenhagen.
World Health Organization 1978, Primary Health Care: Report of the International
Conference on Primary Health Care, Alma Ata, USSR, 6-12 September 1978, WHO,
Geneva.
World Health Organization 1986, Ottawa Charter for Health Promotion, WHO,
Geneva.
World Health Organization 1997, The Jakarta Declaration on Leading Health
Promotion into the 21st Century, WHO, Geneva.
World Health Organization 2005, The Bangkok Charter for Health Promotion in a
Globalised World, WHO, Geneva.
25
Chapter 2 – Education for Health
Chapter 2
EDUCATION FOR HEALTH
About this chapter .............................................................................................26
What is education for health? ...........................................................................27
The aim of education for health ........................................................................28
Changing theory and practice: a timeline ........................................................29
From health education to ‘education for health’ ............................................29
Stage 1: 1910 - 1960s Education through provision of health information...................29
Stage 2: mid 1960s - 1970s Education through varied audio-visual channels .............29
Stage 3: 1970s - mid 1980s Education incorporating adult learning principles..............30
Stage 4: 1986 – mid 1990s Education for health within the Ottawa Charter Framework .........30
The Ottawa Charter for Health Promotion 1986............................................31
Stage 5: mid 1990s - 2000s Education with more emphasis on a settings approach and
the social determinants of health ...........................................................................31
The Jakarta Declaration 1997 ......................................................................31
The Bangkok Charter 2005 ..........................................................................32
Key theoretical and practice frameworks.........................................................32
Primary Health Care.........................................................................................32
Adult Learning ..................................................................................................32
Education for Critical Consciousness ...............................................................33
Turning the theory into practice .......................................................................33
Your education for health role ..........................................................................33
Working with young people ..............................................................................34
Education for health in a cross cultural setting .................................................34
Unlearning ....................................................................................................35
Turning the theory into practice: a case study ..................................................36
Useful websites ..................................................................................................37
Bibliography .......................................................................................................37
About this chapter
This chapter emphasises the importance of health education to working in a health
promoting way in communities. It provides important background that can help to
inform your practice.
The chapter aims to:
•
Summarise the theory underpinning the use of education to improve health
status, (“education for health” theory)
•
Explain how education for health relates to health promotion
•
track the changes in health education theory and practice to the current time
•
give advice about how to include education for health processes in work
practice
As a theoretical framework this chapter underpins many of the strategies described
in other chapters of this resource. The chapter content particularly draws, with
permission, on the work of experts in the health promotion field in Australia.
26
 See related chapters:
•
Chapter 3 Sharing Health Information offers a format for planning and
evaluating information sharing sessions
•
Chapter 5 Planning and Evaluating a Health Promotion Project outlines a
step-by-step process for planning a health promotion or public health project.
It offers information and guidelines which you may find useful for setting
learning objectives, organising education activities and evaluating them
•
‘Working with Groups’ in Chapter 4 Strategies for Health Promotion includes
a guide for small group education sessions
•
‘Using Media’ in Chapter 4 Strategies for Health Promotion includes
information about health education resources
 For further information read the recommended text Promoting Health: The
Primary Health Care Approach by Andrea Wass (2000)
What is education for health?
Health education is an essential element of any strategy designed to promote
health. It is one of the bases from which contemporary health promotion has
developed, and plays a central role in most health promotion strategies. So health
education and health promotion are not interchangeable terms.
 See Spectrum of Health Promotion Interventions in Chapter 1 Public Health in
Context
The WHO definition states that “Health education comprises consciously
constructed opportunities for learning involving some form of communication
designed to improve health literacy, including improving knowledge, and developing
life skills which are conducive to individual and community health.” (WHO 1998:4)
Green and Kreuter (1991:17) defined health education as “any combination of
learning experiences designed to facilitate voluntary actions conducive to health”.
Like public health and health promotion, health education has evolved over the
decades. Wass writes that health education fell from favour with the rise of the new
public health movement, because its focus in the past was on educating for
individual behaviour change without take into account the context of social and
environmental changes needed to support the change. Health education, however,
also went through a shift in emphasis, with more recognition of the role it can play in
bringing about social change. (Wass 2000:229-230)
Freudenberg (1984:40) writes that “if one defines health education more broadly as those efforts that educate and mobilise people to create more healthful
environments, institutions and policies (as well as lifestyles) - one can find a rich
tradition of health education for social change”. This definition acknowledges
education for health as an integral part of health promotion and primary health care
practise.
27
Health Education is not:
• telling people to follow good health behaviour
• educating for compliance
• assuming the “power over” role of “expert”
• disempowering
• teaching without learning
• the same thing as health information, although providing health knowledge is
a fundamental part of the education process.
So health education does not focus narrowly on trying to change the risk-taking
behaviour of individuals or groups. Such an approach runs the risk of blaming the
victim for high risk behaviour and/or poor health. Health education focuses more
broadly on changing the factors that impose risk, and the social conditions that lead
to illness.
Health education may be offered in a variety of ways - as part of a planned program,
opportunistically, or in response to people’s requests. It may use a variety of
strategies. It may focus on individuals, families, groups, or communities, or even
whole populations. In each scenario, education activities need to acknowledge and
respond to people’s needs, interests and priorities.
The aim of education for health
Education for health aims to empower people so they can exercise more control
over the factors that determine health - especially the social determinants.
At the community level, education for health can help people to collectively respond
to health issues and to change some of the structural and socio-economic
determinants of health, such as food supply, poor housing and environmental
factors.
At the individual level, education for health can help to change a person’s health
behaviour and well being, through changing determinants such as smoking, high
risk use of alcohol, diet and physical activity, sense of control and coping skills.
Education for health aims to:
• help people to reflect on their experiences and aspects of life that affect
health
• foster the motivation and confidence necessary to make decisions and take
action to improve health
• help people acquire the skills needed to take action and to deal with a variety
of situations they encounter
• provide information about the underlying social, economic and environmental
conditions impacting on health
• provide information about individual risk factors and risk behaviours
• develop people’s skills and confidence to use the health system
• enable people to take more control over their health
In summary, education for health can build people’s capacity to achieve better
health.
28
Changing theory and practice: a timeline
From health education to ‘education for health’
The current focus of education for health within a health promotion
framework has moved a long way from the roots of health education in
Australia. The following timeline uses and builds on a four stage progression
described by Ritchie in 1991.
Stage 1: 1910 - 1960s Education through provision of health information
This approach was characterised by:
•
providing people with logical, rational and scientific information about health
•
a belief that people would adopt appropriate attitudes and behaviours if they
were given the facts
•
some limited successes, but generally, the approach did not work. Providing
health information alone did not lead to changed behaviour
“Disappointingly, two decades later, despite the consistent inadequacy of this approach so
clearly demonstrated in reviews and evaluations…many health professionals have not
moved out of this stage, and continue to use these inappropriate methods when attempting
to promote better health behaviour”.
Ritchie 1991:158
Stage 2: mid 1960s - 1970s Education through varied audio-visual channels
This approach focused on tackling people’s risk behaviours. It was characterised by:
•
focus on preventable diseases such as heart disease and cancer and
tackling risk behaviours such as tobacco smoking with health information
and simple education (Catford 2004:3)
•
sophisticated social marketing approaches used in health promotion to raise
awareness and set health agendas
•
bombarding clients with information in a variety of forms - TV, posters, radio,
written material
•
belief that patients would retain information, and change behaviour, if they
received the information in a form that attracted them (called the ‘hypodermic
needle approach’ by Rogers, in Ritchie 1991)
29
•
health professionals continuing, as the experts, to make the decisions about
what information was shared
Stage 3: 1970s - mid 1980s Education incorporating adult learning principles
The 1978 the landmark Declaration of Alma Ata identified education about prevailing
health problems, and the methods of preventing and controlling them, as an
essential part of primary health care (PHC). The scene was set for a major change
in the approach to health education.
The approach was characterised by:
•
including the patient or community member as an active participant in the
education process
•
recognition that people can change, but on their own terms
•
belief that information needs to be relevant and meaningful to be effective
•
recognition that learning can be enhanced by opportunities for discussion,
for challenging new ideas and for reflection
•
acknowledgment that the social and environmental conditions within which a
person lives may prevent them from making changes or taking control of
their health
•
continuing emphasis on individuals changing their behaviour or choosing not
to
•
concern raised about the danger of ‘victim blaming’ when people are unable
to make changes. It was argued that many people have limited control over
their lives, and lack resources to take the recommended steps
Stage 4: 1986 – mid 1990s Education for health within the Ottawa Charter Framework
This approach is characterised by:
•
recognition of education for health as one component of a broad approach to
improving health
•
less focus on disease prevention or management
•
more acknowledgment that the determinants of health are social and
environmental
•
a range of education approaches to suit the diverse but complementary
methods and approaches of health promotion
30
The Ottawa Charter for Health Promotion 1986
The Ottawa Charter outlines five action areas for health promotion with a role for
health education in each area:
–
–
–
–
–
strengthening community action through an enabling and supporting role
developing personal skills in others both to practise desired health behaviour
and to build their personal capacity to make wise health choices
creating supportive environments to better support and sustain individual change
building healthy public policy through influencing policy decision makers
reorienting health services towards prevention and health promotion
 For more about the Ottawa Charter see Chapter 4 Strategies for Health
Promotion
Stage 5: mid 1990s - 2000s Education with more emphasis on a settings
approach and the social determinants of health
This approach is characterised by:
•
recognition that settings can serve as supportive environments for health
education activities. Reaching people through the places and networks where
they live and meet, such as schools, clubs, workplaces, marketplaces,
hospitals and other services, community organizations and other venues
•
greater focus on education for changes to organizations, systems and the
environment
•
continuing emphasis on complementary interventions
•
using ‘social marketing’ approaches, where the educator identifies the
determinants of health behaviour for particular ‘market segments’ (eg.
adolescents) and targets strategies to this group or ‘segment’.
•
building on what has been learned to change the wider agenda of social
determinants and reduce health inequities, with education for health being a
vital element of this continuing health promotion agenda
The Jakarta Declaration 1997
The Ottawa Charter for Health Promotion was strengthened by the outcomes of the
Jakarta Declaration. The Declaration describes health promotion as “an essential
element of health development, as a process of enabling people to increase control
over and to improve their health”. Health promotion through investments and
actions, aims to:
• act on the determinants of health and create the greatest gain for people
• contribute significantly to the reduction of inequities in health to ensure
human rights
• build social capital
The ultimate goal is to increase health expectancy, and to narrow the gap between
countries and groups (WHO 1997).
31
The Bangkok Charter 2005
The Bangkok Charter for Health Promotion in a Globalised World builds on these
values, principles and actions. It states that enjoying the highest attainable standard
of health is a critical human right. The Charter aims to address the determinants of
health and emphasises that all sectors and settings must advocate, invest, build
capital, regulate and legislate, partner and build alliances.
“Health promotion has an established repertoire of proven effective strategies which
need to be fully utilized.” (WHO 2005:1)
Education for health is one of the proven strategies.
Key theoretical and practice frameworks
The principles of Primary Health Care, Adult Education and Education for
Critical Consciousness inform the way we approach education for health
activities.
Primary Health Care
The Declaration of Alma Ata (1978) states that Primary Health Care activities need
to include education concerning prevailing health problems and the methods of
preventing and controlling them. To accord with the principles of Primary Health
Care education approaches need to:
•
•
acknowledge the skills and knowledge people bring to the process
determine learning needs and approaches in partnership with community
members
encourage dialogue and two-way learning
•
Adult Learning
Education for health approaches are underpinned by the adult learning model
described by Knowles (1973, 1980) and the educational philosophy of Freire (1974,
1996).
Knowles’ model of adult learning (andragogy) advocates that education must be
learner centred rather than teacher centred and that education should address the
needs and interests of the learners. The model is based on several underlying
assumptions:
•
•
•
•
adults are self directed learners
adults have a great deal of experience which can serve as a resource for
learning
readiness to learn is affected by the need to know or do something
orientation to learning is problem or life centred
 Read articles about adult learning on the website:
http://adulted.about.com/cs/learningtheory/
32
Education for Critical Consciousness
The concept of education for critical consciousness, or critical consciousnessraising, was developed by the Brazilian educator Paolo Freire (1974).
This approach seeks to challenge the political and controlling practice of education
in which the powerful impose ideas on the less powerful. Educators work with
people to examine the underlying issues behind the problems that they identify, and
to change the structures around them. As a health education approach it continues
to have relevance to public health practise - it seeks to change the environment as
well as the individual.
You are probably already familiar with process used in education for critical
consciousness, as they have helped to shape various problem posing/problem
solving and community development models. The process involves four steps:
1. Reflecting upon aspects of people’s own reality (eg. poor health,
housing)
2. Looking at the root causes
3. Examining the implications and consequences of these issues
4. Developing a plan of action to deal with the problems collectively
identified
“This process of critical reflection and action is described by Freire as dialogue, a two way
process occurring between teachers and learners in which they are both teacher-learners” .
Wass 2000:232
Turning the theory into practice
Your education for health role
 Plan your education strategies to take into account audience, timing, setting,
credibility of the educator, method of evaluation.
 be a resource person
 work with and support others
 stimulate, not impose change
 facilitate in a way which encourages people to understand their problems and
choose the most appropriate solutions for themselves
 start where people are at and not where one thinks they should be
 listen carefully, take time to understand the perspective and issues of others
 communicate clearly
 research and provide information
33
 present a basis for informed choice
 enable people to share and examine their ideas, plan and put into practice their
decisions for change
 enable people to evaluate education for health activities and outcomes
 encourage involvement, develop credibility, trust and an effective working
relationship
 negotiate, manage conflict
 network, lobby, advocate
Working with young people
You may have opportunities to work in an education role with school age children
and young people:
•
•
•
•
as part of your community based health promotion programs in a range of
settings
as part of your well person’s screening role
in partnership with school and other training staff
to support programs offered by others
There are many resources to support health education programs with younger
audiences, including kits, websites and downloadable materials.
 Ask teaching staff about what is available through their education programs and
how to access it
 Share your health resources with staff at the school and other education settings
 Build your own workplace database of useful local, NT, interstate and national
health education resources
Education for health in a cross cultural setting
When working in a cross cultural setting aim to:
 listen and learn from the people you are working with
 learn about local history, issues and living conditions
 respect people’s cultural beliefs, knowledge and practices
 respect people’s health beliefs, knowledge and practices
 recognise that historical and cultural factors affect people’s health and well being
 recognise the expertise of people you are working with
 work in partnership with the learning community and others
34
 understand that effective education for health needs to be community initiated
and driven
 examine and support local solutions
 examine your own cultural beliefs
 avoid imposing your cultural bias on others
 ensure that decisions about the learning process and resulting action is with the
learning community not the educator
(Hunter 1995; Soong and Fejo 1976; Wass 2000; WHO 1988)
Working with people from other cultures
Because our own culture is so familiar to us, we tend to believe that the way we think, act
and judge our world is shared by all others, and tend to judge unfavourably others who do
not portray similar values, assuming that ours is the right way. Our upbringing, our education
and our own ‘enculturation’ make it difficult for us to reflect on and challenge notions that are
considered common sense or traditional in our culture. If we are going to work effectively
with others we need to ensure that we reflect on those beliefs and values which we take for
granted, so that we can respond effectively in the face of differing values.
Wass 2000:71
Unlearning
30 years ago a NT report by Soong & Fejo advised that it may be necessary to
“unlearn” some of our training and the assumptions which shape practice. It is
interesting to reflect on their 1976 advice…
Beware of assuming that:
• people will immediately appreciate our health advice
• western health practices are best for Aboriginal people and no modification
is necessary
• non Aboriginal health professionals can solve health problems for
Aboriginal people
• people perceive health and sickness in the same ways
• scientific facts have more validity than other explanations
• the ways we have been taught are the best ways of teaching others
(Soong & Fejo 1976)
Recommended reading:
Lowell A, Maypilama E, Biritjalawuy D, 2003, Indigenous Health and Education:
Exploring the Connections, Cooperative Research Centre for Aboriginal and
Tropical Health, Darwin
35
Turning the theory into practice: a case study
An effective education for health process
An effective education for health process was demonstrated in Wadeye in 2000/01. Scabies
had been identified as a major problem for the community especially for small children. Clinic
staff were concerned about this and began talking with the community about what could be
done to lower the rates of scabies.
The clinic was aware that other communities in the NT had successfully reduced the rates of
scabies in their communities by holding ‘Scabies or Skin Health Days’ where the entire
community was treated for scabies on one day. The Wadeye community decided to try this
approach.
In the three months leading up to their ‘Scabies Day’ four female Elders worked closely with
AHWs, nurses and doctors to promote the message ‘healthy house makes healthy skin
makes healthy body’. A local artist developed a logo for ‘Scabies Day’, which was used on
promotional materials such as t-shirts and stickers.
The Wadeye community held their first ‘Scabies Day’ in June 2000. Fifty community
volunteers worked in teams to deliver donated soap, washing powder and the 5% permethrin
cream to all the households in the community. The community store donated food for a
celebration barbeque, which was held in the afternoon. Community Elders led a corroboree
to end the day. Six weeks after the intervention the prevalence of scabies in children five and
under had fallen from 33% to 3%.
Following on from this first ‘Scabies Day’ the importance of healthy skin has continued to be
promoted in Wadeye. Depending on the prevalence of scabies, each year the community
has decided to hold either a mass treatment day or a community clean up day. The local
Environmental Health team has made sure that each household has access to clotheslines,
constructing new clotheslines and repairing broken lines where necessary. Together with the
Community Council the Environmental Health team have run a monthly ‘Clean House and
Yard’ competition with a washing machine as a first prize. An ongoing scabies screening
program for children aged five and under is led by a team of local women.
Wong et al: 2001; Wong et al: 2002
Nicola Slavin, Environmental Health Officer
36
Useful websites
http://www.nt.gov.au/health/healthdev/health_promotion/promotion_ed_resou
rces.shtml Health education resources and their sources are listed for
alcohol, diabetes, environmental health, heart health, kidney nutrition,
respiratory, sexual health, social and emotional and other health issues
http://adulted.about.com/cs/learningtheory/
http://www.health.nsw.gov.au/public-health/healthpromotion/abouthp/glossary.html
http://www.wpro.who.int/hpr/docs/glossary.pdf
http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/
http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/
 See websites listed in Chapter 4 Strategies for Health Promotion
Bibliography
Catford, J. (2004) Health promotion's record card: how principled are we 20 years
on?, Health Promotion International, Vol 19 No 1, pp. 1-4, Oxford University Press,
United Kingdom
Ewles L & Simnett I 2003, Promoting Health: A Practical Guide to Health Education,
5th edn, John Wiley & Sons, Chichester, England.
Freire P 1974, Education for Critical Consciousness, Sheed & Ward, London.
Freire P 1996, Pedagogy of the Oppressed, trans Myra Bergman Ramos, Penguin,
Harmondsworth, England.
Freudenberg N 1988, Training Health Educators for Social Change.In Health
Promotion: A Resource Book. R. Anderson and I. Kickbusch (Eds.) Chichester,
England, John Wiley
Glanz K, Lewis FM & Rimer BK (eds) 2002, Health Behavior and Health Education :
Theory, Research, and Practice, 3rd edn, Jossey-Bass, San Francisco.
Glanz k, Rimer b, Marcus Lewis F (Eds.) 2002, Health Behavior and Health
Education: Theory, Research, and Practice, 3rd edn, San Francisco, Jossey-Bass
Green LW & Kreuter MW 2005, Health Promotion Planning: An Educational and
Environmental Approach, 4th edn, Mayfield, Mountain View, California.
Hunter E 1995, Is there a role for prevention in Aboriginal mental health? Australian
Journal of Public Health, vol 19(6), pp573-579.
Knowles M 2005, The Adult Learner: A Neglected Species, 6th edn, Gulf Publishing,
Houston.
Knowles MS 1980, The Modern Practice of Adult Education: From Pedagogy to
Andragogy, Association Press, Chicago.
37
National Heart Foundation (NSW Division) 1995, Action for Change, All About Heart
Health, by J Ritchie, eds S Walker, J Shaw & J Ritchie, National Heart Foundation,
[Sydney].
New South Wales Department of Health, Health Promotion Glossary,
http://www.health.nsw.gov.au/public-health/health-promotion/abouthp/glossary.html
Ritchie JE 1991, From health education to education for health in Australia: A
historical perspective, Health Promotion International, vol 6(2), pp157-163.
Soong FS & Fejo W 1976, Health education approaches in Aboriginal communities
in the Northern Territory: What we have learned, Medical Journal of Australia
Special Supplement (2), pp1-5.
Tsey, K 1996, Aboriginal health workers : agents of change?
Australian and New Zealand Journal of Public Health: 20(3), 227-229.
Wass A 1994, Promoting Health: The Primary Health Care Approach, Harcourt
Brace, Sydney.
Wong L, Amega B, Connors C, Barker R, Dulla M, Currie B 2001, Outcome of an
interventional program for scabies in an Indigenous community, Medical Journal of
Australia 175:367-370
Wong L, Amega B, Connors C, Barker R, Dulla M, Ninnal A, Cumaiyi M,
Kolumboort L, Currie B, 2002, Factors supporting sustainability of a
community based scabies controlled program, Australian Journal of Dermatology
45:274-277
Conference on Primary Health Care, Alma Ata, USSR, 6-12 September 1978,
WHO, Geneva.
Geneva.
World Health Organization 1988, Education for Health: A Manual on Health
Education in Primary Health Care, WHO, Geneva.
World Health Organization. 1998, Health Promotion Glossary, WHO, Geneva
[online] [cited June 2005] http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf
Promotion into the 21st Century, WHO, Geneva (online) (cited June 2005)
http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/
Globalised World, WHO, Geneva [online] (cited March 2006)
http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/
38
Chapter 3 – Sharing Health Information
Chapter 3
SHARING HEALTH INFORMATION
Related chapters ............................................................................................... 40
About information sharing ............................................................................... 40
Information Privacy Principles ......................................................................... 41
Where information can be found ..................................................................... 41
Why share health information .......................................................................... 42
What information can be shared ...................................................................... 43
Who information can be shared with ............................................................... 44
When and where to share information ............................................................ 44
How to share health information...................................................................... 45
Ways of sharing health information ................................................................. 46
Doing brief interventions .............................................................................. 46
Story telling ................................................................................................. 47
Using paintings ............................................................................................ 49
Using case studies ...................................................................................... 50
Using performing arts – theatre, video, dance, music, song ........................ 51
Using print media ........................................................................................ 51
Using electronic media - MARVIN ............................................................... 52
Information sharing sessions ....................................................................... 53
Meetings...................................................................................................... 53
Reports for the community about projects and programs............................. 54
Health days and health weeks ..................................................................... 54
Using resources that support information sharing ............................................ 54
Using tables and graphs to present data ......................................................... 55
Line graphs ................................................................................................. 55
Pictorial charts ............................................................................................. 56
Pie charts .................................................................................................... 57
Bar charts .................................................................................................... 57
Tally sheets ................................................................................................. 58
Overlays ...................................................................................................... 58
Organising information sharing sessions ....................................................... 58
Planning worksheet 1 .................................................................................. 59
Planning worksheet 2 .................................................................................. 60
Planning Worksheet 3 ................................................................................. 61
Bibliography ...................................................................................................... 62
About this chapter
This chapter outlines the why, what, who, where, when and how of sharing health
information in an effective way. It has been included in the manual as a chapter on
its own because community members and health professionals have repeatedly
emphasised the importance of information sharing. Sharing of health can help to
empower individuals, groups, communities and service providers to make positive
decisions about health. The chapter should not be read in isolation, but considered
together with the content of the related chapters listed below.
39
Related chapters
Chapter 2 Education for Health outlines the theory of using education processes in
work practice.
Chapter 6 A Health Promoting Health Centre offers important advice for sharing
health information, along with the chapter ‘Strategies for Health Promotion’.
Chapter 5 Planning and Evaluating a Health Promotion Project includes data
collection, documentation, and reporting processes.
About information sharing
In this chapter the term health information means any information that can help
increase people’s understanding of health and health issues. Health information that
is shared needs to be appropriate, accurate and well presented. It needs to be
communicated well. This can be challenging when there are language and cultural
differences between people – remember that for up to 70% of indigenous people in
the NT english is not the language spoken at home. There is a high risk of
miscommunication and much miscommunication goes unrecognised.
 Listen to Aboriginal people talking about communication and sharing health
information on the Sharing True Stories website:
Sharing information is an exchange, a two way process. There are many ways to
share different kinds of information. How you choose to do it will depend on the type
of information, who is sharing it, with whom, why it is being shared, and available
resources.
Policy on Information Sharing is well established in the NT…
It is essential for THS staff to ensure information is shared with communities, learn from
communities, and in partnership, plan and implement public health strategies to meet
community identified priorities. Information flow must be two-way, and all interactions based
on respect. Sharing information with people at community level enables them to discuss its
implications for them, decide what they will do themselves, and what assistance they require
from THS or other service providers.
Contemporary health promotion strategies include sharing health information at the
individual, family and community levels to establish a dialogue that explores and identifies
priorities and achievable solutions. The purpose is to enable individuals and groups to take
greater responsibility for, and control of, their own health and build problem solving and
decision making capacity. The role of THS staff is to support communities to develop local
solutions to local health problems.
Territory Health Services 1998a:12
40
Information Privacy Principles
When considering the collection, use or sharing of clients’ health information, you
need to be aware of the relevant legislation, policies and guidelines for respecting
the privacy of personal information.
For DHCS staff the rules for protecting privacy are set out in 10 Information Privacy
Principles (IPPs) in the Schedule at the end of the NT Information Act. The
requirements of the IPPs can be divided into four categories: collection of
information, use and disclosure, management of information and openness. For
advice on how the IPPs should be applied contact the Information Privacy Unit on
8999 2455 or email [email protected].
Download the IPPs and the DHCS Privacy Policy from:
http://internal.health.nt.gov.au/orgsup/ipar_100/ip_intro.shtml (select ‘Information
and Privacy’ from the topics menu on the DHCS homepage), or from:
www.infoprivacyhealth.nt.gov.au. If you need more information see NT Information
Commissioner’s website: www.nt.gov.au/justice/infocomm/privacy/index.shtml.
The Information Privacy Code of Conduct (1997) continues to guide DHCS staff on
what is acceptable, and what is not, in the collection, storage, access and use of
personal information. The Code takes second place to the IPPs, but is still useful for
day-to-day guidance on how to deal with privacy issues. Parts 2, 3 and 4 are about
security and the work environment, handling of health information, the management
of data collections and access to health information for health research.
Staff working in the private and NGO health sector are required to comply with the
National Privacy Principles (NPPs) under the Commonwealth Privacy Act 1988.
The rules under the IPPs and the NPPs have much in common. Download the
‘Guidelines on Privacy in the Private Health Sector’ and a ‘Short Guide for the
Private Health Sector’ at: www.privacy.gov.au/health.
Where information can be found
Useful information from within the community may come from a variety of sources.
It may come from community residents or specific community records such as:
•
health centre records and hospital files
•
community profiles
•
community web pages and related websites
•
council records (if accessible)
•
CDEP records
•
school
•
church
•
store turnover figures
41
•
project reports, photos, films, audio tapes
Useful information from outside the community may come from a variety of
sources such as:
•
community profiles developed through government departments or other
agencies
•
non-government organisations who work with the community
•
surveys and reports
•
national and NT health statistics
•
community development plans
•
films/videos, photos, audio tapes
•
journals and books
•
internet and computer-based software resources
These resources can be found in (for example):
• libraries
• DHCS programs such as Alcohol and Other Drugs; Nutrition and Physical
Activity; Environmental Health; Health Promotion Strategy; Mental Health;
Preventable Chronic Diseases; Family and Childrens’ Services; Maternal, Child
and Youth Health
• Department of Local Government, Housing and Sport
• Department of Planning and Infrastructure (maps, aerial photos, etc)
• Australian Bureau of Statistics
• Internet websites and linked documents
Why share health information
Reasons for sharing health information include:
• raising awareness, building knowledge and understanding about health
• increasing awareness of the links between health and such things as living
conditions and lifestyle
• putting an individual’s or community’s health status into a public health framework
(the bigger picture)
42
• increasing service providers’ understanding of Aboriginal people’s knowledge,
attitudes and health practices
• providing a forum for communicating and working together
• decreasing the chances of duplication of effort and increasing the chances of
cooperative action
• providing tools for decision making and action planning
• enabling people to match their own experience with the information shared, think
about what it means for them, consider options and make decisions about what
to do
What do people value
The purpose of providing information at a community level is two-fold: first, to demystify an
issue, process or structure and second, to get people talking. It is useful in communicative
practice to view health information as having two equally important components: statistics
and stories. All statistics are built up from stories, and effective information programs
incorporate the story approach…Before practitioners ask ‘What do people need?’ or ‘What
are their problems and how can they be addressed?’, they need to ask first ‘What do people
know?’ and second ’What do people value?’
Weeramanthri 1996:3
What information can be shared
Health information can be powerful information. The types of information you share
may include:
professional health knowledge and advice
• information about health promotion and disease prevention
• information about intervention, treatment and outcomes, including details about
what can happen as a result of receiving or not receiving treatment
• information and advice about specific issues such as environmental health, food
and nutrition, physical activity, alcohol, tobacco and other drugs
• information about how the body works and factors that can cause problems
health statistics
• health statistics about the community
• health statistics about the NT and how it compares nationally and internationally
information about services, programs and funding
• details about health services, programs and resources available, including what
is offered and contact information
• funding information
information about research and evaluation findings, projects and community action
• results from community screenings, interventions or actions
43
•
•
•
progress reports or evaluations of programs and projects
ideas for action including what has worked or not worked in other places
other research findings and activities
 When sharing health information respect people’s ownership of the information,
rights to privacy, and confidentiality
 Using interpreters can help to ensure that information is shared and understood
correctly
Who information can be shared with
Information can be shared with everyone! The important thing is to match the type of
information you share with the people you share it with, who include:
•
individuals
•
families
•
community groups or whole communities
•
other members of the health team
•
other service providers such as the school, childcare centre, council
•
colleagues beyond the health team
•
workers in other government departments
•
workers in non government organizations
When and where to share information
Suitable information may be shared anywhere, anytime with people who are
receptive.
The best times or places to share information may be:
• as part of day-to-day work practice
• at the time when the individual, group or community most want to hear it, are
ready to hear it, or need to hear it
• as soon as possible after a relevant event while an issue is fresh in people’s
minds
• when you can link information sharing to a community event such as school
activities, sports days, cultural activities
• during health days or health weeks
44
• when people invite you to men’s or women’s places
How to share health information
There are many options for sharing health information and no clear formula for doing
it. Information sharing is a process. How the information is shared is as important as
what information is shared. How it is shared contributes to the impact of the
information, whether it is understood, whether it is remembered and how it is used.
Effective working partnerships between non-Aboriginal and Aboriginal staff, and
between the health team and other community members are important for effective
sharing of information. Partnerships need to be built on sound communication and
mutual respect.
 Do not overload people with new information - be realistic about what information
can be shared in the time available, and what can be achieved as a result of that
sharing
 Do not underestimate your audience
 Do not underestimate what you can learn from your audience
An information sharing session in response to a request from Galiwin’ku Community Elders
We found that a number of the health education resources we’d prepared, while adequate in
some ways, didn’t really address the range of information people wanted. We weren’t quite
prepared for the depth of questioning through the translators.
The session provided the opportunity to critically reflect, learn from the experience and apply
that learning in future practice.
Gillian Gorham, Nightcliff Renal Unit
 Decide on the best person/people to share the information with the particular
audience
45
 Think about language and the most appropriate way to explain things clearly.
Share information in people’s first language when possible.
 Think about how to ask questions in a way which invites people to respond, to
share their knowledge, concerns and ideas
Talking about the Grandmothers’ Women’s Health Program
The grandmothers know lots of things about how to stay strong and healthy. Kardyia [nonAboriginal] know about clinic things. The grandmothers know about family and law. The
women and girls need to learn all the things to be strong and healthy. They need to learn
Kardyia things from the AHWs, and they need to learn law and culture from the
grandmothers.
Some of the health problems that people are having today are hard for Yapa [Walpiri people]
to understand. Problems like poor nutrition, sugar, cancer, STDs, those things never used to
be things that Yapa had to worry for. People from outside, like nurses and doctors, try to tell
Yapa about these problems… what they should be doing about the problems. Sometimes
those nurses and doctors don’t know how to tell the story the right way. Sometimes they tell
the story in ways that make Yapa shamed or angry… Kardiya staff need to be told when they
are doing things wrong way and making things hard for me and the women… When the
grandmothers know the Kardiya staff are trying to do things right way, they will tell the
women to listen.
Nola Wilson, Aboriginal Health Worker, Nyirrpi Community
Ways of sharing health information
There are many ways to share health information in an effective way. You don’t
necessarily need a polished presentation or a professional product to do it well.
Methods of sharing health information may include:
Doing brief interventions
Brief interventions involve making the most of any opportunity to raise awareness,
share health information, and get a person thinking about making changes to
improve their health. At the very least, every brief intervention should provide your
client with some form of accurate health information.
You have opportunities to share health information as part of a brief intervention
when you do health assessments, do well women’s and well men’s checks, do
maternal and child health checks, take a client’s health history, give back test
results, give treatment or referral.
 See the ‘Brief Intervention’ section in Chapter 4 Strategies for Health Promotion
 See Brady M & McKenzie-Taylor M 2003, Talking about Alcohol with Aboriginal
and Torres Strait Islander Patients: A Brief Intervention Tool for Health
Professionals, Commonwealth Dept of Health & Aging, Canberra
 See Living With Alcohol: A handbook for Community Health Teams by Territory
Health Services 1998b
46
 See Alcohol Handbook for Frontline Workers by A Laycock, Broken Hill Centre
for Remote Health Research 2004
Note that while these resources are written for alcohol intervention, the intervention
process can be applied to a range of health issues.
Story telling
Story telling is a traditional way of passing on information in Aboriginal culture, and
some Aboriginal people are very experienced and highly regarded as story tellers.
Story telling may be useful for sharing health information and can be a good
foundation on which to build knowledge and discussion. Individuals may share their
personal story on a one-to-one basis (as in a brief intervention), or a health
information story may be shared with a group. People can compare stories and
experiences, empathise, seek common ground and make individual or collective
decisions.
People’s stories may include information about:
• family, relationships, community, and culture
• health related practices, beliefs, attitudes, knowledge, values and life experience
• what has worked well, or not been successful, in the community before
Service providers’ stories may include information about:
•
statistics, scientific test results or knowledge and western health practices
•
health related practices, beliefs, attitudes, knowledge, values and life experience
•
health stories from other communities
Key issues that are spoken about as part of story telling can be summarised and
repeated back to the person or group for clarification. If the person or people give
permission to use their stories, then this information can be an important addition to
the health information you share with others. Stories used in this resource are
examples. Other powerful examples are people’s stories transposed in Giving Away
the Grog: Aboriginal Accounts of Drinking and Not Drinking by Brady (1995).
 Be sure to cross-check information with other sources (validate)
 Keep confidentiality in your mind at all times. Always ensure you have permission
to share personal information, and check who you are able to share it with
 See Chapter 5 Planning and Evaluating a Health Promotion Project
47
Example of story telling: The Aboriginal Living With Alcohol Storyboard
The Storyboard is an excellent communication tool that was developed as a resource for the
Living With Alcohol Program. It was based on some real research that was completed in the
NT in 1988/9 and the NHMRC alcohol guidelines. It uses storytelling to share information in
a non-threatening way. It is a square covered felt board on which felt shapes representing
people of all ages and alcohol are moved around to tell stories about the use and misuse of
alcohol. The stories give messages based on the three choices people have in regards to
alcohol, ie. not to drink, to drink carefully or to drink at unsafe levels.
Each ‘person’ on the board gives an opportunity to share information through telling different
stories and describing different situations. We have stories that centre around youth,
families, individuals, pregnancy, health issues, nutrition, responsible behaviour, people
making changes, culture and passing down traditional stories.
After we’ve told the stories, we encourage feedback by asking the group. “How do you see
your community?” and “How would you like to see your community in the future? The people
will rearrange the board to demonstrate how they see their community and discussion will
generate from that.
The board is designed to initiate discussion and response from people. It helps create the
talking environment between us and the people. We explain that we are not there to tell them
to drink or not to drink. We talk them through the options available to address alcohol issues
and explore ideas that come up. We provide some ideas and thoughts and let the
discussion go.
We obviously need to record all discussions but seek the approval of participants beforehand
and always clarify anything before it is finally documented. Our main methods of
documentation are written and photographic. We make it very clear to the people that we will
not record anything that they do not agree with or want us to. It’s extremely important to let
people know that whatever is recorded is their information and that we will be checking it
back with them.
After a decade of using the storyboard, we find it is still a very powerful tool that is
specifically requested by community people. AHWs in the NT, WA and QLD have been
trained in using the board, and a modified version is being used successfully in South Africa.
Gwen Walley, Alcohol and Other Drugs Services, Central Australia 2005
A storyboard resource based on this model has recently been developed for the
Preventable Chronic Diseases Program.
Another THS program which effectively uses the story telling process is the Strong
Women, Strong Babies, Strong Culture Program.
48
Figure 1: the storyboard
There are many ways to tell stories - through spoken stories, paintings, murals,
sculpture, film, theatre, dance, songs, posters, books, radio stories, multi-media
websites, other art forms or a combination of these. Ways of sharing information
may be developed locally for use within the community. Alternatively, stories
presented in different media may be available through DHCS program areas, other
services in your area, and other organisations and groups.
Using paintings
Paintings can be a powerful way to tell health stories and an appropriate way to
acknowledge the skills and resources of community members. Paintings often affirm
traditional law and leadership while telling important stories in a medium that people
relate to and respect. They have the potential to benefit the artist and the community
while sharing health information. They take on historical significance, for example:
The following presentation describes a painting by Millie Micks, an AHW from
Canteen Creek. The painting was presented to the then THS Secretary, Mr Ray
Norman at a Strategic Planning Workshop in 1992. It hangs in Health House,
Darwin.
49
An example of story through painting
The painting represents the process of negotiation for policy and advice to Aboriginal
communities in joint consultation with Government Departments.
The process of decision making is very different and the process in itself is very important.
Decisions take longer but have more value and we need our people to have their say in
policy changes and advice.
This process relates to other aspects of culture eg. close family ties, extended family and
tribal language groups. Since our education, values and life experience are very different, we
find understanding the system very difficult and not flexible enough to incorporate our values
and beliefs. This puts us individuals or Aboriginal groups in a very difficult position.
I believe the lessons learnt are important enough to be discussed. We offer this presentation
as a contribution to this process.
Presented by Kathy Abbott, Senior AHW, Wallace Rock-Hole
Using case studies
Case studies that tell the story of particular people or group (with permission) can be
a powerful way of raising issues and passing on information. Suitable case studies
may be found locally, through people you know. They may be published in journals,
such as the Aboriginal and Islander Health Worker Journal. Other sources include
government publications, such as Sharing Good Tucker Stories: A Guide for
Aboriginal and Torres Strait Islander Communities by Bear-Wingfield (1996), and
Giving Away the Grog: Aboriginal Accounts of Drinking and Not Drinking by Brady
(1995).
 Contact the Darwin Health Library for publication updates
 See references at the end of this chapter
50
Using performing arts – theatre, video, dance, music, song
Performance is a potentially powerful medium for telling stories, raising issues and
passing on messages. Opportunities may include working on a theatre or video
performance with a local school or community group, having a performer or group
come to work in the community, using resources from other places.
 Ask staff from program areas about resources. Be on the lookout for new
examples, performers and recordings. For example:
•
•
•
Specific health recordings such as animated DVDs and CDs about
environmental health issues
See http://www.nt.gov.au/nreta/arts/links/ ; http://www.musicnt.com.au/
Music available through, for example, the Central Australia Aboriginal Media
Association
 For a list of national and local resources go to ABC Message Stick Online,
Indigenous Links Page: http://www.abc.net.au/message/links.htm
The page provides links including arts, music, literature, media, multimedia,
theatre and events.
Using print media
Print media can be a useful way of recording and sharing information. Consider
posters, community fliers, newsletters, bulletins, magazines and books. Information
may be published by the community, non-government, government and commercial
organizations. It can take different forms - comic strips, pictures and designs with
and without text, photos and articles
 Be open to possibilities and look out for formats that people respond positively to.
Some examples:
• The Chronicle - Publication of the Chronic Diseases Network NT
• Institute for Aboriginal Development (IAD) Press, National Indigenous
Publishing at http://www.iad.edu.au/press/iadpresshome.htm
• Downloadable brochures from the internet such as those available on
http://www.healthyactive.gov.au/
• Environmental Health Issues Comic Strips by Human Services Training
Advisory Council
51
Using electronic media - MARVIN
Information technology resources can present information in powerful ways.
MARVIN is an internationally acclaimed, award winning computer animation
program that has been developed in the NT as a health learning and communication
tool. MARVIN (Messaging Architecture for the Retrieval of Versatile Information and
News) software is inexpensive, easy to use and responsive to local needs. It can
take complex health and policy information and make it community specific for a
fraction of the time and cost of any other film/video/animation technology.
MARVIN features animated 3D characters that resemble community people
speaking their own language to pass on health messages. For example, if an
outbreak of a disease occurs in a remote area, or an environmental health issue
becomes of particular concern, a community specific multi-media rich resource in
language (or not as requested) can be developed within a few days of working with
people in health, school and council. The resource can then be quickly adapted, so
that within 2 days it can look and sound as if it was built specifically for, by and with
another local community with the same need.
MARVIN resources have been developed in the NT to share information about many
topics including mental health, clinic orientation, consent resources, patient
responsibility resources, Aboriginal Health Worker training, aged care, substance
misuse, environmental health issues, immunisation, AIDS/HIV and CDC resources.
Enquire through program areas or contact the NT Institute for Community
Engagement and Development (NTICED) at www.nticed.com or the NT DHCS,
Interactive Communications & Development Unit on 0427250057 or 0889992453
52
Information sharing sessions
It may be appropriate to arrange information sharing sessions with particular groups.
Consider the best ways to present information and to document the session. Ask
permission to write down or tape what is being said, and record what you need to do
to follow-up requests. Asking for and recording the evaluation comments of the
audience, as well as the presenters, will help you to reflect on the session and
improve future ones. Evaluation questions may be as simple as “What were the
good things/not-so-good things about the presentation?” and “What can you suggest
for improving the next session we do together?”
 See the two worksheets at the end of the chapter. They may be helpful for
session planning and evaluation
Meetings
Whole community meetings may be a good way to make public announcements, but
are not necessarily the best way to share health information. However information
sharing sessions may take the form of meetings with particular groups. A meeting
may be needed to seek permission to proceed with health activities, including the
activity of information sharing, as shown by the following example.
From experience…
The meetings organised (by the grandmothers at Nyirrpi) allowed information to be
disseminated, considered and used for making decisions. When I arrived some old women
had been saying “keep that woman away from us”. They saw me as the epitome of the
‘round-up whitefella’. They changed their approach completely when they were given
information by their own senior women and the AHW. The grandmothers were invited by
their AHW and senior women to a meeting at which I was present, were given information in
their own language and invited to discuss it. They could then see their authority being
formally acknowledged by the ‘health service’.
Valmai McDonald, about Women's Health Educator role, Central Australia
53
Reports for the community about projects and programs
When your project team prepares a report for and with the community, consider
what the community wants and needs to know, what you want to say about the
project and the best way to say it. Information to be shared may include:
•
what the project aimed to do
•
what was planned
•
what actually happened
•
who was involved
•
how it was evaluated
•
what resulted from the project
Consider how the report should be presented.
 See the ‘Planning and Evaluating a Health Promotion Project’ chapter
Health days and health weeks
These provide opportunities to raise awareness about health issues, and to share
health information, through displays and various activities. Support may be available
from staff in program areas.
 See Volume 2 for examples of health days and weeks relating to nutrition and
physical activity, alcohol and other drugs and environmental health
Using resources that support information sharing
Suitable resources may include displays; models or demonstrations; storyboards;
flip-charts, posters and pamphlets; multi media resources such as video, film,
computer software and CD ROM; websites; TV or radio productions; newsletters;
journals or manuals. Using health resources on their own can raise awareness but
will not necessarily lead to action or changes in behaviour. They need to be used as
part of a broader information sharing and health promotion strategy.
 See ‘Using Media’ in Chapter 4 Strategies for Health Promotion
 Search the internet for relevant local, Australian and international resources.
Bookmark useful sites on your ‘favourites’ list for easy reference in the future.
Check for updates on websites that offer health information in the form of
brochures, fact sheets or slideshows, such as:
http://www.druginfo.adf.org.au/
http://www.quitnow.info.au/
http://www.healthinfonet.ecu.edu.au/frames.htm Go to Health Promotion
Resources. See, for example, Wadeye Environmental Health slideshow
 Make your own resources for sharing health information
54
Using tables and graphs to present data
A common way to present different kinds of quantitative data is through tables and
graphs. A table or graph should be simple and self explanatory. It should not need a
written explanation in order to interpret it. When possible, focus on the positive
aspects of the information presented, and use a variety of graphs and tables to take
account of individual preferences.
Tables and graphs can be used as tools for sharing information on a one-to-one
level, or for preparing an overview for the community or interest groups.
 See Maggie Brady, The Grog Book, Revised Edition. Pp 70-71 describes how
data about alcohol related harm was graphed and presented to community
members.
Tables and graphs can be used to show important information quickly, make it easier to
show comparisons, and to show patterns and trends. Tables and graphs may present data in
a concise way, saving on lengthy written reports
Feuerstein 1986:129
Line graphs
A line graph is used to show variations in data plotted over a period of time. Some
examples are:
• plotting days and times when alcohol related harm occurs
• showing changes in incidence of a health problem as a result of public health
strategies
• recording a child’s growth over time
• recording weight loss over a period of healthy eating and exercise
55
Pictorial charts
A pictorial chart is a chart that uses rows of simply drawn symbols or figures. Each
symbol may represent a person, number of people, or a particular unit of
information.
By colouring figures differently, drawing differently shaped figures or setting them
against different coloured backgrounds you can easily see the differences or
similarities within the total number of figures drawn.
56
Pie charts
A pie chart is used to show different parts of a whole in relation to one another.
The whole ‘pie’ represents the whole of the population that the information is about.
The portions or slices can represent the numbers of people who, for example, do or
do not have a health problem. Pie charts can also be used to compare things.
According to Feuerstein (1986:141), the clearest pie chart is the one divided into the
least number of segments.
Reasons for presentation
May 98
Ear
11%
Others
11%
Skin inf
16%
Resp inf
20%
Urine inf
5%
Eye
14%
Diarrhoea
23%
Bar charts
The bar chart allows different items of information occurring at the same time to be compared. The length of each
bar shows the quantity the bar represents (Feuerstein 1986:138).
Reasons for presentation May 98
Others
Resp inf
Urine inf
Diarrhoea
Eye
Skin inf
Ear
10
9
8
7
6
5
4
3
2
1
0
57
Tally sheets
Tally sheets are useful for summarising and analysing information such as
attendance figures or medical records. However, a tally sheet may be useful for
presenting information as well.
In the tally sheet shown below a single stroke represents a single action or person,
for example, a person seen for a particular health problem. It is a counting tool and
an easy way for people to get a picture of what is going on in the community.
Overlays
An overlay can be used to show several sets of results or information at the same
time. For example, graphs, visual symbols or simple drawings may be put together
in transparent overlays to show how different things relate to each other and to build
up a pattern.
Overlays might show results from:
•
changes in alcohol restrictions in a community
•
changes since the store management changed
•
changes after an environmental health project
•
enforcement of tobacco legislation in a community
 For further information see Djoymi et al (1993)
Organising information sharing sessions
The following three worksheets are included to assist health teams in planning and
evaluating information sharing sessions.
 See also Chapter 5 Planning and Evaluating a Health Promotion Project
58
Planning and evaluating information sharing sessions
Planning worksheet 1
Information Sharing Session
Information Sharing Objective/s: what information do you want to share with whom?
Strategies
(How to share the information to
reach the objective)
Actions/Activities
(What to do, how you are
going to present the
session)
Resources required
(Who will do it? What is
needed)
Time frame
(For session)
Evaluation
(What will be measured and how?)
59
Planning worksheet 2
Information Sharing Session: Action/Activities
Date
Prepared by
......................................................................................................
......................................................................................................
How will you structure and present the session?
How will you encourage people to talk about the information?
(What questions will you ask? What stories will you tell?)
Evaluation
Who will observe? Who will document the sessions and how?
(What will be measured and how?)
60
Planning Worksheet 3
Checklist for Evaluating an Information Sharing Session
Was the information shared with the people you wanted /needed to share it with (the
target group)?
• Who attended?
• What percentage, or how many, of your target group attended - everyone or just
a few?
Were people satisfied with the information sharing session?
• Levels of participation (High or low? Active or passive?)
• Did people talk about the information? Did they ask questions?
• Were there questions about the information/issue, meanings of terms, etc.?
• Did people ask for more information or talks?
• What kind of feedback did you get from people?
• Did people talk about it after the sessions? What did/do they say?
• Were any further plans/requests made as result of the information session?
Did the session go according to plan?
• Did all the planned parts of the session happen? If not why not?
• Did you follow the session plan? If not why not?
• Did you use the resources as planned? If not why not?
• Did the sessions happen within the planned time frame?
Were the materials or resources appropriate and good quality?
• Could people tell you what the resource was about?
• Were community people involved in making or choosing the resources? Did the
resources offend anyone in the community?
• Did you need to get approval from any one to use the resources?
• Are the resources worth the money you spent on them?
• Will you be able to use them again?
• Did the resources do the job you wanted them to?
These questions will enable you to collect information for a process evaluation.
61
[email protected].
www.nt.gov.au/justice/infocomm/privacy/index.shtml.
http://www.privacy.gov.au/health/
http://www.nt.gov.au/nreta/arts/links/
http://www.musicnt.com.au/
http://www.abc.net.au/message/links.htm
http://www.iad.edu.au/press/iadpresshome.htm
www.nticed.com
http://www.druginfo.adf.org.au/
http://www.quitnow.info.au/
http://www.healthinfonet.ecu.edu.au/frames.htm
Bibliography
Bear-Wingfield R 1996, Sharing Good Tucker Stories: A Guide for Aboriginal and
Torres Strait Islander Communities, eds D Gignan & R Sharp, Commonwealth
Department of Health and Family Services, Canberra.
Brady M (ed)1995, Giving Away the Grog: Aboriginal Accounts of Drinking and Not
Drinking, Commonwealth Department of Human Services and Health, Canberra.
Brady M & McKenzie-Taylor M 2003, Talking about Alcohol with Aboriginal and
Torres Strait Islander Patients: A Brief Intervention Tool for Health Professionals,
Commonwealth Dept of Health & Aging, Canberra
Brady M 1998b, The Grog Book Revised Edition: Strengthening Indigenous
Community Action on Alcohol, Commonwealth Department of Health and Family
Services, Canberra.
Djoymi T, Plummer C, May J & Barnes T 1993, Aboriginal Health Workers and
Health Information in Rural Northern Territory: Short Report, NT Department of
Health & Community Services, [Darwin].
Feuerstein M 1986, Partners in Evaluation: Evaluating Development and Community
Programmes with Participants, Macmillan, London.
Laycock A 2004, Alcohol Handbook for Frontline Workers, An Initiative of the
FWAHS Alcohol Community Development Project, Broken Hill Centre for Remote
Health Research, Broken Hill
NT Department of Health and Community Services 2005, Building Better
Communities: A Framework for Health and Community Services, Darwin
Territory Health Services 1998, Healthy School-Age Kids, The Northern Territory
School-Age Child Health Surveillance Program Manual for Remote Communities,
Darwin
62
Territory Health Services 1997, Information Privacy Code of Conduct, Territory
Health Services, Darwin.
Territory Health Services 1998a, The Aboriginal Public Health Strategy and
Implementation Guide 1997 - 2002, Territory Health Services, Darwin.
Territory Health Services 1998b, Living With Alcohol: A Handbook for Community
Health Teams, Living with Alcohol Program, Territory Health Services, Darwin.
Wass A 2000, Promoting Health: The Primary Health Care Approach, 2nd edn,
Elsevier, Sydney.
Weeramanthri T 1992, Health information for community action, Aboriginal and
Islander Health Worker Journal, vol 16(5), pp10-12.
Weeramanthri T 1996, Knowledge, language and mortality: Communicating health
information in Aboriginal communities in the Northern Territory, Australian Journal of
Primary Health - Interchange, vol 2(2), pp3-11.
63
Chapter 4 – Strategies for Health Promotion
Chapter 4
STRATEGIES FOR HEALTH PROMOTION
What is ‘health’ ................................................................................................ 66
Health promotion .............................................................................................. 67
The five action areas for health promotion....................................................... 68
Build healthy public policy ........................................................................... 68
Create supportive environments .................................................................. 68
Strengthen community action ...................................................................... 68
Develop personal skills ................................................................................ 69
Reorient health services .............................................................................. 69
The Jakarta Declaration on Health Promotion into the 21st Century ............ 70
The 2005 Bangkok Charter for Health Promotion in a Globalised World ...... 70
The health promoting way of working .............................................................. 71
Health promotion strategies overview ............................................................. 72
Things to think about when choosing strategies .............................................. 72
Contacts: Health Promotion support ............................................................ 73
Working with individuals .................................................................................. 74
Using individual approaches............................................................................ 74
Models of individual health behaviour change ................................................. 74
Brief interventions ............................................................................................ 76
Brief intervention: a definition ...................................................................... 77
Features of brief interventions ..................................................................... 77
Examples of brief interventions.................................................................... 78
Why do brief interventions? ......................................................................... 79
Who can do brief interventions .................................................................... 80
When to do brief interventions ..................................................................... 81
How to do brief interventions ....................................................................... 83
FRAMES – a checklist for getting the brief intervention right ...................... 83
Training and support ................................................................................... 84
Linking brief intervention theory and practice ............................................... 84
Five Step Guide to doing brief interventions ................................................ 85
How to do brief interventions with precontemplators .................................... 91
How to do brief interventions with contemplators ......................................... 92
How to do brief interventions with people preparing for and taking action .... 92
How to do brief interventions to maintain the change .................................. 94
How to support people who have lapsed or relapsed .................................. 95
Motivational interviewing as a brief intervention ........................................... 95
Guide to motivational interviewing ............................................................... 96
Stories about interventions .......................................................................... 98
Working with groups ...................................................................................... 101
Working with groups in health promotion ....................................................... 101
Advantages of working in groups on projects ............................................ 102
Guide for conducting education sessions with small groups ...................... 103
Strategies for working with family groups................................................... 105
Family health ............................................................................................. 105
Reasons for working closely with family groups ......................................... 106
Working with communities............................................................................. 109
What is a ‘community’ ................................................................................... 109
What is ‘community development’ ................................................................. 109
The community development process ....................................................... 110
Community participation ............................................................................ 111
Community capacity building ..................................................................... 111
Community empowerment ......................................................................... 111
64
Working together: partnerships.................................................................. 113
The context of community development in communities ............................ 116
Principles and guidelines for staff working in communities ........................ 118
Free downloadable resources and useful websites for community
development: ............................................................................................. 120
Changing the wider environment ................................................................... 121
Modifications to the environment ................................................................... 121
Policy and Legislation.................................................................................... 122
Technical interventions.................................................................................. 123
Organisational interventions .......................................................................... 125
The use of incentives and disincentives ........................................................ 125
Social advocacy and lobbying ....................................................................... 126
Using media..................................................................................................... 128
About social marketing and media use .......................................................... 128
What media to use? ...................................................................................... 128
Limited reach media ...................................................................................... 129
Making health education and health promotion resources ......................... 132
Evaluating health education and health promotion resources .................... 133
Aboriginal Health Education Resources Database .................................... 134
Mass media ................................................................................................... 134
Using screening .............................................................................................. 136
What is screening .......................................................................................... 136
Types of screening ........................................................................................ 136
Using screening as a health promotion strategy ............................................ 137
Why screen ................................................................................................... 137
Criteria for screening ..................................................................................... 138
Community health surveys ............................................................................ 139
Screening in the Northern Territory ............................................................... 140
Consent......................................................................................................... 141
Screening resources ..................................................................................... 141
Useful websites and on-line resources listed in this chapter ...................... 142
Govt – NT, state, federal ........................................................................... 142
International .............................................................................................. 143
Non-gov organizations, education institutions ............................................ 143
Bibliography .................................................................................................... 143
General ..................................................................................................... 143
Working with Individuals ............................................................................ 144
Working with Groups and Communities ..................................................... 146
Using Media .............................................................................................. 147
Using Screening ........................................................................................ 148
65
About this chapter
This chapter presents an overview of health promotion strategies most commonly
used when working with individuals, groups and communities. These strategies aim
to increase people’s control over their health and the issues that impact upon it.
This chapter includes:
•
some of the theory for health promotion practice
•
a description of the most commonly used health promotion strategies
•
practical guidelines based on the knowledge and experience of health staff
•
case studies and examples of health promotion in action
Community development theory and practice are fundamental to a health promotion
way of working. You will notice this theme running through other chapters in this
book.
 Find a step-by-step guide on how to approach and work with communities in the
section ‘Working with Communities’ in this chapter. This guide was developed in
the Northern Territory.
 Read Chapter 1 Context for Public Health. See also Chapter 2 Education for
Health, Chapter 3 Sharing Health Information, Chapter 5 Planning and Evaluating
a Health Promotion Project
 See NT health promotion strategy developments, project updates, more links:
What is ‘health’
There are several definitions of health (see Chapter 7 Glossary). The one we quote
here comes from the World Health Organization Constitution written in 1948.
Health is a state of complete physical, social and mental well-being, and not merely
the absence of disease or infirmity.
The health of an individual needs to be considered in the context of the family,
group, community environment. Individual and community health are also affected
by what is happening in the wider community such as changes in public policies and
legislation, and technical developments (see Chapter 1 Public Health in Context and
‘Changing the Wider Environment’ in this chapter). Health promotion strategies can
be broad, focusing on changing the environment around the individual. They can
also be specific, focusing on the individual and the groups to which the person
belongs.
66
Health promotion
The first International Conference on Health Promotion took place in Ottawa,
Canada in 1986. The conference was a response to growing expectations for a new
public health movement around the world. Out of this conference came the Ottawa
Charter for Health Promotion, a framework for action to achieve ‘Health For All by
the Year 2000’ and beyond.
From the Ottawa Charter
Health promotion is the process of enabling people to increase control over, and to
improve, their health.
WHO 1986
The Ottawa Charter identifies three approaches for health promotion. These are:
• advocacy for health to create the essential conditions for health
• enabling people to take control of the determinants of health in order to achieve
their fullest potential
• mediating between different interests in society in the pursuit of health (WHO
1986)
The Charter outlines five areas for health promotion action under the new public
health:
• build healthy public policy
• create supportive environments
• strengthen community action
• develop personal skills
• reorient health services
A key strategic concept underpinning the Ottawa Charter is empowerment.
Empowerment is the process by which people interact to individually and collectively
build skills and gain greater control over their lives within their community.
67
The five action areas for health promotion
In the following section, there is an explanation of each of the five action areas taken
directly from the Ottawa Charter (1986). Following each statement, there are some
examples of what community health teams can do, and are doing, to improve health
within each of the action areas.
Build healthy public policy
“Health promotion goes beyond health care. It puts health on the agenda of policy
makers in all sectors and at all levels, directing them to be aware of the health
consequences of their decisions and to accept their responsibilities for health.”
Community health teams can, for example:
• help the community to develop a community policy on alcohol availability
• support the formation of a local store committee and development of a healthy
food policy
• observe whether the law that prohibits the selling of tobacco products to youth
under 18 years of age is being followed and report to the council and local police
if not
Create supportive environments
“Our societies are complex and interrelated. Health cannot be separated from other
goals… the overall guiding principle for the world, nations, regions and communities
alike is the need to encourage reciprocal maintenance - to take care of each other,
our communities and our natural environment…”.
• support activities that enable Aboriginal people to maintain their links to the land
• organise for improved occupational health and safety standards in the workplace
and in public facilities
• support local income generating projects such as market gardens
Strengthen community action
“Health promotion works through concrete and effective community action in setting
priorities, making decisions, planning strategies and implementing them to achieve
better health. At the heart of this process is the empowerment of communities, their
ownership and control of their own endeavours and destinies.
Community development draws on existing human and material resources in the
community to enhance self-help and social support, and to develop flexible systems
for strengthening public participation and direction of health matters. This requires
full and continuous access to information, learning opportunities for health, as well
as funding support.”
68
• provide statistics to support the community’s submission for alcohol reform to the
NT Licensing Commission
• work with the women’s centre to budget, plan, buy food and cook meals for
school children and old people
• support the development of an action plan and funding submission for a dust
suppression project
Develop personal skills
“Health promotion supports personal and social development through providing
information, education for health and enhancing life skills. By so doing, it increases
the options available to people to exercise more control over their own health and
over their environments, and to make choices conducive to health.
Enabling people to learn throughout life, to prepare themselves for all of its stages
and to cope with chronic illness and injuries is essential…”.
• support health team members to attend relevant workforce development activities
such as Aboriginal Cultural Awareness Program (ACAP) and public health skills
training
• help mothers and carers to learn how to use the scales and monitor their babies’
growth
• conduct store tours to educate people about healthy foods, to enable them to
make healthier food choices
Reorient health services
“The role of the health sector must move increasingly in a health promotion
direction, beyond its responsibility for providing clinical and curative services. Health
services need to embrace an expanded mandate which is sensitive and respects
cultural needs. This mandate should support the needs of individuals and
communities for a healthier life, and open channels between the health sector and
broader social, political, economic and physical environmental components.
Reorienting health services also requires stronger attention to health research as
well as changes in professional education and training. This must lead to a change
of attitude and organisation of health services, which refocuses on the total needs of
the individual as a whole person.”
69
• offer a service where there is more balance between health promotion activities
(as described in this book) and treatment services
• include brief intervention processes in day to day work practices
• base work plans on the objectives of the Aboriginal Health and Families Five
Year Framework for Action. See:
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/partb.pdf
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/parta.pdf
The Jakarta Declaration on Health Promotion into the 21st Century
Participants at the 4th International Conference on Health Promotion held in Jakarta
in July 1997 confirmed the Ottawa Charter approaches and action areas.
Health promotion makes a difference
Research and case studies from around the world provide convincing evidence that health
promotion works. Health promotion strategies can develop and change lifestyles, and the
social, economic and environmental conditions which determine health. Health promotion is
a practical approach to achieving greater equity in health.
WHO 1997:3
To take Health Promotion into the 21st Century and meet the new challenges, the
conference participants prioritised five ‘new forms of action’:
1.
2.
3.
4.
5.
promote social responsibility for health
increase investments for health development
consolidate and expand partnerships for health
increase community capacity and empower the individual
secure an infrastructure for health promotion
 Download your copy of the Jakarta Declaration:
http://www.who.int/hpr/NPH/docs/jakarta_declaration_en.pdf
The 2005 Bangkok Charter for Health Promotion in a Globalised World
The 6th Global Conference on Health Promotion "Policy and Partnership for Action:
Addressing the Determinants of Health", was held in August 2005 to identify the
actions and commitments required to address the determinants of ill health in a
globalised world through health promotion. The Bangkok Charter “affirms that
policies and partnerships to empower communities, and to improve health and
health equity, should be at the centre of global and national development”.
Five actions were identified to advance the ‘proven effective strategies’ for health
promotion:
1. advocate for health based on human rights and solidarity
2. invest in sustainable policies, actions and infrastructure to address the
determinants for health
70
3. build capacity for policy development, leadership, health promotion practice,
knowledge transfer and research, and health literacy
4. regulate and legislate to ensure a high level of protection from harm and
enable equal opportunity for health and well-being for all people
5. partner and build alliances with public, private, nongovernmental and
international organizations and civil society to create sustainable actions
 Download your copy of the Bangkok Charter:
http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/print.ht
ml
 For more information about health promotion development see WHO (1997) and
the health promotion texts listed in the Bibliography
The health promoting way of working
There are a number of things that community health teams, support workers and
public health staff can do to support a community and enable community action.
This involves working with individuals, families, other groups and the wider
community to:
• identify community priorities
• support local initiatives that make community residents more able to control and
improve their situation
• find out what people know and what they think is important
• share information
• help with skills development
• help with research and information collection
• help to plan community action
• provide or help to locate resources if needed
 See ‘Community Development’ in the section ‘Working with Communities’
71
Health promotion strategies overview
Health promotion strategies include many possibilities - from an individually focused
brief intervention through to the development of a national policy. Put simply,
strategies are “the method or range of methods you are going to use in the program
[project] to achieve the objectives; that is, how you will do it (Abbott 1990:9)”.
Health promotion uses a range of strategies or interventions focused on individuals,
group and family influences, the community context and broader social, economic,
environmental and public policy influences that impact on health.
The strategies described in this chapter offer you practical and real ways to
strengthen your health promotion practice in communities. They are illustrated in the
following diagram.
Focus
Individual
Family
Groups
Community
Strategies
Brief interventions
Group work
Community
development
Environmental
interventions
Screening
Changes
Skills
Behavioural
Changes
Environmental
Changes
Outcomes
Improved
Health &
well being
Based on Egger et al 1999:10
 See the ‘Spectrum of Health Promotion Interventions’ in Chapter1 Public Health
in Context
 Think about your health promotion work as part of a big picture, with ‘Upstream’
strategies (infrastructure and systems change, policy and legislation) helping to
reduce health inequalities, pushed by community development, action and
advocacy at community level. Health education, information sharing and skill
development strategies are ‘midstream’ strategies which influence disease
prevention and care ‘downstream’. (See Kelleher & Murphy, 2003)
Things to think about when choosing strategies
• All strategies are potentially useful but combinations of strategies usually produce
the best results
• The strategy has to match the objective. The strategy selected will depend on
what the project is trying to achieve and with whom.
• Some knowledge about current health issues (content) and knowledge about the
best ways to approach them (process) are both important. Libraries and other
health professionals are valuable resources
72
• An understanding of team members’ strengths, potential and limitations should
be considered when choosing strategies. Additional training may be necessary
• Strategies for reducing individual risk are important. Use them to complement
strategies which lower average risk in a whole community (Egger et al 1999:179)
Some questions to ask
 When considering which strategy or combination of strategies to use, think about
the following questions:
• who is the project for?
• what are the objectives of the project? What does it want to achieve?
• what does the community think the best strategies would be?
• how ready and willing are people to become involved?
• how long have you got to do the project?
• what skills and knowledge do project team members have individually and
collectively?
• what resources (human, financial and material) are needed? What is
available?
Contacts: Health Promotion support
 For more information and help in planning a health promotion project, or for
information about health promotion training in the Northern Territory contact:
•
Health
Promotion
Strategy
Darwin &
Top End
Central
Australia
Phone
Fax
8985 8029
8985 8016
8951 7550
8951 9126
•
•
For staff details and email contact go to:
http://www.nt.gov.au/health/healthdev/health_promotion/promotion_contacts.shtml
73
Working with individuals
Using individual approaches
Each time health professionals interact with a client in the course of their work they
have an opportunity to find out more about that person and share information.
Interacting with individuals face-to-face “allows better possibilities for success than
perhaps any other communication medium” (Egger et al 1999:42).
Remember it is possible to help people make healthier choices by making the
healthier choice the easy choice (Egger et al 1999:154). For example, providing
quality fresh fruit and vegetables at prices equal or lower than less healthy food
choices means that people are more likely to buy fresh fruit and vegetables - the
choice becomes easier. These influences are outlined in this chapter under the
heading ‘Changing the Wider Environment’ .
Models of individual health behaviour change
Both psychological (internal) and environmental (external) factors motivate people’s
behaviour which, in turn, may affect health. These factors are also influenced by
thoughts, feelings and values. A variety of models and theories have been
developed to explain how these factors interact.
 Find information on these models in Health Promotion Strategies and Methods
(Egger et al 1999) and other health promotion texts listed in the Bibliography
Two important models for understanding the basis for brief interventions with
individuals are the ‘Health Belief Model’ (next page) and ‘The Stages of Behaviour
Change Model’.
 See ‘Brief Interventions’ in this chapter
74
The Health Belief Model
INDIVIDUAL PERCEPTIONS
MODIFYING FACTORS
LIKELIHOOD OF ACTION
Age, sex, ethnicity
Perceived benefits
Personality
versus
Socio-economics
barriers to behavioural
Knowledge
change
Likelihood of behavioural
Perceived susceptibilty/
Perceived threat of
seriousness of disease
disease
change
Cues to action
• education
• symptoms
• media information
Rosenstock in Egger et al 1999:31
75
The Health Belief Model
This model… is one of the oldest attempts to explain health behaviour… [It is based on the
premise that] for a behavioural change to succeed, individuals must have the incentive to
change, feel threatened by their current behaviour, and feel that a change will be beneficial
and be at acceptable cost. They must also feel competent to implement that change.
Egger et al 1999:31
The model in action: an example
A parent will organise immunisation for a child if he/she:
• believes there is a danger of the child contracting the disease (perceived
susceptibility)
• believes that immunisation is effective in eliminating the danger (perceived
benefits)
• trusts that the method is safe and has an acceptable level of risk (possibly
through education and media information)
• has the means to access the vaccination service (no barriers to behaviour
change)
Brief interventions
A suitable strategy for working with individuals to facilitate behaviour change is brief
intervention. Most service providers already use brief intervention approaches even
if they don’t use the term to describe what they do.
This section offers information about interventions and provides a model for doing
brief interventions with individuals. Brief intervention is a one-to-one approach. It
involves making the most of any opportunity to raise awareness, share knowledge
and get a person thinking about making changes to improve their health. It can be
done for any behaviour which affects health, for example, diet, exercise, personal
hygiene, smoking, excessive drinking of alcohol, use of other drugs such as
cannabis or kava. Intervention is part of what health professionals do in primary
health care and other health and community settings. As a public health approach,
brief intervention is complemented by group and community strategies to improve
health.
 See Volume 2 for information about these health issues and more strategies for
working with individuals, groups and communities
 See Chapter 7 Glossary for terms
 See other resources:
•
•
Talking About Alcohol with Aboriginal and TorresStrait Islander Patients
flipchart by Brady M & Hunter E 2003, Aust Govt Department of Health
and Aging
Alcohol Handbook for Frontline Workers, Far West Area Health Service
NSW 2004, or NT Edition
76
•
•
•
•
Brief Motivational Interviewing for Primary Health Care Workers: A
practical Guide to Dealing with Alcohol Problems in the Primary Health
Care Setting, Walsh & Moloney 1999(1994)
CARPA Standard Treatment Manual, 4th edition, 2003
Provide Brief Intervention – CHCCS403A Community Services Common
Competency 2003 (distance education training resource)
Living With Alcohol: A Handbook for Community Health Teams, THS,
1998
 See website www.motivationalinterview.org
 Brief intervention manuals and guides to download free at:
http://www.druginfo.adf.org.au/newsletter.asp?ContentID=brief_intervention_man
uals_and
Brief intervention: a definition
The term ‘brief intervention’ means an intervention that takes very little time. It can
be done by anyone in the health team as part of day-to-day work. Brief interventions
typically consist of 5 to 60 minutes of counseling and education, with usually no
more than three to five sessions (Higgins-Biddle & Babor 1996:4); but a brief
intervention can be as brief as 30 seconds and may be one opportunistic session.
What you do during a brief intervention depends on the person, the setting, whether
the person is ready to change, and whether you are building on previous
interactions.
Brief interventions can be used effectively at any point along the continuum of health
promotion, disease prevention, early intervention and treatment, depending on the
person’s readiness to change. However it is recommended to use a brief
intervention as early as possible to prevent a problem from developing.
Early intervention
Early intervention is recognising a problem, or potential problem, as soon as
possible and doing something to stop the harm that the problem will cause. It
involves screening, detecting and intervening. It offers a brief, structured form of
advice, usually when the problem is first recognised (Jarvis et al 1995:211-212).
Features of brief interventions
Research in health care settings has shown that there are features of brief
interventions which make them appropriate for use with Aboriginal clients in that
they are respectful, sensitive and flexible:
• the interaction is private (not a shame job)
• the process often involves the client telling his or her personal story, in his or her
own words
• the process includes sharing knowledge and talking about options, it gives the
client choices
77
• the health professional’s role is to be non-judgemental, not forceful, not
confrontational
• the client’s decision to change, or not to change, is self-determined
(Brady 2005:199,1995a:13-15)
Examples of brief interventions
• Getting a person who is at risk of developing diabetes to talk about the food they
usually eat, offer nutrition advice, talk about practical ways to healthy eating
• Talking to a person who has diabetes about how to prevent hypoglycaemia, how
to recognise when the “hypos” are coming on and what to eat and do to manage
it
• Showing videos that give suitable information and messages about healthy
eating. Taking an opportunity to ask the viewer if he or she wants to talk about
the information in the video
• Finding out from the mother of an underweight baby about what the baby eats
and what the mother is eating and drinking; passing on information about
weaning foods; asking if she would like to talk to a community nutrition worker
• As part of scabies management, talk with a person about personal hygiene and, if
appropriate, discuss living conditions and work out the best way to get hot
showers and to wash bedding
• When taking a blood pressure reading, share information about the causes and
problems of high blood pressure; talk about exercise and good diet as ways to
reduce blood pressure
• When treating a baby who has a respiratory infection, talking to a mother who
smokes to find out if she knows about passive smoking; using models or pictures
to explain passive smoking; suggesting ways of reduce her baby’s exposure to
cigarette smoke; finding out if she is thinking about quitting
• Showing a person, with a diagram or graph, his or her abnormal pathology results
that relate to effects of alcohol; circling the abnormal result (in red) on the form;
explaining what the results mean; asking if he or she has thought about easing
up or giving up drinking
• Using pictures or models of internal organs to help explain the effects of smoking,
or drinking harmfully
• Offering information about careful drinking to someone who has just started to
drink alcohol
• Talking with a person to find out if they are drinking in a harmful way. If so, talking
about the need to cut down; giving information about careful drinking and the
health effects of alcohol. This may be done over several sessions
78
• Asking open ended questions about a person’s known use of cannabis or kava
and passing on information about health effects. If he or she is receptive, talking
about social/family well-being as it relates to his or her drug use
• Seeking a person’s permission and referring him or her to specialist help, such as
a mental health, family violence or nutrition worker, or an alcohol rehabilitation
program. Including other family members in the discussion and referral process
(with consent) may be helpful
• Talking with a person who has suffered a loss about the how grief may affect his
or her emotions, thoughts, behaviour and physical health. Encouraging the
person to think about who can offer support and who to ask for help; talking about
ways to avoid stress and stay healthy
• Talking with the family member or carer of a person who is drinking too much
alcohol about ways to cope, such as not feeling responsible for the person who is
drinking, sharing the worry and focussing on children’s needs. Talking about how
to stay safe when the person is intoxicated.
Why do brief interventions?
Brief interventions do work. Research over the last 20 years in a variety of settings
has shown that brief intervention can help people decide to change their health
behaviours. Evidence for doing brief interventions:
•
•
•
Studies involving more than 6000 patients found brief interventions for
alcohol use were often as effective as more extensive treatments (Bien et al
in Babor, Higgins-Biddle 2001:10)
Twelve randomised controlled trials concluded that people receiving brief
intervention were twice as likely to reduce drinking over 6 to 12 months as
those who received no intervention. (BieWilk et al in Babor, Higgins-Biddle
2001:10)
Brief interventions were shown to be effective in reducing alcohol
consumption by over 20% in people with hazardous or harmful drinking
levels (Anderson 1996:16)
79
•
•
Studies showed that just a few words from a medical practitioner resulted in
a 5% quit smoking rate, with a little more effort leading to long term smoking
cessation rates of over 10% (Owen 1985:177)
It has also been found that brief intervention is more effective with follow-up
and additional interventions from other health staff (Richmond 1993:209)
We know that more brief interventions are needed at the primary care level. Most
interventions in the western health system are either very early, to prevent the
beginning of a problem, or very late. There is a need for more attention on
interventions that focus on people with risky behaviours that affect health, or with
early signs of illness.
Brief interventions are acknowledged to be cheap, easy and effective.
Brief interventions are accepted and used as an effective tool for a range of health
issues. For example, interventions that use counselling and education for new
mothers are part of regular infant health consultations in community health centres.
In summary, what health professionals say and do can make a difference. It can
help to motivate and support people to make the decisions that are best for them.
Who can do brief interventions
Brief intervention is part of the health team’s everyday work. Good reasons why
health professionals are suitable people to do interventions:
• people expect health professionals to give advice
• their advice is personal, directed to each individual’s health
• people are well aware that health professionals have detailed knowledge of
bodies and internal organs
• the interaction (with the health professional) is private, it is not a shame job
• the advice of the health professional can be used as an excuse by the patient
when other people try to persuade him or her (to drink)
• they often have knowledge of the client, the family, living conditions and what is
happening in the community
(Brady 2005:199, 1995a:12-17)
From interviews with over forty Aboriginal people who had given up drinking alcohol,
Maggie Brady observed “the most notable of the motivations to change was contact
with health professionals. About half of those interviewed stated that they finally
stopped drinking after a severe illness or trauma in combination with the advice of a
doctor.” (Brady 1998a:1-2)
Health professionals are expected to give advice
…it was in ‘88 I gave up drinking, on account of my foot. I’m diabetic and more alcohol I
drank it sort of infection in my body… That’s what happened to me, and then I went to the
hospital and the doctor said to me “you drink?” and I said “yeah”. ‘But for a start’ he said,
“stop drinking”. ok, I did, and that was when I was in hospital… It’s every medical officers’
job, you know, to tell you what’s right and what’s wrong with you, you know, especially when
80
you’re overweight and you are a diabetic, that sort of thing they come up and tell you, “you
not supposed to be drinking” or, “give up smoking, it’s no good for your pressure”. I’m fiftyfive years old now and so I give it a try so I can live bit longer. I feel a lot better you know
giving up smoking and drinking yeah, it’s only my eating that’s the problem now!
From story 3: Mr Singh’s story, Belyuen, NT
Brady 1995b:10-13
Health professionals may give a legitimate excuse to change
…And I said, “no, I’m not taking that. I’m finished now. Doctor told me I only got one life, I
finish, right out.” And they’re laughing at me you know, “you liar. C’mon, c’mon.” “Yeah”, they
said “you used to drink before. What’s wrong with you now? You changing!’ “Yes, I said,
“because doctor told me I only got one life, because you can’t say no to doctor when he’s
told you, you want to believe doctor because he’s a man doctor. When he tell you, he see
you, everything inside your body. He tell you straight. ‘Give it up, don’t you go back to grog’.
Alright. And they said ‘ok’… People coming back with grog, and I keep saying ‘no, no, no.’
Two years, they stop asking me then…gave up smoke and grog as well.
From story 15, Mrs D’s story, Rockhole, NT
Brady 1995b:64-65
Service providers have a responsibility to raise health related behaviours with
people, and to give clear, factual information. Do not assume that people already
know about health risks, or that they cannot change behaviour. People decide for
themselves, but what service providers say and do can make a difference. It can
help to motivate and support people to make the decisions that are best for them.
When to do brief interventions
There are many opportunities for doing brief interventions. A brief intervention can
be used:
• when the intervention is part of a preventive strategy. For example, you can:
− talk to a well person about the benefits of increased exercise and reducing the
amount of fat and sugar in the diet
− advise women who are planning to have a baby that it is best not to drink
alcohol when pregnant or breastfeeding
• when a person has an illness in its early stages, or a short term problem. For
example, an intervention about:
− weight reduction with someone who has high blood pressure
− reducing fat in the diet with someone who is diagnosed with cardio-vascular
disease
− the benefits of not smoking, and how to get support to quit, with someone
diagnosed with a chest infection
− the importance of not drinking alcohol with someone taking particular
medication
− ways to avoid cross infection when a family member has diarrhoea
• when a person is suffering from a chronic, long-term condition. For example, a
person with diabetes will need information about:
81
−
−
−
−
low sugar and low fat foods
the benefits of not smoking
the benefits of drinking little or no alcohol
preventing hypoglycaemia
In summary, a brief intervention can be done within a range of primary health care
activities. You may have opportunities to do a brief intervention when doing health
assessments, well women’s and well men’s checks, when taking a person’s health
history, when giving back relevant test results, when giving treatment or referring to
another service, when following up with a person.
 Never miss an opportunity to do a brief intervention
There are times when it is not appropriate to do a brief intervention. Don’t do a
brief intervention:
•
when a person doesn’t wish to participate in the brief intervention process
•
when person is in a highly emotional state
•
when a person is too sick or injured to share information
•
when a person is drunk or intoxicated on any other drug.
 For advice about dealing with a person who is drunk see:
– ‘Keep Yourself Safe’ p27 in Living With Alcohol: A Handbook for
Community Health Teams by THS (1998)
– ‘Keep Yourself Safe’ p49 in ‘Alcohol Handbook for Frontline Workers’ (NT
Edition) by FWAHS (2004)
Brief interventions will be most effective when used with a range of health
promotion strategies. For example, suppose alcohol is an issue in the community:
 do brief interventions with individuals to make the most of opportunities to raise
awareness about drinking alcohol and its health and social effects. Complement
your brief interventions in the following ways:
• Provide an alcohol education program for school children and other suitable
groups
• Support the community to create and maintain safe drinking environments
• Support enforcement of local policies and legislation concerning supply and
consumption of alcohol
• Broadcast appropriate messages about alcohol over the community media
network
• Support other community actions to reduce alcohol related harm
 see ‘Alcohol and Other Drugs’ chapter in Volume 2: Facts and Approaches
 see ‘Changing the Wider Environment’ in this chapter
82
How to do brief interventions
This section offers a step-by-step process for doing brief interventions. It also offers
examples to illustrate how brief interventions are used in primary health care
practice.
Doing brief interventions requires good communication skills. It is important to:
 listen to what people say
 notice what they do not say
 watch what they do
 think about their situation
 think about what you know about them
 talk with them in a way which is not threatening
 avoid giving a lecture about health behaviour
FRAMES – a checklist for getting the brief intervention right
FRAMES can be a useful guide as well as a checklist for critically reflecting on your
brief intervention. A brief intervention should have the following elements:
F
Feedback
R
Responsibility
A
Advice
M
E
Menu
Empathy
S
Support self-efficacy
of person’s assessment results, personal risks
and expressed concern
emphasis on the person’s personal responsibility
for making changes
clearly expressed, relevant advice about reducing
harm and/or improving health and wellbeing
of person’s alternatives and options is essential
is expressed by the worker. This means being
able to share the other person’s feelings and see
his/her point of view
encourages the person to be optimistic and to
believe he/she has the capacity to change
Other important elements:
•
•
•
Goal setting – the person sets realistic goals for changing the risky or
problem behaviour
Follow-up – with the person to reinforce the behaviour change and make
sure strategies are working for that person
Timing – you can help to move the person towards change when the timing
is right. When a person is contemplating change the motivation is there. Use
the opportunity.
Adapted from ARRTS 2003
83
Training and support
Brief intervention training and support is available.
 Contact the Alcohol and Other Drugs Service in your area, or the DHCS Alcohol
and Other Drugs Program. Ph: 8999 2691
 Contact Health Promotion Strategy, Top End 8999 2804, Central Australia 8951
6917 and ask who offers brief intervention training in your area
 Ask about videos that demonstrate how to do brief interventions and motivational
interviewing. One widely used example is Therapeutic Journeys: Counselling
Aboriginal Clients and Their Families, Series 3: Alcohol and Other Drugs Skills
with Adults and Adolescents, Suchi Productions WA. Ph 0403 465 682
 Search the internet for information about training offered by other organisations
and education institutions.
A useful website: http://www.nceta.flinders.edu.au. Go to Publications, then
Workforce Development, then Resources.
If you do not feel confident about doing interventions in your daily work, first practise
in situations where you feel comfortable. Practise will build confidence and skills.
Linking brief intervention theory and practice
The Stages of Behaviour Change model
The Stages of Behaviour Change model was developed by Prochaska and
DiClemente in 1986. It is used for matching interventions with a person’s readiness
to take on information and make changes. While the model was first developed for
alcohol and other drugs interventions, it can be used for a range of health issues
including diet and physical activity, personal hygiene and other behaviours that
relate to reducing health risk and managing health problems.
Maggie Brady summarises the ‘stages of change model’:
Precontemplation
Contemplation
Preparation
Action
Maintenance
Relapse
- that is, not really thinking about changing
- actually thinking about changing
- making plans about how to change
- deciding to do something and doing it
- keeping going with the change that has been made
- quite normal - needs help to get back on track
This is an idea based on the general population. But listening to Aboriginal people talk (or
reading their stories) shows how real these stages of change can be. It is hard to get from
worrying to making a change.
Adapted from Brady 2005:206-207
Some explanations of the model (including Brady’s 1998 edition of The Grog Book)
describe four stages, merging the ‘preparing for action’ stage with ‘action’ and
describing relapse separately. The five step guide to doing brief interventions on the
following pages uses the four stage approach.
 See CARPA Standard Treatment Manual, 4th edition (2003:264-5)
84
Five Step Guide to doing brief interventions
There are many opportunities for doing brief interventions in various community
settings. What you do and say during each brief intervention will depend on what
has happened before, and the information that has already been shared.
People can move between stages of precontemplation, contemplation, action and
maintenance, as well as lapse or relapse. They don’t necessarily move through the
stages in a sequence, and they may be at a different stage of decision making on
different occasions. For example a person may:
• stay in ‘contemplation’ stage for a long time, not showing much readiness to
change, then move on quickly to take decisive ‘action’
• be a long term ‘precontemplator’ until a life changing event motivates change
to ‘action’
• be committed and ‘maintain’ change for months or even years, then ‘relapse’
• take ‘action’ to change and ‘lapse’ many times before finally sticking to the
change
• take ‘action’ to change in order to please other people, but really be a
‘precontemplator’
• not appear to listen to your health information time after time, but eventually
be ready to ‘contemplate’ change and take ‘action’
There are important messages in these few examples:
1. Ask questions to decide a person’s stage of change each time you see him
or her - don’t make assumptions
2. At the very least, a brief intervention should provide accurate health
information
3. Even people who are successful in making long-term change need brief
intervention and support. Lapse or relapse is normal human behaviour.
4. It is always worth the few minutes it takes to do a brief intervention – don’t
think a person cannot change or doesn’t need information
The following pages offer a five step guide for deciding on and carrying out a brief
intervention. There are examples of the type of conversation you may have with a
person in each Stage of Behaviour Change.
85
Five Step Guide
Step 1
Assess individual need for intervention
Step 2
Ask about issue of concern and determine the person’s
stage in his or her decision to change
‘Stages of
Change’
Precontemplation
Action
Maintenance
Match intervention strategies to the person’s
stage of change
Step 3
‘Stages of
Change’
Contemplation
Precontemplation
Step 4
Step 5
Contemplation
Action
Maintenance
CARRY OUT INTERVENTION
RECORD INTERVENTION IN THE PERSON’S PATIENT FILE
Five step guide to doing brief interventions
L Moloney, revised 2005 (1999)
86
Step 1: Assess the person’s need for intervention
Goal:
To assess the person’s need for intervention
What to do: Assessing every individual’s need for intervention is a routine part of
day-to-day work practice. You may ask general questions which help
you to know more about the person - about what he or she has been
doing lately, how things are going at his/her place, about the family.
Taking a health history always includes questions about:
alcohol:
smoking:
When was the last time you drank alcohol?
How much did you drink then? Is this how much you
usually drink?
How long have you been smoking for?
How much do you usually smoke in one day?
Step 2: Ask about the issue of concern and determine the person’s stage in his or her
decision to change
Goal:
To find out if the health issue of concern that you have identified, is
also a concern for that person. To find out where the person is, in
thinking about change
What to do: First - After identifying that the person may need intervention, discuss
the issue of concern.
Example questions:
 Do you know that smoking can make your lung disease
worse? If you want to, we could talk about ways to help you
cut down or quit.
 Have you thought about not drinking alcohol while you’re
pregnant?
 How do you think your sugar sickness is going?
 Did you know that what you eat affects the sugar in your
blood. Would you like some information about that?
 Last time you came in you planned to wash the blankets, to
see if that also helped with the skin problems. How did you go
with that? Did other family members wash their blankets too?
Because people access primary health care services many times, you
may see the same person in any one of these stages, and will need
to assess where he/she is, at each consultation.
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 Remember, in your work role people will expect you to ask about
their health and to give health advice
 Beware of making assumptions about what people know, value
and believe about health and sickness
 See ‘Education for health in a cross-cultural setting’ in Chapter 2
Education for Health
Second - Determine the person’s stage in his or her decision to
change.
The person’s response to your questions will help to determine the person’s
stage of change.
 Use the following page as a guide.
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How to determine the person’s stage in his or her decision to change
Listen and watch for the person’s response to you.
Person is not thinking about
change
Person is thinking about
changing
Pre contemplation
Contemplation
Person is ready to do
something, has decided
and is making a change
Preparing & Taking
Action
Person is keeping going
with the change that has
been made
Maintenance
is not concerned about issue
has some concern
has expressed concern
has made change
may not want information
may want more information
usually happy to have
more information
wants to maintain change
may not say anything at all
may talk about something else,
or look uncomfortable.
looks interested or asks
questions
happy to talk about
choices and support
usually happy to talk about
how much better things
are
may be thinking about need
to change
wants to make a change
now or very soon
not ready to change yet
may want to plan how to
make the change
Person is thinking: “Do I
want to do something?”
Person is thinking: “Yes, I
do want to make a
change. What can I do,
when and how?
What else can I be doing?
What else needs to
happen?”
Person is thinking: “No, it’s ok.”
“I don’t need to change what I
am doing”
may want to think about
ways to maintain change
through difficult times
Person is thinking: “Yes, I
made the change. How
can I keep it going?”
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Step 3: Match intervention to the person’s stage of change
Goal:
To match intervention to the person’s stage of change at that time
People can move between stages of precontemplation,
contemplation, action and maintenance. They can lapse into their
previous behaviour. A person you see often may be at different
stages on different occasions. It is important to match your
intervention to where the person is, each time you are with them.
Mismatched interventions may lead to frustration and disappointment
for both the client and the worker, who may feel he or she has ‘failed’.
Follow up and future interventions will be determined by what has
gone before.
What to do: Precontemplation
This person is not thinking about changing. Consider using strategies
that raise awareness of the health issue by providing information.
Strategies may include talking about it, referring to posters, playing
videos, perhaps giving a pamphlet. However, do not pressure or try to
tell someone what he/she needs to do – this may simply raise the
person’s defences and entrench resistance.
Contemplation
This person is thinking about changing. Consider using strategies that
may move a person towards a decision to change. Explore the issue.
Ask him or her about the good, and not so good things about the
issue, including how it affects family members. Explore the person’s
concerns with them. Ask what things he or she may find difficult about
changing. Give relevant information. Ask about the differences a
change might make or suggest how change could make things better.
Action
This person is deciding to do something, and is making changes.
Consider using strategies that reinforce the person’s decision about
changing. Ask how he or she will make the change. Talk about
choices and support available. Encourage the person to identify
someone to talk to about it. Give information and any support you
can.
Maintenance
This person is keeping going with the change. Consider using
strategies that reinforce the changes made. Ask how he or she is
going. Give praise about how well he or she doing. Highlight the
benefits of the change he or she has made, talk about how much
better things are, or how much better the person will feel soon. Offer
any support you can to help the person get through difficult times –
this may include talking about how to prevent a lapse or relapse.
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Step 4: Carry out intervention
Goal:
To carry out intervention that matches the person’s stage of change
at that time
What to do: Carry out the required intervention. Record the intervention on the
patient file as a reference for future interventions
How to do brief interventions with precontemplators
What to do: Raise awareness by linking the persons behaviours with personal
health and social well-being. Talk about the health issues/behaviour
and its effect on health and social or family life
Offer to share relevant information about health
Offer time and support if the person wants to talk later
Make efforts to get to know the person, what he or she knows and
thinks, what he or she values and believes
Example 1
Health staff: Have you thought about giving up alcohol while you’re pregnant?
(Person gives no response and looks away)
Health staff: Did you know that when you drink, your baby drinks too? You choose
for your baby if you choose to drink, what do you think about that?
(Person continues to look away)
Health Staff: No alcohol is the best choice for you and your baby. We can talk
about it next time if you like - it’s up to you though, no bossing around.
Example 2
Health staff: That sore on your foot is still bad isn’t it?
Person:
Yeah, it hurts when I walk
Health staff: Are you still smoking?
Person:
Yeah.
Health staff: How do you think smoking might be affecting this foot?
(Person looks disinterested and says: Dunno. Nothing, it’s all right)
Health staff: You know - smoking is bad for your blood circulation. That means it
takes a lot longer for sores to heal, because they’re not getting
enough good blood. Smoking is especially bad for diabetics. It makes
the complications of diabetes worse. The best thing that you could do
for your health now is to give up smoking. Maybe you can think about
that?
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How to do brief interventions with contemplators
People are more likely to change when:
•
their behaviour (for example, alcohol or tobacco use, cannabis use, poor
diet) is causing them too many problems
•
there is something they want that will only be possible if they change
•
they do not like being the way they are now
•
the reasons to change are stronger than the reasons to stay the same
•
their situation or environment changes in a way that helps them to change
•
they feel strong enough to make the change
•
they have help and support to make the change
Your brief intervention role is to help the person to reach this point, so that he or she
can move towards making a change (‘action’ stage).
 See ‘Health Belief Model’ in this chapter
What to do: Explore the person’s concerns as expressed by him or her
Help the person to weigh up the good, not so good things about the
health issue, or about the behaviour, using motivational interviewing
techniques.
 See ‘Motivational Interviewing’ in this chapter
Support the person’s choice of action. Offer further support
How to do brief interventions with people preparing for and taking action
Remember that a person’s ability to make a change will be influenced by the wider
environment. Changes to the wider environment can help to support and sustain a
person’s change, or structures and processes can prevent a person from carrying
out his or her commitment to change.
 See ‘Changing the Wider Environment’ in this chapter
What to do: Build on the person’s motivation or desire for change. Ask the person
to share his or her worries. Highlight the benefits of changing
Help to set realistic personal goals, short term and long term. Ask the
person how he or she will make the changes (strategies)? Explore the
options to behaviour change (for example, how to eat healthier foods
and get more exercise; ways to cut down on alcohol or stop drinking)
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Explore what choices the person has to support his or her change.
(For example, avoid high fat fast food, buy fresh food, walk each day;
drink light beer, go to the pub less often)
Identify services and support available in the community and outside
(for example, local programs non-government and government
organisations and services, phone counselling services)
Help the person identify the times when it may be difficult to stick to
his or her decision, and talk about ways to cope in those situations.
(relapse prevention). Offer some ideas that could help.
 Download suitable resources from the internet
 Keep a range of leaflets, pocket cards and brochures on hand
 Pass on contact details for suitable local and toll free phone
services (for example Quitline 131 848, Men's Info Line 1800 600
636)
Ask the person when he or she would like to do something about it?
Encourage him or her to set a date for change. Record the persons
plan for action
Offer any support you can give, especially through difficult times
As the person takes action, give feedback, praise efforts and
recognise goals reached
Example 3
Health staff:
That was a worry that heart attack! How are you feeling now?
Person:
Bit better, still got pain
Health staff:
Have you thought about making some changes to what you eat and drink
now that you’re back home again?
Person:
Yeah. I’m thinking I should lose some of this weight. The doctor said
I should
Health staff:
That’s a good idea. It would help you feel a lot better and there’ll be less
chance of you having another heart attack. Have you thought about how you can lose some
weight?
Person:
I need to look at what I eat, maybe get some exercise
Health staff:
There’s a video and some other information you may want to look at. And we
can arrange for a nutrition worker to come and talk about what sort of things you might eat
and drink, to help you lose weight. The nutrition worker will be able to help you to plan how
long it might take to lose some weight, and ways to cope when it seems too hard to stick to
that diet.
Person:
That sounds good, I’ll look at that video while I’m here if that’s ok
Health staff:
Great. If you want to talk about it afterwards, I’ll be here.
Example 4
Person:
I’ve been thinking about that test, and that picture you showed me.
I’m worried about my liver. I want to do something about my drinking
Health staff:
So what do you want to do about it?
Person:
I’ve got to stop drinking. It’s no good any more
Health staff:
It’s a good idea. How do you think you’ll do that?
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Person:
I’ll just stop. Too hard to cut down - better to stay away for a while
from my friends who drink. Like that Charlie did. He stopped. Just like that.
Health staff:
Are you going to stop straight away? Will that be easy?
Person:
No, but I’m going to that outstation at the weekend, to my country.
Maybe I’ll stay there for a little while - do some hunting.. There’s no grog there.
Health staff:
That’s sound like a great idea. What about your family, will they go too?
Person:
Yes, they like staying there
Health staff:
Is there somebody there who can bring you in if you need to come back?
Person:
Yeah, we’ll have that truck. Anyway, I’ll be eating good tucker. I’ll be
feeling good soon, I reckon
Health staff:
Well, if you need to come back, come and see me. I’d like to know how
you’re going. You’ll be fine though … we just need to make sure there is no risk of you going
into alcohol withdrawal - it’s important to be sure of that before you leave town.
Remember, some people try many times to change a behaviour before they are able
to maintain the change. These ‘lapses’ are a normal part of the change process
How to do brief interventions to maintain the change
Making a change and sticking to it can be a difficult, sometimes lonely, thing to do. It
is important to take opportunities to provide encouragement and support.
What to do: Ask the person how he or she is going and if the person needs any
more help or support
Ask if he or she has been tempted to change his or her mind. If ‘yes’
then give praise for sticking to the decision. Talk about the strategies
the person used to prevent the relapse.
Give positive feedback - about looking better, sounding better, and
when tests or health checks show improvements in health
Ask whether the person feels better and stronger
Give praise for achieving his or her goals, and for changing
Example 5
Health staff:
I’ve seen you walking in the afternoons
Person:
I’ve been going for a walk to the airstrip every afternoon for a month now feel better already
Health staff:
That’s great. You’re doing really well not to miss even a day, and you’re
looking better too. Look, your blood pressure is lower. And you’ve lost a good amount of
weight with that diet as well as the walking. That heart of yours won’t have to work so hard
Person:
Yes, I don’t want another heart attack, that’s for sure. My clothes are too big
now, I’ve lost that much!
Health Staff: You’ve done really well. Is it hard to stick to it sometimes?
Person:
It’s not as hard now it’s just what I do every day, and I feel so much better.
I’m just going to keep doing it, and I reckon some of the other ladies will come with me soon
Health staff:
Good for you! May I join you sometimes?
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Example 6
Health staff:
How are you going with keeping off the smokes? You were going so well last
time I saw you.
Person:
I’m going ok. Still off the smokes.
Health staff:
Your chest is sounding better. Do you still have your cough?
Person:
Yeah - but I’m not coughing so much now. Not getting so out of breath.
Health staff:
Do you think about going back to the smoking?
Person:
Sometimes…I want to light up when I’m down the club and the others are
smoking. But I feel better since I gave up those cigarettes, so I say “no”.
Health staff:
Well, if you can cope without lighting up there, you must be strong. You’ve
done really well to quit those cigarettes. And you’re looking better too.
Person:
Yeah. I reckon I’ll be dangerous on that footy field next season.
How to support people who have lapsed or relapsed
The term ‘relapse’ usually refers to a return to problem patterns of behaviour after a
problem free period. The word ‘lapse’ is more often used for a brief return to the
behaviour, for example, one occasion of intoxication for a person who is trying to cut
down or stop drinking alcohol.
Maintaining a change in behaviour, such as giving up smoking or sticking to a diet,
often involves maintaining a change in lifestyle. This can be difficult. It’s important to
acknowledge this and to talk about relapse as a normal part of the change process
for many people. Help the person to identify high risk situations, develop coping
skills, work out ways to avoid temptation, and work out what to do if he or she has a
lapse in their change of behaviour (Jarvis et al 1995:177-179).
When a person has a lapse in maintaining his or her change, is important to:
•
be non-judgemental, not to shame the person
•
encourage the person not to feel he or she has failed, but just had a
temporary slip
•
point out that some people try many times before they change for good, and
that this is a normal part of the change process
•
find out what may have led to the lapse, talk about what can be learned
•
encourage the person to try again
 See also CARPA Standard Treatment Manual, 4th edition (2003:265)
 See also Alcohol handbook for Frontline Workers (2004:22-23)
Motivational interviewing as a brief intervention
Brief interventions can include motivational interviews. Motivational interviewing is a
particular method of counselling to help a person recognise and do something about
his or her problem, or potential problem. Many people are ambivalent about
changing behaviour - they both want and don’t want to change. Motivational
interviewing has been found to help these people along the path to change. (Miller
and Rollnick 1991:52) Like other forms of brief intervention, motivational interviewing
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does not try to force the person to make changes. It supports him or her to explore
the good and not so good things, to express his or her own reasons for concern and
the arguments for change (Rollnick, Heather, Bell 1992:25). That’s why it works - the
person talks himself or herself into changing and hears the argument in his or her
own words (instead of having it suggested by you).
It has been well researched and developed as an alcohol and other drugs
intervention. See website: www.motivationalinterview.org
Guide to motivational interviewing
Ask open ended questions to explore the person’s thoughts and feelings about the
good and not so good things about the issue (for example, about being very
overweight, about smoking, about drinking harmfully)
Use reflective listening. Listen to what the person says, and then summarise it back:
(for example, “so, what you’re saying is…”, “so it seems that on the one hand it’s…,
and on the other it’s…”)
Show respect and willingness to understand person’s perspective (empathy). You
do not have to agree, but it is important not to show any disapproval, or to blame.
Give accurate health information that is relevant to him or her. Showing and
explaining test results in graph form, or showing pictures may help.
Help the person clarify his or her personal goals or role in the community - what
he/she wants to be, or what he/she wants to do in life. You could ask “What’s
important to you?” Then help the person to think about whether what he or she is
doing now is helping to get there. (For example, “So what about when you drink…”).
The person needs to see the conflict or discrepancy within himself/herself.
Avoid arguing - this will encourage the person to defend his or her opinion and
behaviour patterns.
Help the person to look at his or her behaviour and how that impacts on others.
At times the person may be unwilling to consider the effects of his or her behaviour.
Go with this and acknowledge the person’s ambivalence or reluctance. Try another
way to move forward with the intervention, for example, let the person know you
were listening, but talk about something else. (This is called ‘rolling with resistance.’)
It is important not to impose new views or goals, but rather to invite the person to
consider new information or perspectives.
Encourage the person to find the proposed solution. Help the person to set realistic
personal goals and make the plans for change. This means he or she will be more
likely to follow it through.
Try to build the person’s confidence. The person needs to believe he or she has the
ability to achieve his or her goals and change behaviour.
Ask the person what things he or she may find difficult about changing.
Offer your help and support. Encourage him or her to identify others in the
community who may be able to offer support. (For example, “Are there other people
who have changed too?”)
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Example of a motivational interview
Health staff:
You say you’ve been drinking for a long time. What do you like about
drinking?
Person:
I like the taste, and when I’m there with my friends we have a good time. All
drinking together, it makes me feel good
Health staff:
What do you mean, feel good?
Person:
More confident, talking and laughing
Health staff:
Is there anything you don’t like about drinking?
Person:
Makes me feel sick sometimes, next day you know. Hangover. Then I’ve got
no money and my family they get mad.
Health staff:
So what you’re saying is, you like drinking because it makes you feel
confident and you can join in talking and laughing, but on the other hand you don’t like
drinking because it makes you feel sick and gives you a hangover. And causes trouble with
your family because you spend the money on grog. Is that right?
Person:
Yeah, that’s right
Health staff:
Does your family get upset with you for any other reason when you’re
drinking?
Person:
What do you mean?
Health staff:
Well, tell me what you’re like if you’ve been drinking too much
Person:
Sometimes I fight with them, shout at them. My kids, they get frightened.
Sometimes they run away from me
Health staff:
Does that worry you?
Person:
I don’t want my kids to be scared of me.
Health staff:
So, what are you like when you’re not drinking?
Person:
I look after my family. We have good times, good family times you know?
Health staff:
So when you’re drinking you get angry with them and fight, but when you’re
not drinking you have good times together. Is that right?
Person:
Suppose so
Health staff:
Which person would you like to be?
Person:
I’d like to be happy with my family, but I can’t be when I’m drinking
Health staff:
What do you think you want to do about that?
Person:
Maybe I should stop that drinking
Health staff:
What would be a good thing about that, if you stop drinking?
Person:
My family they’d be happy with me. And I wouldn’t feel sick maybe
Health staff:
What about your health? What worries you about it?
Person:
I get sick in the gut sometimes, lots of pain - especially when I’m drinking
Health staff:
Yes, you were in hospital a few months ago, weren’t you? Your liver has
been hurt from drinking. What would be hard about giving up the drinking?
Person:
I’d lose my friends, they’re good friends you know. We’ve been drinking
together a long time
Health staff:
So, what would you like to do?
Person:
I need to think about it. I can see it’s best for me to stop that drinking, but it’s
not easy, you know?
Health staff:
I’m here to help you if you decide to stop or ease up. Or if you want to talk to
me some more about this…or to someone else...
Step 5: Record intervention in the person’s patient file
Notes about the brief interventions you do with clients need to be entered in patient
records. Accurate, concise notes will help you to:
• get to know the person and build the client/worker relationship
• document the person’s experiences, concerns, achievements and support
needs
• observe a person’s shifts between the different stages of change
• take past interventions into account each time you have a consultation
• keep a record of what has and hasn’t helped the person to make and
maintain change
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 Note the client’s “stage on change” on each occasion that you do a brief
intervention
An example of patient notes about a brief intervention
Sam has been having bronchial problems and high blood pressure. Doctor advised
stop smoking
Has been smoking 20 years, currently 35 Winfield Blue (strong) per day.
4 unsuccessful attempts to quit. Most successful was for 2 weeks using “cold turkey”.
Regular alcohol drinker 2-4 standard drinks per day, usually 1 alcohol free day per
week.
No other significant drug use.
High level of ambivalence displayed
Wanting to quit for other people, not confident in her ability to quit.
Contemplating change - Motivational interview
Enjoys smoking, two closest friends smoke. Have shared unsuccessful quit stories.
Smoking helps Sam to relax.
Smokes more in evenings especially if going out and with few drinks.
Most worried about health effects. Bronchial problems getting more serious. High
blood pressure recent. Concern about doctor’s advice.
Cost a consideration – aware of $ spent per week.
Outcome - Not yet committed. Believes she won’t succeed.
Plan – Sam will talk to friends Jo and Nancy about quitting. Thinks they will support
her. Hopes to persuade them to quit with her.
Follow up appointment on……..
Adapted from Australian Rural and Remote Training Systems & DHCS 2003,
CHCCS403A Provide Brief Intervention:66
Stories about interventions
Story 1
This is an example of a 40 year old man who has had diabetes for five years, who is
a smoker with a family history of heart disease. His father died at the age of 50 of a
heart attack. He is being seen for routine review. His blood sugar level is high and
has been high every time he has come in. You have identified a need for
intervention.
1.Get his story. What does he know, worry about? How does he think and feel about
his diabetes? You might ask:
Tell me how you think your diabetes is going?
(Instead of telling him it’s bad, get him to tell you)
What did you eat this morning? Who prepared it? Where did you get it from?
(Get specific diet history, draw it out of his everyday life)
What are you worried about, in terms of your diabetes?
(Is he worried? Is he a precontemplator, or does he have some concerns? Knowing
how he feels will help you match the intervention to his stage of change. If he has
some concerns, they can be explored. Motivational interviewing techniques may be
used)
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What do you think causes your diabetes?
(This question is important because people have different belief systems. You need
to connect with that and respect it in order to share information in a way that has
meaning for that person.)
2. Share the information you have - your version of how he is going.
You might show him his blood sugar level results. Show the results in a way that
helps him compare what his result is with what is normal, or optimal. Use a graphical
method to try and give individual feedback.
You might share other information about diabetes, its effects and management.
You might talk about the family history of heart disease, and what you know about
the link between smoking and heart disease. Encourage him to think about what this
might mean for him and his family.
3. Discuss what can be done. This process is about exploring options and choices,
not about telling people what to do. He needs to make decisions for himself about
what is possible, what he wants to do and how he may do it.
What do you think you’d like to do?
If he does not want to do anything, that is his choice. Record it. You may offer further
information and let him know you are ready to help if and when he would like it.
Identifying the barriers to change, as well as the good things about changing, can
help find the solutions.
If he wants to do something, you might offer some options of what could be done. It
might stop there until next time, or you might define some goals together, offer
support, and arrange another appointment.
At this stage you may or may not deal with specifics such as smoking, but you need
to ask and reinforce previous messages. Offer help if he wants to quit.
If he has done something, build on the positive changes with questions such as
“Was it hard?”, “How did you do it?”, “How does that feel?”
Give a little information each time, keeping pace with the client. Do not be afraid of
silences and fill in the gaps with information (it could be too much and misplaced. It
may alienate him).
This process often includes other family members. Involving others, and encouraging
discussion can help to translate, clarify and reinforce the information shared. It can
support the person to define manageable goals and make changes.
Conclusion
The brief intervention process, used in a series of consultations and tailored to the
client, helps to build trust and may be very effective in the long term. The process
brings together his story and your statistics and information. His story is just as
important, if not more than your statistics. Together they are powerful. It enables him
to make connections between what he is thinking and knows about diabetes, and his
feelings about how he is living, his family and other things that are important to him.
After making these connections between head and heart, he may be in a position to
explore concerns and move towards a decision to make some changes. You can
help to facilitate this decision making.
Based on a case study by Tarun Weeramanthri
99
Story 2
This is an example of how a health worker can connect a health problem with a
drinking problem. The people talking are ‘Ronald’ an Aboriginal man, and an
Aboriginal Health Worker.
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Ronald:
AHW:
Hi Ronald, what can I do for you?
Oh - I’ve cut my leg a bit - it needs fixing up
Ok, come and sit down - I’ll take a good look at it. When did this happen?
Oh, a couple of days ago maybe, I don’t really know
It looks a bit infected - it shouldn’t be like this already. I’ll need to clean it up
and put a bandage on it for you. Hey - Are you ok? You don’t look too good.
Are you sick anywhere else?
Oh, not really, just a bit sick in the guts maybe
You’ve got pain in the guts?
Yeah
Where’s the pain? Here, lie down up here and show me. Then I can feel
your stomach and take a proper look. Does it hurt high up about here? What
about down there? Yeah, I can feel your liver a bit here too - does it hurt all
the time?
Oh, it’s bad in the mornings and it hurts on and off
I saw you mob all at the gate the other night - good party? How much grog
did you have?
Well, I don’t know really - I do feel pretty sick after I’ve been drinking
sometimes - but another beer usually fixes me up
Was that how you cut your leg too?
I don't know - I think so - maybe
You know mate - this is between you and me, but I reckon you might be sick
from the grog. It might be the grog that’s giving you a pain in the guts.
Oh - I don't know, I’ve been drinking on and off for a long time - why is it
making me sick now?
Well, you know your body can only take so much grog. Drink too much of it
and it starts to make you sick. From what you say it sounds like it’s making
the inside of your stomach sick, that’s why you’ve got pain, and that’s why
you vomit. It’s your liver that gets rid of the grog - and I can tell from feeling
it that yours is working pretty hard. Means you might be drinking too much.
You know it might even be that the grog’s stopping your cut getting better
too. Too much alcohol in the body stops it from getting better.
Well - you fix it all up then ok?
I can bandage your leg and give you some medicine - but maybe you
should start thinking about grog. Look - take this little book with you and
have a look. Come and see me in a couple of days so I can have another
look at you. And - if you want to - we can talk a bit more. Oh yes - best not
drink while you take that medicine - it’ll give it a chance to work and make
you feel better more quickly.
So - Ronald came back a few days later and his leg was getting better. He said he
hadn’t had a drink and I knew there wasn’t any grog around anyway. We didn’t talk
much more about his drinking but he did feel a bit better after a few days without it. I
gave him a booklet about drinking to take and look at later. I also said he could come
and talk to me any time. So at least maybe he’s thinking about it.
Case study from NT Living With Alcohol Program (1998)
Alcohol and Other Drugs Program
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Working with groups
Health promotion, whether it is lobbying for political change, community
development work or education and training, involves working with groups of people.
As you are aware, groups have dynamics of their own. It is useful to develop skills in
facilitating group work, so that the group works more effectively towards what it is
trying to achieve (Wass 2000:207).
Working with groups in health promotion
There are numerous opportunities to work with naturally occurring groups in
Aboriginal communities. Groups can be composed of two or three people or many.
These include families and groups based on, for example, gender, age, language, a
particular disability or condition. Employment groups, clubs or special interest
groups, such as sporting clubs or art and craft cooperatives also provide
opportunities for group work. You may have the opportunity to bring together small
groups of people who are concerned about a particular issue that is important to
them.
Group strategies can take place in a range of settings:
• where the focus is on prevention: in schools, in the workplace, out bush, at the
women’s centre, at the community store
• where strategies may have more of an intervention orientation: in the health
centre or old people’s home
Useful strategies for working with groups range from providing information through
presentations to school or community group, to working alongside special interest or
lobby groups to facilitate community action. The skills required for giving
presentations differ from those skills required for working in partnership using a
community development or ‘enabling’ approach.
 See the Chapter 2 Education for Health and Chapter 3 Sharing Health
Information.
 See ‘Community Development’ in this chapter.
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Advantages of working in groups on projects
• People are social beings and generally like working with others
• All the resources, abilities and energy of the group are pooled
• There is less chance that mistakes will be made - it is easier to see other
people’s mistakes than to see our own
• Group discussion stimulates ideas that might not occur to an individual working
alone
• Group members support each other and provide security, especially for problem
solving (Queensland Alcohol and Drug Programs Unit 1988:1-8)
Groups can be important for building community capacity. People become aware of
the power they have as a group members and what can be achieved through group
dynamics, action and advocacy.
Characteristics of an effective group
An Effective Group
Has a clear understanding of its purposes and goals.
Is flexible in selecting its procedures as it works towards its goals.
Has achieved a high degree of communication and understanding among its
members…
Is able to initiate and carry on effective decision making, carefully considering
minority viewpoints and securing the commitment of all members to important
decisions.
Achieves an appropriate balance between group productivity and the satisfaction of
individual needs.
Provides for sharing of leadership responsibilities by group members - so that all
members are concerned about contributing ideas, elaborating and clarifying the
ideas of others, giving opinion, and in other ways helping the group to work on its
task and maintain itself as an effective working unit.
Has a high degree of cohesiveness [attractiveness for the members] but not to the
point of stifling individual freedom.
Makes intelligent use of the differing abilities of its members.
Is not dominated by its leader or by any of its members.
Can be objective about reviewing its own processes. It can face its problems and
adjust to needed modifications in its operations.
Maintains a balance between emotional and rational behaviour, channelling
emotions into a productive group effort.
Queensland Alcohol and Drug Programs Unit 1988:1-25
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Tips for working with groups
A set of principles
Over the years I have developed a set of principles that I stick to when working with
community groups. I use them to guide my work. They ensure that dependency is
not created. I don't mind sharing them with you.
Make your role clear to the community and to the group you are working with
Build the confidence of the groups within the community
Give the group encouragement and support
Provide questions which stimulate insight
Ensure that the group considers a range of possibilities and not just one when
setting up programs
Be aware of the limitations of the group
Ensure that goals are achievable
Always be prepared to learn from the group
I don't think that we should:
- lead
- provide answers
- carry the burden of responsibility for organising the action, or
- impose activities on the group
Provided by Bubbles Segall
NT Remote Area Nurse and Community Development Officer 1976 - 2001
Guide for conducting education sessions with small groups
1. Spend time setting up the optimal learning environment, to allow people to
actively participate in discussion and dialogue. Ensure the setting is comfortable
to promote group interaction. Place emphasis on small group work to engage all
participants
2. Find out what people already know. Start with participants’ practical experiences.
Look for shared patterns of experience and knowledge
3. From an analysis of practical experience, add new information and ideas
4. Finally, return to the practical by helping individuals to practice skills and develop
their own action plans (Adapted from National Heart Foundation 1995:18)
 For more information on group work read Wass (2000), pages 207-228, and
Egger, Spark and Lawson (1999) pages 67-84
 For information about DHCS training and resources, contact: Top End: 8922
7901 or 89228747 and Central Australia: 8951 7724 or 8951 7735
Case study one: setting up a self-help meals on wheels service
In the following case study the nutritionist shifted roles in response to changing
group needs and aspirations. The group changed from being participants in a formal
training course to a community action group. The nutritionist changed from being an
expert and teacher to a facilitator and resource. These elements enabled a
sustainable program to be established to meet an ongoing need.
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Facilitating group action
In October 1997 I began teaching the Certificate 1 in Health (Aboriginal
Communities) at Tangentyere Council. It was a course recommended by the Food
and Nutrition Unit in Darwin. I went over to the Training Officer at Tangentyere
Council with the information about the course and offered to teach it. They
advertised it around the Council and town camps. Some of the people who decided
to do the course had met me before but not all. The course was chosen because it
has a strong nutrition component. It also contains things like ‘Introduction to Health,
Homemaker Skills’, ‘Shopping Wise’ and ‘Senior First Aid’. The course also has
electives and the next module planned is ‘Care Giving - Older People’. We have
completed four modules now.
We started with a group of five women. Three were employed by the Homemakers
and Old People’s Service (HOPS) and two were with CDEP. After the group had
completed two modules they decided they wanted to start a Meals on Wheels project
to feed 40 old people in the town camps. They felt that the service was really
needed. They’d gained in confidence since they started the training and they also
knew that I would support them in whatever way I could. We went out and talked to
the old people. They said that they’d like to try the idea and agreed to pay some
money out of their pension cheque each fortnight.
We worked together for about three months during the first stages of the project. We
decided on the recipes together and I typed them out onto A3 paper and had them
laminated. I helped set up lists for the ordering of the food. We worked together as a
team. I washed dishes too. They taught me things and I taught them things. After a
few months I gradually began to pull out and kept in touch by visiting for morning tea
occasionally and assisting them when I was asked.
Now, almost a decade later, the program is still servicing the old people in the town
camps by providing a hot meal five days a week.
Alison McLay, Nutritionist, Nutrition and Physical Activity Program, Central Australia
Case study two: taking the message to the people
This case study shows how Health Promotion Officers worked closely with
Aboriginal Health Workers to develop a project for well men’s checkups in East
Arnhem Land. The project aimed to raise men’s awareness of health issues and to
encourage them to make lifestyle changes to improve their health. The project team
approached community football teams to talk about fitness and winning games.
They used a mix of strategies, including screening followed by brief interventions,
media for group and community education, and incentives.
Well Men’s Checkups - A program of the East Arnhem Health Promotion Unit
Men, especially Aboriginal men, rarely go to the Health Centre when they are sick, let alone
when they are healthy. Providing health education to groups of young men can be difficult difficult to find them, to raise their interest in health issues and to identify what is important to
them. Five key concepts/strategies were included in the design of the well men’s checkups.
The health centre was taken to the people: Aboriginal Health Workers and Health Promotion
Officers tested blood pressure; height/weight; blood sugar levels; cholesterol; haemoglobin;
sweat loss; and peak flow. The National Heart Foundation’s healthy heart assessment was
modified to include information on smoking, dehydration and alcohol.
104
Health education was integrated into group activities that men enjoy and already participate
in: Approaching men in settings where they train and play football was a perfect way to
target groups of men.
Messages were made relevant to the men and their activities: Messages were targeted at
how to improve the players’ chances of winning - by getting fitter, stronger, healthier and
smarter. Discussions included the importance of water to body functions; how smoking
reduces the lungs’ ability to absorb oxygen; the detrimental affects of drinking kava or
alcohol the night before playing football, and the positive benefits of eating a high
carbohydrate meal to increase energy levels before playing.
Healthy lifestyle role models provided inspiration to younger men: To increase knowledge of
men’s health issues and promote interest in the well men’s checkups, a local AFL player who
speaks the language was identified. He visited schools and football teams to talk about
healthy lifestyles and the dangers of smoking. A video of the local community football grand
final was also put together with messages about smoking, nutrition and fitness…
Incentives were provided for men to attend well men’s checkups: Barbecues were held at the
health centre after the men’s check-ups.
Extracts and adaptations from an article by Smith and King 1998:69-71
Strategies for working with family groups
Broadening care to include family interventions is essential when working with
Aboriginal people, because of the importance and extent of the family group in
Aboriginal culture. Members of the extended family may have responsibilities for
caring for individuals with whom they have a particular relationship. For example, a
grandmother may be expected to take a caring and educative role in the antenatal
care of her grand-daughter.
Family health
The dynamics of family groups impact on the health of people living in them. When
thinking about family health, consider these two points:
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“…It is through the family that individuals may be exposed to, or protected from, aspects of
the social, economic and physical environment…
…Most people live much of their lives as members of a family, and it is within the context of
family life and dynamics that they learn much about how people respond to life experiences
and relate to each other. Families can influence the life of an individual quite profoundly”
Wass 2000:49
Reasons for working closely with family groups
Advantages for health staff
Developing a relationship with a family will help staff to:
• win the trust of individual family members and the family as a whole
• identify which family members may be able to help translate important health
information
• appreciate the priority of family obligations and concerns
• understand what is important to people and what they know and believe
• understand the range of factors impacting on the family’s health such as the
family’s living environment, level of income, available resources
• motivate family members to take action to prevent the chronic diseases, such as
cardiovascular disease and diabetes, that are genetically linked
Advantages for the family
Consulting with health staff as a family group may help family members to:
• talk together about issues which affect individual health such as money, food
availability, who looks after people, beliefs, knowledge
• have their questions answered about the health of another family member
• support a family member who is trying to stick to a behaviour change, such as
improving diet, quitting smoking or cutting down on drinking alcohol
• increase their knowledge and understanding about how to care for unwell family
members
• receive ongoing support and feedback on how things are going
Working with family groups
When a child is not growing well we talk to the mother and father about their baby. At the
second meeting we talk to the whole family including the mother, father, aunties, uncles and
grandparents from both sides. This is the right way of doing things here at Yuendumu. At the
third meeting a couple of people who went to the first two meetings leave and go back to
their own camps to talk to their own families about making the kids healthy at Yuendumu.
This is the way we spread the message about health at Yuendumu.
Lottie Nabangardi, Community Nutrition Worker,
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in Sharing Good Tucker Stories by Bear-wingfield 1996:129
Case study: working with a family member
In this case study, a family member approaches the Aboriginal Health Worker(AHW)
for advice. Because of the AHW’s family relationship, she was able to respond in a
way and at a pace that enabled her niece to make her own decisions. The AHW
shared her expert knowledge and offered her support.
Working with a family member
My niece Jane came to see me in the health centre one day. She came because she
felt sick, but while there she started to tell me about her husband. She was worried
about him. He had started to drink every week. What was she going to do?
Now I knew Jane and her husband for a long time, they had been a happy, healthy
family mostly and had not been drinkers. Now it seemed her husband had started to
drink; I had seen him going down to the club most days.
What worried me was that wherever he was, drinking or not, Jane was always with
him. Did this mean that she was drinking too? I asked Jane about this, I told her that
it would be confidential, no one else need know what we talked about.
She talked about how the drinking had started. How their little boy had been really
sick and had been in hospital in town, then in the Child Health Unit for some weeks
while he got better. Jane and her husband were hanging around in town for a while.
The little boy was looked after by the nurses, and their other kids were back in the
community with their grandmother. Friends and family in town were drinking a lot of
alcohol and it was easy for Jane and her husband to get involved.
When they got home, her husband continued his drinking, he started to hang around
with the drinking group and things quickly got out of control. All their money went on
grog, they were nearly always at the club, hardly ever at home. When they were at
home they slept.
I asked Jane what she wanted to do. She said she wanted to stop all the drinking
before it got too bad. She thought that if she could stop her husband from drinking
then she would stop too - she only drank because he did.
I talked about the sort of harm that too much alcohol can do to the body and showed
Jane some pictures of alcohol damaged organs. I also talked about the harm that too
much drinking can cause the family, but I think Jane could already see that.
I explained about careful drinking, that some people can drink a little bit, and if they
eat well while they’re drinking, and don't drink all the time, they can be OK.
I suggested that she talk to her husband about how she felt; talk to him of her
worries for the children and their future as a family; talk to him before it got out of
control. I told her she would need to talk to him when he was sober, not drunk, and
that if she wanted I could talk to them both together then, and maybe explain again
about some of the damage that drinking too much alcohol can do.
107
I also suggested some things they could do to help them keep away from drinking. I
suggested going to their outstation more often, painting, going hunting or maybe
taking the kids out with their grandmother and teaching them some traditional ways.
Maybe they could play some sport in the community; maybe they could enrol in a
training course.
I explained that the choice would have to be theirs but that I would help them as
much as I could. If they needed other specialised help, we could talk about that too
and arrange it.
So I gave Jane some information pamphlets that explained a bit about alcohol. I
suggested that she talk to her husband and then come back and let me know what
happened.
Material provided by Living With Alcohol Program
Alcohol and Other Drugs Program 1998
Research findings: helping you to work with family members
An international “Family Coping” research project was conducted over three years
with indigenous families in the Northern Territory. In the study family members
talked about how their health is affected, the problems they have and the strategies
they use to cope when a family member is drinking too much alcohol.
The study found that many people struggle to understand and manage these
problems in difficult family circumstances. It highlighted the need for health staff to
work with families as well as the person drinking harmfully, to:
•
•
•
think ‘family support’ and work to reduce family stress
think in terms of networks of concerned people
focus on empowering family members to;
- think of and try new ways to cope
- share the worry, talk, back each other up and put resources together
- focus on sources of strength such as bringing children up safely,
upholding traditional ways and a tradition of strong family support
 See Orford J, Templeton L, Copello A, Velleman R, Bradbury C 2001, Worrying
For Drinkers In The Family: An Interview Study with Indigenous Australians in
Urban Areas and Remote Communities in the NT, Living with Alcohol program,
Territory Health Services, Darwin
 See Volume 2, which describes strategies and activities for working with groups
in different areas of public health. Some of the group activities include: doing
shop tours, establishing a community night patrol, organising a bush tucker trip,
organising a health week, or working on a dust suppression project.
108
Working with communities
Working with a community has the potential to address some of the structural, social
and environmental issues that lead to poor health. A key challenge for health staff is
to encourage and support community-led and community controlled activities (Wass
2000:157). Although community development projects are focused on the
community, we can use community development skills and approaches when
working with individuals and groups as well. This section describes a number of
interrelated community development terms and concepts.
What is a ‘community’
The word ‘community’ can have several different meanings. The definition we are
using is from the World Health Organisation.
Community
A specific group of people, often living in a defined geographical area, who share a
common culture, values and norms, are arranged in a social structure according to
relationships which the community has developed over a period of time. Members of
a community gain their personal and social identity by sharing common beliefs,
values and norms which have been developed by the community in the past and
may be modified in the future. They exhibit some awareness of their identity as a
group, and share common needs and a commitment to meeting them
WHO 1998:5
 See Chapter 7 Glossary for more detail, especially about ‘Aboriginal
communities’
What is ‘community development’
Community development is based on the idea that local people know what the
issues and problems are and how to solve them. The scope of community
development work can vary from small initiatives within a small group, to large
initiatives that involve the whole community. A community development approach
brings together and recognises the strengths and knowledge of local people. It can
help communities to undertake projects in planned and structured ways.
Community development refers to the process of facilitating the community’s
awareness of the factors and forces which affect their health and quality of life, and
ultimately helping to empower them with the skills needed for taking control over and
improving those conditions in their community which affect their health and way of
life. It often involves helping them to identify issues of concern and facilitating their
efforts to bring about change in these areas.
Hawe et al 1990:203
109
When NT Health Promotion Officers collectively defined community development in
1991 they also led an important shift in NT health promotion approaches. Their definition is
still relevent to what we have learnt about doing community development work since then…
“When a community uses a process through which people get together; communicate;
identify priority needs; plan; and take action to resolve problems and achieve outcomes
which are desired by the community.”
Workshop Report National Better Health Program: Orientation and Planning Inservice for the
Aboriginal Community Health Promotion Project in the NT 1991
 Think about these characteristics of best practice community development
work:
• a long-term endeavour
• well planned with people working together
• inclusive and equitable
• empowering and reducing power imbalances
• holistic and integrated into the bigger picture
• initiated and supported by community members
• of benefit to the community
• grounded in experience that leads to best practice
• aiming to build capacity and improve quality of life
(adapted from Frank F & Smith A 1999)
The community development process
Below is a basic cycle for a community development project. It also describes the
stages that a health promotion project is likely to go through.
People identify the
problem or issue
People evaluate
the results of their
work together
People see the
benefit of their
efforts
People learn
together and
develop their skills
People decide
what to do about it
People identify the
resources they
need
People do the work
together
 Also see Chapter 5 Planning and Evaluating a Health Promotion Project
110
Community participation
Community participation, in all stages of the cycle is fundamental to Primary Health
Care and Health Promotion. Community participation can range from informing a
community about a project, to having a partnership, to community control. This
participation continuum and power shift is shown below.
Participation Continuum
Imposing on or informing
Consultation
Least participation
Partnership
Community Control
Most participation
Adapted from Arnstein in Wass 2000:61
Community capacity building
Capacity is simply the ways and means needed to do what has to be done. It is
much broader than simply skills, people and plans. It includes motivation,
commitment, resources and all that is needed to make a process successful.
Capacity building is an approach to “the development of sustainable skills,
organisational structures, resources and commitment to health improvement in
health and other sectors, to prolong and multiply health gains many times over.
Hawe et al 2000 in NSW Health 2001:3
How can you help to build community capacity?
Capacity building can be described as the ‘invisible work’ of health promotion – it’s
about the ‘how’. To work in a capacity building way you need to recognise, respect
and value pre-existing capacities, develop trust and be responsive to the context
you are working in (environmental constraints). You need to avoid pre-packaged
ideas and strategies, and work to develop strategies that are well planned and
integrated into priorities and goals that are identified by the community. (NSW
Health 2001:3, 5-7)
Community empowerment
Empowerment is at the heart of health promotion work (Laverack 2004:33),
and consists of personal, group and social aspects of power and capacity. (Labonte,
1999).
Like participation, empowerment may be viewed as a continuum ranging from
personal empowerment (individual action), to organisational action (small mutual
groups, community organizations, partnerships), to collective community action
(social and political) action.
111
Individual action
Personal
action
collective action
groups
Small mutual Community
organization
Partnerships
Social and
political action
Adapted from Laverack 2004:48
 See Chapter 7 Glossary
The skills needed to practise health promotion in an empowering way are mainly
communication skills (eg. effective listening, group facilitation, respectful
interpersonal skills) and an ability to analyse (eg. group dynamics).
(Laverack 2004: 65-66).
‘Bottom up’ health promotion approaches that enable people to identify their health
problems, solutions and actions and to determine program design, implementation
and evaluation are central to community development and empowerment.
Empowerment and capacity building also go hand-in-hand. They lead to people
having greater control over the social and environmental determinants of health.
Western Desert Dialysis – an example of community empowerment and control
The journey of this group from the original idea to the development of a unique model of
dialysis provision offers a valuable case study of indigenous determination and grass roots
engagement.
In November 2000 a momentous event took place for Aboriginal people (Yanangu) from the
Western Desert of Central Australia. With the support of Sotheby’s Australia, PapunyaTula
Artists, art collectors and philanthropists, an auction was held at the Art Gallery of New
South Wales. The aim was to raise money to assist Yanangu from the remote cross-border
region of the Northern Territory and Western Australia, to return home to their communities
on renal dialysis.
The $1.1 million raised by the auction far exceeded expectations and the Western Desert
Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation was formed in June 2003.
This name means ‘Making all our families well’ and recognises that to be truly healthy
Yanangu must be at home, in their own country, with family nearby. In November 2004,
exactly 4 years after the auction, a Dialysis Room’ was opened within the Pintubi Homelands
Health Service clinic in Walungurru (Kintore) A huge celebration was held in the community
for people who had been involved. Many travelled a long way, including 8 dialysis patients.
What we have achieved so far is significant in a number of ways:
- People raised a substantial amount of money through their own endeavours.
- Popular opinion at the time of the auction was that no one could do dialysis in remote
Indigenous communities like Walungurru, but Yanangu were determined to make it work.
- Independent money meant that creative options could be explored with a model developed
by Yanangu to suit their own needs.
- The Committee has diligently looked after the money from the auction, whilst meeting the
cultural obligations of looking after family on dialysis living in Alice Springs.
- Yanangu have shown that safe dialysis can be provided in one of the most remote parts of
Australia, and that experienced renal staff are attracted to work with them, despite a national
workforce shortage.
- Yanangu are able to speak up about the issues that face their own communities.
The fact that people managed to achieve their objective against the odds, is a health
promotion success shared by the whole of the Western Desert region.
Responding to needs and concerns:
Family members often accompany dialysis patients when they move into town,
experiencing a similar dislocation and a range of problems. Yanangu leaders
112
concerns led to WDNWPT establishing a Patient Support Program for those in Alice
Springs, so part-time Support Workers now assist patients and their families with the
many issues facing them when they move to Alice Springs.
We have established a ‘Dialysis House’ in Alice Springs where patients can come
with their family to have dialysis in their own place, supported by their own staff,
before going out to Walungurru.
WDNWPT chairs the Central Australian Renal Social Well-Being Action Group
which lobbies and advocates for all dialysis patients.
Our Governing Committee are working hard to better meet the needs of Yanangu.
They are facing the challenge of consolidating a sustainable organisation and
coping with ever increasing need. In 2001 when the Appeal began, we supported 7
people from the Western Desert receiving dialysis, today there are 23.
For the past twelve months we have been working to evaluate our service and its’
impact upon the health and well-being of our members. Our report will be available
later this year, however preliminary findings have shown measurable benefits for
Yanangu on dialysis and their families, helped in negotiations for financial support
from governments and informed the membership of specific issues.
Return to country:
Since 2001, we have used some of the donated funds to offer all patients from the
Western Desert up to six short trips home a year. Patients have been able to look
forward to trips home, to see family or attend important community events whilst
coordinating visits with their routine, institutional dialysis treatment. This has led to
increased optimism about the future and a reduction in hospitalisation for our
members who previously stayed too long trying to visit families, and became sick as
a result.
The last words, should come from Amy Nampitjinpa who was the first person to
return to Walungurru on dialysis. Indeed she was the first person to receive
haemodialysis outside the hospital in Central Australia, EVER!
Talking about being in town a long time
Rawalatju nyinarra nyinarra kulinigilpi yuwa palya lingku tjinguru tjunkula nganampa,
kutju each yananyi holiday.Anangutjutangku wangkarra nyaanu.
Tjana watjanu, “Yuwa rawakunu nyinayi palatjatjuta, Anangu palatjatjuta
dialysisngka. Nyarratja tjunumara tjanampa.”. Tjana wangkangu, “Rawa nyinatjala
family wiyarringuya, kutju kutju wiyarringani – towngka”
It had taken ages, but eventually we heard about it. Yea, it’s really good, when it’s
out there (the machine at Kintore), each one of us can go for a holiday. All Yanangu
have spoke up for it and got it to happen. They said, “ Definitely those people have
had to live too long on dialysis (in town). It should happen out there (Kintore). After
living in town for such a long time, our family are dying one after another, just dying
in town”.
Sarah Brown, Manager
Western Desert Nganampa Walytja Palyantjaku Tjutaku Aboriginal Corporation, 2005
Working together: partnerships
The value of partnerships for health was recognised in the 1978 Alma-Ata
declaration “Health for All by the year 2000”. Landmark health promotion statements
113
such as the Ottawa Charter, The Jakarta Declaration and The Bangkok Charter
recognise that partnerships are key to obtaining real health gain.
In a public health context the term ‘partnership’ is often used. It may describe:
•
the community development approach you take in your day-to-day work, which
is based on people working together in a spirit of partnership
•
links, alliances and formal arrangements between organizations, or between the
community and other sectors or agencies. Such partnerships are based on
overlapping interests, such as delivery of health services.
The principles are the same. A partnership can be defined as “a mutually beneficial
relationship that is transparent and accountable and based on agreed ethical
principles, mutual understanding, respect and trust.” (Moodie & Hulme 2004:120)
An example of partnership between workers…
“Both Yolngu and Balanda, when we come to that work we have that relationship
between Balanda and Yolngu - we working together, by communication,
understanding one another, feed back one another. We just have good relationship
and communication to give a good message to the people, to bring that knowledge
together from Balanda to Yolngu, so Yolngu can understand what the real story is
about.”
Gurimangu, Health Educator
“Sharing True Stories: Improving Communication in Indigenous Health Care”
website http://www.sharingtruestories.com
An example of partnership between organizations, services and communities…
The Katherine West Health Board Aboriginal Corporation (KWHB) was incorporated
under the Commonwealth Aboriginal Councils and Associations Act in February
1998. It was established to implement the Katherine West Coordinated Care Trial,
covering the communities west of Katherine to the NT/WA border. Under the
arrangements of the Trial, NT and Commonwealth Governments contributed funds to
a 'pool' that was put under the control of an elected Board of Aboriginal community
representatives in the region. The Board could choose to either directly provide
health services or purchase services from any provider, (including government). This
legal arrangement has led to direct management of both clinical and public health
services in communities in the region.
Jirntangku Miyrta, Katherine West Co-ordination Care Trial,
Local Evaluation Final Report, Menzies School of Health Research 2000
Partnerships take time and effort to establish and can only succeed and continue to
grow if there is mutual trust, respect and equality. They can bring a sense of real
achievement and fulfilment into your work. Partnerships enhance opportunities to
learn from each other and move forward together. Trust, accountability and
communication are what keep partners together.
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The following statement expresses the concept of working in partnership.
Culture is the true vine
Culture itself is a true vine and all of us are like a gardener.
Department of Health C/S [and Community Services]
Doctors, RAN
Health Worker
SWSBSC [Strong Women, Strong Babies, Strong Culture]
Women Centre
Teacher, Health Promotion
We people should produce good fruit by working together from the root of the tree.
If the branch is not working then something is wrong with the branch. Maybe the branch
needs help?
…We should be concerned about one another, helping our community in health side and
other areas. Whoever remains working then we will bear much fruit in the community by
helping underweight, unhealthy, skinny babies, pregnant women and people with other
sicknesses.
We all should be working side by side to make this community strong and healthy by
sharing, talking, helping our Yolngu [Aboriginal people] to make them strong. If we work
together then we cannot fall down. We will stand firm, for example we are just starting to
build the foundation to be strong for our future generation for our children to be healthy.
The Health Team, Milingimbi Health Centre, East Arnhem Land
 See ‘Partnerships to Promote Health’ in Moodie R & Hulme A (Ed) 2004, Hands
On Health Promotion, IP Communications, Victoria
 Download Partnerships Analysis Tool: A resource for establishing, developing
and maintaining productive partnerships at http://www.vichealth.vic.gov.au Go to
‘Publications’; ‘Partnerships’
 Look for opportunities to work with other organisations on joint projects
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The context of community development in communities
Aboriginal communities have a constant stream of visitors from a range of
organisations. Each has its own agendas. At any one time, the community will have
any number of plans, projects, decisions, problems and ideas on the go. A survey
done during 1987 in the Pitjantjatjara homelands found that in one community there
were 142 separate meetings during a three month period (UPK video, Nganampa
Health Council 1987). It is safe to assume that this situation is the same today for
most larger communities.
Aboriginal people may feel pressured with so many people all wanting something.
The time and energy that community residents will have for health projects will vary.
Working together with other agencies can reduce the number of visits to a
community and improve the quality of the visit.
The following diagram was published in 1990 to show the many NT and
Commonwealth Government departments and non-government agencies that
regularly visited remote and rural communities to deliver services and provide
resources. The situation now is equally complex.
116
Figure 2 : Stuart Phillpot 1990:53
117
Figure 3: Breaking down the walls
Adapted from Ebrahim and Ranken 1988:60
Principles and guidelines for staff working in communities
The following principles and guidelines were developed by a group of DHCS staff
experienced in community development approaches. These principles and
guidelines need to be thought about within the context of people’s values, beliefs,
language, relationship to country, and cultural and historical backgrounds.
Approaching the community
 Have an open mind
 Be prepared to spend time learning about the community - people, language,
ways, values. Each community will be different
 Be prepared to be flexible and take the opportunity to discuss issues when
people raise them
 Recognise that the world view you carry may be very different to the world
view of the community
 Find out what the protocols are for visiting the community such as dress,
time, who to approach, where to and where not to go, and local politics to
avoid
From experience…
When I started working at Port Keats, other people who had been working with the
community for some time were the front people. I took my time, stood back,
watched and listened. I talked with people about their lives and how they were
getting on. I talked about my life and family too. It took a while to establish trust.
Now people know me, which makes it easier when visiting or when I see people
visiting Darwin. I always ask how they and their families are and talk about what is
happening. It’s a wonderful feeling.
Lyn O’Donoghue, as Senior Aboriginal Health Promotion Officer
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Interacting with the community
 Respect the views and ideas of community residents - do not impose your
own
 Realise that every community is complex - it has strengths and weaknesses
which community residents will identify
 Community residents can be sensitive about their home - respect their
privacy when discussing it with others
 Recognise that you have skills and knowledge to offer the community - do not
be afraid to share them. Likewise Aboriginal people have skills and
knowledge to share with you. Learning is a two way process
 Use plain English, not jargon
 Recognise the diversity of people living in the community - make sure you get
a representative view by approaching a wide range of people, taking note of
protocols
 Be prepared to talk about yourself, your family, your job and what it and you
could offer the community
From experience…
You … have to know when it is the right time to talk. Your business might have to
wait until another time, a more appropriate time. People might have other things on
their minds. People will tell you when they’re ready to listen. I might say
“something’s changed with social security and you women need to know about it”.
And the women will say “Alright, we’re going down the creek fishing this afternoon.
Come down then and talk to us.” They’ll tell you exactly when they’ll be ready to
listen.
Olive Rogers, Aboriginal Nutrition Adviser
Working with the community
 Recognise mutual and different goals
 Assist without doing for people. This principle is essential to ensure that the
program is suitable for the community, addresses the needs of the
community, and belongs to the community
 Take leadership from community residents in planning on how to achieve
their goals - it is their process
 Be prepared for the fact that nothing might happen in your time frames, or
that the community might have other priorities. Cultural activities will often
take priority over other things
 You do not have to be everything to everybody. Know what your personal
boundaries are. Be honest about what they are with people in the community
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From experience…
I always say to people, “this is your place. I’m the outsider. You tell me what’s right
to do.” We take our direction from the community members - as well as using
common sense, courtesy and always aiming to respect community values and
beliefs. If we’re given conflicting directions or information, we always clarify it. One
time someone passed away. Some people down one end of the community said
“You mob might as well pack up and go home, because of sorry business and you
won’t be able to do anything anyway”. We checked with the Council and they said
“Oh no, this time it’s not an issue for you. You can work but just keep a low profile at
the time of the funeral.”
Gwen Walley, Alcohol and Other Drugs Program
 For information on how to get a broader view and understanding of the
community with which you work read:
•
‘Community Profiles’ in Chapter 5 ‘Planning and Evaluating a Health
Promotion Project’
•
‘Community Mapping’ in the ‘Environmental Health’ Volume 2
Free downloadable resources and useful websites for community development:
Frank F & Smith A 1999, The Community Development Handbook: A Tool To Build
Community Capacity
http://www.sdc.gc.ca/asp/gateway.asp?hr=en/epb/sid/cia/comm_deve/handbook.sht
ml&hs=cyd
VicHealth Integrated Health Promotion Resource Kit, based on a social model of
health at:
http://www.health.vic.gov.au/healthpromotion/resources_links/integrated.htm
The Community Partnerships Kit sets out a step by step community action model
that can be applied to public health issues. It was designed as a resource for groups
wishing to undertake community action to prevent or address drug use:
http://www.communitybuilders.nsw.gov.au/building_stronger/safer/commpshipkit.ht
ml
http://www.community.gov.au has links to sites and project reports
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Changing the wider environment
Not all change within a community is implemented through local community action.
Local activities are often supported by essential interventions at other levels. This
section, originally based on information in Egger et al (1999:143-178), contains
examples of broad strategies which support changes in public health within
communities. These are:
•
modifications to the environment
•
policy and legislation
•
technical interventions
•
organisational interventions
•
the use of incentives and disincentives
•
advocacy and lobbying
Changes to the health environment often represent the greatest challenge to the
health practitioner, but can also be the most cost and time effective strategies for
influencing health behaviour. Many of the underlying causes of ill health are socioeconomic. It is important for health practitioners to recognise and attempt to
influence these determinants at local, regional and national level.
In the context of the charter of the ‘new’ public health …
Baum suggests that: “we must be prepared to be troublemakers for health - to rock the boat,
to challenge the status quo and, perhaps most importantly, to question our own way of
working and ensure our practice matches the rhetoric”.
Baum in Egger et al 1999:139
Modifications to the environment
Modifications can be made to the physical environment that will have a positive
benefit for individual and community health. Changing the physical environment is
often easier and more successful than putting resources into trying to change
entrenched behaviours. There have been major gains in health in the area of injury
prevention.
121
Examples of gains in the area of injury prevention by modifying the physical
environment include:
• reducing traffic accidents by widening and fencing roads and clearing verges of
scrub to improve visibility
• reducing the number of children drowning in swimming pools through use of
safety fences around pools
• decreasing accidents in elderly people’s homes by involving local community
groups in a project to improve home safety features
Other examples of changing the physical environment for health benefits include
putting up shade covers over playgrounds to protect children from the sun and
planting trees to provide shade and to cut down on dust. The following is a story
about how Julalikari Council in Tennant Creek worked with the local Aboriginal
Health Promotion Officer on a project to plant fruit and shade trees at outstations in
the Barkly. Community participation was key to the process as outstation residents
would be the owners and carers of the trees after the planting.
Planting trees for health benefits
Most remote communities are in need of trees for dust suppression and for the provision of
fruit and shade. The project included installing more water tanks for exclusive use in dust
suppression and tree planting and establishing a small orchard of 250 mango trees. The
Aboriginal Health Promotion Officer, Marlene, worked with us on this project. She found out
what people wanted and talked about the importance of fruit for good nutrition. She told us
about the … funds and helped with co-ordinating the project.
The four outstations that we established fruit trees on are Illuwur, Connells Lagoon, Blue
Bush and Nammerinni. When we visited some of the outstations we were pleased with the
growth of the trees and efforts of community members in looking after the tress. Community
members are extremely proud of their trees and look forward to harvesting the fruits.
Information provided by Julalikari Buramana
Aboriginal Corporation, “The Land Management Unit”
Policy and Legislation
Public policy and legislation are used to encourage practices that support and
promote public health, discourage those practices that are unhealthy, harmful or
inequitable, and control communicable diseases and risk factors in the environment.
The actions of people at community level can influence policy development and lead
to the creation of ‘healthy public policy’. Some policies have become law; for
example, as smoking has become less acceptable in enclosed public places it has
been followed by legislative changes to that effect.
In some circumstances, effective enforcement of legislation by policing can be a
very effective way of influencing behaviour. For example, enforcement of the
wearing of seat belts and the introduction of breathalysers for alcohol have resulted
in a decrease in road traffic accidents in most areas where they have been
introduced. These measures were only effective when they were made compulsory
and people’s compliance was monitored by the police (Egger et al 1999:147).
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 See ‘Environmental Health’, ‘Alcohol and Other Drugs’, and ‘Nutrition and
Physical Activity’ chapters for the main pieces of legislation that relate to each
area
An example of community support for public policy change and legislation
We know that as more information about the health effects of active and passive smoking
becomes available, community support and pressure for smoking restrictions and policies in
public places grow.
This was found to be the case in the NT where one in five deaths is directly related to
smoking. While the rate of smoking is higher than anywhere else in Australia, surveys
showed that the majority of Territorians (including smokers) supported smoke-free areas in
enclosed public places. ‘No smoking’ rules were applied in many community venues prior to
the passing of the Tobacco Control Act (2002) which came into effect in 2003. The Act aims
to reduce the harm to people's health from tobacco by:
- discouraging people from smoking
- reducing exposure to environmental tobacco smoke
- supporting people to stop smoking
The laws now prohibit or partially prohibit smoking in many public places.
For information about Smoke Free NT go to:
www.nt.gov.au/health/healthdev/aodp/tap/smokefree/index.shtml
Information from NT Alcohol and Other Drugs Program and website
Healthy public policy recognises that many factors determine whether we will be
healthy or not, and that there are broad determinants of health that we, as
individuals, have little control over. These include gender, culture and genetic
makeup and social determinants. The social determinants of health when applied to
the Australian rural and remote indigenous health context include income and social
status, stress, early childhood development, education, employment and work
conditions, social support and (substance misuse). (Dade Smith 2004: 68-72). This
range of social determinants provides many opportunities to use healthy public
policy to address the risk and protective factors that affect health and social
outcomes. Remember that the actions of people at community level can influence
policy makers to create opportunities for better health.
 See ‘Five action areas for health promotion’ at the beginning of this chapter
 See Chapter 6 A Health Promoting Health Centre for a section on policies
Technical interventions
Technical interventions may involve changes in health brought about by
improvements in medical, scientific, engineering or other technology. While these
interventions have been developed by specialists, getting them accepted by the
public is often the role of public health practitioners and others working at the
community level.
123
Some examples of technical interventions and their health benefits are:
• immunisation for vaccine preventable diseases
• fluoridation of water supply to improve dental health
• control of animal vectors such as mosquitoes to prevent diseases such as Ross
River Fever
• hand powered washing machines for remote Aboriginal communities to improve
personal hygiene
• development of solar electrical systems enabling remote communities to have
refrigeration to keep food fresh
The following example from the Centre for Appropriate Technology in Alice Springs
describes a bush-hardy engineering solution to a problem of commercial technology
being inappropriate for the setting.
Hand Powered Washing Machine
The hand powered washing machine was designed in response to the needs
expressed by women’s groups in remote communities who wanted to wash blankets
but didn’t have access to electricity and couldn’t get electric machines repaired.
Commercial Washing Machines in remote communities were getting damaged by
dust and some were only lasting six to eight months. It was expensive to keep
repairing and maintaining the machines so an alternative was needed.
Features
The Hand Powered Washing Machine is simple to operate. Through pumping the
machine’s handle, a plastic agitator is plunged up and down…The machine is filled
with a hose or bucket and …emptied through a flexible drain pipe attached to the
base of the bowl. It does not require any complicated plumbing.
Product Information Sheet, Centre for Appropriate Technology, Alice Springs
 For information about the work and services of CAT go to: www.icat.org.au/

Figure 4: Hand Powered Washing Machine
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Organisational interventions
A ‘settings approach’ can be a low cost, easy way to reach specific populations and
groups. Some of the settings for working with groups of people are workplaces,
schools, health centres, prisons and hospitals. The policies of these places often
influence the lives of community members, beyond the particular setting.
Some examples of organisational interventions to improve health include:
 healthy food being sold at school and workplace canteens
 sound policies and protocols for occupational health and safety
 ‘smoke free’ workplace policies
The following example shows the result of two government departments, Education
and Health, jointly working together to promote healthy food choices in schools.
School Canteens and Tuck Shops
NT School Canteen Guidelines provides up-to-date information about the role of the
canteen, dietary guidelines for children and adolescents, hygiene, general nutrition
guidelines and sample meal ideas. This information helps those involved with
operating canteens. The guidelines provide a positive message about healthy eating
for children and adolescents.
Tummy Rumbles was written specifically for remote area canteens and covers such
areas as availability of food, old and new ways with foods, facilities, menus,
preparation and storage of food, hygiene and nutrition.
The booklets are available from regional nutritionists
Darwin
Ph: 8922 8723
Alice Springs Ph: 8951 6902
Katherine
Ph: 8973 8946
Tennant Creek
Ph: 8962 4269
Nhulunbuy
Ph: 8987 0313
The use of incentives and disincentives
The use of incentives and disincentives is another useful strategy for health
promotion. An example of this strategy is making the cost of health insurance lower
for those people who do not smoke. In the examples below the cost of health
promoting products is made lower and the cost of health damaging products higher.
Incentive
• reducing the cost of light beer
• reducing the cost of fresh fruit and
vegetables.
• reducing the price of personal and
home hygiene items such as soap
and washing powder
Disincentive
•
•
•
increasing the cost of regular
beer
increasing the price of sweets
increasing the cost of
cigarettes and tobacco
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The following is an example of the use of this type of economic intervention.
A Food and Nutrition Policy and Strategy
Over a number of months (early 1990s) managers of the ALPA [Arnhem Land
Progress Association] stores, with the help of dietitians from Territory Health
Services and researchers from the Menzies School of Health Research (MSHR) in
Darwin, developed a food and nutrition policy for stores. The idea was to increase
the variety of healthy foods available in ALPA stores, and to encourage people to
buy and eat more of these foods…The price of cigarettes was increased by 30 cents
to provide money to pay for the freight of fruit and vegetables to the communities. At
first, half the freight was paid for on the fruit and vegetables to make them cheaper
for people to buy. After six months all the freight on fruit and vegetables was
subsidised…
In Bear-Wingfield 1996:48
ALPA continues (2005) to subsidise the freight on fruit and vegetables to 100% in
order to lower the price and increase the consumption of healthy food. ALPAs Food
and Nutrition Strategy aims to increase the awareness of health and nutrition and
empower community members to make healthy dietary choices. Stores and
takeaways provide a wide range of nutritious foods such as wholemeal breads, diet
soft drinks and cordial, low fat dairy products, lean meats and artificial sweeteners.
Takeaways offer hot meals, fresh sandwiches, salads and fruit.
A 340% increase in consumption of diet soft drinks and a 234% increase in
consumption of lean meat products has been measured since May 2003.
From ALPA website http://www.alpa.asn.au/ Information downloaded 5/2005
Social advocacy and lobbying
Social advocacy and lobbying are recognised as part of a health professional’s role.
They are effective ways to work for public policy reform. Health professionals can:
• act as advocates and lobbyists themselves, or
• encourage and support other community members to take up advocacy and
lobbying
There are a number of national and NT organisations that advocate for better health
for the community. Some examples are:
•
•
•
•
•
•
Consumer Health Awareness Network NT,
www.tedgp.asn.au/channt/chaant.htm
Consumer’s Health Forum, www.chf.org.au
Public Health Association, www.phaa.net.au
Australian Nutrition Foundation, www.nutritionaustralia.org
NT Tobacco Control Coalition, through www.heartfoundation.com.au
Aboriginal Medical Services Alliance (Northern Territory) (AMSANT),
www.amsant.com.au
126
There are good resources you share with community members to help with
advocacy and lobbying. For example:
 See Brady M 2005, The Grog Book: Revised Edition, Chapter 3, ‘Action’
Case study of advocacy and lobbying: Rally Against Grog
Below is an extract of a newspaper article. It demonstrates how community
members grouped together to advocate and lobby for issues they felt strongly about.
This collective action was used to gain media attention and to put the issues onto
the political and policy agenda.
Women in the Centre Rally Against Grog
In one of the largest rallies ever seen in Alice Springs, almost 400 Aboriginal women
and children from Central Australian communities joined forces recently. With many
of them in traditional dress, the women were protesting about alcohol abuse by their
men and the extension of town-based drinking facilities in Alice Springs. The march
was organised to give women a chance to be heard and put their side of the story.
Elders from 16 of the communities marched behind women in a show of support for
the women’s actions.
Spokeswomen Rosemary Kunoth-Monks and Alison Hunt said that women bore the
brunt of violence and other social problems associated with alcohol abuse, and had
put up with it for long enough.
The Minister for Health and Community Services, Steve Hatton commented that the
march was a positive move towards helping Aboriginal people to make their own
decisions about dealing with alcohol abuse.
After the march, the women met with the Chief Minister, Marshall Perron, and other
key Government officials. The women asked for closure of take-away liquor outlets,
suspension of plans for the Tangentyere Council to build licensed clubs in Alice
Springs, prohibition of liquor sales at Aboriginal sporting events, access to the money
used for grog be made more difficult for Aboriginal drinkers …
… The march was a great success in getting across the women’s point of view and
led to a separate meeting between the elders and the NT Government…A council of
traditional elders will be formed as a result of this meeting…Mr Perron will look at the
requests coming out of both meetings in relation to today’s liquor laws and discuss
options for change with Aboriginal people directly.
Extracts from an article which appeared in ‘Aboriginal News’ (produced by the Office
of Aboriginal Communications, Department of the Chief Minister) June 1990, Vol 6
(3):2-3
This event, along with the report of the NT Legislative Assembly Sessional
Committee on the Use and Abuse of Alcohol by the Community, helped to prompt
the Government to establish the NT Living with Alcohol Program in 1991.
 See ‘Alcohol and Other Drugs’ chapter in Volume 2
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Using media
The use of media is a strategy often used in conjunction with other strategies. For
example, we might show a video about the effects of smoking as part of a health
education session or give someone a fact sheet on the best foods for a healthy
heart as part of a brief intervention.
We can think about media as either:
• targeting individuals or groups (limited reach media) through the use of
pamphlets, fact sheets, posters, videos, computer software
• available to everyone (mass media) through the use of television, radio,
newspapers and magazines
About social marketing and media use
The term ‘social marketing’ is often used with media strategies. Social marketing
uses media as an educational and motivational tool to encourage people to make
healthy choices. Social marketing is defined as “the design and implementation of
programs aimed at increasing the voluntary acceptance of social ideas or practices”.
To be effective the activities promoted need to be ‘do-able’, accessible and
affordable at the community level (Egger et al 1999:89-90). Messages and
strategies usually target particular groups or ‘market segments’ based on factors
such as risk factors (eg. smoking), demographics (eg. young women), or stages of
behaviour change (see ‘Brief Interventions’ at beginning of this chapter).
While it is unlikely to encourage people to make healthy choices when used on its
own, social marketing and media use may be an effective strategy as part of an
integrated health promotion program.
What media to use?
The type and style of the media used in a
health promotion project will depend on:
• the message to be shared
• how the resource will be used
• the needs of the target group
• the cost of buying or producing the resource
 See the section on ‘Working with Groups’ in
this chapter
128
Limited reach media
Various types of media are used in health education and health promotion. Select
the type of media according to where, how and with whom it is to be used. For
example, print media may be an effective way to support one-to-one education and
intervention (Paul & Redman 1997), and may be ‘personalised’ by circling relevant
points or adding notes on a pamphlet. Interactive software, such as MARVIN, may
be a powerful and engaging tool (see Chapter 3). Videos may be useful for training
individuals or groups.
Use limited reach media to support your work. For example:
 Ask people to tell you what they see happening in the poster or video. Build on
the discussion by adding relevant information
 Sit with people and go though the material with them. Discuss the most important
parts and talk about the images. Draw out the important points and make links
with their situation
 Give them a copy to take away and think about. They may want to share the
information with other people
 See Chapter 2 Education for Health and Chapter 3 Sharing Health Information
Some types of limited reach media:
129
Type
Characteristics
Pamphlets, brochures,
fact sheets, booklets
Newsletters
− best distributed through service outlets (health
centre, women’s centre, council office, stores etc.)
− useful in one to one education
− useful as part of a brief intervention
− useful for passing on information about sensitive
issues
− can increase knowledge and affect attitudes
− more effective if used to support other strategies
− can be produced by interested community members
and health centre staff
− useful for information sharing
− can be illustrated for visual reinforcement of the
written message
− can provide effective visual representation of an
idea
− groups can design or produce them themselves
− more effective if used to support other strategies
Posters
− support a project theme
− reinforces group identity
− can be designed by community group
T-shirts
Videos and
Computer software
Songs, dance and stories
Banners and murals
− instructional and motivational
− can be paused for discussion along the way
− useful for personal viewing as back-up to other
strategies
− can be used opportunistically
− useful for skills training
− commonly used in Aboriginal culture as a means to
instruct
− can be created locally and transmitted more widely
(see mass media section)
− useful for passing on information about sensitive
issues
− can reinforce traditional values and practices
−
−
−
−
useful for awareness raising
provide a visual message
groups can design or produce them themselves
more effective if used to support other strategies
Based on Egger et al 1999:106-117 and Ewles and Simnett 1985:183-197
130
Case study: using media to raise awareness
This project shows how various types of media were used along with other activities
to increase awareness and create an environment for behaviour change. The
project was funded through the (then) NT Health Promotion Incentive Funds
scheme. It won a National Heart Foundation award for the Best Nutrition Project in
1997.
Galiwin’ku Health Centre staff facilitated the process. The community was involved
from the initial decision to apply for funding, to planning the project and
implementing the strategies.
Health Promotion through the Visual Arts – a health promotion mural project at
Galiwin’ku
In September 1996 a community meeting was convened to identify health needs and
possible health promotion activities. Discussion at the meeting highlighted the need
to have health education messages in public places. A decision was made to apply
for funding for a Health Promotion through the Visual Arts Project.
The project used a community consultation approach and commissioned a local
artist to tell health related stories on three separate murals relating to Nutrition,
Smoking and Environmental Health. At the completion of each mural, there was a
launch and celebration for the community. The theme of each mural was extended
over a two week period…
Through discussions at the Health Centre it was decided that Health Workers could
wear t-shirts design around a ‘No Smoking’ theme over the promotion time. School
children were asked to design the t-shirts and screen print them…
The Council decided to have a Market Day on ‘World No Tobacco Day’ to coincide
with the launch of the Mural…The local ‘Salt Water Band’ played in the evening and
health videos were viewed…
Community activities related to the health promotion project included:
No smoking signs and designated no smoking areas at the Council, School and
Health Centre
Magnetic Signs for community vehicles with health messages displayed and
changed regularly
Community Market Days selling fresh local produce…
Video nights with a health video shown before the main film
Cold water fountains installed at the School and in public places to promote drinking
water as an alternative to soft drinks.
Formation of a group to support smokers thinking of giving up
Based on an article by Michelle Dowden printed in ‘The Chronicle’, Vol 1.3,
August 1997, Territory Health Services, Darwin
131
The following example is a song about diabetes. It reinforces the health behaviours
to prevent diabetes - eating nutritious foods and exercising.
Diabetes Song sung by Munupi Group
A LONG TIME AGO OUR GRANDFATHERS AND GRANDMOTHERS
WERE NEVER SICK
Our grandfathers and grandmothers they used to walk out bush.
There they gathered bush tucker. And that’s what they ate.
Chorus
This is the name of the bush tucker, wallaby, possum, carpet snake, buffalo, magpie
geese, mangrove worm, chicky worm, oyster, turtle, dugong and crab.
And that’s why they never got sick.
Today we are eating white mans’ food. It has plenty fat and sugar.
And that’s why we get sick.
Chorus
Let’s go walking and play games. No sitting around in one place. Be like our
grandfathers and our grandmothers.
A song from the ‘Bush Tucker Workshop Video’.
Translated by Anne Marie Puruntatameri and Alberta Puruntatameri
Making health education and health promotion resources
It has been shown that the most effective education for health resources are those
which have been developed locally. Making resources will be more successful if:
• the materials are made with the involvement of interested local people and health
staff
• the materials are pre-tested (evaluated) by a small group of local people before
being distributed
Often the best way to approach the development of a resource is to organise a
workshop. The health team will have a chance to look at issues and problems
together with interested local people. The workshop can provide an opportunity for
discussing the underlying causes of the problems as well.
Health education messages should:
• make people wake up and listen
• make people think ‘this message is for me’
• be clear, so that people understand
• make people want to do what the message says (Northern Territory Department
of Health and Community Services 1989)
132
Evaluating health education and health promotion resources
There are a number of things to think about when choosing or making health
education and health promotion resources. The following checklist may be a useful
evaluation tool.
About information:
• Is the information accurate and up to date?
About target group:
• Is the resource suitable for the target group?
• Does it give information that people have asked for?
• Is it culturally acceptable? Will it upset or offend anyone?
• Can the target group understand the message?
• Will anyone outside the target group be upset or offended by it?
• Does it make the person feel like it’s ‘talking’ to them personally?
About design:
• Is the resource eye catching and interesting to look at?
• Are the diagrams/photos/images clear in what they are trying to say?
• Are the photos or images acceptable to people in the community?
• Is information well presented?
• Are written words large enough to read easily?
About accessibility and language:
• Does the resource use language, words and images people can understand?
• What is the language? Can people read/understand it?
• Does it use straightforward words and sentences?
• Does it use many technical words?
• Are the ideas explained clearly?
• Are pictures, diagrams or images suitable and clear?
About message:
• Is the message or purpose clear?
• Does it give clear directions to the reader or viewer?
• Is the message put in a positive way?
• Are there any conflicting or hidden messages that might confuse people?
• Does it seem to persuade the person to do something?
About cost and benefit:
• Is it worth the money you spend on it?
• Can you afford to buy it or make it? Do you need extra funds for it?
• Can you share the cost with anyone else in the community or anyone else in
THS?
• How many copies are needed, or how many times will you be able to use it?
• How long will it last?
• Has another community got the resource? Can you borrow it from them? Can you
adapt it?
133
Aboriginal Health Education Resources Database
The Aboriginal Health Education Resources Database provides information about
useful health education resources which have either been designed specifically for
Aboriginal people, or could easily be adapted to use with Aboriginal people.
The database provides information about where to get the health education
resources which may suit your needs. There is also a list of contacts for people who
can help you with information and delivery of your public health program.
 The database can be found on the DHCS Intranet or at:
www.nt.gov.au/health/healthdev/health_promotion/publications/resource_databas
e.shtml
 Print copies of the database and examples of resources are available. Contact
Health Promotion Strategy or local health promotion staff.
 Also see resources such as The Indigenous Health Promotion Resources Guide:
A National Information Guide for Aboriginal and Torres Strait Islander Health
Workers, 5th edn, published by The Aboriginal and Islander Health Worker
Journal (2005)
Mass media
Through the mass media, a message goes out to everyone. There are two main
approaches to using the mass media in health promotion – media advocacy to raise
the profile of health issues, and social marketing which uses mass media to “sell”
health by influencing health behaviours or promoting products.
A well-developed media campaign may be a useful way to raise awareness or to
influence public opinion to improve heath. It has been shown, however, that mass
media methods alone are “unlikely to be successful in helping people develop new
skills and behaviours. It is important to bear this in mind when considering use of the
mass media” (Wass 2000:136).
134
Mass media to reach whole communities
Type
Television
Radio
Newspapers and
magazines
Characteristics
− fosters awareness and interest
− increases knowledge
− encourages behavioural modelling and
image creation
− BRACS systems can broadcast locally
appropriate messages
−
−
−
−
−
informative
interactive (talkback)
cost effective and useful in creating
individual and public awareness
provides information suitable for all to
hear
− can broadcast in local languages
− CAAMA and TEABBA can broadcast
locally appropriate messages
− information depends on style of publication and how often it is printed
− local papers like to use local stories
− cover wide range of topics
− more effective if used to support other
strategies
Based on Egger et al 1993:53-67
 Check the media protocols of your employing organization. It is likely that you will
need to have your contact and material approved and overseen by management
 Use the same process for developing and evaluating mass media material as for
limited reach material
 Mass media can be expensive to develop and distribute or broadcast. Look for
ways to get free coverage
135
Use of mass media in remote areas of the NT
Getting information direct to NT Aboriginal communities through Indigenous radio and
television
Imparja Television broadcasts throughout the NT [the exception is Darwin], and advertising
time can be purchased on that station. CAAMA (Central Australian Aboriginal Media
Association) Radio in Alice Springs broadcasts across the NT, and TEABBA (the Top End
Aboriginal Bush Broadcasters Association) based in Darwin broadcasts to most Top End
communities. These two radio stations serve as umbrella organisations for many smaller
RIBS units (Remote Indigenous Broadcasting Sector) which can broadcast programming
locally within a community.
Most large communities have a RIBS unit, though not all are actively broadcasting their own
programming. The RIBS units make it possible for information to be targeted directly to
particular communities or language groups, while the larger radio stations like CAAMA and
TEABBA are most effective for reaching a wider audience.
Both CAAMA and TEABBA will produce community announcements or carry interviews on
important topics, though there may be a small fee charged for the production and broadcast
of information. Radio Larrakia is an Aboriginal station licensed to broadcast to the Darwin
area itself. Another regional media association operating within the Territory is Warlpiri
Media, based at Yuendumu.
CAAMA Productions, the video production house of CAAMA, also produces television or
video programs for clients. For a national audience, the National Indigenous Radio Service,
based with the National Indigenous Media Association of Australia in Brisbane, carries radio
programs on a national satellite service picked up by Indigenous radio stations around the
country.
Information from staff of Diploma of Broadcasting and Journalism Batchelor College and The
Australian Indigenous Communications Association Incorporated (AICA)
Using screening
What is screening
Screening means checking people who think or feel they are healthy to find if they
have certain health problems or risk factors they did not know about before.
Screening can be done by:
• asking questions, for example, about smoking
•
examining the person, for example, checking blood pressure
•
doing tests, for example, a blood test for iron levels
A screening test is not expected to be diagnostic (NHMRC 1993). So a person who
has a positive screening test will usually need further tests to identify specific health
problems. For example, a Mantoux test might indicate contact with tuberculosis but
further testing will need to be done to diagnose of rule out that the person has
tuberculosis.
Types of screening
Mass (untargeted) screening means screening a whole population. More often
screening is targeted to a group of people who are more likely to have a problem,
136
for example, screening all adults for risk factors for chronic diseases, cervical
screening for all women of reproductive age.
Opportunistic screening is screening individuals when you have an opportunity, for
example, when they attend the health centre for some other reason such as a cold
or a minor injury, for example:
• offer a diabetes check to an adult who has a family history of diabetes
• when checking blood pressure, ask about smoking and alcohol consumption
Problems identified by screening should be followed by appropriate action, such as:
• brief intervention
• referral
• full diagnostic examination or testing
• treatment
• family consultation
Using screening as a health promotion strategy
Screening is an opportunity for education for health. It can be used as a tool to
mobilise community, group or individual action. When community results are fed
back and compared with NT and national figures, people may ask questions about
how to prevent the problem and decide to improve their situation.
When individuals are fed back results of their screening test, you have an
opportunity for doing an early or brief intervention. This timely and personal
information may help the person to change his or her health behaviour, or
encourage the person to maintain positive health behaviours.
In summary, screening can be used in a way that helps to motivate and support
people to develop skills and to make decisions, collectively or individually, which are
right for them. Used in this way screening becomes an effective health promotion
strategy.
 For more information see Chapter 3 Sharing Health Information
 See ‘Brief Interventions’ in this chapter
Why screen
• To detect health problems or risk factors early so people can be offered treatment
or other interventions to either stop a disease developing, or to prevent complications or early death
• To reinforce with people who do not show risk factors that what they are doing is
right. Feeding back the results of screening provides opportunities to give encouragement and praise to those people who live a healthy lifestyle
137
• To alert people, even those who do not currently show risk factors, that they are
predisposed to developing health problems:
− the family living environment and lifestyle may predispose people to developing problems; for example, eating the same foods as others who have
developed nutrition related problems, and smoking passively. These lifestyle
factors are modifiable
− the family health history may suggest that individuals are predisposed to
developing certain health problems. While genetic pre-disposition is not
modifiable, there are things that you can encourage individuals and families to
do which lower the risk
− both lifestyle and genetic predispositions may by present in one individual or
group
• To raise community awareness about shared health problems, or a set of risk
factors, that can stimulate community level action
• To complement a range of health promotion strategies
Information gathered through screening can also be used to:
• help plan services by collecting baseline and ongoing information about the
prevalence of disease, health related problems, or risk factors
• raise people’s awareness about the prevalence of a health problem in their
community
Criteria for screening
There are good public health reasons for screening certain populations, or subpopulations. However, you need to think carefully about the role of screening and
whether the time, energy and money involved are justified. Screening can intrude
into people’s lives and invade their privacy. It can label people with a problem, or as
unwell, when in fact they have simply failed a screening test.
The following criteria for screening have been adopted by the WHO and National
Health and Medical Research Council (NHMRC) when planning screening
programs.
WHO criteria for screening - which diseases to screen for?
The condition sought should be an important health problem for the individual and
community.
There should be an accepted treatment or useful intervention for patients with the disease.
The natural history of the disease should be adequately understood.
There should be a latent or early symptomatic stage.
There should be a suitable and acceptable screening test or examination.
Facilities for diagnosis and treatment should be available.
There should be an agreed policy on whom to treat as patients.
Treatment started at an early stage should be of more benefit than treatment started later.
The cost should be economically balanced in relation to possible expenditure on medical
care as a whole.
Case finding should be a continuing process and not a once and for all project.
Wilson and Jungner 1968 cited in Mak et al 1998:646
138
A screening test should be
Simple, quick and easy to interpret
Acceptable to the public
Accurate
Repeatable
Sensitive (gives a positive result when an individual has the condition)
Specific (gives a negative result when an individual does not have the condition)
Cochrane A and Holland W, 1971:6
Community health surveys
In the past, community health surveys (or health audits) have taken place in many
Aboriginal communities. They were often ‘one-off’ surveys or happened intermittently. A team of health professionals would travel to a community to record a wide
variety of factors in as many people as possible.
These often included:
• physical measurements, for example, height, weight to work out body mass index
• risk factors, for example, smoking and alcohol consumption
• a variety of tests which involve the taking of specimens for laboratory analysis, for
example, blood and urine specimens
From the point of view of population health, these community health surveys are
‘prevalence surveys’. They “document the presence of risk factors and disease in a
population” (Mak et al 1998:646). The results may or may not have been fed back to
the community.
Screening… can reduce Aboriginal people to objects of knowledge, and this knowledge may
help to maintain the domination of non-Aboriginal people over Aboriginal people in our
society…. Screening should not occur as an activity on its own; it should only be
implemented as part of a process of early intervention. However, too often inadequate
thought is given to ensuring that the resources are available to follow-up and manage the
problems identified in the screening.
Scrimgeour 1996:5
 Evaluate any screening program in which you participate
 Always provide feedback to the community
“Sometimes Aboriginal communities request community health surveys… health
professionals have an ethical obligation to carefully discuss all the costs and benefits of a
survey prior to its implementation to ensure that community residents do not have unrealistic
expectations of what the survey will or can achieve. A community’s request for a survey
doesn’t justify doing the survey…”
Mak et al 1998:645
Minimum acceptable criteria for community health surveys
139
The following list of criteria can be used when planning community surveys:
1. Community groups are consulted and involved in planning the community health survey
and approve of its aims and methods.
2. The community has sufficient time to think and talk about the community health survey.
3. There is adequate provision for individuals to decline participation.
4. Community health surveys and screening activities (other than those in guidelines
accepted by the local primary health care services) are approved by an ethics committee
with adequate Aboriginal representation.
5. The community health survey meets the National Health and Medical Research Council
criteria for research in Aboriginal Communities.
6. The community health survey meets the criteria for scientific validity, hypothesis testing
and measurement which would be expected in any research project.
7. The costs, including opportunity costs, of both the survey and the follow-up of screendetected abnormalities, should be estimated and presented to the participating communities
and the ethics committee.
8. There is adequate provision for the feedback of results to individual participants and to
the community.
9. There is adequate provision for the appropriate follow-up of screen detected
abnormalities by either the researchers and /or the primary health care team.
10. There are plans, involving the community’s members and health care service(s), for
community interventions following the survey if appropriate.
Mak et al 1998:647
You need to be aware of when a screening program is part of routine community
health care delivery to improve health and when it is for a specific research project.
 See ‘consent’ (below)
Screening in the Northern Territory
Screening guidelines have been developed for children and adults in the NT based
on the WHO screening criteria.
 See resource list at the end of this section
Screening activities which are already established or are being developed as part of
routine primary health care include:
• routine screening tests of antenatal women
• screening of babies soon after birth with a Guthrie test
• growth monitoring for children
• school-age screening
• screening for cervical cancer and STDs as part of well women’s checks
• screening for chronic disease risk factors such as high blood pressure and
smoking
These activities may be done opportunistically, or as part of a recall system, or during ‘Health Weeks’.
140
Consent
Some forms of screening are a regular part of a comprehensive Primary Health
Care (PHC) service, for example, ante-natal checks and growth monitoring of babies
and young children.
Screening activities which are not part of the day-to-day PHC service require formal
consent.
It is important that individuals and community councils understand why screening is
being offered so they can give their informed consent and can say ‘no’ to screening
if they do not want to take part.
Screening for research purposes requires ethics committee approval.
 See the chapter ‘Planning and Evaluating a Health Promotion Project’
Screening resources
Growth Assessment and Action - Guidelines and Strategic Plan, 1998-2003
guidelines for:
• measuring weight, height and haemoglobin in children
• making action plans for children with growth faltering
• feedback on nutritional status to communities and districts
Available from Maternal, Child and Youth Health teams (Top End 89228015, 8922
7712 and Central Australia 8955 6102).
Healthy School-Age Kids: The NT School-Age Child Health Surveillance Program
Manual for Remote Communities (1998)
This Manual is for health and education professionals who work in remote areas.
The Manual contains :
• Screening schedule for school-age children living in remote areas
• guidelines for planning and conducting school-age checks
• guidelines for referral to other services
• key areas for health promotion
Available from Maternal, Child and Youth Health teams (Top End 89228015, 8922
7712 and Central Australia 8955 6102).
141
Central Australian Rural Practitioners Association (CARPA) 1997, Health Screening
in Central Australia, CARPA, Alice Springs.
These Guidelines include:
• definitions, basic principles and criteria for screening
• advice about how to screen – logistics
• screening children and adults
• screening for sexually transmitted diseases
• screening for trachoma
Available from CARPA PO Box 8143, Alice Springs, NT 0871
E-mail: [email protected]
Central Australian Rural Practitioners Association (CARPA) 2003, Standard
Treatment Manual 4th edition, CARPA, Alice Springs
•
includes a section on adult health checks
Congress Alukura and Nganampa Health, Women’s Business Manual, 3rd edition,
Nganampa Health, Alice Springs
•
was published as a companion manual for the CARPA Guidelines and includes
advice about women’s health screening
These two screening resources are recommended by the Preventable Chronic
Diseases Program (Top End Coordinator 8922 8637, Central Australian Coordinator
89556131)
Useful websites and on-line resources listed in this
chapter
Govt – NT, state, federal
www.nt.gov.au/health/healthdev/health_promotion/publications/resource_database.sht
ml
www.nt.gov.au/health/healthdev/aodp/tap/smokefree/index.shtml
http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/partb.pdf
http://www.health.vic.gov.au/healthpromotion/resources_links/integrated.htm
http://www.communitybuilders.nsw.gov.au/building_stronger/safer/commpshipkit.html
http://www.communitybuilders.nsw.gov.au/getting_organised/capacity/pctbox.html
http://www.druginfo.adf.org.au/newsletter.asp?ContentID=brief_intervention_manuals_a
nd
http://www.community.gov.au
142
International
www.motivationalinterview.org
http://www.who.int/hpr/NPH/docs/jakarta_declaration_en.pdf
http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/print.html
http://www.sdc.gc.ca/asp/gateway.asp?hr=en/epb/sid/cia/comm_deve/handbook.shtml&
hs=cyd
Non-gov organizations, education institutions
http://www.nceta.flinders.edu.au
www.icat.org.au/
http://www.alpa.asn.au/
www.tedgp.asn.au/channt/chaant.htm
www.chf.org.au
www.phaa.net.au
www.nutritionaustralia.org
www.heartfoundation.com.au
www.amsant.com.au
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Scrimgeour D 1996, Screening issues for Aboriginal people, CARPA Newsletter
No 24, pp 4-10
Territory Health Services (May) 1998, Northern Territory Coordinated Care Trials,
Health Screening and Surveillance, Territory Health Services, Darwin
Territory Health Services (November) 1998, Territory Health Services Remote Area
Well Men's and Well Women's Screening Guidelines, Territory Health Services,
[Darwin]
Wilson JMG & Jungner G 1968, Principles and Practice of Screening for Disease,
Public Health Papers, No 34, WHO, Geneva
148
Chapter 5 – Planning and Evaluation a Health Promotion Project
Chapter 5
PLANNING AND EVALUATING A HEALTH
PROMOTION PROJECT
Getting started: research in planning and evaluation .................................. 151
What is research ........................................................................................... 152
Research tools: ways to collect information ................................................... 152
Quantitative and qualitative data ............................................................... 153
Literature search ........................................................................................... 154
Why do a literature search? ....................................................................... 154
Start your literature search ........................................................................ 154
Library Services and Collections ............................................................... 155
Ethical matters ................................................................................................ 156
Thinking about planning a health promotion project ................................... 158
Why plan ....................................................................................................... 158
Forming the project team .............................................................................. 159
Reflection-action approach ............................................................................ 159
The planning cycle ........................................................................................ 161
Doing a community profile ............................................................................. 161
What information can be included in a community profile .......................... 162
Where to get information for the community profile .................................... 163
Steps for planning a health promotion project ............................................. 163
Major steps in planning, sustaining and evaluating a health promotion project .......... 163
Step 1: identify the issues or health problems in the community .................... 164
Needs assessment .................................................................................... 164
Classifying needs ...................................................................................... 164
How to find out about community needs .................................................... 165
Sharing information from the needs assessment ....................................... 166
Consider baseline data .............................................................................. 166
Step 2: prioritise the issues or health problems ............................................. 166
Questions to guide how needs are prioritised ............................................ 166
Before proceeding ..................................................................................... 168
Funding a health promotion project ........................................................... 168
Step 3: identify risk factors and set the goal for the project ............................ 169
Step 4: determine contributing factors and state objectives for the project .... 169
Analyse the problem to determine risk factors and contributing factors ..... 169
Problem analysis ....................................................................................... 170
Developing the project goal and objectives................................................ 171
Step 5: determine what the strategies will be ................................................ 173
Questions to ask to help determine strategies ........................................... 174
Relationship between the goal, objectives and strategies .......................... 174
Step 6: develop the action plan ..................................................................... 176
Questions to help identify resources .......................................................... 177
Step 7: sustain the project ............................................................................. 178
Questions to consider when planning for sustainability .............................. 178
Step 8: evaluate the project ........................................................................... 179
Documenting the project ................................................................................ 180
Questions to help plan the documentation..................................................... 180
What needs to be documented ...................................................................... 180
Common methods of recording project activities and progress .................. 181
Personal field journal ................................................................................. 181
149
Recording a project plan ............................................................................... 182
Thinking about evaluating the project ........................................................... 185
Why evaluate? .............................................................................................. 185
Who is the evaluation for? ............................................................................. 185
Stakeholders in evaluation ........................................................................ 185
Planning the evaluation .................................................................................. 187
The Eight Stage Model of Evaluation ............................................................ 188
Types of evaluation ................................................................................... 189
Focus questions for process, impact and outcome evaluations ..................... 189
Linking evaluation questions with the project plan ..................................... 189
Collecting information for a process evaluation ............................................. 190
Collecting information for impact and outcome evaluations ........................... 191
How to collect the information ....................................................................... 192
When to collect the information for process, impact and outcome evaluation 193
Step 1: baseline data ................................................................................. 193
Step 2: information for process evaluation ................................................. 194
Step 3: information for an impact evaluation .............................................. 195
Example of process and impact evaluation processes............................... 195
Step 4: information for an outcome evaluation ........................................... 196
Information gathering tools for planning and evaluation ............................. 198
Questionnaires .............................................................................................. 198
Steps in questionnaire development .......................................................... 198
Tips on writing a questionnaire ...................................................................... 198
Interviews ...................................................................................................... 199
Structured and semi-structured interviews ................................................. 200
Interviewing tips......................................................................................... 200
Surveys ......................................................................................................... 201
Some ways to choose the sample ............................................................. 201
Generalising results ................................................................................... 202
Analysing the data .......................................................................................... 203
How to analyse qualitative data ..................................................................... 203
How to analyse quantitative data ................................................................... 205
Share the results ....................................................................................... 206
Reporting on the project................................................................................. 206
Useful websites ............................................................................................... 211
Bibliography .................................................................................................... 211
150
About this chapter
This chapter describes processes to use for planning, evaluating and sustaining health
promotion projects. It includes:
•
some theoretical background
•
some examples from health promotion projects
•
some worksheets that health teams may find helpful in planning and undertaking
their own project work
 Before starting to plan a project with interested community residents, see the
chapters ‘Education for Health’, ‘Sharing Health Information’ and ‘Strategies for
Health Promotion’
There are many ways to do program planning and evaluation but all are based on
similar principles. This chapter describes one way that health promotion staff have
found useful in the field. Try it - see if you feel comfortable with it.
The information in this chapter outlines an ideal process for planning and evaluation. If
it is not possible to do all the steps, the priorities to aim for are:
1. undertake some joint planning with interested community residents
2. document the project
3. conduct a process evaluation of work done
4. reflect with interested community residents on how the work is going
5. strive for improvement in both process and outcome
For ‘hands on’ help with health promotion planning and evaluation in the Northern
Territory, contact Health Promotion Strategy Unit or local health promotion officers:
Getting started: research in planning and evaluation
A sound starting point for a health promotion project is finding out more about the
community, its needs and what has already been done about the identified issue or
problem in the past. It’s also important to find out what has been done elsewhere to
tackle the issue and the information and lessons learned through evaluation. Being well
informed is crucial to evidence based health promotion practice.
The practical use of evidence in planning and implementing your health promotion
project increases the chance of success.
 Begin by doing some research
151
What is research
Research
The root meaning of the word ‘research’ is to search again or to examine carefully
Macquarie Dictionary 2001:1606
Research is a rigorous,systematic inquiry or investigation, and its purpose is to validate
and/or refine existing knowledge and to generate new knowledge
Axford et al 1999: 3
It is useful to think of research as a search for answers to questions. Project planning
and evaluation have different sets of questions to be answered. Effective planning and
evaluation depend on using research processes and tools to collect information, in
order to:
•
decide which issue or problem the project will address (by conducting a needs
assessment)
•
find out what things cause the issue or problem (by analysing the chosen problem
and conducting a literature search)
•
determine how the project is going and how effective it is in meeting its goal and
objectives (by collecting baseline data and planning the evaluation)
Research tools: ways to collect information
Research tools have technical names for activities that people often do naturally to find
something out. The difference is that people ‘doing research’ are generally more
systematic in the way they go about these activities. Some ways of gathering
information include:
•
observation: watching and listening to people as they go about the activities of a
project or their daily lives; looking for any changes in the community over time
•
participant observation: a special kind of observation where you participate in the
project activities with the people you are observing
•
surveys: using a questionnaire, which is a written list of questions, used to collect
the data you need from people. Questionnaires can be used either in interviews or
can be self-completed
•
interviews: talking to people, either individually or in groups, usually using some
form of questionnaire. Interviews can be done face-to-face or by telephone
•
analysing routinely kept records: finding specific data in health centre records such
as the number of people with diabetes or who smoke tobacco; analysing store
turnover records for the amount of tobacco being sold over a year
•
looking at other documents, such as: community profiles, reports written on
previous projects or work in the community, records kept during a project that give
information about participants (number attending and so on)
152
•
doing a literature search to find out what people have written about a problem or
issue
 See ‘Information Gathering Skills in Planning and Evaluation’
It is important to record information collected in relation to the project accurately and
comprehensively.
Quantitative and qualitative data
Some of the data collected by the research tools listed above will be ‘quantitative’ and
some will be ‘qualitative’.
Quantitative data
Quantitative data are collected as numbers and amounts. These data can be counted,
analysed statistically and used to compare with other quantitative data.
Examples:
 the number of people attending the education sessions: 40 people attended this
week and 25 attended last week
 the number of people with diabetes: 20 people with diabetes in community X this
year compared with 5 people ten years ago - an increase of 300 per cent (assuming
the population has not changed)
Qualitative data
Qualitative data are collected as words. These data are descriptions that can include
observations, beliefs, ideas, opinions, feelings, perceptions, experiences, and so on.
The way the data are collected, recorded, and analysed (sorted, grouped and
summarised) should be logical and systematic. Mathematical calculations cannot be
done on qualitative information.
Examples:
•
what people thought about an education session. ‘People used the following words
to describe the education session: well organised, good information, new
information, well presented’
•
what people believe about diabetes. ‘People reported the following beliefs about
diabetes: caused by bad food, caused by too much alcohol, caused by sitting down
too much’
Both quantitative and qualitative data are valuable and complement each other. When
used together, they give a more complete picture of the situation and provide valuable
information for planning and evaluating a health promotion project.
The following Information Pyramid may be helpful for thinking about how data,
information and knowledge are related.
153
Data are facts, quantities, characters, numbers and words that make up the broad base of the
pyramid. They are the raw materials for constructing information and knowledge.
Information is derived from data that have been processed in some way, by being organised
and subjected to a framework of interpretation.
Knowledge is achieved when people examine information, think about it, discuss it, compare it,
and relate it to other sources of information.
Action: The top layer of the diagram represents action, that is, what is to be done now we have
the knowledge which helps us to understand the problem. The point of collecting data,
processing data to produce information, and increasing our knowledge, is to increase our level
of understanding so that we may take appropriate actions.
From Kalucy and Jolley 1996:3
Literature search
One important type of research is reading about the work that others have done and
the ideas others have had about the issue or problem. A literature search is a
systematic and thorough search of all types of published literature in order to identify as
many items as possible that are relevant to a particular topic. Published literature
include books, journal articles, newspaper articles, reports, papers given at
conferences or seminars, theses, patents and many other types of publications. The
format of the publication could be web based, paper based, via an electronic database
or audio-visual.
Why do a literature search?
•
•
•
•
•
•
•
To save time by learning about what others have done
To learn more about the underlying causes of the issue or problem
To discover more about the people most affected by the issue or problem
To find strategies which have been successfully used in the past
To learn how successful strategies might be applied locally
To locate research tools (for example, questionnaires) which have been used to
collect baseline data or to evaluate similar projects
To help set a realistic goal and objectives for the project based on what is learnt
about the success levels of similar projects
Start your literature search
Before embarking upon a literature search, it is useful to have as clear an idea as
possible of what you need to know.
•
What kind of question do you have? What is your information need? Do you require
current or historical information?
154
•
Once you have decided what you want to know, write it down as a sentence or a
short paragraph. For example, “we are planning a program to reduce smoking in
young Aboriginal males living in remote communities.”
•
The next step is to look at your question and identify the key words or concepts. For
example, program, reduce, smoking, young, Aboriginal, males, remote
communities.
•
The next step is to identify alternative words, synonyms and variant spelling in case
you either do not find enough information or you get the wrong sort of information.
A Thesaurus is a tool that can suggest alternatives to the words you have in mind.
For example, Indigenous, cigarette, tobacco, adolescents, boys, prevention.
•
You now have to link your keywords or phrases in order to search the library
catalogue, electronic databases or the Internet to find the information you require.
For example, if you are looking for books written on your topic, search the library
catalogue. If you don’t know the title or the author you can type in keywords such
as Aboriginal and male and smoking.
•
The DHCS Health Library catalogue does not index articles published in journals,
only the journal title itself. Instead you will need to use the journal databases to find
details of articles on your subject. When searching journal databases remember
that each have unique features that help you to get the best possible results for
your search strategy. (e.g. dates, if it has abstracts etc).
•
Contact your nearest Health Library for assistance when searching for information.
Library Services and Collections
The Department of Health and Community Services (DHCS) has a network of libraries
throughout the Northern Territory, in Darwin, Alice Springs, East Arnhem, Katherine
and Tennant Creek. Library services are available to all staff of DHCS, NT Clinical
School, Menzies School of Health Research and health professionals in the NT
Community.
Library staff respond to telephone, fax, e-mail and in person requests for information.
Staff are available to:
• conduct orientation sessions for new staff
• respond to staff working in remote locations
• give instruction and help with literature searching
• help with searching our electronic databases.
• provide one-on-one and group training to help you to become an effective,
independent user of information resources
The Library collections include a comprehensive range of printed and web based
resources. Different subject areas include: evidence based medicine, clinical practice,
public and environmental health, allied health, mental health, Aboriginal Health, alcohol
and other drugs, nursing, community care, health policy, health management and
health economics.
 ‘Subject guide’ brochures list recommended books, journals and databases and
internet sites for each topic. A ‘latest titles’ newsletter is also produced regularly
155
 Access library databases through the DHCS intranet
http://internal.health.nt.gov.au/orgsup/croc/index.shtml
 For internet access to the library catalogue http://www.libcat.health.nt.gov.au
 See the DHCS Internet or Intranet site for contact details and opening hours
NT Health Libraries
Darwin
8922 8961
Alice Springs
8951 7966
East Arnhem
8987 0262
Katherine
8973 9036
Tennant Creek
8951 7966
Ethical matters
The majority of academic research work carried out in communities has to be approved
by an Ethics Committee. However the type of research and evaluation you will do as
part of project planning will probably not need Ethics Committee approval. You will be
working as part of a project team that will include interested community residents, and
you will be facilitating community participation as an essential part of good health
promotion practice.
 If you are unsure, check with the relevant Committee
Human Ethics Committee of Northern Territory Department of Health and
Community Services and Menzies School of Health Research
PO Box 41096, Casuarina NT 0811
Phone: 8922 8624
Central Australian Human Research Ethics Committee
PO Box 4066, Alice Springs NT 0871
Phone: 8951 4700
Even when you do not need Ethics Committee approval, you have particular ethical
responsibilities in your work.
Ethical
Right or morally acceptable
National Statement on Ethical conduct in Research Involving Humans 1999:65
In accordance with the rules or standards for right conduct or practice, esp. the
standards of a profession.
The Macquarie Encyclopedic Dictionary 1995:314
156
 Think about the following:
•
confidentiality: information you collect in planning and evaluating the project must
be used only by you, and only for the purpose of the project. It should not be given
to other people without the permission of the community
•
anonymity: information collected and recorded should be anonymous, that is, not
related to names
•
privacy: respect people’s rights to privacy when they are answering questions. Let
them leave questions unanswered if they do not wish to provide the information
requested
•
free and informed consent: this concept means that people must not be
pressured to answer questions or be deceived in any way. They need to be fully
informed about the purpose of your work. This process presents special challenges
when collecting information from people for whom English is not the first language
 See: The National Health and Medical Research Council (NHMRC) paper on
‘Guidelines on Ethical Matters in Aboriginal and Torres Strait Islander Health
Research’ http://www.nhmrc.gov.au/publications/pdf/e52.pdf
 See: National Statement on Ethical Conduct in Research Involving Humans
http://www.nhmrc.gov.au/publications/synopses/e35syn.htm
Download free, or order copies through:
NHMRC National Mail and Marketing
PO Box 7077
Canberra BC ACT 2610
Phone: (02) 6269 1000
Free Call: 1800 020 103 ext 9520
Email: [email protected]
157
Thinking about planning a health promotion project
Once some people have decided what they want to do, they just go for it - without
much thinking about what to do first, or how to do it. Instead, we advise that you do
some planning. Good planning is the first step in a well managed project.
Why plan
Good planning involves people spending time together discussing the project and
recording the project plan. Good planning and recording of the plan are essential for a
number of reasons:
•
to find out what the situation is now - where the community is ‘at’
•
to make sure the community and project team know and agree on what issue the
project is addressing
•
so that the project team is clear about what the project wants to achieve and how it
will achieve it
•
to work out lines of communication within the project team and between the team
and the community
•
to work out how the plan and the project will be documented (written,
photographed, video recorded and so on)
•
to assess and prepare for the amount of time and resources needed
•
to make a plan for evaluating the project - to see what is working in the project and
what the problems are, and whether the project is achieving its goal and objectives
•
so that all people involved know what their tasks are and can be accountable for
their contributions
•
to share the ideas and information about the project and how it worked with other
people so they might be able to build on it later or learn from it
•
to use for submissions for resources (financial and material) from outside
organisations or departments
•
to support project continuity in the event that project team members change
•
so that the project team members do not have to keep all the details in their heads!
158
Forming the project team
To plan a health promotion project, it will be necessary to form a project team. The
composition of the team and roles within the team will vary according to:
•
type, size and focus of the project
•
who has skills, experience, information and knowledge
•
who is motivated, interested and has group or community support
•
other cultural considerations (kinship, language, and so on)
•
who has time to be involved
Planning will involve all members of the project team and, from time to time, will also
include some members of the broader community. Often the project team will only be
working with a group of interested community residents. This situation is not unusual.
Not everyone is interested in working on all health issues.
Start small and where the energy is. The most important thing is to be working with
people on issues that they regard as a priority, not issues that the project team regards
as a priority. These will be the issues people are willing to work towards solving.
Reflection-action approach
Something to keep in mind when doing planning and community development work is
an approach referred to as ‘reflection-action’ or ‘action research’. The essence of the
reflection-action cycle is about taking time and making the effort to review and reflect
on all aspects of a project. It is about continuous learning and improvement.
The elements of the reflection-action cycle include doing, then looking, questioning,
collecting information, analysing the information, discussing, understanding, replanning, doing some more and then re-looking at the situation - “evaluating as you go
along” (Colin and Garrow 1996).
The concept is illustrated in Figure 5.
159
Figure 5: Reflection-Action Cycle
Based on Hope and Timmel 1984:11 and Colin and Garrow 1996:33
Most real learning and mobilisation for change take place when a community
experiences some dissatisfaction with some aspect of their current situation. When
health staff work as facilitators for change, they can help community members to stop
and think critically about their situation. People can then identify information, skills and
resources that they need to address the problem.
Using a reflection-action approach to work means that community development can be
ongoing. Taking this approach within each project also means that projects remain
responsive to the community. Projects can change, adapt to new information and
circumstances and continue to be relevant. Each new project will build on past
successes and increase community and individual pride, power and confidence.
 See also Chapter 4 ‘Strategies for Health Promotion’
 For a useful article about action research, see: Wadsworth, Y. (1998) What is
Participatory Action Research? Action Research International, Paper 2. Available
160
on-line: http://www.scu.edu.au/schools/gcm/ar/ari/p-ywadsworth98.html. Links to
other action research resources and articles
The planning cycle
There are many steps involved in developing a plan from needs assessment through to
evaluation. Figure 6: Planning Cycle illustrates the constantly evolving nature of
planning, implementing, and evaluating.
 Notice the similarity to the reflection - action cycle described previously
Collect
information
Identify the health
problem or issue
Evaluate. Ask questions,
How’s it going? What’s
working? What isn’t working?
Collect
information
Why?
Implement the
Develop a plan
(new) plan.
Work with community
to make changes to the plan.
Implement the
strategies
Evaluate. Ask questions,
How’s it going? What’s
working? What isn’t working?
Collect
information
Why?
Figure 6: Planning Cycle
Doing a community profile
Early in the planning process, consider whether the project team has enough
information about the community. It is essential to have an accurate and up-to-date
‘picture’ or ‘profile’ of the community. This community profile consists of important
information that describes the community. The community health centre may have
already compiled a community profile.
 If you do have access to a community profile, consider adding to it or updating it
 If a community profile needs to be developed, think about what it should include
 In either case, do it with community residents. It is a good way to get people talking
and thinking about their community and what they want to do. It is an opportunity to
share good stories as well as worries.
 Check the community website if there is one. Look at information about the
community on sites such as Local Government Association of the NT
http://www.lgant.nt.gov.au/
161
 Think about the best way to keep the information accessible, including the best
place to store it
What information can be included in a community profile
 Consider the following list of the many types of information that could be included in
a community profile:
The community in general
• geography and climate
• history of the community
• major community issues
• cultural information such as regular cultural events
• community strengths such as ‘good news’ stories about artists, bands, sports
teams, projects
Information about the people who live in the community
• population statistics: age, sex
• major health issues in the community (morbidity and mortality statistics)
• the different groupings: religious, language, family
• leaders and potential leaders (traditional custodians, powerful families and
significant people)
A map of the community
• places of cultural significance such as sacred site
• different language group areas
• types and sizes of buildings and how they are sited
• siting and plans for community infrastructure such as the rubbish tip, sewerage
works, water supply, roads, airstrip, cemetery
Note: Service Land Availability Program (SLAP) maps are available from the NT
Department of Infrastructure, Planning and Environment in the major centres.
Economic factors
• sources of funding and income
• who the community employs and their work
162
For the purposes of the project, it is wise to consider at the same time:
•
•
power relationships between and within groups (political, economic, traditional
and gender) that could influence the project
existing and past project submissions, plans and surveys
Where to get information for the community profile
Some possible places to collect information are: health centre records; community
council records; Community Development Plans records; Department of Infrastructure,
Planning and Environment; Department of Community Development, Sport & Cultural
Affairs; Department of Health & Community Services(DHCS); District Medical Officer
Profiles; DHCS website; Australian Bureau of Statistics (ABS) Census Data; Power and
Water Corporation; reports on previous projects in the community; talking with local
people.
As you learn more about the community and its important issues, you may find out
about other people or organisations who can provide helpful information.
Steps for planning a health promotion project
This section presents a step-by-step process for developing a plan and preparing for a
health promotion project.
Planning requires a critical analysis of the problem to be addressed. Problem analysis
is important for developing a goal and objectives for the project that are realistic and
achievable. Once the goal and objectives are set, strategies for achieving them can be
determined. Resources needed in the project, and ways to obtain them, are then
identified. The planning process also includes deciding how the project will be
managed, sustained and evaluated.
Other resources that may assist your planning are available on the web.
 See Planning and Evaluation Wizard, South Australian Community Health
Research Unit, http://som.flinders.edu.au/FUSA/SACHRU/PEW/index.htm
 See ‘Quality Improvement Program Planning System’ (QIPPS),
http://qipps.cs.latrobe.edu.au/
Major steps in planning, sustaining and evaluating a health promotion project
1. Identify the issues or health problems in the community
2. Prioritise the issues or health problems to identify the one that the project will
address
3. Identify risk factors and set the goal for the project
4. Determine contributing factors and state objectives for the project
5. Determine what the strategies will be
163
6. Develop the action plan for the project. DO IT!
7. Sustain the project or keep the project (or some parts of it) going
8. Evaluate the project
 Remember to consider Steps 7 and 8 from the very beginning of the planning
process
All of these steps are explored in more detail in the following pages. Much of this
section is based on a foundation text: Evaluating Health Promotion: A Health Worker’s
Guide by Hawe, Degeling and Hall (1990).
Step 1: identify the issues or health problems in the community
Needs assessment
Clarifying need is an essential part of deciding what issue or problem the project will
address. The term ‘needs assessment’ is used to describe a process of collecting
information that will give a good indication of the priority needs of a community. It
provides an opportunity for the community to become involved in the planning from the
beginning. It helps with allocating resources and making decisions about where to start
with health promotion work.
A definition of ‘needs’
Health needs are understood as being those states, conditions or factors in the
community that, if absent, will prevent people from achieving complete physical, mental
and social health. This would include such things as minimum provision of basic health
services and information, a safe physical environment, good food and housing,
productive work and activity, and a network of emotionally supportive and stimulating
relationships.
Hawe et al 1990:210
Classifying needs
When doing a needs assessment, it is important to consider that needs will be thought
of differently, depending on whom you consult. Needs are sometimes classified as:
•
•
•
•
normative needs
felt needs
expressed needs
comparative needs
Normative needs
Normative needs are needs based on the opinion and experience of ‘experts’
according to current research and findings. For example: Health experts consider that
164
there is no safe level of tobacco smoking. Therefore, a primary health care provider
may strongly advise a client who is a smoker to quit smoking.
The NHMRC recommend that all children be vaccinated against specific diseases.
Suppose it was discovered that many children in a particular population of children
were not immunised against these diseases. This situation would indicate a need for an
immunisation project.
Felt needs
Felt needs are those things that groups or individuals say they want, or the problems
that they think need addressing. For example:
•
many women from a community say that people are drinking at the pub too early in
the morning. The community may decide to address this issue by having the pub
open in the afternoon.
•
the community is demanding more fruit and vegetables in the store. The store
manager may decide to look for a reliable and cheaper source of fruit and
vegetables to meet the demand.
Expressed needs
Expressed needs are shown by the number of people using community facilities and
services. For example:
•
waiting lists for childcare may express a need for more childcare centres
•
very few people using the community sporting facilities may express a need for
alternative activities
Comparative needs
Comparative needs are shown by comparing what is available to one group of people
with what is available to another group. For example:
•
calls for the Council Offices in community X to have a No Smoking Policy because
the Council Offices in Community Y have this policy
•
community A says it should have a basketball court because Community B has one
When determining needs of a community or group, focus on a range of needs and use
of variety of tools to determine each type of need.
 Read more about needs and needs assessments in Hawe et al (1990) and other
references listed in the Bibliography
How to find out about community needs
 Analyse a community profile
 Use a variety of research methods detailed in ‘Information Gathering Tools’ later in
the chapter
165
An example of a needs assessment by survey...
In a Top End community, a community health centre team decided to do a needs
assessment. They were keen to know what community residents thought were the
major issues that they could all work on together. The health team decided to ask the
following questions:
What makes people worried in this place?
What can we do together to make things better in this place?
An Aboriginal Health Worker and a nurse went together to interview family groups. The
Aboriginal Health Worker asked the questions in the language of the family and
translated the answers to the nurse who wrote them down in English. The health team
analysed the data and fed the results back to the community for discussion.
Information from Health Promotion Strategy files
Sharing information from the needs assessment
Sharing the results of the needs assessment with the community is a key part of the
planning process. This process will:
•
raise community awareness about the issues and possible underlying causes
•
stimulate discussion about ways to address the issues
•
get the community more involved in planning and decision-making about the project
 See Chapter 3 ‘Sharing Health Information’
Consider baseline data
Some of the information gathered during the needs assessment may be able to be
used as ‘baseline data’. Baseline data describe the situation or condition at the time the
project or intervention starts. Data collected later during the evaluation is then
compared against the baseline data to see the effect of the project.
See the section on ‘Planning the Evaluation’ in this chapter for information on how to
use baseline data.
Step 2: prioritise the issues or health problems
At the end of Step 1, the project team will have a list of major issues and potential
target groups for the project. There are always competing needs or issues in any
community. Limitations such as time and resources mean that not everything can get
addressed. Issues will need to be prioritised. Needs and priorities vary from individual
to individual, family to family, group to group. It is important to work out criteria to sort
out which issue the project will address.
Questions to guide how needs are prioritised
The following list of questions may help to expand group thinking and discussion on
prioritising needs:
How many people in the community are concerned about the issue?
166
•
What is the felt need and how has this been demonstrated?
•
What kind of community support is necessary for a project to succeed?
•
Who needs to be involved? Are the ‘right’ people concerned and involved?
•
How much support does the project or activity really have?
How serious is the issue or problem?
•
Is the problem affecting a lot of people? (How many directly? Indirectly?)
•
What proportion of the population does it affect?
•
What sort of damage is it doing to Aboriginal culture, physical health, mental health,
other aspects of life?
•
What will happen if nothing is done about the situation?
How easy is it to change?
•
What has already been tried or done which may affect a new approach to the issue
or problem? (Bad past experiences can and do affect community motivation to get
involved)
•
How much assistance will people need to change the situation?
•
How likely are they to have success? What are the barriers and what are the
helping factors (enablers)?
•
How many other things need to change before this particular problem can change?
What kind of resources will it need?
•
Human Resources
- What kind of human resources will it need initially? In the long term?
- What human resources are available within the community?
- How much training and external support will be required?
- Will there be a need to involve people outside the community?
- How easy will it be to get outside help if needed?
•
Funding
- How much will different options cost?
- Where will the money come from? How long will it take to receive it?
•
Materials and equipment
- What kind of materials will be required? What materials are available locally that
could be used?
- Is any equipment needed? Are any buildings required?
167
Before proceeding
•
Did a number of community residents participate in identifying the problem?
•
Have a wide range of people and organisations been consulted?
•
Has all the relevant information been reviewed (literature, community profile)?
•
Did people have accurate information about the problem, causes and possible
solutions?
•
Was this information used in the discussions and consultations?
•
Has the information been fed back to the wider community?
•
Has the project team got the information that it will use as baseline data?
Funding a health promotion project
When thinking about planning a health promotion project, there are two ways to
resource the project:
 use resources available locally
 seek funding from your organization/department, other departments and
organizations, from the Commonwealth, from the private sector or fund raising
activities. Often funds are tied to priorities based on ‘normative needs’. However a
project funded according to these needs can include other community identified
priorities
Confidence gained through participation in successful, well planned projects can
mobilise community action and will. There are numerous examples of situations where
community residents have taken on an idea from outside the community and become
more fully involved in controlling and participating in activities. The following case study
is an example.
Case study: Lajamanu Food and Nutrition Guidelines Project
Increasing community participation and control
The Lajamanu Food and Nutrition Guidelines project came out of improvements in the
supply of healthy food at Lajamanu Store and Takeaway outlet in 2003. To ensure
these improvements would be sustained at the community’s only food outlet, the
Katherine West Health Board worked with Lajamanu Progress Association and
involved community members in promoting healthy food choices and developing a set
of standards to guide future store managers. The guidelines set out the food choices,
variety and quality the community wants to have continuing access to.
Lajamanu community members know that they can use their power as store customers
to demand food that is better for health outcomes.
The project won the 2005 Heart Foundation Kellogg Local Government Award.
“In the Lajamanu Store I get along very well with Jim Butler, the Store manager, and
sometimes when I need help he is always there for me.
In the Lajamanu Takeaway I work with Bones and Chrissy that cook very healthy and
nice food and we work together as a team because they always tell me about the new
168
healthy foods so I can tell my people in the community to buy them and show them
how to cook the same back at home.
I also work very close with the Katherine West Health Board Nutritionist, Alexandra
Walker. Last year Alex taught me about Nutrition but this year I’m going to Batchelor
College to study and have my degree in Nutrition.
I am involved in all of Alex’s projects in Lajamanu like teaching kids at school how to
eat healthy, making them try raw veggies and playing nutrition games to have a little bit
of fun; at the end of the day the kids received a bag full of resources about health and
some healthy foods.
I also explain to my community the results of the Market Basket Survey so they can
know the cost of foods at the Store, the variety and quality of fresh fruits and veggies.
At the Women’s Centre we showed a video about healthy eating and how to look after
Babies, Oldies and ourselves. We cooked soup with lots of veggies of different colors,
brown rice and diced meat; and the Girls had fun cooking wholemeal damper. We also
had diet cordial and fruits.
I also worked with a Nutrition student from QUT, Margie Daly, to develop a resource
that explains the relationship between nutrition and the human body.
For all the good work we’ve done we won an Award from the Heart Foundation that we
received in Darwin at the Crowne Plaza Hotel which made me feel very proud and I
went with Lynette Tasman (Store President), Chrissy and Alex. We also won a High
Commendation from the National panel.
I hope that I keep working as a Nutrition worker in Lajamanu, maybe one day I might
be the expert in Nutrition in my community.”
Kathy Long, Food and Nutrition Worker, Lajamanu
Published in Kid’s Tracks, Issue 2, April 2005
Step 3: identify risk factors and set the goal for the project
Step 4: determine contributing factors and state objectives for the project
There is overlap between Steps 3 and 4, so they are considered together. Both depend
on an analysis of the problem addressed by the project.
Analyse the problem to determine risk factors and contributing factors
Addressing a problem successfully will require the project to focus on the underlying
causes or issues that led to the problem in the first place. In other words, the goal and
objectives of a project need to relate to the underlying causes or issues. Developing a
clear and organised goal and objectives that relate to each other requires some critical
analysis of the problem.
Some terms defined
‘Risk factors’ are any aspect of behaviour, society or the environment that are directly
linked to the health problem. Risk factors lead to or directly cause the problem. Note
that some risk factors can be changed, while others are not able to be modified, for
example, family history of a condition.
Hawe et al 1990:213
169
Examples of risk factors:
•
eating high fat food (behavioural) and having a family history of heart disease
(biological) are both risk factors for heart disease. People can change their food
choices (modifiable) but not their genetics (non-modifiable)
•
direct exposure to bacteria and germs (environmental) may be a risk factor for
diarrhoea. Exposure can be changed
‘Contributing factors’ are any aspect of behaviour, society or the environment that
leads to the risk factors developing. Contributing factors enable or reinforce the risk
factors. They can relate to individual, financial, political, educational, environmental, or
other issues.
Hawe et al 1990:204
Examples of contributing factors:
•
lack of knowledge about low fat diets (educational) and high cost of low-fat foods in
the store (financial) are both contributing factors to the risk factor ‘eating a high fat
diet’
•
poor housing conditions (environmental) and lack of home hygiene (behavioural)
are both contributing factors to the risk factor ‘exposure to bacteria and germs’
Problem analysis
The way to analyse the problem is to first state what it is, and then ask questions like
‘why’ and ‘how’ to identify the causes of the problem. At this point, you may need to
search through research reports, articles and books to see what others have
discovered about the problem.
 See ‘Literature search’ at the beginning of this chapter
The following diagram shows the relationship of risk factors and contributing factors to
the project goal and objectives.
State what the problem or concern is
Identify the risk factors
for the problem
(Ask: why is this a problem? How
does this happen?)
Develop the goal
The goal states what
should change about
one of the risk factors
Develop the objectives
Identify the contributing factors
(Ask: why are there risk factors?
How does this happen?)
The objectives state what
should change or happen about the
contributing factors
170
Steps 3 and 4
The issue or problem targeted by the health promotion project will probably have more
than one risk factor. The project will aim to make a change in one of these risk factors
(as stated in the project goal). Analysis of the health problem helps the project team to
see what complementary projects are needed (either planned by the team or others) to
change the other risk factors.
Developing the project goal and objectives
The goal and objectives:
•
make the plan clear and focus the energies of the project team
•
let people know what they can expect to happen as a result of the project
•
are the basis for planning the evaluation of the project
Goal
The goal is about making changes to the risk factor addressed by the
project.
The goal indicates what the planned, longer term outcome of the project
is.
It is also intended to inspire, motivate and focus people and encourage
team cooperation.
Objectives
Objectives state what changes the project will make to the contributing
factors.
The objectives indicate what the impact will be on the contributing
factors during the timeframe of the project.
The objectives are about what has to change in the short term to get
closer to achieving the project goal.
A well written ‘goal and objectives’ states who will achieve how much of what by when.
Developing a clear, achievable goal and objectives requires good baseline data.
171
Example: problem analysis and development of goal and objectives
State the Problem or Concern
The number of 12-17 year old
males coming to the health centre
with respiratory problems in MayJuly of each year has progressively
increased by at least 5% every
year for the last 5 years.
Identify the risk factors
·
·
·
·
Smoking tobacco (45% of 1217 year old males in this
community smoke tobacco)
High levels of dust
Exposure to bacteria and
viruses.
Overcrowding in houses
Identify the contributing factors
Develop the goal
Reduce the number of 12-17 year old
males who smoke tobacco to 25% (of
the total in this age group) within 2 years
Develop the objectives
·
12-17 year old males unaware 1. Within 6 months, 70% of 12-17 year old
of linkage between smoking
males will have increased their knowledge
tobacco
and
respiratory
of relationship between smoking tobacco
problems
and respiratory problems by at least 50%
·
Store operators not complying 2. Increase compliance with NT legislation by
store operators to 100% within 6 months
with NT legislation about selling
tobacco products to under 18
year olds
·
Older people are supplying 3. Reduce by 50% within 12 months the
cigarettes to 12-17 year old
number of 18-24 year olds supplying
males
cigarettes to under 18 year olds
While there may be many contributing factors, it is advisable to focus on three or four in
order to keep the project manageable and achievable. Perhaps there are other people
in the community willing to tackle the other contributing factors.
172
Before proceeding
•
Are the risk factors directly linked to the priority health issue/problem?
•
Does the goal address one of the risk factors?
•
Do the contributing factors relate to the risk factor chosen?
•
Do the objectives address the contributing factors?
•
Do the risk factors and contributing factors relate to the situation of the target
group?
•
Are the goal and objectives specific and measurable (who will achieve how much of
what by when)?
•
At the end of this chapter, there is a worksheet that can be used for problem
analysis. It is part of the documentation of a full project plan
 See ‘Documenting the Project’ in this chapter
Step 5: determine what the strategies will be
After the objectives are developed, the strategies are determined. Strategies describe
what it is that the project team will do, to try and make the changes required to achieve
the objectives.
Strategies can include things like:
− conducting education sessions about
drug use
− making a video about hygiene
− organising store tours to promote
healthy food
− supporting a health committee
− developing a ‘no smoking’ policy
− training to repair plumbing
− establishing a Night Patrol
− having cooking classes
− planting shade and fruit trees
− providing hand powered washing
machines for each household
− meeting with parents about petrol
sniffing
− offering well women’s and men’s
checkups
− training in how to budget
− doing
screening
and
brief
interventions
− organising an awareness raising
health week
− having a disco or sports event
− organising daily rubbish collection
− advocating for cheaper fruit and
vegetables
− presenting a data feedback session
 See Chapter 4 ‘Strategies for Health Promotion’ in this volume
 See Volume 2 for ideas for alcohol and other drugs, environmental health, nutrition
and physical activity and mental health strategies
173
Questions to ask to help determine strategies
•
How will we achieve our objectives?
•
What are the most useful and appropriate strategies for the target group?
•
Will interested community residents be involved in carrying out the strategies?
•
Who else might have ideas that could help us?
•
Is there anything else that we need to find out first?
•
What strategies have been used in the past to address this issue?
•
How well did the past strategies work? Were there any problems? What can we
learn from them?
•
In general, what resources are needed for each strategy? Do we have them or can
we get them?
Before proceeding
•
Were interested community residents/target group members involved in deciding on
the strategies?
•
Will the strategies be appropriate for the target group?
•
Do the strategies reflect the essence of the Ottawa Charter? (See Chapter 4
‘Strategies for Health Promotion’.)
•
Do the strategies offer cultural security? Do they recognise, promote and respect
cultural practices?
 See ‘cultural security’ in Chapter 1 Public Health in Context and Chapter 7
Glossary
Relationship between the goal, objectives and strategies
The process for planning a project begins with the big picture (issue or problem). It is
an analysis of the big picture issue that gives the framework for developing the plan from the longer term goal, to more specific objectives, down to the actual strategies,
and finally the detail of individual actions.
The flow diagram in Figure 3 is an overview of the relationship between problem
analysis and plan development.
174
Find out the issues
(Need Assessment)
State the health
issue or problem
Prioritise the issues
Develop the long term GOAL
how much of
what by when)
Resources
Strategy
(Who & What)
Activities
Strategy
(Tasks to do)
Evaluation
(How is it going?)
What will be
done to reach
the objectives?
Develop
OBJECTIVE
Develop
OBJECTIVE
(Who will do
how much of
what by when)
(Who will do
how much of
what by when)
Strategy
Strategy Strategy
Strategy
(By When)
Develop
OBJECTIVE
(Who will do
Determine
contributing
factors
Time Frame
Determine risk
factors
Figure 7: Analysing the problem and developing the plan
175
Step 6: develop the action plan
Once the strategies of the project are determined, the project team can write the action
plan. The action plan includes all the specific activities, large and small, that will need
to be done to implement each of the strategies. It also says who will carry out these
activities, when they will be completed and how they will be evaluated.
The more details are worked out for the strategies, the easier it will be to accurately
identify all the activities to be done. If the project is large, with many stages, it may not
be possible to detail all the specific activities at the beginning of the project. If the
project objectives must occur in a special time sequence, wait for some early work in
the project to be completed before working out the detail of the later phases.
Detailed documentation of the activities, responsibilities and time frames will help each
team member to plan his or her part of the project. Detailed documentation is also
important for maintaining accountability within the team and between the team and the
community or funding agency.
 See ‘Documenting the Project’
The action plan will also list the resources required to do the project successfully.
Resources will be required throughout the whole project, from needs assessment
through putting strategies into action to final report writing.
Resources can include human resources, financial resources, materials, equipment
and venues.
Examples of resources
Human Resources
- The project team
- Additional community
residents
- Other organisations or
groups working on
similar projects
- Key informants
- Stakeholders
Financial resources
-
Existing budget
Donations
Community funding
User pays/
contributions
Other available funds
Materials, equipment,
venues
-
-
Education aids
Art and craft materials
Display materials
Data recording sheets,
folders, evaluation
sheets
Food
Music, equipment
Vehicles, machinery,
tools
Computers, TV, videos,
DVDs, cameras
Places and buildings
176
The best resources for a community health promotion project are those that come from
the community or are developed by interested community residents. Projects that use a
community development approach value and build on existing skills and knowledge,
support people to develop further skills and confidence and to decide how things
should be done.
“For participation to be empowering it must not only involve the development of skills
and abilities, but also a political concern to enable people to decide and take action”
(Laverack 2004:78)
If projects use human resources from outside the community all the time, community
members may feel that their resources are not valued, or that they have no resources
of their own. Such an approach could be disempowering and would be unlikely to bring
about an effective level of community participation and sustainable change.
Use the resources of the community whenever possible. It will build community
confidence, self-reliance and enthusiasm. It is more likely to improve people’s
individual and community experience of capacity.
 See chapter 4 ‘Strategies for Health Promotion’
Questions to help identify resources
•
Who can help to put the strategies into action?
•
What skills are there in the community that can be drawn on and built upon?
•
What venues or places need to be organised? Are they appropriate for the
activities? Will people feel comfortable there?
•
What equipment is needed? Is it in the community? Will the project team need to
borrow or buy equipment?
•
Do we need any money for the project? Can it be funded by the community
council, community residents or health centre budget?
•
Where will we get the education resources?
•
What resources have worked well in the past with the target group?
Before proceeding
•
Have all members of the project team been involved in developing the action plan?
•
Are the activities achievable with the current resources (time, money, staffing,
equipment, and so on)?
•
Are the resources appropriate?
•
Does the project use community residents’ skills, knowledge and resources?
•
Do people know what their responsibilities are?
•
Are they confident, willing and able to carry them out?
177
Step 7: sustain the project
Planning for sustainability means thinking of ways to keep the project (or important
parts of it) going after its official end. It then becomes an ongoing part of community
activity.
Many factors can threaten the sustainability of the project. Project teams need to be on
the lookout for these factors and have a plan for dealing with them. Sustainability
needs to be considered from the initial planning stages of a project.
Questions to consider when planning for sustainability
•
How will the project team assess the ongoing need for the project?
•
Are community residents involved in the management of the project?
•
What skills and facilities are required by the community to manage and maintain the
project?
•
Is training needed? Is it available? How will the community access it?
•
Who can continue the work?
•
How will the community secure ongoing access to financial and other resources to
do the project?
•
How will interest, commitment and ownership be maintained?
•
How will the direction and focus of the project be maintained?
•
Is there further support required from outside the community?
•
If yes, how will the community secure this outside support?
•
Is there enough flexibility in the project to respond to changing circumstances?
People will be more likely to keep the project going if
•
they feel that the project is theirs and that they have control over it
•
they are working together well
•
they can see positive changes happening because of the project
•
they are learning new skills and their confidence is increasing
•
they get recognition for their work
•
all elements of the project are suitable and relevant to them - language, style, pace
of work, strategies, evaluation methods, resources
•
the people from outside the community, who are working on the project, are
credible to the community
178
•
accountability to the community has been built into the project
Read the following case study and identify which factors listed above have helped to
sustain the Strong Women, Strong Babies, Strong Culture Project.
Strong Women, Strong Babies, Strong Culture
A Case Study in Project Sustainability
The Strong Women Program began in early 1993 because many Aboriginal women,
nutritionists and doctors were concerned about babies being born too small, not
growing well and being anaemic.
Strong Women workers … work with the health workers, pregnant mothers and
community people to make sure that young pregnant girls are going for their pregnancy
check-ups early and eating well.
Strong Women workers… are selected by the Aboriginal community to work on this
program. These women have specialised cultural knowledge related to their local
community. Strong women workers work hand in hand with nutritionists, community
based health workers, local schools and other women in the community.
We also have Strong Women committee members at each camp so that if pregnant
women need certain bush medicine or bush tucker, the Strong Women workers,
committee members and the old women go out and collect bush medicine or bush
tucker for them.
This program utilised the knowledge and skills of both Aboriginal people and the
medical and nutritional professionals. The outcome was an effective program
implemented by Aboriginal people themselves.
The initial 18 month trial of the program has proved to be very successful and effective.
Funds have now been provided by the Northern Territory Government for the program
to operate for the next three years with proposed expansion into other regions and
communities.
Extracts from Fejo 1994,
The Strong Women, Strong Babies, Strong Culture Program
in Aboriginal and Islander Health Worker Journal 18 (6):16
and Bear-Wingfield 1996:107-113
More than a decade on … this widely acclaimed program continues to succeed and
grow. It has been extended to many NT communities and used as a model in WA and
in PNG. It is an excellent example of a sustainable health promotion program.
Step 8: evaluate the project
There is a whole section on evaluation, what it is and how to do it.
 See ‘Thinking about Evaluating the Project’ later in this chapter
179
Documenting the project
Documentation will be a major component of the project. It is very important for a
number of reasons:
•
to use in project evaluation
•
to have an accurate record of the events
•
for ongoing feedback about project progress to the community, other stakeholders
and funders
•
for putting together the final reports
The whole project team, plus interested community residents, needs to be involved in
decisions about what gets documented and the methods used. There may be many
methods used to document the project. The methods of recording will be determined by
the type of information and its later use. For example, financial information may be best
recorded in a spreadsheet, while information about an activity might be recorded by
taking notes and photographs.
Decide which aspects of the project will be documented, how they will be documented
and who should be involved in the documentation.
Look at the information being collected from time to time to make sure that it is meeting
the project team’s needs.
Questions to help plan the documentation
•
Who wants and needs to have information about the project?
•
What are the different kinds of information that will need to be recorded?
•
What special information will the different stakeholders require?
•
What are some suitable methods of recording the information?
•
Which methods will be acceptable (for example, permission to use photos, videos)?
•
Who will take responsibility for keeping records?
What needs to be documented
•
Processes and outcomes of needs assessment
•
Meetings
•
Project plans and changes to plans
•
Management information such as who is involved, funding and how the money is
spent, resources and equipment used
180
•
Processes used throughout the project
•
Events that occur during the project that impact on it
•
Strategies and activities and what happened
•
Evaluation information such as data to compare with baseline data
•
Who is attending project activities
•
Anything else that is significant to the project
Common methods of recording project activities and progress
−
−
−
−
Writing notes and reports
Taking minutes of meetings
Making posters or banners
Developing spreadsheets
−
−
−
−
Making a tape recording
Making a video
Taking photos
Doing paintings
Note: minutes of meetings are brief notes that record what was talked about.
 Record the decisions made and responsibilities allocated in meetings
 Make sure all the relevant people get copies of the minutes
Collecting relevant information and documenting it accurately are vital for evaluation.
 See ‘Thinking about Evaluating the Project ‘ (next section)
Personal field journal
We recommend that you also keep a personal record or ‘field journal’ of your
involvement in the project. As well as being good documentation of what you are doing,
it will help you to reflect on and understand your work and your environment.
181
Recording a project plan
There are several ways of recording a plan. The main point is that it includes all the
necessary information and is easy to use by all members of the project team. Following
is an example of one way to record a plan.
 Photocopy and use the blank worksheets at the end of this chapter
The following example of a completed worksheet is for a health promotion project
called ‘Breathe Easy’. The problem is ‘The number of 12–17 year old males coming to
the health centre with respiratory problems in May–July of each year has progressively
increased by at least 5% every year for the last 5 years’.
The project focuses on ‘smoking tobacco’ as a key risk factor for the ‘respiratory
problem’ in this target group. This example shows strategies for only one of the
objectives. A ‘real life’ project will have strategies for all of the objectives.
182
Example: worksheet for Problem Analysis
Problem:
The number of 12 – 17 year old males coming to the health centre with respiratory problems in May – July of each year has
progressively increased by at least 5% every year for the last 5 years
Risk Factors
What leads directly to or
causes the problem?
Smoking tobacco (45% of 12 –17 year old males in this community smoke tobacco)
High dust levels
Exposure to bacteria and viruses
Overcrowding in houses
Chosen Risk Factor:
Choose one risk factor to address
Goal:
Goal addresses the risk factor
Smoking tobacco (in 12-17 year old males).
Reduce the number of 12-17 year old males who smoke tobacco to
25% (of the total in this age group) within 2 years.
Contributing Factors:
Objectives:
Factors which lead or contribute to the risk factors
Choose which contributing factors will be addressed.
Write objectives to match the contributing factor/s
12-17 year old males unaware of linkage between smoking tobacco 1. Within 6 months, 70% of 12-17 year old males will have increased
and respiratory problems
their knowledge of relationship between smoking tobacco and
respiratory problems by at least 50%
Store operators not complying with NT tobacco legislation about selling 2. Increase compliance with NT tobacco legislation by store
tobacco products to under 18 year olds
operators to 100% within 6 months
Older people are supplying cigarettes to 12-17 year old males
3. Reduce by 50% within 12 months the number of 18-24 year olds
supplying cigarettes to under 18 year olds
183
Example: Worksheet for Health Promotion Project Planning (‘Breathe Easy’ Health Promotion Project)
What is the problem?
The number of 12 – 17 year old males coming to the health centre with respiratory problems in May – July of each year has progressively increased by at least
5% every year for the last 5 years.
Project Goal: What the project will achieve in the longer term (outcome) : who will achieve how much of what by when?
Reduce the number of 12-17 year old males who smoke tobacco to 25% (of the total in this age group) within 2 years.
Objective 1: What needs to be achieved to reach the goal: who will achieve how much of what by when?
Within 6 months, 70% of 12-17 year old males will have increased their knowledge of link between smoking tobacco and respiratory problems by at least 50%.
Strategies
(How to achieve Objective 1)
Develop and implement
school sessions on effects
of smoking for post
primary classes
Engage male non-school
attendees (aged less than
18 yrs) in development of
resources with nonsmoking messages
Actions/Activities
(Tasks to do)
Resources required
Time frame
(When will it be done by?)
Evaluation
Negotiate with Principal
for time and resources
Meeting date & time, names of
health staff to talk to Principal
1 week
Principal’s agreement to commit
time and resources.
Work with Aboriginal
teachers to develop
session plans
Time, recording materials,
ideas from other schools,
Curriculum Adviser (Ed Dept)
1 Month
Session developed
Conduct sessions
Venue, videos, worksheets,
model of body
Second school term
Sessions documented, student
satisfaction surveys, pre and post
test of knowledge
Identify source of funding.
Check that project meets
criteria, complete funding
submission.
Funding submission form/letter.
Assistance from Health
Promotion Officers to complete
form
3 months
Conduct production
sessions
Art materials, venue, access to
laminating, copying
1 month after funding
received
Good quality resources produced,
increased knowledge of key
messages
Display in community
buildings
Space (permission to use)
Within one month of
production sessions
Target group response and
understanding of resources
(Who will do it? What is needed?)
(How will the team know how it is
going? What will be measured?)
Funding approved
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Thinking about evaluating the project
Evaluating a project is about looking critically at what is happening in the project and
making a judgement about its value, worth or benefit (see the word ‘value’ in
evaluate). Evaluation is important because it can tell us:
•
how the project is going
•
what effect it is having
•
what changes we need to make to improve it
Often people get slightly threatened by the thought of evaluation. It may suggest
criticism by others. The essence of evaluation is not to lay blame or fault on people,
but to find ways of doing things better and to show what has gone well. Evaluation is
a positive process. There are some ways of evaluating that you will be able to
integrate easily into the project work.
Why evaluate?
Some reasons to evaluate include:
•
to see if the project is working
•
to see if it achieved what was planned
•
to justify doing the project
•
to know what changes to make
•
to see if the effort is worth it
•
to justify the resources used
•
to share experiences
Who is the evaluation for?
Because evaluation is about making a judgement about the value of the project,
people’s own values, knowledge, responsibilities and accountabilities will affect the
results they want and expect from it. Therefore, it is very important that everyone
with an interest in the project (each ‘stakeholder’) is clear about what the project is
for - a result that comes from good planning.
Stakeholders in evaluation
The community
The community will be expecting the project team to:
•
keep people informed and involved
•
check that the project processes and activities are appropriate
185
•
ensure the project is responding to agreed community needs
•
make sure the project provides a good chance for change
The project team itself
The project team will want to evaluate the project to:
•
see that the project is going according to plan
•
confirm that it meets community needs
•
know whether it achieved its goal and objectives
•
know that community residents participated
•
get feedback on its work
•
be professional in its work
Employers
Members of the project team employed by an organisation outside the community
must also be accountable to their employer. Employers will be expecting to see that:
•
money was well spent
•
time doing the project was justified
•
the project contributes to knowledge and understanding
•
the experiences are shared with others
Funding bodies
The funding body or agency might be looking to see that:
•
all the money got spent in the right way
•
the project happened within the time frame
•
the project achieved its goal and objectives
The project team is accountable to the funding body to:
•
maintain accurate financial records
•
justify spending
•
report on progress
•
share knowledge and experience
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Remember that different stakeholders may have different expectations or interests
to be met or preserved. They may judge the value of the project by a different set of
criteria than those listed above.
Planning the evaluation
Evaluation is a type of research and it will need to be planned right from the
beginning of the project. It is important to plan so that the information required for
the evaluation can be obtained during the project. If evaluation is not thought about
until the end of the project, valuable information may have been lost. Before
planning the evaluation the project team needs to consider some basic questions:
•
who are we evaluating for?
•
what do they want to know?
•
what do we want to know?
•
how are we going to find out?
•
what does the information mean?
When the project takes a community development approach, then community
partnership in evaluation means that people take a significant role in deciding when,
how and what to evaluate. Community residents need to be involved in selecting the
methods to be used in collecting and analysing data, in preparing reports, and in
deciding how to use the results and put their recommendations into practice
(Feuerstein 1986:12).
Evaluation that empowers participants is characterised by “…respect for all parties
as equal yet possessing different values, concerns and meanings, all of which are
equally important; a determination to seek all parties’ perceptions; an opportunity for
all to discuss and interpret findings in order to reach a consensus on the best
explanation.” (Labonte & Robertson (1996), Wadsworth and McGuiness (1992) in
Laverack 2004:118)
Just as a written plan is prepared for the project (with a goal, objectives, strategies,
activities, resources and timeframes), it is also wise to produce a written plan for the
evaluation.
 There are many publications on health program evaluation that include models.
See ‘Bibliography’ at the end of this chapter.
 There are useful websites for planning evaluation. See:
‘Planning and Evaluation Wizard’, a software tool for people working on health
promotion projects
http://som.flinders.edu.au/FUSA/SACHRU/PEW/howto/planning.htm
‘More information about evaluation’:
http://www.healthpromotion.act.gov.au/howto/evaluation/moreinfo.asp
187
The Eight Stage Model of Evaluation
The Eight Stage Model of Evaluation is one way to plan the evaluation. More recent
models are available but this one is a particularly useful guide. It offers specific
questions to focus the planning of the evaluation into manageable stages. (based on
Macpherson 1986).
Figure 8: Eight Stage Model of Evaluation
Source: Macpherson 1986:4
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Types of evaluation
Process evaluation
May be the first type of evaluation you use, as it is suitable for early stages in a
project. It focuses on the process of delivery – the strategies and activities of the
project, quality of resources, who the project is reaching and the views of the
participants (staff and community participants)
Impact evaluation
Measures the immediate effects of the project and indicates whether objectives are
being reached. It shows you whether you are on the path to achieving the project
goal. Impact evaluation is conducted after process evaluation.
Outcome evaluation
Measures the longer term effects of the project. It indicates whether the project is
achieving its goal. Outcome evaluation is done after impact evaluation.
Based on Hawe in Moodie & Hulme 2004:17-19
Focus questions for process, impact and outcome evaluations
One of the main components of evaluation research is collecting information. The
information is used to demonstrate how the project is going and what it has
achieved. To get the best information, you need to ask the following questions.
Linking evaluation questions with the project plan
Part of the plan
Evaluation questions to answer
The Issue
How do we know it is a problem?
 Do an analysis of the problem, a literature search and
define and collect baseline data
Strategies
Objectives
The Goal
Did we reach our target group?
Were the people satisfied with the project?
Did the activities go according to plan?
Were the resources used suitable for the job?
 Do a process evaluation
Have we achieved our objectives?
Has the project made the changes it planned to
along the way?
 Do an impact evaluation
Have we achieved our goal?
Has the project achieved the longer term changes it
planned to?
 Do an outcome evaluation
189
Collecting information for a process evaluation
In a process evaluation, the strategies, activities and resources of the project are
evaluated. Specific questions for a process evaluation may be:
Is the project getting to the people it is aimed at (the target group)?
•
Who attended /is participating?
•
What percentage or how many of the target group are participating - everyone or
just a few? (If the intended target group was very specific, then the information
will also have to be very specific.)
Are people satisfied with the program?
•
Levels of participation (high or low? active or passive?)
•
Do they keep participating or drop out?
•
What kind of feedback are you getting from people?
•
Are people talking about it? What do they say?
Is the project going according to plan?
•
Are all the different parts that were planned happening? If not, why not?
•
Are people carrying out their agreed responsibilities? If not, why not?
•
Has the project team followed the plan? If not, why not?
•
Has the project team used the resources as planned? If not, why not?
•
Is the project within budget?
•
Are the activities happening within the planned time frame?
Are the health education resources appropriate and good quality?
•
Can people tell you what the resource is about?
•
Were interested community residents involved in making or choosing the
resources? Do the resources offend anyone in the community?
•
Did you need to get approval from any Aboriginal people to use the resources?
•
Are the resources worth the money you spent on them?
•
Will you be able to use them again?
190
•
Did the resources do the job you wanted them to?
Here are some useful questions to ask to determine if resources are appropriate and
good quality.
Helpful Hints For Evaluating Leaflets and Other Resources
Attraction:
Does the leaflet create interest?
Catch people’s
attention? What do people like most and least about it?
Comprehension:
Is the leaflet easy to understand? Is there anything
confusing in the leaflet?
Acceptability:
Is there anything offensive or irritating in the leaflet?
Does it conflict with cultural norms (especially if
translated insensitively into other languages)?
Personal
Involvement:
Does the leaflet seem to be directed at the reader
personally?
Persuasion:
Is the leaflet convincing? Does it seem to persuade the
reader to do something?
Hawe et al 1990:70
Collecting information for impact and outcome evaluations
Impact and outcome evaluations both measure change. The kind of data you will
collect and the information you will look for will depend on what the project is trying
to do or change - it must match the project goal and objectives.
Some examples of the type of things that can be measured for impact and outcome
evaluations are:
How people behave
For example:
- what people buy from the store
- how many people smoke tobacco (males, females, ages)
- how many people drink alcohol unsafely (males, females, ages)
- how many people throw rubbish on the ground
What people know
For example:
- which foods are low in sugar
- the link between unsafe sex and STDs
- what smoking tobacco does to the body
- how alcohol affects diabetes
How ill people are (morbidity) and how many people die (mortality)
For example:
- how many and who has diabetes
- how many and who has died from heart disease
- how many babies are not growing well
- how many and who has respiratory problems
191
What people believe and feel about themselves, an issue or other people
For example:
- what people believe about how much control they have over their lives
- what people believe causes illness
- what people feel about participating in a health promotion project
- what people feel about others who drink a lot of alcohol
How people participate in community life and activities (community participation)
For example:
- numbers of people participating in community meetings
- people talking about their community and planning together
- levels of participation in cultural and sporting activities
- people working together to sustain a project in the longer term
How people live, work and play
For example:
- what proportion of the population has a safe and functional home
- number of people who have meaningful, paid employment
- policies in place to protect health (‘No Smoking’ policy in the council offices)
- access to recreational facilities (oval, basketball court, art/craft activities)
How to collect the information
There are many ways to gather information that will help the project team evaluate
the project. It is important that the team is very clear about:
•
what information needs to be collected
•
how it will be collected (method)
•
the likelihood that the chosen method/s will provide the information needed
•
the necessity of using the same method to collect information later in the project
Methods of collecting information are described in the sections ‘Research tools:
ways to collect information’, ‘Documenting the project’ and ‘Information gathering
tools in planning and evaluation’.
192
When to collect the information for process, impact and outcome
evaluation
1
Baseline Data
Starting
situation
4
Outcome
Evaluation
2
Process
Evaluation
Goal
Strategies
3
Impact
Evaluation
Objectives
Step 1: baseline data
Baseline data describe the situation before the project or intervention happens.
Therefore, baseline information must be collected before the start of a project. It is
used during the project to indicate progress towards the goal and objectives and
after the project to measure the amount of change. The information collected in the
needs assessment can be part of the baseline data.
It is important that the information collected and used for baseline data actually
describes the situation that the project goal and objectives are addressing. If the
information is not relevant, you will not be able to evaluate the goal and objectives
properly.
Records from the Northern Territory Living With Alcohol (LWA) program, Alcohol
and Other Drugs Program, provide a good example of the use of baseline data in
evaluation (see below).
 See ‘Alcohol and Other Drugs’ chapter in Volume 2 for information about Alcohol
and Other Drugs Program activities
Baseline data and evaluation: an example from program records
Northern Territory Living With Alcohol (LWA) Program
Goal
To reduce alcohol related harm in the Northern Territory by 2000.
Objective
193
To reduce alcohol related road accidents by 56 per cent. (Note: This objective is one
of several objectives. Only one is used for the purpose of this example).
Program Activities
Examples of strategies used to reach this particular objective included:
− ‘Drinksense’ program promoting responsible drinking among patrons of hotels
and clubs
− media campaign discouraging drink driving
− strengthening of legislation to increase severity of penalties for drivers exceeding
0.05
− increased Random Breath Testing (RBT) by Police
Data
Year
1991*
1992
1993
1994
1995
1996
1997
Number Of
Accidents
1749
1721
2295
2518
2726
2665
2325
No. AlcoholPercentage
Related
Alcohol-Related
357
20.4%
284
16.5%
351
15.3%
342
13.6%
307
11.3%
366
13.7%
249
10.7%
*LWA Program began in November 1991
Although not shown in the table, in the period 1982-1990 the annual percentages of
alcohol related accidents fluctuated, but was consistently within the range 19.7 per
cent to 25.3 per cent. The 1991 figure of 20.4 per cent is used as baseline to
measure progress towards the objective of a 56 per cent reduction by the year 2000.
These data indicate a steady decline since the establishment of the program.
Comparison of the 1997 figure with the 1991 baseline figure shows the reduction:
=
Baseline Figure-1997 Figure
Baseline Figure
x 100
20.4 – 10.7 x 100 = 47.5%
20.4
This information suggests steady progress towards the objective of a 56 per cent
reduction by 2000.
=
Step 2: information for process evaluation
Data used to measure the project strategies are collected as the project proceeds.
Data collection needs to be coordinated with the actioning of the strategies.
For example, the numbers of men who came to the well men’s check and education
session need to be recorded at the time. What people thought about a video being
shown in the health centre needs to be observed while they are watching and their
responses collected just after the video is finished.
As shown in the planning section of this chapter, the strategies of a project are the
methods that the project is using to achieve its objectives. The strategies must be
evaluated before the objectives can be evaluated. If the strategies are not going well
194
(see the four questions about process evaluation explored before) then there is little
chance of reaching the objectives. Therefore, there is little point evaluating whether
the objectives have been reached.
 Analyse why the strategies are not going well and plan again
Step 3: information for an impact evaluation
In order to see whether the objectives have been achieved, it is necessary to collect
data which relate to the objectives:
•
immediately before the corresponding strategies are put into action
•
then after the strategies are completed
Compare the two sets of information. Is there a difference? What is the difference?
Is it what was being aimed for? Has the objective been achieved?
Example of process and impact evaluation processes
Objective
Double school children’s knowledge about the link
between smoking tobacco and health, by the end of the
week.
Strategy
Deliver education session to school children on link
between smoking tobacco and ill health. Do it in
partnership with Aboriginal teacher
Step 1
Collect baseline data
Before actioning the strategy, find out children’s
experiences with smoking tobacco. Conduct a simple
test finding out what children know and believe.
You now have baseline data.
Step 2
Implement the strategy
and conduct a process
evaluation
Show the effects of tobacco on the body. Build on
children’s stories and experiences. Conduct a process
evaluation to make sure that the strategy was well
implemented.
Step 3
Conduct an impact
evaluation
After the strategy has be actioned, conduct a simple
test. What do the children know and believe now?
The difference in knowledge and beliefs now compared
with before the education session is the measure for
the impact evaluation.
195
Step 4: information for an outcome evaluation
Collecting data to measure the goal is done at the end of the project. It is then
compared with the baseline data that described the situation just before the project
started.
The goal is reached by achieving the project objectives. If the impact evaluation
shows that the objectives have not been met, then there is little point measuring to
see if the goal has been met.
Sometimes changes will need to be monitored on a regular basis after the project
has been implemented. It may take some time for the longer term outcomes to show
up. It will also be necessary to see if any changes that occurred immediately after
the project have been maintained.
The amount of time required for monitoring change and before final evaluation of the
goal will vary, depending on what the goal is and how quickly change can be
expected. This time factor is something the project team will have to think about and
discuss when planning the evaluation. Knowledge levels may change before
attitudes or beliefs change. Behaviours, policies, legislation and other social factors
may need to change before health status will change. Some health conditions are
more readily changed than others.
The information in the following case study is used to show an example of an
outcome evaluation and how the different types of evaluation are related to each
other.
Outcome Evaluation: A Case Study
Taps, showers, kitchen sinks and toilets: Anything to do with Chronic
Diseases?
…Ramingining Community has over the last 12 months improved the functionality of
the health hardware in most of the (54) local houses and this seems to have had a
remarkable effect on the health of the people.
By surveying the houses (as part of the Environmental Health Infrastructure
Minimum Standards Project – EHIMS) and testing every power point, tap, shower,
toilet and then providing a list of all the problems to the tradesmen, the Community
has been able to improve the functionality of the houses dramatically.
The houses were rated for health functionality out of a possible 21[points]. In 1997
the Mean Rating was 8.9/21, in 1998 this rose to 13.6/21.
At the same time there seems to have been some impressive movement on the
health front. The numbers of people treated at the health centre [presentations for
treatment] have dropped from around 300 a month (the mean over the 6 months
prior to the project) to 150 a month (the mean over the same 6 months of the
following year).
Dramatic drops seem to have occurred in the numbers of –
Skin infections/scabies cases - down 69%
Respiratory infections - down 39%
196
Diarrhoea and Vomiting - down 35%.
[Note: These health problems have been linked to poor environmental conditions.]
Extracts from a report by Bill Hardy (1998) published in ‘The Chronicle’ 2(4):1
The goal of this project might be to reduce by 50% the number of people being
treated each month at the health centre for environmental related health problems
within 12 months of starting the program.
The objective might be to increase the functionality of the houses by 50% with 12
months of starting the program.
The major strategy might be to fix all damaged and non-functional taps, toilets,
showers and kitchen sinks and faulty power points.
Step 1
Collect baseline data
Step 2
Implement the strategy
and conduct a process
evaluation
Step 3
Conduct an impact
evaluation
Step 4
Conduct an outcome
evaluation
Before the strategy is actioned: Assess the functionality
of houses and rate them out of 21 possible points. The
mean rating is 8.9 points out of 21 points this figure will
be the baseline figure to measure achievement of the
objective. Check health centre records for the number
of treatments per month in the 6 months before the
project. There is an average of 300 treatments per
month. This figure will be the baseline figure to
measure achievement of the goal.
A plumber is employed and provided with a list of
houses with damaged plumbing. The plumber carries
out the repair work. At the same time an electrician is
employed to repair faulty power points. Conduct a
process evaluation to assess how well the strategy was
carried out.
Assess the functionality of houses and rate them out of
21 possible points. Compare this figure with the
baseline figure. The mean rating is 13.6 points out of
21 points. There has been an increase of 52.8%. This
figure is the measure for the impact evaluation. The
objective has been achieved.
Check health centre records for the number of
treatments per month in the 6 months after the project.
There is an average of 150 treatments per month.
There has been a reduction of 50%. This figure is the
measure for the outcome evaluation. The goal has
been achieved.
197
Information gathering tools for planning and evaluation
Questionnaires
A questionnaire is one of the most commonly used ways to collect data for project
planning and evaluation. Before you develop your own questionnaire, check the
literature to see if an appropriate questionnaire already exists. If not, here is a
suggested process for writing your own questionnaire.
Steps in questionnaire development
Step 1
Write down the broad areas you want to cover in your questionnaire.
Do not turn them into questions just yet. The point is to make sure
you have covered all topic areas adequately
Step 2
Think about what you are trying to measure (knowledge? attitude?
belief? behaviour?). The purpose will determine the style of question
Step 3
Write your questions:
•
Are all questions relevant and necessary? Is the language
appropriate and specific enough?
•
If self-administered (that is, the person fills in the
questionnaire), are instructions on how to complete the
questionnaire clear?
•
Is it well laid out on the page with space to write answers?
•
Is it too long? Long questionnaires are very tedious
Step 4
Get feedback on the questionnaire from colleagues
Step 5
Modify your questionnaire based on comments from colleagues
Step 6
Pilot the modified questionnaire with a few people from the target
group. Piloting means testing your questionnaire to make sure that
there are no flaws in it and you are getting the information that you
need
Step 7
Revise the questionnaire
Step 8
Do a second pilot
Step 9
Do a final revision before asking people to complete the questionnaire
Tips on writing a questionnaire
 Keep the questionnaire simple and clear
 There are different ways to ask questions. Consider having a mix of question
types as follows:
Open ended
For example: what did you like least about the session?
198
Closed
For example: do you smoke tobacco? (circle one) Yes/No
Likert Scale
For example:
it’s okay to drink alcohol and then drive if there is not much traffic about
(circle answer)
strongly
agree
agree
not sure
disagree
strongly
disagree
Multiple choice
For example:
what is the legal Blood Alcohol Concentration (BAC) when driving a motor
vehicle? (tick one box)
0.5
0.00
0.05
0.08
 There are some question types to avoid:
- overly long questions
- asking two questions in one (‘double-barrelled’ questions)
- questions using unfamiliar technical language or strange words
- questions that suggest an answer (‘leading’ questions)
 Put sensitive questions later in the questionnaire
 Ensure questions are in a logical sequence
 Ensure questions will generate valid and reliable data (see ‘Glossary’)
 Think carefully about how you are going to analyse the data and whether any of
the responses can be quantified
 There are many useful books on questionnaire design. See:
- ‘Bibliography’ at the end of this chapter
- “Glossary of questionnaire design and psychology’ on Audience Dialogue
website (Aust) http://www.audiencedialogue.org/gloss-quest.html
Interviews
Interviewing is one of the most important methods used in project planning and
evaluation. An interview is a face-to-face meeting between two or more people
where an interviewer asks questions to obtain information from one or more
respondents. Sometimes interviews take place by telephone.
There are two main types of interviews:
•
individual interview, where there is one interviewer and one respondent
199
•
group interview, where there is one interviewer and several respondents
 See ‘Bibliography’ for some useful books and articles on interviewing methods
Structured and semi-structured interviews
An interview can be ‘structured’ or ‘semi-structured’.
Structured interviews
Structured interviews are interviews in which the question and answer categories
have been pre-determined. Specific questions are asked in a specific order. The
interviewer uses a questionnaire that is followed exactly. Therefore, respondents are
limited in how they can answer the questions.
This type of interview can produce both qualitative and quantitative data.
Semi-structured interviews
Semi-structured interviews have no fixed wording of questions or ordering of
questions. The interviewer has a list of the main topics and some open questions
(called ‘probes’) to be covered so that the interview does not go too far off track.
Respondents have more scope in how they answer the questions. This type of
interview generates qualitative data.
Interviewing tips
 Choose the right setting. Find a place that will be comfortable for the respondent
 Be organised. The respondent has given his/her time to be interviewed
 At the beginning of the interview explain who you are and why you want to do the
interview, and how the information will be used (see ‘Ethical matter’ in this
chapter)
 If you intend to use a tape recorder, ask first. Remember that some people do not
feel comfortable speaking with a tape recorder running
 Relax. If you do, there is more chance that the person you are interviewing will
also relax
 If people are used to speaking in a language other than English try to get an
interpreter. Aboriginal people may feel more comfortable with an Aboriginal
interviewer, young people with other young people and so on
 Listen carefully. Be aware of your body language
 Do not express an opinion; remain impartial. Especially, do not argue
 When you get to the end of the interview, ask the person if there is anything else
he/she would like to say or if there are any questions. Thank the person for
his/her time and interest
 See the ‘Bibliography’ for references about interviewing
200
Surveys
A survey is the gathering of information about a topic, area or group of people.
Surveys commonly use questionnaires to collect the data.
Ideally, a survey could include everyone in the target population (group of people) of
interest. When the population is relatively small (for instance, the population of
people over 50 years of age in a community of 200 people), it will be practical to
survey everyone in that population. In the planning and evaluation of most
community projects, you will probably be able to survey the whole population of
interest.
When the population is large, surveying everyone is expensive, time-consuming and
unnecessary. A sample of people taken from the population can tell us what we
want to know about the whole population. However, how you choose the sample is
critical and will determine what conclusions you can draw.
Some ways to choose the sample
Simple Random Sampling
Everyone in the target population has an equal chance of being chosen in the
sample. Individuals are chosen at random, that is, by picking names out of a hat or
by giving everyone a number, and using a random number table (from a statistics
book) to select the ones for the sample.
Systematic Random Sampling
An example of this kind of sampling is selecting every tenth name from the electoral
role or telephone book to include in the sample, until the required sample size is
reached. Another example is selecting every fourth patient file from the filing
cabinet. The first file name is selected randomly.
Opportunistic (or Convenience or Street Intercept) Sampling
Using this method, anyone could be part of the sample. An example would be
standing outside the store and interviewing any available person.
This sample is not representative of the wider population you are interested in, but is
easy to do. The findings of the survey will only be true for people you included in the
sample and not the whole population.
201
Snowball Sampling
This method is useful for selecting a sample from populations with people who do
not wish to be identified, for example illicit drug users. One illicit drug user is found
who is willing to participate in the survey. This person then ‘recruits’ other individuals
from the population of illicit drug users. Each of these may also be willing to recruit.
You cannot say the results are true for the whole population of illicit drug users.
Sample Size
The guidelines for deciding on the size of the sample are complex. The following
may help you to decide.
Total Number in
Group
100
200
300
1000
Suggested
Number in
Sample
15
20
50
50
Percentage
%
5%
10%
10%
5%
Feuerstein 1986:70
Generalising results
The ability to say that the results from your sample survey are true for the population
is called ‘generalising’ the results.
Being able to generalise results will depend on two factors:
•
whether you have chosen a random sample
•
the size of your sample and the percentage of the population it therefore
represents
Most people who carry out planning and evaluation of community projects will not be
especially concerned about generalising results to similar populations outside the
community. If you are, Health Gains Planning Unit on 8922 7241 in Darwin can give
advice on how best to choose your sample.
202
Analysing the data
Once you have collected the data for the needs assessment or the evaluation, you
need to sort it out and make sense of what it means.
For most small projects, the project team will be able to do the data analysis.
 See ‘Quantitative and qualitative data’ at the beginning of this chapter
How to analyse qualitative data
Qualitative data, consisting of words, can be analysed logically and systematically.
There are four basic steps to analysing qualitative data (based on Hawe et al
1990:148-150).
 Organise the data
Get the data into a format that is easy to work with. For example, notes from tape
recordings will have to be transcribed. Notes from butchers’ paper will have to be
categorised and typed up. After organising the data, you should have an overall
picture of the complete set of data.
 Shape the data into information
After looking at the data, assess what type of themes are coming through. This
analysis is done by sorting. Note down the different categories or types of
responses found. You can use separate cards or sheets of paper to do this step.
Start to separate the data into groups that share similar characteristics. Starting
with a large number of categories will make it easier to allocate all the data. After
becoming more familiar with the data and thinking about the relationships
between the groups, it may be possible to reduce the number of categories.
 Interpret and summarise the information
Do not try to quantify the responses (for example, you cannot say “half the people
said....”.) Instead look for the range of views expressed. It is possible to say
“some....” or “others...”, but you cannot say “most....” or “few....”. It is important to
make sure all opinions or views are represented in the summary.
 Explain the information
When trying to explain what the information means, it is advisable to discuss it at
length with others in the team. It is always better to be cautious about leaping to
conclusions or making assumptions. The result of thinking about the information
and relating it to what the team already knows will lead to an increase in
knowledge and action.
 See the ‘Information Pyramid’ at the beginning of the chapter
203
Here is an example of making sense of qualitative data (using a tally sheet):
The Question: “What did you like least about the program?”
Responses
Room too stuffy and crowded, venue | |
Group leader’s superior attitude | | | | | | | | | |
Film on childbearing | | | |
Too much talk about mother’s role not father’s | | |
Nothing, I enjoyed it. I liked it all | | | |
Not enough time for discussion | | |
No childcare facilities | |
Other people allowed to talk too much | |
Group leader not able to control discussion | | | | | | | |
A common practice [in analysing qualitative data] is do something like a long-hand
version of what researcher’s call ‘factor analysis’....
Take the first questionnaire and write down what your respondent said. Let’s say it
was ‘The room was too stuffy and crowded. Superior attitude of group leader’...
Then take the next questionnaire and read the respondent’s answer to the same
question. Let’s say [the person] said: ‘Venue. The film on child-rearing.’ Because
‘venue’ is a bit like what the first person also mentioned, you would write this up next
to the first person’s words about the room and mark next to it to indicate that two
people had now said this. The comment about the film is a new idea so it gets listed
on its own, still on the left hand side, beneath the others.... You can see that you
start to build up a picture of the most common (negative) feelings about your
programme and your analysis sheet could end up looking something like [the one
above]...
Extracts from Hawe et al 1990:149-150
 Remember that you cannot do calculations on these data. For example, you
cannot say that 80 per cent of people thought the group leader had a superior
attitude or 15 per cent enjoyed the whole thing. The tally marks are only to help in
identifying general themes
If someone does not comment on all the points listed, you do not really know why:
•
the person could have thought about it and decided it was not worth mentioning
•
or the person simply did not think of it!
A reasonable analysis of the question “What did you like least about the program?”
would be:
204
Although a few respondents could not nominate anything they didn’t like about the
programme, the most common problem that participants mentioned was the group
leaders. This mostly concerned what participants described as their ‘superior
attitude’ but also included criticism of their capacity to control discussion and allow
more people to contribute. Other things participants noted were the limitations of the
venue and facilities (the small room, no childcare facilities), the film and an
overemphasis on the role of the mother (as opposed to the role of the father).
Hawe et al 1990:150
There are several computer programs specifically designed to analyse qualitative
data. Programs that are well supported in the NT include ‘NUDIST’, ‘NVIVO’ and
‘SPSS’. For information contact the Menzies School of Health Research on 8922
8196. DHCS Health Gains Planning Unit can also provide advice and support for
qualitative data analysis, ph 8922 7241.
How to analyse quantitative data
Keep your analysis as simple as possible. Useful calculations to use are the
frequency, the mean or average and percentages (Feuerstein 1986:120-123).
•
The frequency with which something occurs means the number of times that it is
repeated at specific intervals
•
The mean (or average) of a group of numbers is the sum of those numbers
divided by the total number of those numbers
•
A percentage means a part in relation to its whole or a proportion. To calculate a
percentage, divide the number of people or things in a group by the total number
in that group and multiply by 100
Example: Children presenting at the health centre
Under 1
|||| |||| ||||
|||| |||| ||||
|||| |||| |||
Age in years
1–4
|||| ||||
|||| ||||
|||| |||
Cough
|||| |||| ||||
|||| |||| ||
Cough with
Fever
|||| |||| ||||
|||| |||
Symptoms
Diarrhoea
5–9
10 – 14
|||
|||
|||| ||||
|||| ||||
||||
||
|||| ||||
|||| |
||
|
Based on an example in Feuerstein 1986:103
205
Frequencies and percentages can be calculated from the data in this table. The
results are shown below.
Example: Number of children presenting with symptoms by age group
Age (years)
Under 1 Year
1-4
5-9
10 -14
Total
No of individual children with symptoms
(frequency)
93
63
9
6
171
Percentage
%
54.4%
36.8%
5.3%
3.5%
100%
A person interpreting this information would note the high percentage of children
who are under five years of age and have symptoms of diarrhoea, coughs and/or
fever.
There are computer programs especially designed for analysing quantitative data.
‘Epi Info’ (a word processing, database, and statistics system for Epidemiology) is
available free of charge through DHCS. Or ask about STATA, SAS and SPSS
software, which can be used for both quantitative and qualitative data analysis. For
more information, contact the Health Gains Planning Unit on 8922 7241.
Share the results
 Show other interested people in the community what the results were and
discuss these results with them
 Explain what the team thinks they mean. Do they agree or not?
 Discuss with people any changes the team is thinking about making to the project
as a result of the evaluation. Get people’s ideas
 See chapter 3 ‘Sharing Health Information’ for more detail on feeding back
information in ways that are meaningful to community members
 Refer back the ‘Information Pyramid’ and the ‘Reflection-Action Cycle’ at the
beginning of this chapter
Reporting on the project
Project reports can be about the whole project, from needs assessment through to
what was done in evaluation. Reports can also be more specific; for example, there
may be a report just on the needs assessment or a report just on the process
evaluation.
The following questions can be used to guide report planning. They can be
discussed by the project team and interested community residents.
Who is the report for?
206
•
•
•
•
•
The community, the funding body, your organization/department, other
organisations?
What do they want to know about the project?
What does the project team want to say to them about the project?
Can we make one report for all audiences or do we need several different
types?
What language or languages should we use?
What will the report include?
Consider:
•
•
•
•
•
•
•
•
•
•
•
•
background reasons for the project
any statistics or evidence of the need for the project.
methodology used for collecting the information
what the project was aiming to do - the goal and objectives of the project
what was planned for the project; what strategies were used
who was involved
what actually happened in the project
how the project was evaluated. What methodologies were used
what resulted from the project. Any statistics or evidence of change as a result of
the project, including what the project did not achieve
what has been learned
recommendations
a summary of key points
What will the report look like?
•
•
•
•
Will it be a written report or a video?
Will it include stories, pictures, photos?
Who will put the report together?
What resources are needed to get the report together?
Is it interesting to look at and read?
Is it interesting to all the audiences it is aimed at?
Who should get copies of the report?
Interested community members, council, funding body, government and community
organisations, key stakeholders, project team?
There are many good examples of evaluation reports held by the different program
areas in DHCS. Ask through your professional networks and/or contact program
areas such as Alcohol and Other Drugs, Nutrition and Physical Activity,
Environmental Health, Preventable Chronic Diseases, Maternal and Child Health,
and Mental Health.
207
Worksheet for problem analysis
Problem:
Risk Factors
What leads directly to or
causes the problem.
Chosen Risk Factor: choose one risk factor to address.
Goal: addresses the chosen risk factor.
Contributing Factors:
Objectives: choose which contributing factors will be addressed. Write
objectives to match the contributing factor/s.
factors that lead to or contribute to the chosen risk factor.
208
Health Promotion Project Planning Worksheet
What is the problem?
Project Goal: What the project will achieve in the longer term (outcome) : who will achieve how much of what by when
Objective 1: What needs to be achieved to reach the goal: who will achieve how much of what by when
Strategies
Actions/Activities
(Tasks to do)
Resources required
Time frame
Evaluation
(How will the team know how it is going?
What will be measured?)
209
Project Planning Worksheet (continued)
Objective 2: What needs to be achieved to reach the goal: who will achieve how much of what by when
Strategies
Actions/Activities
(Tasks to do)
Resources required
Time frame
Evaluation
(How will the team know how it
is going?
measured?)
What
will
be
210
Useful websites
‘Quality Improvement Program Planning System’, a planning resource with a focus
on health promotion and community development
http://qipps.cs.latrobe.edu.au/
Health Promotion ‘Planning and Evaluation Wizard’
http://som.flinders.edu.au/FUSA/SACHRU/PEW/howto/planning.htm
http://www.healthpromotion.act.gov.au/howto/evaluation/moreinfo.asp
“Glossary of questionnaire design and psychology’ on Audience Dialogue website
(Aust) http://www.audiencedialogue.org/gloss-quest.html
See ‘Project Planning and Evaluation Glossary of Definitions”, South Australian
Community Health Research Unit at: http://www.sachru.sa.gov.au/pew/glossary.htm
‘Guidelines on Ethical Matters in Aboriginal and Torres Strait Islander Health
Research’ http://www.nhmrc.gov.au/publications/pdf/e52.pdf
‘National Statement on Ethical Conduct in Research Involving Humans’
http://www.nhmrc.gov.au/publications/synopses/e35syn.htm
About action research: article by Y Wadsworth with links to other action research
resources and articles
http://www.scu.edu.au/schools/gcm/ar/ari/p-ywadsworth98.html.
Local Government Association of the NT http://www.lgant.nt.gov.au/
Bibliography
Axford R, Minichiello V, Sullivan G & Greenwood K 1999, Handbook for Research
Methods in Health Sciences, Addison-Wesley, Sydney
Barnett L & Abbatt F 1994, District Action Research and Education: A Resource
Book for Problem-Solving in Health Systems, 2nd Edition, Macmillan, London.
Torres Strait Islander Communities, eds C Dignan & R Sharp, Commonwealth
Central Sydney Area Health Service and NSW Health 1994, Program Management
Guidelines for Health Promotion, CSAHS & NSW Health, Sydney.
211
Central Sydney Area Health Service 1995a, Finding the Funding: A Brief Guide to
Preparing Grant Submissions for Health Promotion Programs, by S Coppel , L King
& P Finlay, Health Promotion Unit, Central Sydney Area Health Service, Sydney.
Central Sydney Area Health Service 1995b, The 12 Piece Puzzle: A Quick Guide to
Piecing Together Health Promotion Programs, by S Coppel, L King & P Finlay,
Health Promotion Unit, Central Sydney Area Health Service, Sydney.
Chung D & Abbott D 1994, What is Research? Research and Evaluation in
Community Health Series Paper, 1, South Australian Community Health Research
Unit, Adelaide.
Colin T & Garrow A 1996, Thinking, Listening, Looking, Understanding and Acting
as You Go Along: Steps to Evaluating Indigenous Health Promotion Projects,
Council of Remote Area Nurses of Australia, Alice Springs.
Daly J, Kellehear A & Gliksman M 1997, The Public Health Researcher: A
Methodological Guide, Oxford University Press, Melbourne.
Davies L & Kempnich B 1994 (1991), Surveys and Questionnaire Design, Research
and Evaluation in Community Health Series Paper, 3, South Australian Community
Health Research Unit, Adelaide.
Dignan MB & Carr PA 1992, Program Planning for Health Education and Promotion,
2nd Edition, Lea & Febiger, Philadelphia.
Ebrahim GJ & Ranken JP 1988, Primary Health Care: Reorienting Organisational
Support, Macmillan, London.
5th Edition, John Wiley & Sons, Chichester, England.
Fejo L 1994, The strong women, strong babies, strong culture program, Aboriginal
and Islander Health Worker Journal, vol 18 (6), p16.
Gash S 2000, Effective Literature Searching For Research 2nd Edition, Gower,
Hampshire
Green LW & Kreuter MW 2005, Health Program Planning: An Educational and
Ecological Approach, 4th Edition, Mayfield, Mountain View, California.
Green LW & Lewis FM 1986, Measurement and Evaluation in Health Education and
Health Promotion, Mayfield, Palo Alto, California.
Guide, MacLennan & Petty, Sydney.
Hope A & Timmel S 2003, Training for Transformation: A Handbook for Community
Workers, Revised Edition, Books 1-3, Mambo Press, Gweru, Zimbabwe.
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Kalucy L & Jolley G 1996, Dealing with Data: ‘An Introduction to Using Service and
Survey Data’, Research and Evaluation in Community Health Series Paper, 5, South
Kreuter MW, Lezin NA, Kreuter MW & Green LW 2003, Community Health
Promotion Ideas That Work: A Field-Book for Practitioners, 2nd Edition, Jones &
Bartlett, Sudbury, Massachusetts.
Laverack G 2004, Health Promotion Practice: Power and Empowerment, Sage
publications, London
Macpherson AS 1986, The Evaluation Book, Community Health Information Section,
Department of Public Health, Toronto.
Macquarie: Australia’s National Dictionary 2001, 3 ed. Macquarie Library Pty Ltd, NSW.
Macquarie Encyclopedic Dictionary 2005, 4th Edition, Eds A Delbridge, JRL Bernard,
D Blair, S Butler, P Peters & Tardiff, Macquarie Library, Sydney.
May A, Crawford J, Marconi J & Radoslovich H 1997, The Preparing the Ground for
Healthy Communities Manual: A New Approach to Workforce Planning and
Development in Primary Health Care, Rural Health Training Unit, Adelaide.
McKenzie JF & Smeltzer JL 2005, Planning, Implementing, and Evaluating Health
Promotion Programs: A Primer, 4th Edition, Allyn & Bacon, Boston.
Minichello V, Sullivan G et al (ed) Handbook for Research Methods in Health
Sciences, Addison-Wesley, Sydney, NSW, 1999
Morton J 1994 (1991), Program Planning: A Guide, Research and Evaluation in
Community Health Series Paper, 4, South Australian Community Health Research
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National Health and Medical Research Council 1996, Promoting the Health of
Australians: Case Studies of Achievements in Improving the Health of the
Population, Commonwealth Department of Health and Family Services, Canberra.
National Health and Medical Research Council 1999, National Statement on Ethical
Conduct in Research Involving Humans, Commonwealth of Australia, Canberra
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O’Connor ML & Parker E 2001, Health Promotion: Principles and Practice in the
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Publications, Newbury Park, California.
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Porteous NL, Sheldrick BJ & Stewart PJ 1997, Program Evaluation Tool Kit: A
Blueprint for Public Health Management, Ottawa-Carleton Health Department,
Ottawa.
Simnett I 1995, Managing Health Promotion: Developing Healthy Organizations and
Communities, John Wiley & Sons, Chichester, England.
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Aboriginal Health, Darwin
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Wadsworth Y 1997, Everyday Evaluation on the Run, 2nd Edition, Action Research
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214
Chapter 6 – A Health Promoting Health Centre
Chapter 6
A HEALTH PROMOTING HEALTH CENTRE
What is a healthy workplace? ........................................................................ 216
What is a healthy and health promoting health centre? ................................. 216
Primary Health Care ...................................................................................... 217
Essential primary health care services .......................................................... 218
The DHCS Remote Health Branch Atlas ................................................... 218
Accessing resources for best practise in primary health care ........................ 220
Quality improvement processes for primary health care services .................. 220
The health centre: the people......................................................................... 222
The multidisciplinary team ............................................................................. 222
Aboriginal Health Workers (AHWs)............................................................ 222
Remote Area Nurses (RANs) .................................................................... 225
Visiting Team Members ............................................................................. 226
Teamwork ................................................................................................. 227
The health centre: the place ........................................................................... 230
A functional, safe and comfortable place to work........................................... 230
The building and grounds .............................................................................. 230
Improving access to the health centre ....................................................... 232
Increasing access to health information......................................................... 236
The health centre: the policies ....................................................................... 237
What is policy ................................................................................................ 237
The different levels of policy ...................................................................... 237
Policies and planning................................................................................. 237
Policies that guide the work of the health centre ........................................ 238
Local health centre policies ........................................................................... 240
Written policies .......................................................................................... 240
Local health centre operating guides ............................................................. 245
Primary Health Care in action ........................................................................ 247
Websites listed in this chapter ....................................................................... 252
Bibliography .................................................................................................... 252
About this chapter
The aim of this chapter is to guide the further development of health promoting
community health centres as settings that provide:
•
a focal point for primary health care activities
•
quality evidence-based treatment services
•
public health programs which focus on early intervention, prevention and health
promotion
This chapter provides advice about how to:
•
promote teamwork and networking
•
encourage a community health centre environment that is safe, comfortable and
accessible to all members of the community
•
be informed about the policies that guide and support work
215
•
support best practice by sharing stories about Primary Health Care in action
•
encourage local involvement and community control
What is a healthy workplace?
A Healthy workplace is one that:
•
Creates a healthy, supportive and safe work environment
•
Ensures that health promotion and health protection are integral to
management practices
•
Fosters work style and lifestyles conducive to health
•
Ensures total organisational participation
•
Extends positive effects to the local and surrounding community and
environment (WHO 1999 in McMurray 2003:336)
What is a healthy and health promoting health centre?
A health promoting health centre is a place in which staff:
•
understand and value a broad definition of ‘health’
•
think about socio-environmental determinants of health when analysing health
problems and planning interventions
•
implement Primary Health Care based on current recommended standards
•
provide a high standard of clinical care
•
apply the five action areas of the Ottawa Charter for Health Promotion and use
approaches of advocating, enabling and mediating
•
take a balanced approach to disease and injury management and rehabilitation,
prevention and health promotion
•
aim for continuous quality improvement in all services and programs
•
offer cultural security, recognising and incorporating local Aboriginal culture
(knowledge, values, attitudes, beliefs, practices) in all aspects of work
•
find ways to work in community settings outside the health centre
•
work together as a team, making the most of each other’s skills, experience,
knowledge, personal attributes and cultural background
•
provide training and education for health, using the principles of adult learning
•
provide services that are flexible and responsive to individual, group and
community needs
216
•
emphasise the collection and use of health information that is accurate,
appropriate, up to date and takes into account the Information Privacy Principles
contained in the Information Act.
 To see the act online go to: http://www.infoprivacyhealth.nt.gov.au
•
share health information with individuals, groups and the community in a
meaningful way
•
understand and apply government and organisational policies
•
encourage and support local community members to participate in setting
priorities, planning, running and evaluating their own health programs
•
support the development and work of local health committees and district or
regional health boards
•
ensure that all people have access to health centre services, and work to ensure
that pathways of care between services are well managed and supported
•
promote and model healthy living practices
•
support the work of others whose activities are also important to the health of
individuals, groups and the community
While the health centre represents the service provider (eg. DHCS) at the
community level, we know from sound evidence that community participation and
involvement will help to reduce inequities in health, help to address the underlying
causes of poor Aboriginal health and have a positive impact on mortality. Everyone
needs to work in partnership.
The importance of partnerships and community engagement for health services is
emphasised in NT government policy.
 See NT Aboriginal Health and Families: A Five Year Framework for Action - Part
A: Building Better Communities, p 29
For a copy Ph:
8999 2660
 See NT Building healthier Communities: a Framework for health and Community
Services 2004 – 2009, p 28-30
http://www.nt.gov.au/health/building_healthier_communities.pdf
For a copy Ph:
89992400
 Or use the DHCS intranet, or ask your DHCS manager, or navigate through the
DHCS website: http://www.nt.gov.au/health/
Primary Health Care
In this resource the term Primary Health Care (PHC) means “a philosophy
permeating the entire health system, a strategy for organising health care, a level of
care and a set of activities” (Chamberlain & Beckingham in Wass 2000:9).
217
Primary Health Care includes at least:
- education concerning the prevailing health problems and the methods of
preventing and controlling them
- promotion of food supply and proper nutrition
- an adequate supply of safe water and basic sanitation
- maternal and child health care, including family planning
- immunization against the major infectious diseases
- prevention and control of locally endemic diseases
- appropriate treatment of common diseases and injuries; and
- provision of essential drugs….
WHO 1978:4
 Also see Chapter 7, ‘Glossary’
DHCS has a policy of supporting the provision of Primary Health Care (Aboriginal
Health and Families: A Five Year Framework for Action 2005, NT Aboriginal Health
Policy 1996:5). We need to strengthen and extend our primary health care services
by:
•
focusing more on early intervention, prevention and health promotion
•
increasing community participation and strengthening community capacity
•
adhering to recognised standards in the delivery of all services
•
improving access to PHC services
Essential primary health care services
The consistent application of evidence-based best practice across the Public Health
and Primary Health Care service system is a priority focus of DHCS in the Northern
Territory.
The DHCS Remote Health Branch Atlas
The DHCS Remote Health Branch Atlas is a manual for the delivery of Primary
Health Care services in remote communities across the Northern Territory. It is an
essential document for guiding practice in all DHCS health centres and a valuable
resource for remote health. It describes systems and standards, and provides other
relevant information.
The Atlas is being developed for use as an electronic document. It is due for release
in late 2006 via the DHCS intranet. Sections available in hard copy on request.
The Atlas includes specific, essential information under the following headings:
1. Workplace Orientation
2. Departmental/Branch Information
3. General Health Centre/Organisational information
4. Role of the Health Centre Manager
218
5. Community Relationships
6. Cultural considerations
7. Medical Records
8. Recall
9. Referrals
10. Patient Travel
11. Quality Assurance
12. Health Programs
13. Emergencies / Evacuations and Retrievals
14. Clinical Protocols
15. Births and Deaths
16. Pharmacy
17. Stores and Ordering
18. Pathology
19. Medicare
20. Communication / IT
21. Staff Travel
22. Vehicles
23. Equipment and other Assets
24. Accommodation
25. Visitors
26. OH&S
27. Infection Control
28. Employment matters
29. Staff Development
Under each heading is further information including procedural guidelines and
service standards. For example:
12
Health Programs
12.1
12.2
GAA
Well Women’s screening
12.3
12.4
12.5
12.6
12.7
12.8
12.9
Well Men’s Screening
Chronic Disease
Healthy School age kids
Immunisations
STI screening
TB screening
RHD
For information about the Atlas and the website address ask your manager or phone
8985 8001 or 89517757.
219
Accessing resources for best practise in primary health care
“Practice needs to be continuously reviewed, continuously questioned and, where
appropriate, decisions made based on available evidence.”
Craig J & Smyth R (et al) 2002
DHCS aims to increase the use of evidence and research to inform policy and
practice. To help staff access resources and to support clinical decision making
Library Services has Clinical Resources on Call (CROC).
Resources available on CROC include E-journals, E-Text books, evidence based
databases, drug databases, citation databases, full-text databases.
 See www.hcn.com.au/croc (user ID and Password required)
 See ‘Literature Search’ in Chapter 5 Planning and Evaluating a Health Promotion
Project
 Talk to library staff about your resource needs
NT Health Libraries
Darwin
8922 8961
Alice Springs
8951 7966
East Arnhem
8987 0262
Katherine
8973 9036
Tennant Creek
8951 7966
Quality improvement processes for primary health care services
DHCS is committed to implementing quality improvement processes throughout
services in the Northern Territory.
 See Glossary definition, ‘quality improvement’
Health centres need to apply for and comply with relevant standards in key areas
such as record management, infection control and occupational health and safety,
incident monitoring and processes for complaints and feedback. A range of
nationally recognised service standards is available. These standards may be used
to help implement quality improvement processes in NT health services and
settings.
The Australian Council on Healthcare Standards (ACHS) is an leading independent
authority on the measurement and implementation of quality improvement systems
for Australian health care facilities. It provides quality improvement resources and
services. NT hospitals and some services have membership. Visit the website:
http://www.achs.org.au/
The Quality Improvement Council is responsible for the coordination of the QIC
Standards and Accreditation Program, and use of the QIC Standards. Some NT
services are accredited against QIC standards. Standards include:
• Community and Primary Health Care Services Module (2004)
• Integrated Health Services Module (2004)
• Home Based Care Services Module (2004)
• Alcohol, Tobacco and Other Drug Services Module (2004)
220
• Maternal and Infant Care Services Module (1999)
• Mental Health Services Module (2005)
Visit the website: http://www.qic.org.au/
Information about QIC in the NT is also available through the Institute for Healthy
Communities Australia Limited (IHCA) ph 07 3844 2222. Visit the website:
http://www.ihca.com.au
Audit and Best practice for Chronic Disease (ABCD) project – an example of a
quality improvement process in NT community health centres
ABCD is a continuous quality improvement project that aims to improve health
outcomes by helping health services to improve their systems for delivery of best
practice care. An action-research approach is used to work with health centre staff
and identify strengths and weaknesses in their systems, set goals for improvement,
develop strategies to achieve these goals and assess the effectiveness of these
strategies in improving chronic illness care. The CQI process used in the ABCD
project is illustrated below:
Figure 1. Outline of the ABCD
approach
1: Agreement signed between health
services staff and research team specifies
roles and responsibilities of both parties
2: Bilateral orientation to local service
environment and project and training for
service staff on ABCD processes
6: Service staff refine and
implement action plans
5: Workshop involving service staff
and research team to get a shared
understanding of audit and system
assessment reports, determine
priorities, set goals and develop
action plans to achieve goals
3: Audit of clinical practice against
best practice guidelines and
assessment of system development
to support best practice
4: Analysis of audit and system
assessment data and reporting
back to health service staff
After two annual cycles of the CQI intervention, results indicate that services which
show evidence of functioning well in their systems, and that have stronger linkages
in the community, also deliver a higher number of recommended services.
ABCD has operated in a range of government and non-government health centres
across the Top End of the Northern Territory since 2002. Funding has been granted
until 2011 to extend the ABCD project to other jurisdictions to investigate how the
approaches developed for ABCD can be introduced and supported as routine
practice in Indigenous primary care settings.
Information from ABCD Project Final Report (2007:5)
221
The health centre: the people
The multidisciplinary team
In the NT, staffing arrangements for delivery of health services in communities vary
from place to place. In many communities, Aboriginal Health Workers (AHWs) and
Remote Area Nurses (RANs) are the resident, full-time primary health care
providers. In communities that do not have resident nursing or medical staff, AHWs
provide the primary health care services.
Other resident members of the multidisciplinary team may include:
•
community based workers such as Community Nutrition Workers; Strong
Women, Strong Babies, Strong Culture Workers; Environmental Health Workers;
Aboriginal Mental Health Workers; other workers in specific programs
•
support staff such as drivers, cleaners, liaison and administrative officers
•
General Practitioners (in some communities)
Non resident members of the multidisciplinary team may include:
•
members of the mobile nursing team
•
District Medical Officers (DMOs)
•
Dentists and Dental Therapists
•
Allied Health Professionals
•
Community Services staff
•
Public health support staff such as Health Promotion Officers, Communicable
Disease staff, Preventable Chronic Diseases staff, Environmental Health
Officers and Nutritionists
•
Department/organisation manager/s
Be aware that Aboriginal workers are underrepresented in the health and community
services industry. Improving Aboriginal representation in the health workforce and
ensuring access to career and development opportunities is a NT priority. (DHCS
2005: 37) Community health service teams have an important role in this change.
Aboriginal Health Workers (AHWs)
The title ‘Aboriginal Health Worker’ refers to an Aboriginal person who has
completed specific education and training. Aboriginal Health Workers are
recognised as a professional group and are required to be registered by the
Aboriginal Health Worker Registration Board (NT). Aboriginal Health Worker training
started formally in 1976 when Health Department staff provided basic skills training.
222
AHW education and training evolved into accredited courses at various levels.
Registered training organizations (RTOs) that deliver, or have delivered, accredited
AHW training in the NT include Batchelor Institute, Central Australian Aboriginal
Congress in Alice Springs, Central Australian Remote Health Development
Services, Anyinginyi Congress in Tennant Creek and Danila Dilba Health Service in
Darwin.
The AHW career structure classification system is linked to competency levels,
education and experience. The current NT system was introduced in 1997 and
relates to the National Competency Standards.
‘National Competency Standards for Aboriginal Health Workers and Torres Strait
Islander Health Workers’ were first endorsed in 1998. The Standards provide a
guide to develop training, to assess staff and to promote quality service delivery. A
recent review of the Standards has been undertaken and from early 2007 the
Aboriginal Health Worker Qualifications Framework is endorsed as part of the
Health Training Package (HLT07) within the Australian Qualifications Framework.
Working Together
I have been a health worker off and on for over ten years. When I started in 1984, it
was under the supervision of the missionaries at Ntaria (Hermannsburg). I began as
a cleaner at the community hospital and the nurse asked me if I would go to Darwin
and train as a nurses’ aide. I agreed because I wanted to help people and learn
about Western medicine. The nurses at Ntaria were good to work with. They
realised how much we could teach each other and were always willing to listen to
advice from Aboriginal Health Workers (AHW). I felt I was trusted by the nurse I
worked with and in 1986 I did my training to become a health worker.
Often in the past, the non Aboriginal nurse had been in charge and the health
workers have not been in the role of decision makers. We usually worked under the
supervision of the non Aboriginal nurse. In my experience, the best nurses I have
worked with have been those who are willing to work in partnership with AHWs.
Today I work as a member of a team, not as an assistant. Although there is a nurse
in the charge position, myself and the other AHWs are very much involved in the
decisions, planning and running of our health centre. I feel we help each other by
acting like a bridge between cultures. Non Aboriginal staff who do not work in
partnership can find that they have a lot of misunderstandings and not achieve very
much with Aboriginal people.
Napanangka Susan Abbott, Senior AHW, in Franks and Curr 1996:23
223
Traditional healer (traditional health practitioner)
Community health teams also work with traditional healers who are respected for
their knowledge of traditional medicines and healing techniques. Talk with the
Aboriginal Health Workers about referring to and working with the traditional healers.
Many people will choose to use a combination of traditional healing methods and
western medicine.
It is essential that all members of the multidisciplinary team work together to provide
a comprehensive and responsive primary health care service that offers cultural
security to the community.
Roles and responsibilities of AHWs
AHWs bring a range of skills, knowledge and understanding to the health team.
They uphold traditional and cultural values within the local health service. The role of
the AHW can promote and support traditional healing methods.
In general the role of the AHW is to:
•
participate in the delivery of Primary Health Care to individuals, families and
groups within the community and outstations
•
provide the first point of contact for clients attending the community health
centre, including responsibility for initial diagnosis and referral to the RAN or
doctor, if necessary
•
provide a cultural link between the community and government and nongovernment health services and programs
•
For more information see local Aboriginal Health Worker Person and
Position Profiles
The role of an AHW is often challenging. AHWs have multiple priorities and
obligations, high expectations placed on them and increasing technology demands.
Much has been written on the subject.
See Josif and Elderton 1992, Franks and Curr 1992 and Tregenza and Abbott 1995
in the Bibliography.
224
(Note: Josif and Elderton and Franks and Curr have been published together as a
report titled Final Report to Rural Health Support Education and Training (RHSET)
Program on the Recruitment, Retention and Education of Aboriginal Health Workers
in the Northern Territory by Northern Territory Department of Health and Community
Services 1994).
 Source new research and resources about the AHW roles and experiences
through DHCS Library Services
 Check the library for copies of Aboriginal & Islander Health Worker Journal
Aboriginal Health Workers: another co-worker or the most important member
of the team?
We have all heard it many times, that nurses come and go and that Aboriginal
Health Workers (AHWs) have to live in the communities for the rest of their lives. We
have to remember this is true and that most AHWs accept quite a lot of flack for the
behaviours and attitudes of nurses.
Personally I believe that AHWs are the most important member[s] of the health
team. They are the health care providers, co-workers, cultural brokers and the link to
the community for the rest of the team.
... My real cultural training came from the AHWs. They were always willing to teach
me. As long as nurses show interest, respect and are willing to listen, in my
experience, the AHWs are always prepared to teach staff about cultural issues...
Brycen Brook, RAN, in Franks and Curr 1996:146
Remote Area Nurses (RANs)
A RAN is an advanced nurse practitioner who works as a primary health care
provider. RANs either live in or visit communities that are isolated from hospitals,
main town centres and other medical facilities.
Roles and responsibilities of RANs
As a member of a multidisciplinary team, their role is to:
•
support the delivery of comprehensive quality Primary Health Care to
individuals, groups and communities
•
provide education and training
•
promote health and well-being and encourage community participation and
action
•
ensure that the health centre’s management systems function smoothly
The role of the RAN is often challenging. Some of the challenges of working as a
RAN include the following:
•
RANs take on additional clinical responsibility that would not be expected in
other situations
225
•
RANs may not be familiar with local culture, protocols or expectations
•
RANs are most often away from their families, their usual sources of support and
their own culture. At times they may be lonely and stressed
•
Remote area work always demands longer hours and RANs are often on call,
which can be trying and tiring
•
RANs work as a part of a team whose members are often based far from each
other
Debriefing and crisis counselling
NT Remote Health has a ‘critical incident policy’ to guide action and clarify
responsibility during times of crisis and critical incidents.
 See ‘Incident Reporting’ in the Remote Health Atlas, Section 26 OH&S
Remote area staff are supported formally and informally during these times. They
may be referred to counselling services within DHCS or to external service
providers. Counselling is often backed up by peer support.
 Think about talking with other team members about your concerns. They may
well have experienced similar problems and worries
 As a member of a multidisciplinary team, you will have a network of people
outside the community you can talk to as well
The Council for Remote Area Nurses of Australia (CRANA) has set up a 24 hour
Bush Crisis Line to support remote area health practitioners.
Bush Crisis Line : 1800 805 391
(Free call from anywhere in Australia)
CRANA publications include booklets called ‘Surviving Traumatic Stress: A guide for
remote area health practitioners and their families’, and ‘Avoiding Burnout’.
For a copy call 8953 5244 or fax 8953 5245 or email [email protected]
 Visit the website: http://www.crana.org.au
Visiting Team Members
The health centre can help the community to access information and a range of
specialist and public health services. Some members of the multidisciplinary team
have been visiting communities for a long time and have developed close
relationships with local people. They are a valuable resource.
The resident team members are a valuable resource to visiting team members in
providing local information, expertise and community links. It is important that the
health centre is seen by the community as a resource centre which has strong links
to other programs and services.
Visitors from other programs and services are expected to seek the community
council’s permission and to have appropriate permits.
226
Making the most of community visits
Part of the resident health team’s role is to negotiate with visiting staff and organise
visiting times. Visits have to be convenient for the community, for resident staff and
for visitors. In order to make the most of community visits:
 obtain information about the programs and services that visitors represent
 find out what can be expected from the visit
 ask for written objectives before the visit
 organise a debriefing meeting with visiting staff before they leave the community.
You can talk about what happened, what was achieved, what needs to be
followed up, what problems came up, if any
Keeping everyone informed about visiting staff
 Talk to the council or other relevant groups about forthcoming visits and the
results of visits
 As soon as you know when visiting staff are coming, consider putting posters or
fliers around the community
 Consider using local media to broadcast the messages. See ‘Using Media’ in the
Chapter 4 ‘Strategies for Health Promotion’
 Write up a schedule of visits on the health centre whiteboard
Other considerations
 Keep in mind that visiting staff such as Environmental Health Officers and Family
and Children’s Services staff have to meet certain legislative requirements. This
means their work may take priority over visitors from other program areas
 Talk together about whether there needs to be a regular ‘visitor free’ time
 Consider how visits fit with local health priorities and health centre plans
 Bear in mind that visits may be subject to change at short notice because of
events in the community
Teamwork
A team approach will benefit your work with individuals, groups and communities.
‘Teamwork’ is the process whereby the talents and resources of various people
(service providers) are coordinated to achieve a common goal. Collaborative and
cooperative efforts are needed.
Through team planning the day-to-day responsibilities of each member of the
team should be clearly defined. In turn each member reports back to the team on
their accomplishments. AHWs, nurses and medical officers all have a clinical, health
promotion and public health role, the exact nature of which is negotiated locally so
that local needs are met.
Freeman and Rotem 1999:54
227
An effective team is one that has:
•
commitment to clear common goals
•
good communication
•
effective leadership
•
clarity of individual and collective roles and responsibilities
•
respect for each other’s knowledge, skills, strengths and weaknesses
Team members need to meet regularly to:
•
share information and learn and plan together
•
think about how services are being delivered and aim for improvement
•
build the team and work towards achieving the goals of the health centre
A health team exercise:
Think together about how well you are operating as a team. Talk about the following
questions:
Are you all aware of the health centre’s goals?
Do you all agree with the goals and their order of priority?
Do you think that you could improve communication in your team in any way?
Is everyone involved (as much as they would like to be) in the making of important
decisions?
Are there ways in which the community can be more involved in setting priorities
and planning with the team?
Based on the original Northern Territory Bush Book,
Northern Territory Department of Health 1979:6
There are various team building exercises and resources recommended by DHCS
Workforce Support Unit, the People and Organisational Learning Unit and other
training organisations. Check your current workforce development calendar or
contact:
DHCS Top End:
8922 7901 or 8922 8747
DHCS Central Australia:
8951 7724 or 8951 7735
The health centre team: more about roles and responsibilities
If you look at well functioning community health teams, they are likely to have
worked at developing flexibility, especially with regard to roles and responsibilities.
They make the most of ‘what they have and who they are’. Roles and
responsibilities that team members take on (or are delegated) depend on:
•
position profile
228
•
gender
•
person’s skills, knowledge, expertise and experience
•
range of skills, knowledge, expertise and experience within the whole team
•
place in a kinship system
•
relationships with community members
•
language skills
•
how long a person has worked and intends to work in the community
•
community preferences
In order to make the most of the skills and experience of each team member:
 review each other’s strengths, interests, roles and responsibilities
 make sure the entire team are invited to participate in regular meetings and that
there are opportunities for collective decision making
 provide opportunities for the team to relax together in an informal way (as well as
come together for formal meetings)
 invite your (town based) manager/s to a meeting to discuss changes in roles and
responsibilities
229
The health centre: the place
A functional, safe and comfortable place to work
There is a variety of health centres in the NT. There are differences in their age,
design, and the kinds of materials used to build them. No matter what conditions you
find yourself working in, you can still make the health centre a safe, functional and
interesting place where people feel comfortable and welcome.
The possibilities and challenges will be different in each health centre, and will
depend on:
•
how the centre has been built, decorated and maintained
•
how accessible it is to all groups within the community
•
what systems are in place, for example to support confidentiality of information
•
to what extent policies are applied, for example occupational health and safety
policies and a cultural safety/security policy
 See Chapter 1 ‘Public Health in Context’ for information and resources about
cultural security
The building and grounds
 Talk about the following sample checklist. Can you think about other things that
you can do to improve the building and grounds?
230
A Health Centre Checklist : the building and grounds
Comments
Signage
Is there a large, clear sign on the front of the building to let everyone know that the building is the community health
centre? Does it say when the health centre is open and closed, and who is on call?
Waiting areas and treatment rooms
Do you have separate rooms for private treatment for:
- men’s business/ women’s business/ sensitive issues that may require private counselling ?
- an emergency area?
Do you have equipment to play music or educational videos/DVDs in the waiting areas?
Are public toilets easily accessed?
Is the waiting area comfortable and functional?
Moving in and around the health centre
Can the front doors be opened easily by different groups (children, women carrying babies, old and frail people)?
Is the inside of the health centre easy for people to move around in? Can people easily move around the outside of
the health centre?
Security
Is there adequate after hours security for the building and grounds? Security for pharmaceuticals?
The health centre grounds
Are the grounds kept clean and tidy? Is rubbish removed regularly?
Are there outside, pleasant places for group meetings or private conversations?
Cleaning
Does the health centre get cleaned regularly? For example:
Floors washed everyday? Surfaces wiped down regularly? Bathroom / toilet cleaned everyday? Toilet paper
checked? Condom availability checked? Linen washed regularly?
If there is not a cleaner, does the team have a cleaning schedule? Does the team share the work in a way that
everyone thinks is fair?
Drinking water facilities
Is there water available for people to drink while they are waiting?
231
Improving access to the health centre
Making the health centre more accessible means exploring different ways of making
sure that all people have access to appropriate services. People also need to feel
confident that their rights to privacy and confidentiality are respected and
dissatisfactions with services are resolved.
Some access issues are addressed at the systems level. For example, innovation
and technology is helping to address service delivery issues to remote areas. DHCS
is developing a health information network to help staff access medical expertise in
the major centres, through video and information technology links.
The network will also help clients to access information and services on-line.
There is also NT HealthDirect, a free 24 hour telephone health advice and public
information line for people in the NT.
NT healthdirect 1800 186 026
System level developments such as these continue to be underpinned by good local
access in the community.
Access issues that your team can talk about include
•
Health centre opening hours and after hours emergency call out
•
Flexibility and standard of service delivery, especially with reference to local
cultural activities
•
Appropriateness of the service delivery
•
Where the health centre is situated or whose land it is built on
•
Whether or not local policies support improved access
•
The extent to which health staff work out in the community
•
How the health centre team works together and how the place ‘feels’
•
The extent to which information about the health of the community is shared and
how it is shared
•
The relationships that exist between the health centre and other sections of
DHCS, and other services and organisations in the community
•
The information you are able to pass on to the community about other DHCS
programs and services
•
Community preferences for access to both male and female health care
providers
•
Men’s and women’s clinic areas respected and used appropriately
•
The extent to which community members are engaged in providing input,
making decisions and evaluating the work of the health centre
232
Considering health centre opening hours
There is no overall organisational policy on health centre opening hours. Hours still
vary slightly across the NT according to:
•
community needs and preferences
•
conditions of employment
•
staffing levels
•
administrative needs
•
special project needs
•
environmental conditions such as seasonal differences
When opening hours are decided they need to be publicised.
There are regional differences in health centre opening hours. Compare the
following situations.
Central Australia
There are no standard opening hours in Central Australia. Opening hours are
negotiated at a community level between the health centre team and the council or
health council (if there is one). Some centres are closed for the afternoon, or part of
it, so that staff can be out and about in the community.
Opening hours may vary during the seasons. For example, in winter the centre may
open late in the morning. In summer, health centres may open earlier as people are
up early and don't move about in the heat of the afternoon. Summer is ceremonial
time so community populations may drop considerably or may increase if the
ceremony is in that community.
Information provided by Melanie van Haaren, DON, Alice Springs Remote Services
1999, & Michelle Evison-Rose Nursing Director, Central Australia Remote Health
2006
233
The Top End
In the Top End the opening hours of the health service vary depending on
community need and community based health programs. While most health centres
are open during NTG office hours local times are determined by the Health Centre
Manager in consultation with staff, council and the community.
Generally staff allow half an hour every morning for on-call handover and to plan the
days work before opening for clinical business by 0830 hrs. One afternoon each
week is used for formal staff meetings, planning sessions, ordering supplies, and inservice education.
Seasonal variations occur at some locations due to ‘bush holidays’, increased tourist
numbers, and the transient nature of some population groups.
Regardless of the time emergency services are provided.
Information provided by Christopher Cliffe,
Nursing Director (Top End Remote) 2006
 See also the DHCS Remote Health Branch Atlas, Section 3.6 ‘Health Centre
Hours of Business’
Increasing access for men
One of the issues often raised is that men do not access the health centre very
much. Different solutions have been tried to increase men’s access, such as:
•
alternative programs for men
•
a separate ‘clinic’ time for men
•
a separate entrance and waiting area in or near the health centre
•
construction of the health centre in ‘two halves’, with one side for men and the
other for women
•
the recruitment and training of male as well as female AHWs
•
access to both male and female RANs and doctors
234
Case study: increasing men’s access to health services
Gapuwiyak Men’s Health Centre – an accessible and sustainable service
Gapuwiyak is an Aboriginal community in North East Arnhem Land. The people of
Gapuwiyak have a very strong culture. In the past, the men have been embarrassed
and shamed to go to the health centre. Men will not go to see women about health
problems unless they are very sick, sometimes not at all. In 1996 we started to talk
about setting up a men’s health centre.
We had help from Virginia from Miwatj Health to apply to OATSIS for money. The
Community Council gave us an old donga and a rusty old car to visit outstations, do
filming and visit old men in our area. The Gapuwiyak Men’s Health Centre was
opened in May 1997. We had two barbeques so all the men could see that they now
had their own health centre.
More and more men started to come to the health centre, we are really busy now.
The centre is staffed by men: a Senior Aboriginal Health Worker, two Trainee
Aboriginal Health Workers and an STD/AIDS Educator (half-time). When men and
women shared the health centre very few men came, maybe 30 or 40 per month.
Now more than 200 are coming each month for different treatments. The men are
very happy to have their own health centre.
We always do well men’s check-ups when men come to the health centre and also
on our home visits. These include diabetes checks, blood pressure, heart checks,
skin checks, and blood tests for different problems. We always offer health
education.
Some of the other things we’re doing are:
making a shower available to men who have a skin problem (or if they have no hot
water in their house)
talking about the dangers of smoking, and showing videos (while people wait)
developing educational videos in the local language (with help from Heather at
Miwatj Health)
showing these videos at the health centre and also on community television.
Sometimes we take young ones to a quiet place out bush to sit down and talk about
things without anyone bothering us. We are doing STD screening and we’ve set up
a register. We’ve also installed two condom dispensing machines in the community.
If anyone would like to know more about our project you can contact us by phoning
8987 9135.
Information provided by Terrence Guyula and Tim Duggan,1999
Gapuwiyak Men’s Health Centre
2006 update: The Mens’ Health Centre continues to be a successful and well-used
community resource and service. Up to 300 men access the range of health
services each month. It is also used as a comfortable place for men to talk and
spend time together.
Information provided by William Costigan 2006
Gapuwiyak Men’s Health Centre
235
Increasing access to health information
The health centre is a setting in which health information can be shared with
community residents as part of regular work practice. The use of videos, computers
and displays to share information can make the health centre an interesting place to
learn about health. The following activities can be part of a broader education for
health strategy.
 Display appropriate posters or pamphlets around the health centre and change
them often
 Play health related videos in the waiting area
 Show people how to use the computer based software designed to share health
information. (eg. MARVIN and other resources – ask regional program staff)
 Organise displays around particular themes. Encourage student AHWs to turn
their health assignments into displays for local people to look at and talk about.
Involve school children in drawing pictures to illustrate the theme
 Set up demonstrations and experiments. Staff from programs such as Mental
Health, Environmental Health, Nutrition and Physical Activity, Alcohol and Other
Drugs and Preventable Chronic Diseases Program can provide assistance
 Include details of education for health activities in your business plans
 See Chapter 2 ‘Education for Health’, which includes advice on the actions you
can take to include education for health processes in work practice
 See the Chapter 3 ‘Sharing Health Information’. The chapter outlines the why,
what, who, where, when and how of sharing health information in an effective
way
 See the section ‘Using Media’ in chapter 4 ‘Strategies for Health Promotion’
 See the section ‘Brief Interventions” in the chapter 4 ‘Strategies for Health
Promotion’, for advice on effective ways of sharing health information during oneto-one interactions in the health centre
 Find out about the short training course in these skills. Training providers can
customise training to suit your group needs.
 See the Health Education Resources Database and NT Health promotion
Storybook on the DHCS website:
www.nt.gov.au/health/healthdev/health_promotion/publications/resource_databas
e.shtml. For a hard copy Ph 89992420
http://www.nt.gov.au/health/healthdev/health_promotion/promotion_storybook.sht
ml
 Contact Workforce Development Branch, your local Health Promotion Officer or
health training provider for information about training
236
The health centre: the policies
What is policy
The word ‘policy’ is used in a variety of ways to cover many, quite different types of
statement, intention and action. ‘Policy’ may refer to the following:
A very general statement of intentions and objectives...
The past set of actions of government in a particular area...
A specific statement of future intentions...
A set of standing rules that are intended to guide to action, or inaction...
Palmer and Short 1994:23
The different levels of policy
•
National policies, such as the The National Strategic Framework for Aboriginal
and Torres Strait Islander Health 2003 and National Drug Strategy 2004
•
State or Territory policies, such as the NT Community Engagement Policy and
the Sustainable Indigenous Housing Strategy (which is an overarching
agreement between the NT and Commonwealth governments)
•
NT Department of Health and Community Services policies, such as Building
Healthier Communities: A Framework for Health and Community Services 2004–
2009; Environmental Health Standards for Remote Communities in the NT; NT
Strategic Framework for Suicide Prevention; the NT Aboriginal Employment and
Career Development Strategy, NT Preventable Chronic Disease Strategy
•
Regional and local service area policies, such as those contained in the Remote
Health Atlas and Remote Health Program Business Plans, and use of CARPA
Treatment manual and Women’s Health Manual
•
Local Health Centre Policies, such as the use of bush medicine as standard
treatment option for a range of skin infections
Policies and planning
Health centres are expected to develop and work to annual business and action
plans. Plans often include details of joint activities and are the work of a multidisciplinary team. These plans map out health centre strategies and activities and
set overall goals. The community team meets regularly to review progress and plan
for the next period.
These plans are informed by:
•
ongoing community needs assessment, evaluation and community priorities,
informed through community engagement processes and input from a
community health committee, regional health board or similar group
•
‘Community Health Profiles’ which have been prepared for that community by
DHCS or developed within the community
237
•
DHCS Corporate Governance Framework and Divisional Business Plans
•
NT Government, DHCS, regional and local policies, protocols and guidelines
Policies that guide the work of the health centre
It is important to be familiar with major policies as they will:
•
guide and support your every day work
•
provide the rationale for your every day work
•
provide information about government’s intentions and goals
•
inform health centre planning
•
inform the development of local policies so they are consistent
NT Government policies that guide your work
Include policies endorsed by Cabinet such as:
DHCS Corporate Governance Framework
Building Healthier Communities: A Framework for Health and Community Services
2004-2009
For a copy contact: 8999 2400
Aboriginal Health and Families: A Five Year Framework for Action
NT Domestic and Family Violence Strategies 2002-2007
NT Food and Nutrition Policy 1995-2000, Nutrition and Physical Activity Action Plans
2001-2006
Department of Health and Community Services policies include
Policies endorsed by DHCS Executive:
NT Preventable Chronic Disease Strategy - Overview and Framework 1999.
For a copy contact:
8922 8978
The THS Aboriginal Employment and Career Development Strategy
DHCS business plans outlining strategies and actions for programs and service
areas in each division. For a copy contact the division or see the website:
http://www.health.nt.gov.au/health/corporate/business_plans/business_plans.shtml
Regional business plans. Or for a copy contact:
Central Australia
8951 5294
East Arnhem and Katherine 8999 2556
238
Environmental Health Standards for Remote Communities in the NT
For a copy contact:
8922 7152
Access to legislation and policies
 View Northern Territory Government Legislation on the NTPS Intranet or
http://www.nt.gov.au/dcm/legislation/current.shtml
 If you do not have access, order copies from Government Printing Office on 8999
4036 or fax 8999 4001
 See the DHCS policies on the intranet or internet:
http://www.nt.gov.au/health/publications.shtml#policiesstrategies
 DHCS divisional business plans which outline strategies and actions for
programs and service areas in each division.
 Ask your manager or access via intranet or internet:
http://www.nt.gov.au/health/corporate/business_plans/business_plans.shtml#divi
sional_plans
 See other NT Government policies online: http://www.nt.gov.au
239
Local health centre policies
Health centres may develop policies in response to local needs. Local health centre
policies are general statements that describe what should or should not happen.
Local policies are developed by the people most affected by the policy and
endorsed by the local council or health board. Local health centre protocols and
guidelines are the step-by-step process for how the policies are to be actioned.
Written policies
There are a number of benefits attached to having written policies:
•
the policy is written down for all to see so that people are clear about
expectations and rules
•
they help to keep things running smoothly, efficiently and safely
•
everyone has a chance to follow the same rules or guidelines
•
there is a much greater chance that the quality of the service will remain the
same even when staff change
•
decisions and actions are strengthened
•
they help to review and improve service (evaluation)
From experience...
New health staff need to fit in with the way a place already works. They shouldn’t go
changing things, especially at first. They need to wait until people know them and
they understand the way things work and the reasons for things being the way they
are before suggesting any changes.
I remember a situation where the permanent nurse went away on holidays for two
months. The relieving agency nurse decided that she didn’t like the way that the
pharmaceuticals were organised alphabetically on the shelves. She also wasn’t
pleased with the ordering system. By the time the nurse came back from holidays,
both systems were completely changed.
The health centre had been using the same system for years. The AHWs went
along with the relieving nurse’s actions because, after all, she was a nurse. Even
though they were angry about it, they said nothing to her. After she left, everything
was changed back to normal. Part of the reason why the whole thing happened was
that the health centre had no written protocols. Big mistake. What a waste of time.
Remote Area Nurse, Top End
But you can have too much of a good thing. Too many policies for little things can
become very restrictive and make it difficult for people to be flexible and responsive.
240
Working with policy at the local level
The following table provides guidance about how to use policy effectively.
Policy Status
What needs to be done?
A policy has been developed elsewhere and you are required to follow it
-
get copies
become familiar with the policy
get help from the area that developed the policy (if you need it)
educate others and then follow the policy
let management know if/when the policy is not appropriate.
A policy is being used but it has never been written down
-
discuss the matter with everyone involved, including DHCS manager/s
write the policy out clearly
ensure the policy is consistent with other policies
get team agreement about the contents
obtain endorsement from local community (council or health board)
decide who else needs to know about the policy
plan a review of the policy
A policy has been written down but it is not being used or is only partly used
-
gather some background information (who, when, why, how of the old policy)
look at the policy and think about why it is not as useful as it could be
consult with DHCS specialist services and/or management
revise the policy if necessary
let people know about the changes
plan a review of the revised policy
Health staff or the community think that a particular - read the step-by-step guide on the next page
issue or problem needs to have a policy developed
for it
241
How to develop a local health centre policy
For many issues a standard set of systems and procedures will be in place, determined by a regional or system-wide policy.
If the health staff or the community think that a particular issue or problem needs to have a local policy, the following steps can be used.
An example: Health Centre Opening Hours
Find out about who thinks that a
policy is needed and why

Get some background information.
Find out if a policy already exists
and what has already been tried
(and how).
Health staff talked: “We never get a chance to get out of the health centre to do more
work out in the community. The nutritionist gave us lots of good ideas about how we
could work more with the store. We could help develop a ‘good tucker’ policy. Some of
the school teachers want us to get involved in doing some health projects with the
primary school children. Maybe we can close the health centre for some time each
week.”

There was a policy some years ago on closing the health centre two afternoons a week
but the RAN left and the AHWs changed. The policy was forgotten. It had never been
written down. We will find out about health centre opening hours policies in other
communities.


Together with the health team, think
about who in the community needs
to be included in talking about the
issues.
The health team decided to invite some council members, some of the frequent users of
the health centre, the nutrition worker, the store manager and a school teacher to a
meeting.


Organise a meeting to discuss the A meeting was arranged at the school on a day that was convenient for most people to
issue.
attend.


242
At the meeting you could talk about:
- obvious and underlying causes of
the problem/issue
- its effects
- the extent of the problem (how
big a problem do people think it
is?)
- the level of support for
developing and implementing a
policy
Some of the issues talked about were:
- Health staff feel they should keep the health centre open all day and that community
residents expect it to be open.
- staff do not have the time to work out in the community on issues that could have an
impact on preventing some of the ill health in the community, like diabetes and skin
sores in children. Some of the community residents said they were worried about all
the people who were getting diabetes and then kidney disease.
- the store manager, nutrition worker and school teacher said they would like to work
with the health staff on some of these issues.
- dome of the community residents said they would not like the health centre to be
closed in case there was an emergency. The council members agreed.


Then consider:
Some of the options and solutions discussed were:
- different options and realistic - the need for health staff to have some specific times to work outside the health
centre
solutions
- the need for people to feel that they could get emergency care
- who will take responsibility
- closing the health centre for two afternoons a week had worked well in the past
- signs could be posted around the community to let people know about the times the
health centre would be closed, where health staff would be and a contact number in
case of an emergency
- one member of staff could be rostered to be at the health centre in case of
emergencies but use the time to plan health lessons for the school children
- what is an ‘emergency’ would need to be clearly stated and the community alerted
about it.


Clarify to ensure everyone is on the
same track and understands what
the decisions will mean for them and
the community.
- Revisit the reasons to close the health centre for two afternoons a week
- Decide how to handle people who are not happy with the new policy, emphasising
that there are two issues to explain; the need to have time for health promotion work,
while still being available to provide acute care.


243
Write down the agreements that
have been reached and set a date
to look at the policy again to check
how it is working.
- Write down the policy. Have it endorsed by the council or health committee and THS
management.
- Make a plan of action for the next two months and decide who will take responsibility
for each action


Obtain council/health board
endorsement.
- Give a copy of the policy to the Council, other people and agencies in the community
who should know and THS manager/s.
- Keep a record of the meeting - who was there, what was said, what the decisions

were. Attach plan of action.
- Decide how to let people know (via BRAACS, posters and flyers around the
community, presentation at council)
Let everyone in the community know
- Put a large notice on the health centre door
about the new policy.

Trial the policy

- Is it working properly?
- Talk about ways to measure whether the policy is working.
- Meet again in two months to see how things are going.

Review the policy and make any
changes that may be needed

-
Look at the policy again after a year to see if any changes are needed.
Consult on the changes.
Write the changes down.
Let people know about the changes.
 Consider keeping local policies and their protocols together as a local health centre operating guide. This guide will need to be updated regularly
 See the section on operating guides later in this section
244
Case study: local health centre policy
In a Health Centre in the Barkly area staff saw the need to manage public
expectations of the health centre. At times staff were called at night for services they
did not consider to be an emergency.
Staff decided to do two things:
1. they let the community know exactly what they considered to be an emergency;
2. they worked on educating the community about the after-hours policy. The
following messages were printed in the local newsletter and on posters.
What is an EMERGENCY / BIG SICKNESS?
BIG INJURIES - Falls, heavy bleeding, wounds
BITES - snake, spider, centipede, dog, scorpion
FEVER - high temperature, sweating, burning up
BREATHING - too fast, having trouble breathing
ANYONE TAKING FITS
MOTOR VEHICLE ACCIDENTS
CHEST PAINS - including blood pressure
MENTAL HEALTH PROBLEMS - any worrying problems
ABDOMINAL PAIN - stomach pain with vomiting and/or fever
NATAL - (pregnant ladies)
IF YOU ARE REALLY WORRIED - STILL COME TO THE HEALTH CENTRE DON’T WAIT
COME STRAIGHT AWAY
When staff were still being called by the occasional non-emergency call out, they put
out the following message.
A Community Message
...The Health Workers work very hard during the day and they want to relax with
their family at night, watching TV or talking. The Health Workers do not mind if they
have to stay up all night in the health centre if there is a big sickness or a sudden
sickness, but when it is a small problem, it should wait until the health centre is open
the next day.
Local health centre operating guides
Local operating guides are put together at the health centre. They are regularly
updated in order to inform staff and others about important, local systems and
practices. They describe the how, why, what, when and where of doing things (or
not doing things). They contain copies of local policies and protocols and other
useful information.
 Keep the policy folder and relevant manuals together with the local operating
guide in a handy place
245
Example of information that can be included in
a local health centre operating guide
Community Profile:
· including history of the community and local area, population profile,
environmental information, map of area, major illnesses
· a contact list for the community, for example old people’s program, meals on
wheels, the school, the women’s centre (names, position/s held, address,
phone numbers)
Complementary policies and protocols for local service delivery
· local disaster plan
· night patrol policy
· community policing policy
· outstation resource centre policy
· store policies
Other protocols and procedures
Outstations
- details about outstations that you visit
- details about outstations that are not visited and why
- the policy about attending emergencies at outstations (how far to travel, for
what reasons, what to take and so on)
Police
- What criteria do you use to call the police out in the middle of the night?
- When do you call straight away, when to you wait until the next day?
Night Patrol
- When do you call night patrol?
Evacuation procedures
- Airstrips: a set of written guidelines about what is to be done and who is to do
it, including who is responsible for maintenance and viability checking especially in the wet season or for night flights
- contact details for the Emergency Services Officer
Contact lists of outside programs and agencies (fax, phone and postal addresses)
- information on external resources and support
- information about the structure, services and programs of DHCS
246
Primary Health Care in action
The following examples show how community health teams, working within a
community health centre setting, facilitated community participation. Through these
stories of community engagement, health teams enabled community members to
increase control over their health.
 Look for other examples of ‘Primary Health Care in action’ throughout this
resource
Case study: Re-scheduling for primary health care
The Numbulwar Health Centre experience
A few years ago the health team at Numbulwar was worried that people with chronic
health problems were not getting the ongoing care they needed. Staff were
spending nearly all of their time attending to patients who needed acute care. This
left little time for patient follow up, or for screening, early intervention and other
health programs. After talking about their concerns the team decided to change the
way their working day was structured.
Since the end of 2003 morning clinics have been offered in the health centre for
people who need emergency treatment and acute care. In the afternoons staff do
home visits or collect people who are due to attend at the health centre. Afternoons
are used for screening, health checks, immunisation and follow up work. The
allocation of program roles and tasks is based on each team member’s skills and
special interests.
The change was simple to set up and organise. When the daily schedule was
changed signs were put up around the community to let people know. Staff have
continued to stick to the policy. People know they can still come the health centre in
the afternoons if they are really sick or injured, but they know they will be sent away
if the problem can safely wait until the next morning.
This straightforward change has made a profound and measurable difference to
health at Numbulwar, especially in the area of child health. The child health worker
is able to visit families every month to check weight, skin and ears of pre-school age
children. Immunisations, antenatal and well women’s checks, and well men’s checks
are kept up to date. People with chronic diseases have ongoing monitoring and
care. Mental health programs are implemented.
Because members of the health team are working around the community every
afternoon people are more willing to talk about their health and to have consultations
before they get really sick. This has resulted in a drop in emergency evacuations
and hospital admissions over the past three years, especially for children.
Staff continuity has been an important factor in sustaining this way of working. And
on reflection, rewarding and well-managed work has in turn helped to retain staff on
the Numbulwar health team
Information provided by Numbulwar Health Centre team, 2006
247
Case study: encouraging self-care
There are regular health checks and minor treatments that some health centres
encourage people to do for themselves. These include cleaning and dressing cuts
and sores; blood sugar level monitoring; and blood pressure monitoring
A Self Help Health Care Trolley: The Ti Tree Experience
The concept of a self help trolley is based on the principles of Primary Health Care.
It can enable people to be more in control of their health, through participation and
education.
The self help trolley at Ti Tree Health Centre enabled people to check their blood
sugar levels. It was placed in the waiting area and stocked with an Advantage
glucometer; a box of tissues; a sharps container; a record of acceptable ranges, and
a note pad. People did their own tests and noted the results, then staff talked with
them about the result, diet, exercise and so on, before making a record on the
person’s file.
To start the project two women who had diabetes were asked to help. They learnt
how to use the glucometer and record the results. Word got around that these
women using that ‘sugar machine’ themselves. People came in to see and staff
offered to teach them how to use the equipment and to interpret the results.
Benefits:
People were more aware of the normal ranges of BSL and more familiar with
changes in their own blood sugar levels
People with diabetes talked more freely and openly about their condition
Staff were freed up for other tasks
People shared responsibility for monitoring their own health indicators
The success of the self-help trolley was expanded to use of an automatic blood
pressure monitor and children’s eye care procedures
Information initially provided by Gayle Blennerhassett, RAN
Case study: using bush medicine
248
Using Bauhinia root in Elliott Health Centre
Some years ago in 1993 an Aboriginal woman brought her son to the health centre
with a grossly swollen and infected thumb. He was febrile (had a fever), had a lump
in the axilla and was lethargic (had no energy). He required evacuation to Tennant
Creek Hospital for lancing of the thumb and intravenous antibiotic therapy. The
child’s mother, however, refused to give consent for the evacuation.
On the following Monday the mother returned to the health centre to inform us that
the child was at school and his thumb was almost healed. So what had happened?
The mother had used a particular bush medicine called bauhinia root.
Over the next 18 months we experimented with preparing and using a variety of
bush medicines for skin sores that community women were pleased to bring us. We
tried lemon grass and hakia bark, orange tree, and ti tree. Finally the bauhinia root
was the only medicine that would last in glass storage for up to 6-8 weeks.
Despite the anecdotal information we were getting from the results, Territory Health
Services was not happy that we were using bush medicine as their usefulness and
safety had not been scientifically proven.
A review of the Elliott monthly statistics showed that sores, boils and scabies were
the most common problems seen and treated in the health centre. We decided to do
a scientific study comparing bauhinia root with three other commonly used western
preparations.
After extensive community consultation we obtained consent from 360 Aboriginal
and non-Aboriginal people to participate in the study. We designed a research
project which met accepted research standards.
Results of the study showed that :
- the bauhinia root preparation was as good at reducing sore size as the western
preparations
- monthly reports indicated significant reduction in skin conditions over the six month
study period, and
- there was a reduction in the number of presentations of children with bad head
sores and scabies.
Overall the bush medicine was considered better than the western preparations
because it is used traditionally. There were other benefits of the research project:
School children (both Aboriginal and other) participated in groups with the women
who collected the roots and prepared them.
Using bush medicine in the health centre legitimised the use of traditional remedies.
By collecting and preparing the ingredients themselves, people have more control
over their lives. They have become more involved in their treatment and
dependence on western style treatment was reduced.
Health staff took the opportunity to talk to children about the need for daily showers,
washing and airing bed clothes, not having sick dogs sitting on beds and clothes,
kidney disease, and how it can occur, if sores are not treated.
249
An ongoing practice of education of families regarding hygiene and the use of bush
medicine was established. A number of mothers who understood the scabies and
sores problem now help other mothers with their children’s hygiene - so a treatment
oriented strategy became a preventive strategy.
Elliott Health Centre still uses bauhinia root for the treatment of skin sores in 2006. It
has become a standard treatment.
Information provided by Elliot Health Centre staff
Case study: working with the grandmothers
In this example, health staff worked closely with the grandmothers in the community
and a number of other individuals, programs and organisations. The project aimed
to increase knowledge and understanding of issues and increase numbers of
women having pap smears and doing breast self-examination. Another aim of the
project was to demonstrate a commitment to providing health services in a way that
was appropriate for the community.
250
The Women’s Health Project
In the remote Aboriginal community of Ntaria (Hermannsberg), the staff of the health
centre started a project to change the attitude of local women towards prevention
strategies for cervical and breast cancers, because they were worried that not
enough women were involved in regular ‘pap’ screening and breast self
examination.
In 1998, Glenda Lucas (RAN), who played a key role in the project, approached
other team members about their views on women’s health issues. She expressed
concern that, as non-Aboriginal health professionals, nursing and medical staff may
not be delivering services that are culturally accessible and acceptable to
community women or AHWs. She asked, “How can we find out the views of
community members? Who are the key people who need to be involved?”
Personal letters were sent to the senior community members. She explained her
concerns about women’s health in Ntaria (and surrounding communities). The
letters gained a very favourable response - particularly from the women who had
recently attended a cultural law meeting attended by women from throughout the
Territory. These women believe that the health of Aboriginal women and breakdown
of cultural law are very much interrelated.
September was Ntaria’s Women’s Cancer Prevention Month. Ntaria community
health centre received funding for women’s health resources.The aims of the project
were decided through a series of health team meetings with women in the
community.
One senior woman suggested that before non Aboriginal health staff could raise
their issues with Arrernte women, they would have to be made aware of some
important cultural knowledge (Women’s Business). The project therefore began with
a Women’s Cultural Health Workshop, a camp held over two days on the traditional
lands (belonging to Mavis Malbunka).
The camp brought together as many women as possible to talk about women’s
health from a cultural perspective as well as from the non-Aboriginal health
perspective. This camp decided on activities for the rest of September. It also
informed the women of activities they could participate in during that month, which
included visits from town based health staff and other organisations. The visitors
provided information on services and general health education on STDs, Well
Women’s Checks and Cancer prevention. The continence nurse adviser visited as
well.
After the camp, the Department’s Communicable Disease team came and did well
women’s checks and screening at the health centre during a week following the
women’s camp. A range of educational videos, printed material and CD-Rom
resources on various women’s heath issues were made available at the health
centre and could be accessed at any time. Tea and light snacks were provided
during times when large numbers of women were expected in the health centre.
This type of women’s camp was held over four years as a strategy to involve women
in health education activities. The impetus came from the senior AHW Kumantjai
Long who encouraged Glenda to organise the camps; “this is your job, you have to
do this”.
251
Information provided by Kerry Taylor, Centre for Remote Health, Alice Springs
http://www.infoprivacyhealth.nt.gov.au
http://www.nt.gov.au/health/building_healthier_communities.pdf
http://www.nt.gov.au/health/
www.hcn.com.au/croc
http://www.achs.org.au/
http://www.qic.org.au/
http://www.ihca.com.au
http://www.crana.org.au
http://www.nt.gov.au/health/healthdev/health_promotion/publications/resource_data
base.shtml
http://www.nt.gov.au/health/healthdev/health_promotion/promotion_storybook.shtml
http://www.nt.gov.au/dcm/legislation/current.shtml
http://www.nt.gov.au/health/publications.shtml#policiesstrategies
http://www.nt.gov.au/health/corporate/business_plans/business_plans.shtml#divisio
nal_plans
http://www.nt.gov.au
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healthier Communities: a Framework for health and Community Services 2004 –
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Guide for Field Staff, 2nd edn, ed DS Jacobs, Northern Territory Department of
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Palmer GR & Short SD 2000, Health Care & Public Policy: An Australian Analysis,
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254
Chapter 7 - Glossary
Chapter 7 Glossary
Foreword ......................................................................................................... 255
List of terms .................................................................................................... 255
Reflective practice ..................................................................................... 267
Useful Glossary Websites .............................................................................. 268
Bibliography .................................................................................................... 269
Foreword
Our reasons for selecting specific definitions from a range of choices are based on the
following: compatibility with the overall direction; ethos and content of the resource; clarity
of expression; appropriateness of meaning; credibility and ‘status’ of the source, and the
extent of its current use in the field and the views of staff.
All references have been quoted directly from the original source
without adaptation.
List of terms
Alma Ata Declaration
Bangkok Charter
Brief interventions
Capacity building
Community
Community capacity
Community control
Community development
Continuous quality improvement
Contributing factor
Cultural security
Determinants of health
Disease
Disease prevention
Early intervention
Empowerment
Epidemiology
Evaluation
Health
Health behaviour
Health development
Health education
Health hardware
Health indicator
Health outcomes
Health promotion
Health sector
Health services
Jakarta Declaration
Lifestyle
Living conditions
Medical model
Mental health and well being
Mental health promotion
Morbidity
Mortality
Motivational interviewing
Network
‘New’ Public Health
Ottawa charter
Partnerships
Policy
Population
Population health
Prevalence
Prevention
Primary Health Care
Program
Project
Public health
Qualitative data
Quality improvement
Quantitative data
Reliability
Risk factor
Standards
Strategy
Social capital
255
Health status
Incidence
Intersectoral collaboration
Intervention Program
Social determinants
Target group
Validity
Alma Ata Declaration on Primary Health Care
See Primary Health Care.
Bangkok Charter
The Bangkok Charter for Health Promotion in a Globalised World identifies actions,
commitments and pledges required to address the determinants of health in a
globalized world through health promotion. The Charter refers to the ‘proven
effective strategies’ for health promotion, and states that in order to fully utilize the
strategies, all sectors and settings must act to:
• advocate for health based on human rights and solidarity
• invest in sustainable policies, actions and infrastructure to address the
determinants of health
• build capacity for policy development, leadership, health promotion practice,
knowledge transfer and research, and health literacy
• regulate and legislate to ensure a high level of protection from harm and enable
equal opportunity for health and well-being for all people
• partner and build alliances with public, private, nongovernmental and
international organizations and civil society to create sustainable actions. (WHO
2005:1)
Brief intervention
These interventions are of low intensity and short duration; typically consisting of 5
to 60 minutes of counselling and education, with usually no more than three to five
sessions. They are intended to provide an early intervention… (Higgens-Biddle &
Babor 1996:4).
Note:
although first used in the Alcohol and Other Drugs field the term has
much wider application. The term brief intervention is often used
interchangeably with minimal intervention; the preferred term is brief
intervention.
See Motivational Interviewing, Disease Prevention and Intervention Program.
Capacity building
… Capacity building … involves developing skills and systems within health services
in order to enable them, in turn, to increase communities’ ability to foster good
health (King & Ritchie 1999:4).
The concept of capacity building for health promotion, then, embraces:
• building the capacity of health workers, in terms of commitment and skills for
working in a health promoting way (in some cases this refers to primary health
care workers, in others to all health workers)
• building the capacity of health organisations, in terms of their commitment, policy,
systems and resources to promote health. This would include incorporating
health promotion principles and practices into primary health care and public
health systems
256
• building the capacity of communities and community members in terms of their
skills, practices and orientation to improving health and solving local health
problems ( King & Ritchie 1999:13).
Community
A specific group of people, often living in a defined geographical area, who share a
common culture, values and norms, are arranged in a social structure according to
relationships which the community has developed over a period of time. Members of
a community gain their personal and social identity by sharing common beliefs,
values and norms which have been developed by the community in the past and
may be modified in the future. They exhibit some awareness of their identity as a
group, and share common needs and a commitment to meeting them.
In many societies, particularly those in developed countries, individuals do not
belong to a single, distinct community, but rather maintain membership of a range of
communities based on variables such as geography, occupation, social and leisure
interests (WHO 1998:5).
In the case of Aboriginal communities:
Aboriginal communities are rarely communal, having been thrown together, at least
in remote Australia, as a result of historical and administrative expediency. Even in
groups of people who share the same language and social organisation, and who
have lived together for 50 years or more, cohesive “communalism” is non-existent…
While the uncritical and bland use of the term “community” continues, with its
concomitant allusions to homogeneity, communalism and collective decisionmaking, policy decisions and intervention programs…can go badly askew (Maggie
Brady cited by Kunitz 1994:113).
Community capacity
1. The characteristics of communities that affect their ability to identify, mobilise,
and address social and public health problems, and
2. The cultivation and use of transferable knowledge, skills, systems, and resources
that affect community - and individual - level changes consistent with public
health-related goals and objectives (Goodman et al 1998:259).
Community control
Community control is the local community having control of issues that directly affect
their community.
Implicit in this definition is the clear statement that Aboriginal people must determine
and control the pace, shape and manner of change and decision-making at local,
regional, state and national levels (National Aboriginal Health Strategy Working
Party 1989:xiv).
Community development
Community development refers to the process of facilitating the community’s
awareness of the factors and forces which affect their health and quality of life, and
ultimately helping to empower them with the skills needed for taking control over and
improving those conditions in their community which affect their health and way of
257
life. It often involves helping them to identify issues of concern and facilitating their
efforts to bring about change in these areas (Hawe et al 1990:203).
Processes that enable individuals and groups in the community to contribute to
debate and decision-making about a particular activity. In relation to community
health, this means opportunities for community members to participate in:
• planning, implementing, managing and evaluating community health services
• identifying health issues and ways of addressing them.
… Community participation … enables services and programs to be tailored to meet
the needs of the community being served, and the content of the services to be
relevant to local conditions (Baum et al [eds] 1992:299-300).
Continuous quality improvement
See Quality improvement/Quality assurance
Contributing factor
Any aspect of behaviour, society, or the environment, or anything else which
contributes to a risk factor for a health problem, eg. not having easy access to
purchase condoms is a contributing factor for having sex without a condom, which is
in turn a risk factor for contracting HIV…
…we prefer to maintain a distinction on the basis that a risk factor is directly linked
with the health problem and a contributing factor is linked to the health problem via
the risk factor - that is, it is a factor which contributes to or helps to explain the risk
factor (Hawe et al 1990:204).
See Risk factor.
Cultural security
Cultural security is a commitment to the principle that the construct and provision of
services offered by the health system will not compromise the legitimate cultural
rights, views and values of Aboriginal people. It is recognition, appreciation and
response to the impact of cultural diversity on the utilisation and provision of
effective clinical care, public health and health systems administration…
Cultural security is about ensuring that the delivery of health services is such that no
one person is afforded a less favourable outcome simply because he or she holds a
different cultural outlook. (WA Dept of Health 2004:2)
Determinants of health
The range of personal, social, economic and environmental factors which determine
the health status of individuals or populations (WHO 1998:6).
These can include peace, shelter, education, food, income, a stable ecosystem,
sustainable resources, social justice, and equity. (WHO 1986:1)
258
Disease
Literally, dis-ease, the opposite of ease, when something is wrong with a bodily
function. The words disease, illness and sickness are loosely interchangeable, but
are better regarded as not wholly synonymous. Susser has suggested that they be
used as follows:
Disease is a physiological/psychological dysfunction.
Illness is a subjective state of the person who feels aware of not being well;
Sickness is a state of social dysfunction, ie., a role that the individual assumes when
ill (ed Last 1995:48).
Disease prevention
Disease prevention covers measures not only to prevent the occurrence of disease,
such as risk factor reduction, but also to arrest its progress and reduce its
consequences once established (WHO 1998:4).
Early intervention
An early intervention consists of the identification of persons or groups whose
drinking behaviour places them at risk and of persons in the early stages of
destructive drinking practices (Cohen 1982, in Institute of Medicine 1990:45).
An early intervention is recognising a problem as soon as possible and doing
something to stop the harm that the problem will cause (Territory Health Services
1998:45).
Note:
although first used in the Alcohol and Other Drugs field the term ‘early
intervention’ has much wider application.
See Disease prevention and Intervention program.
Empowerment
In health promotion, empowerment is a process through which people gain greater
control over decisions and actions affecting their health.
Empowerment may be a social, cultural, psychological or political process through
which individuals and social groups are able to express their needs, present their
concerns, devise strategies for involvement in decision making, and achieve
political, social and cultural action to meet those needs.
A distinction is made between individual and community empowerment. Individual
empowerment refers primarily to the individuals’ ability to make decisions and have
control over their personal life. Community empowerment involves individuals acting
collectively to gain greater control over the determinants of health and the quality of
life in their community, and is an important goal in community action for health.
(WHO 1998:6)
Environmental Health comprises those aspects of human health, including quality of
life, that are determined wholly or partially by factors in the social and physical
environment. It also refers to the theory and practice of assessing, correcting,
controlling or preventing those factors in the environment that can potentially affect
adversely the health and quality of life of present and future generations (UK
259
Commission on Environment and Health 18 March 1996 in Environmental Health
News, Volume 11 No 12, 22 March 1996).
Epidemiology
The study of the distribution and determinants of health-related states or events in
specified populations, and the application of this study to the control of health
problems. “Study” includes surveillance, observation, hypothesis testing, analytical
research, and experiments. “Distribution” refers to analysis by time, place and
classes of persons affected. “Determinants” are all the physical, biological, social,
cultural, and behavioural factors that influence health. “Health-related states and
events” include diseases, causes of death, behaviour such as use of tobacco,
reactions to preventive regimens, and provision and use of health services.
“Specified populations” are those with identifiable characteristics such as precisely
defined numbers. “Application to control...” makes explicit the aim of epidemiology to promote, protect, and restore health (ed Last 1995:55-56).
Evaluation
Evaluation is the process by which we judge the worth or value of something.
(Suchman in Hawe et al 1990:6).
See Qualitative Data and Quantitative Data.
Health
1. A state of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity (WHO Constitution of 1948 in WHO 1998:1).
2. Health is a resource for everyday life, not the object of living. it is a positive
concept emphasising social and personal resources as well as physical
capabilities (WHO 1986).
3. Health is not just the physical well-being of the individual but the social,
emotional, and cultural well-being of the whole community. This is the whole-oflife view and it also includes the cyclical concept of life-death-life (National
Aboriginal Health Strategy Working Party 1989:x).
Health behaviour
The combination of knowledge, practices and attitudes that together contribute to
motivate the actions we take regarding health. Health behaviour may promote and
preserve good health, or if the behaviour is harmful, eg., tobacco smoking, may be a
determinant of disease. (ed Last 1995:74).
See also Lifestyle.
Health development
Health development is the process of continuous, progressive improvements of the
health status of individuals and groups in a population.
The Jakarta declaration describes health promotion as an essential element of
health development (WHO 1998)
260
Health education
Health education is any combination of learning experiences designed to facilitate
voluntary actions conducive to health (Green & Kreuter 1991:17).
Note:
Freudenberg broadens the concept of health education:
…those efforts that educate and mobilise people to create more
healthful environments, institutions and policies (as well as lifestyles)
(Freudenberg 1984:40).
Health hardware
The physical equipment necessary for healthy, hygienic living in [a] remote area.
The equipment must have design and installation characteristics which allow it to
function and to maintain or improve health status. In a water supply system this will
include both the bore and the basin plug (Pholeras et al 1993:v).
Note:
the term was first popularised by Professor Fred Hollows (eds Reid &
Trompf 1991:343).
Health indicator
A health indicator is a characteristic of an individual, population, or environment
which is subject to measurement (directly or indirectly) and can be used to describe
one or more aspects of the health of an individual or population (quality, quantity
and time) (WHO 1998:9).
Health outcomes
A change in the health status of an individual, group or population which is
attributable to a planned intervention or series of interventions, regardless of
whether such an intervention was intended to change health status (WHO 1998:10).
Health promotion
Health promotion is the process of enabling people to increase control over, and to
improve, their health. To reach a state of complete physical, mental and social wellbeing, an individual or group must be able to identify and to realise aspirations, to
satisfy needs, and to change or cope with the environment. Health is, therefore,
seen as a resource for everyday life, not the objective of living. Health is a positive
concept emphasising social and personal resources, as well as physical capacities.
Therefore, health promotion is not just the responsibility of the health sector, but
goes beyond healthy life-styles to well-being (WHO 1986).
Health sector
The health sector consists of organized public and private health services (including
health promotion, disease prevention, diagnostic, treatment and care services), the
policies and activities of health departments and ministries, health related nongovernment organizations and community groups, and professional associations
(WHO 1998:12).
Health services
Services that are performed by health care professionals, or by others under their
direction, for the purpose of promoting, maintaining, or restoring health. In addition
261
to personal health care, health services include measures for health protection,
health promotion and disease prevention (ed Last 1995:74-75).
Health status
A description and/or measurement of the health of an individual or population at a
particular point in time against identifiable standards, usually by reference to health
indicators (WHO 1998:12).
Incidence (Syn: incidence number)
The number of instances of illness commencing, or persons falling ill, during a given
period in a specified population. More generally, the number of new events, eg., new
cases of a disease in a defined population, within a specified period of time. The
term incidence is sometimes used to denote INCIDENCE RATE (ed Last 1995:82).
Intersectoral collaboration
A recognised relationship between part or parts of different sectors of society which
has been formed to take action on an issue to achieve health outcomes or
intermediate health outcomes in a way which is more effective, efficient or
sustainable than might be achieved by the health sector acting alone (WHO
1998:14).
Intervention program
In disease prevention a planned course of action usually targeted on a specific
group or discrete population at risk of some identifiable disease or disorder, in order
to reduce the risk of this disease or disorder.
Note:
Intervention programmes are usually concerned with changing risk
factors or risk behaviours in the target group or population, often using
health education (Nutbeam 1986:120).
See also Health Promotion
Jakarta Declaration
The Jakarta Declaration on Leading Health Promotion into the 21st Century from
July 1997 confirmed that [the Ottawa Charter] strategies and action areas are
relevant for all countries…The Jakarta Declaration identifies five priorities:
Promote social responsibility for health
Increase investments for health development
Expand partnerships for health promotion
Increase community capacity and empower the individual
Secure an infrastructure for health promotion
(WHO 1998:2)
Lifestyle
Lifestyle is a way of living based on identifiable patterns of behaviour which are
determined by the interplay between an individual’s personal characteristics, social
interactions, and socioeconomic and environmental living conditions (WHO
1998:16).
262
See also Health Behaviour
Living conditions
Living conditions are the everyday environment of people, where they live, play and
work. These living conditions are a product of social and economic circumstances
and the physical environment - all of which can impact upon health - and are largely
outside of the immediate control of the individual (WHO 1998:16).
Medical model
The traditional approach to the diagnosis and treatment of illness as practiced by
physicians in the Western World since the time of Koch and Pasteur. The physician
focuses on the defect, or dysfunction, within the patient using a problem-solving
approach. The medical history, physical examination, and diagnostic tests provide
the basis for the identification and treatment of a specific illness. The medical model
is thus focused on the physical and biologic aspects of specific diseases and
conditions (Anderson et al 1994:968).
Mental health and wellbeing
Mental health is … a state of emotional and social wellbeing in which the individual
realises his or her own abilities, can cope with the normal stresses of life, can work
productively or fruitfully, and is able to make a contribution to his or her community.
(WHO 2001:1)
In this positive sense mental health is the foundation for wellbeing and effective
functioning for an individual and for a community. This core concept of mental health
is consistent with its wide and varied interpretation across cultures. (WHO 2004:11)
Mental health is integral to the definition of health. See Health
Mental health promotion
The promotion of mental health is situated within the larger field of health promotion,
and sits alongside the prevention of mental disorders and the treatment and
rehabilitation of people with mental illnesses and disabilities. Like health promotion,
mental health promotion involves actions that support people to adopt and maintain
healthy lifestyles and which create supportive living conditions or environments for
health.
(WHO 2004:5)
Morbidity
Any departure, subjective or objective, from a state of physiological or psychological
well-being. In this sense, sickness, illness and morbid condition are similarly defined
and synonymous (but see Disease)
(ed Last 1995:108).
Mortality
Relative frequency of death, or death rate, as in district or community. (Macquarie
Dictionary 1987:1116).
263
Motivational interviewing
Motivational interviewing is a particular way to help people recognize and do
something about their present or potential problems. It is particularly useful with
people who are reluctant to change and ambivalent about changing … In
motivational interviewing, the counselor does not assume an authoritarian role …
The strategies of motivational interviewing are more persuasive than coercive, more
supportive than argumentative … When this approach is done properly, it is the
client who presents the arguments for change, rather than the therapist (Miller &
Rollnick 1991:52).
Network
A grouping of individuals, organizations and agencies organized on a non
hierarchical basis around common issues or concerns, which are pursued
proactively and systematically, based on commitment and trust (WHO 1998:16).
‘New’ Public Health
See Public Health
Ottawa Charter
See Health Promotion
Partnerships
A partnership for health promotion is a voluntary agreement between two or more
partners to work cooperatively towards a set of shared health outcomes. Such
partnerships may form part of inter-sectoral collaboration for health, or be based on
alliances for health promotion. (WHO 1998:17)
A partnership is … a mutually beneficial relationship that is transparent and
accountable and based on agreed ethical principles, mutual understanding, respect
and trust. (Moodie & Hulme 2004:120)
Policy
The term ‘policy’ is used in a variety of ways to cover many, quite different types of
statement, intention and action. ‘Policy’ may refer to the following:
• A very general statement of intentions and objectives …
• The past set of actions of government in a particular area …
• A specific statement of future intentions …
• A set of standing rules that are intended to guide to action, or inaction …
(Palmer & Short 1994:23).
Population
All the inhabitants of a given country or area considered together; the number of
inhabitants of a given country or area (ed Last 1995:126).
Population health
A population health approach focuses on improving the health status of the
population. Action is directed at the health of an entire population, or sub-population,
rather than individuals. Focusing on the health of populations also necessitates the
264
reduction in inequalities in health status between population groups. An underlying
assumption of a population health approach is that reductions in health inequities
require reductions in material and social inequities…
A population health approach recognizes the complex interplay between the
determinants of health. It uses a variety of strategies and settings to act on the
health determinants in partnership with sectors outside the traditional health system
or sector.
(Public Health Agency of Canada, 2002)
Prevalence
The number of events, eg., instances of a given disease or other condition, in a
given population at a designated time; sometimes used to mean PREVALENCE RATE .
When used without qualification, the term usually refers to the situation at a
specified point in time (point prevalence). Note that this is a number, not a rate (Last
[ed] 1995:129).
Prevention
See Disease prevention
Primary Health Care
Primary health care is essential health care based on practical, scientifically sound
and socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation and at a cost
that the community and country can afford to maintain at every stage of their
development in the spirit of self-reliance and self-determination. It forms an integral
part both of the country’s health system, of which it is the central function and main
focus, and of the overall social and economic development of the community. It is
the first level of contact of individuals, the family and community with the national
health system bringing health care as close as possible to where people live and
work, and constitutes the first element of a continuing health care process (WHO
1978:2-3).
Program
In health services generally, ‘program’ is increasingly being used to describe a
number of related services. The process of turning a group of services into a
‘program’ usually involves either an organisational grouping or the development of
specified goals.
A further and increasing use is to group services or activities together on the basis
of particular funding categories defined by Commonwealth and/or state
governments as in the Home and Community Care Program (HACC), or in program
budgeting. This use tends to reflect a bureaucratic perspective on funding
categories, rather than how health services are actually delivered at the local level
(ed Baum et al 1992:307).
Project
A coherent series of activities, which together make up one strategy or more than
one strategy, carried out with a group of participants for the purpose of improving
the health status of the target group. This can be individual behaviour change, or
265
environmental, legislative or other change. A [project]* is usually planned in
response to an established health need (Hawe et al 1990:211)
Note:
Hawe uses the term ‘programme’ instead of ‘project’.
Public health
1. Public health is primarily concerned with the prevention of disease and injury in
whole communities as distinct from the role of clinical practice, which is primarily
concerned with the treatment of individuals (Lawson 1991:1).
2. Public health is the organised response by society to protect and promote health,
and to prevent illness, injury and disability. The starting point for identifying public
health issues, problems and priorities, and for designing and implementing
interventions, is the population as a whole, or population sub-groups.
Definition taken from A Memorandum Of Understanding: to establish the National
Public Health Partnership for Australia, 1997, and a modification of that proposed
in Last, JM. Public Health and Ecology, Connecticut, Appleton and Lange, 1987.
The scope of Public Health activities and processes can be grouped into three
key areas:
Public health intelligence is involved with gathering and analysing information
about the determinants of health, the causes of ill health and the patterns and
trends of health and ill health in the populations.
Public health intervention refers to developing policy, setting priorities for
action, developing plans, coordinating services, strategies and interventions
aimed at prevention, protection and promotion of the health of the community,
where promotion is the action taken to solve public health problems.
Public health infrastructure refers to the administrative, legislative and
informational systems developed for making priorities, for developing policy, for
funding, for monitoring and surveillance, for research and evaluation, for program
delivery, and includes the workforce required to accomplish these tasks (National
Public Health Partnership 1997:2).
3. A distinction has been made in the health promotion literature between public
health and a new public health for the purposes of emphasising significantly
different approaches to the description and analysis of the determinants of health,
and the methods of solving public health problems. This new public health is
distinguished by its basis in a comprehensive understanding of the ways in which
lifestyles and living conditions determine health status, and a recognition of the
need to mobilise resources and make sound investments in policies, programmes
and services which create, maintain and protect health by supporting healthy
lifestyles and creating supportive environments for health. Such a distinction
between “old” and “new” may not be necessary in the future as the mainstream
concept of public health develops and expands (WHO 1998:3).
Qualitative data
Data which describe the range of response and variation between responses but do
not record frequency of response. Cannot be used with tests of statistical
significance (Hawe et al 1990:212).
266
Quality improvement
‘Improvement’ is the process of enhancing, upgrading or enriching the quality of
provision or standard of outcomes. ‘Quality improvement’ is, however, often used as
a generic term to cover both quality and standard improvement. It is also a term
used to imply both a rationale for quality processes (internal or external to the
institution) and the actions undertaken by an institution following a quality evaluation
event. (www.qualityresearchinternational.com/glossary/ downloaded 31/1/07))
Quantitative data
Data which are recorded as frequency of response; response options may be
categorical (eg male/female); ordinal eg (never/often/sometimes) or numerical
(number of cigarettes smoked per day). Hypotheses may be supported or rejected
by applying tests of statistical significance to quantitative data (Hawe et al
1990:212).
Reflective practice
A process whereby practitioners review their practice, consider ways in which they
could have done things better or differently and record what they have learnt.
(Foundation for Integrated Health 2006)
Reflective practice is an essential aspect of quality improvement.
Reliability
A property of questionnaires, surveys or any other measurement tool. Expresses the
degree to which the same score is produced on repeated measures with a given
instrument, in the absence of any real change. Repeated measures refer to
measurements taken with the same instrument either by the same person at
different times (test-retest reliability) or by different people (inter-observer reliability)
(Hawe et al 1990:213).
Risk factor
Any aspect of behaviour, society or the environment which is directly linked to a
health problem in an established or proposed causal pathway. A health problem
may have one or more than one risk factor, eg. smoking and elevated levels of
serum cholesterol are both risk factors for heart disease (Hawe et al 1990:213).
See also Contributing factor.
Standards
Standards explicitly define and describe the characteristics of quality and
effectiveness in relation to a particular activity. The Community Health Accreditation
and Standards Program (CHASP) standards for community health have been
written to reflect core community health concepts and principles (ed Baum et al
1992:309).
Strategy
The method or range of methods you are going to use in the program to achieve the
objectives; that is, how you will do it (Abbott 1990:9)
267
Social capital
Social capital represents the degree of social cohesion which exists in communities.
It refers to the processes between people which establish networks, norms, and
social trust, and facilitate co-ordination and co-operation for mutual benefit… The
stronger these networks and bonds, the more likely it is that members of a
community will cooperate for mutual benefit. In this way social capital create health,
and may enhance the benefits of investments for health (WHO 1998:19).
Social determinants
Social determinants of health include the social gradient ((whereby)…life
expectancy is shorter and most diseases are more common further down the social
ladder in each society); stress; early life …(development and education); social
exclusion; work; unemployment; social support; addiction; food; transport. (WHO
2003:10-29).
See Determinants of Health
See Population Health
Target group
Those members of a community for whose benefit a health goal is constructed and
a health intervention carried out. These people are usually programme participants
or intervention group although in some cases the participants might be another
group of people who will pass on the benefit to the target group. For example, a
parent drug education program may be aimed at reducing drug abuse in children, in
which case the children are the target group and the parents are the intervention
group (Hawe et al 1990:215).
Validity
A property of questionnaires, surveys, or any other research measurement tool.
Expresses the degree to which the tool measures what it purports to measure; for
example, to what extent a questionnaire can be a valid measure of smoking status
(Hawe et al 1990:215).
Useful Glossary Websites
WHO Health Promotion Glossary
http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1.pdf
Rychetnik L, Hawe P, Waters E, Barratt A, Frommer, A Glossary for Evidence Based
Public Health, M Journal of Epidemiology and Community Health 2004;58:538-545
http://jech.bmjjournals.com/cgi/content/full/58/7/538
Public health agency of Canada, Healthy Living Glossary
http://www.phac-aspc.gc.ca/hl-vs-strat/hl-vs/glossary_e.html
There are numerous web-published health glossaries relating to specific health
fields. Search using key words relevant to your needs, such as environmental health
glossary
268
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271
Appendix
Appendix of case studies from first edition
These case studies were included in the first edition published in 1999. They have
been taken from the main text to enable the second edition to include some more
recent case studies and community stories.
Nyirrpi Grandmothers’ Women’s Health Program - increasing community
participation and control
The Nyirrpi Grandmothers’ Women’s Health Program is run by the Grandmothers,
Valerie Naparula and Margaret Napanardi, and me, the Aboriginal Health Worker.
We have been having the program at Nyirrpi for two and a half years. The program
shows that it is good for the health staff and the grandmothers to work together.
Nyirrpi is a community of two hundred people, 400 km north west of Alice Springs. I
have been the Aboriginal Health Worker there for five years. I became interested in
working as an Aboriginal Health Worker because there was no one at Nyirrpi to do
women’s health. Colin is the nurse at Nyirrpi. Before Colin came I used to help
Sister Joy. I used to get the women to come and see her. The women would listen
to me because I speak Walpiri to them and I speak slowly. They used to get shy of
the Kardyia [white] sister because she only came sometimes. I wasn’t working then,
but I used to help her to get the women. Then she asked me to become a health
worker so we went to the council to ask. They said yes, we want you to be our AHW.
The people at Nyirrpi respect me because I go to the clinic [health centre] every day
and I go away for training. They say I am a good worker. They trust me.
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Appendix
It was hard to get young women and old women to come for their women’s checks.
The women used to be scared and cross when they would see that Kardyia
women’s health sister come. They used to say, “tell that woman to stay away from
us”. But not now.
Colin and Valmai talked with me about starting up the Grandmothers’ Program. We
had a big meeting in the women’s centre. Valerie told the women what those
women’s checks were for. We talked about a woman who passed away from that
cancer. At that meeting there were a lot of grandmothers. They said it was alright for
me to do young women, but Valmai must do the older women.
Now the women are happy to have their women’s checks from me and Valmai. The
Grandmothers help me talk to them and explain about women’s check ups.
When we started the program we started to take the women and girls out bush to
teach them right way. In 1996 and 1997 sometimes we went out bush with Valmai
and Jo and did some things like smoking babies, singing and dancing. I talked with
Valerie, Margaret and Esther about taking the women and girls out bush to teach
them about women’s health business. I learned to use the video camera. I learned
to use the magnel kit and flip charts for teaching. We learned to use our order book
to hire the truck and to buy food from the store for going out bush. Now we organise
everything ourselves. We have made a video about how we teach the women and
young girls. The women and girls are very happy going out bush on these trips.
They used to say, “when are we going for a picnic again?”
Nola Wilson, Aboriginal Health Worker, Nyrripi
The NT Aboriginal Hearing Program
Ear disease and the resulting conductive hearing loss is a health issue with
educational implications. Research has shown that the incidence of chronic ear
disease (otitis media) and the resulting permanent conductive hearing loss amongst
Aboriginal infants and children are extremely high. Up to 60 per cent of this
population suffer from otitis media that results in an educationally significant hearing
loss.
The NT Department of Education and Territory Health Services (THS) established a
joint Departmental Committee to address these issues. In 1990 this committee
gained all Aboriginal membership and became the NT Aboriginal Hearing Program
Coordinating Committee Incorporated. This Committee represents 15 communities
across the NT and provides advice, strategic direction and support to the operational
Program. Two of the Committee’s recommendations that have been implemented
are:
the establishment of an intersectoral, multidisciplinary program (NT Aboriginal
Hearing Program) to address the educational, audiological and medical
management of ear disease and conductive hearing loss.
the establishment a coordinator position, jointly funded, having responsibilities to
both Departments and being responsible for managing, coordinating and monitoring
the resource activities of both Departments.
The NT Department of Education and THS agreed that the NT Aboriginal Hearing
Program would implement a number of activities
273
Appendix
community awareness programs
community prevention programs
teacher / assistant teacher education, training and support
Aboriginal Health Worker education, training and support
developing community based hearing health and education and early intervention
programs
developing the supporting resources
The NT Department of Education funds five education officers dedicated to the NT
Aboriginal Hearing Program. These Officers are qualified educators with experience
in Aboriginal education and working in rural and remote communities. They are the
key to the Program's intersectoral activities across the NT. They provide the link
between the Program and communities.
Territory Health Services funds a senior Aboriginal Health Worker dedicated to the
NT Aboriginal Hearing Program and provides medical and audiological resources
that deliver services and support the strategies of the Aboriginal Hearing Program.
The Coordinator, an education professional, is located within THS.
The Commonwealth agency Australian Hearing Services is responsible for the
provision of amplification devices and also provides support to the Program.
Information provided by Tony Neale,
Coordinator NT Aboriginal Hearing Program
An education for health example from a community in Central Australia
An effective education for health process was demonstrated in Harts Range (Atitjere)
in 1993/4. The nurse had been talking to mothers and AHWs about the link between
skin sores and other sickness, and had also raised awareness about the link
between poor health in dogs and children’s skin health.
When Commonwealth funding for dog programs became available, the community
council took the opportunity to arrange skills training for an Aboriginal Health Worker.
He was trained in skills to treat parasites and give contraceptive medicine to the
dogs; this training was given by a visiting veterinary surgeon from Alice Springs. He
also found that dog owners needed accurate information to understand the treatment
and its effects, one of which may cause the death of some dogs.
The AHWs and some community members started a local project to wash and feed
the dogs. As dog health improved, so did skin health amongst family groups. People
could see the positive results of their efforts combined with the veterinary treatments.
The four AHWs in Haarts Range and Alcoota, as part of their ongoing professional
development activities with the then Open College staff, decided to develop some
local resources to help pass on information about dog health, and about other health
issues they felt were important. The nurse, as a resource person, prepared a
submission to receive National Health Advancement funding through the Health
Promotion Unit. The funds were used to develop and print posters to promote
positive messages about breast feeding, bush food, bush medicine and dog health.
People supported the project and the health workers with enthusiasm, and the
resources were made and displayed in many places around the community and
other areas around Central Australia.
274
Appendix
The project helped to stimulate further personal and community action such as
establishment of a campfire cooking program at the Women’s Centre, which involved
the store and linked with a literacy program being run by the NT Open College.
Related projects were researched such as the Strong Women, Strong Babies, Strong
Culture program. Gardening and clean community programs were established.
Many of the benefits of these activities came from taking effective education for
health approaches within a Primary Health Care model. Working partnerships
between Aboriginal and non-Aboriginal staff were strengthened as health staff
planned together and helped each other to learn new skills and knowledge. By
building on individual strengths and well established relationships, various roles and
tasks were worked out. AHWs’ education roles in the community were extended,
which raised personal confidence and profiles within the community for each AHW.
Staff worked together to decide the best way to share health information with other
community members - when to work with groups such as participants at the
Women’s Centre, and when to talk one-to-one. They planned when it was best for
the nurse to share information about other health related topics, such as sexual
health, contraception and so on. This was so that female AHWs and other women of
the community could deal with the cultural aspects of these topics in Arrernte.
The development of such working relationships and approaches takes time, a
personal commitment and constant self-evaluation. These processes are integral to
effective education for health outcomes. People need to feel ownership of programs.
Information provided by Vicki James and Kerry Taylor, Alice Springs
275

Bush Book - Department of Health

Transcription

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