Bush Book - Department of Health
Transcription
Bush Book - Department of Health
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 About this chapter ............................................................................................ 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 About this chapter ............................................................................................ 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 Websites listed in this chapter ......................................................................... 62 Bibliography ...................................................................................................... 62 Chapter 4 STRATEGIES FOR HEALTH PROMOTION ...................................64 About this chapter ............................................................................................ 66 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 About this chapter .......................................................................................... 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 About this chapter ............................................................................................ 16 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 Websites listed in this chapter ......................................................................... 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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 Chapter 1 – Public Health in Context 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. Wilkinson R & Marmot M (eds) 1998, The Solid Facts: Social Determinants of 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health • 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health 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 Chapter 2 – Education for Health National Aboriginal Health Strategy Working Party 1989, A National Aboriginal Health Strategy, National Aboriginal Health Strategy Working Party, Canberra. 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 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 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 World Health Organization 1997, The Jakarta Declaration on Leading Health Promotion into the 21st Century, WHO, Geneva (online) (cited June 2005) http://www.who.int/healthpromotion/conferences/previous/jakarta/declaration/en/ World Health Organization 2005, The Bangkok Charter for Health Promotion in a 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 About this chapter ............................................................................................ 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 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 Websites listed in this chapter ......................................................................... 62 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 Chapter 3 – Sharing Health Information 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: http://www.sharingtruestories.com 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information • 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 Chapter 3 – Sharing Health Information • 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 Chapter 3 – Sharing Health Information • • • 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 Chapter 3 – Sharing Health Information • 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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.healthyactive.gov.au/ 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information 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 Chapter 3 – Sharing Health Information Planning and evaluating information sharing sessions 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 Chapter 3 – Sharing Health Information Planning and evaluating information sharing sessions 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. See Chapter 5 Planning and Evaluating a Health Promotion Project 61 Chapter 3 – Sharing Health Information Websites listed in this chapter http://www.sharingtruestories.com [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 http://www.healthyactive.gov.au/ 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 Chapter 3 – Sharing Health Information 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 About this chapter ............................................................................................ 66 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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: http://www.nt.gov.au/health/healthdev/health_promotion/promotion_main.shtml 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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…”. Community health teams can, for example: • 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 Chapter 4 – Strategies for Health Promotion Community health teams can, for example: • 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…”. Community health teams can, for example: • 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 Chapter 4 – Strategies for Health Promotion Community health teams can, for example: • 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion • 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? See Chapter 5 Planning and Evaluating a Health Promotion Project 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion • • • • 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 Chapter 4 – Strategies for Health Promotion • 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 Chapter 4 – Strategies for Health Promotion • 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 Chapter 4 – Strategies for Health Promotion • • 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion − − − − 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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. 87 Chapter 4 – Strategies for Health Promotion 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. 88 Chapter 4 – Strategies for Health Promotion 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?” 89 Chapter 4 – Strategies for Health Promotion 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. 90 Chapter 4 – Strategies for Health Promotion 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? 91 Chapter 4 – Strategies for Health Promotion 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) 92 Chapter 4 – Strategies for Health Promotion 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? 93 Chapter 4 – Strategies for Health Promotion 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? 94 Chapter 4 – Strategies for Health Promotion 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 95 Chapter 4 – Strategies for Health Promotion 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?”) 96 Chapter 4 – Strategies for Health Promotion 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 97 Chapter 4 – Strategies for Health Promotion 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) 98 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 100 Chapter 4 – Strategies for Health Promotion 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. 101 Chapter 4 – Strategies for Health Promotion 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 1988:1-25 102 Chapter 4 – Strategies for Health Promotion 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. 103 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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: 105 Chapter 4 – Strategies for Health Promotion “…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, 106 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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. 114 Chapter 4 – Strategies for Health Promotion 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 115 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion Figure 2 : Stuart Phillpot 1990:53 117 Chapter 4 – Strategies for Health Promotion 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 118 Chapter 4 – Strategies for Health Promotion 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 119 Chapter 4 – Strategies for Health Promotion 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 120 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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). 122 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 124 Chapter 4 – Strategies for Health Promotion 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 125 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 2 127 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion • 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 Chapter 4 – Strategies for Health Promotion 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 http://www.nt.gov.au/health/healthdev/health_promotion/promotion_main.shtml http://www.nt.gov.au/health/healthdev/health_promotion/promotion_contacts.shtml 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.nt.gov.au/health/comm_health/abhealth_strategy/apact/parta.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 Chapter 4 – Strategies for Health Promotion 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 http://www.sharingtruestories.com 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 Bibliography General Aboriginal and Islander Health Worker Journal 2005, The Indigenous Health Promotion Resources Guide: A National Information Guide for Aboriginal and Torres Strait Islander Health Workers, 5th edn, Sydney Baum F 2004, The New Public Health: An Australian Perspective, 2nd edn, Oxford University Press, Melbourne. 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Butler P, Legge D, Wilson G & Wright M 1995, Towards Best Practice in Primary Health Care, A working paper of the Best Practice in Primary Health Care Project, Centre for Development and Innovation in Health, [Northcote, Victoria]. Dhillon HS & Philip L 1994, Health Promotion and Community Action for Health in Developing Countries, Division of Health Education, WHO, Geneva. Feuerstein M 1986, Partners in Evaluation: Evaluating Development and Community Programmes with Participants, Macmillan, London. Hope A & Timmel S 2003, Training for Transformation: A Handbook for Community Workers, revised edn, Books 1-3, Mambo Press, Gweru, Zimbabwe. Kreuter MW, Lezin NA, Kreuter MW & Green LW 2003, Community Health Promotion Ideas That Work: A Field-Book for Practitioners, 2nd edn, Jones & Bartlett, Sudbury, Massachusetts. Labonte, R. (1999). Social capital and community development: Practitioner Emptor. Australian and New Zealand Journal of Public Health, 23(4), 430-433. 146 Chapter 4 – Strategies for Health Promotion Laverack G 2004, Health Promotion Practice: Power and Empowerment, Sage publications, London Menzies School of Health Research 2000,Jirntangku Miyrta: Katherine West Coordination Care Trial, Local Evaluation Team Final Report, Menzies School of Health Research, Darwin Moodie R& Hulme A 2004, Hands On Health Promotion, IP Communications, Victoria New South Wales Health 2001, A Framework for Building Capacity to Improve Health, Sydney Northern Family Health Society - Prince George 2003, Basics of Community Development NFHS-pg.org, downloaded 5/2005 Phillpot S 1990, Training Needs Analysis of Community Government Councils in the Northern Territory, Community Government Council Series, Northern Territory Local Government Industry Training Committee, Darwin. Remocker A J & Storch ET 1999, Action Speaks Louder: A Handbook of Structured Group Techniques, 6th edn, Churchill Livingstone, Edinburgh. Sinatra J & Murphy P 1997, Landscape for Health: Settlement Planning and Development for Better Health in Rural and Remote Indigenous Australia, RMIT Outreach Australia Program, Melbourne. Smith G & King R 1998, Well men’s checkups - A program of the East Arnhem Health Promotion Unit, Health Promotion Journal of Australia, vol 8(1), pp69-71. Smith D, Pyett P & McCarthy L, Community Development Interventions to improve Aboriginal Health: building an evidence base, Co-operative Research Centre for Aboriginal Health (CRCAH) Victorian Health Promotion Foundation Territory Health Services 1998, The Aboriginal Public Health Strategy and Implementation Guide 1997 - 2002, Territory Health Services, Darwin. Using Media Chapman S & Lupton D 1994, The Fight for Public Health: Principles and Practice of Media Advocacy, BMJ, London. Northern Territory Department of Health and Community Services 1989, Aboriginal Health Promotion Training Manual, Northern Territory Department of Health and Community Services, [Darwin]. Paul CL & Redman S 1997, A review of the effectiveness of print material in changing health-related knowledge, attitudes and behaviour, Health Promotion Journal of Australia, vol 7(2), pp91-99. Wass A 2000, Promoting Health: The Primary Health Care Approach, 2nd edn, Elsevier, Sydney Wallack L, Dorfman L, Jernigan D & Themba M 1993, Media Advocacy and Public Health: Power for Prevention, Sage, Newbury Park, California. 147 Chapter 4 – Strategies for Health Promotion Werner D & Bower B 1982, Helping Health Workers Learn: A Book of Methods, Aids, and Ideas for Instructors at the Village Level, Hesperian Foundation, Palo Alto, California. Using Screening Braveman PA & Tarimo E 1994, Screening in Primary Health Care: Setting Priorities with Limited Resources, WHO, Geneva Cochrane AL & Holland WW 1971, Validation of Screening Procedures, British Medical Bulletin, Vol 27 No 1: pp 3-8 Hall DMB (ed) 2003, Health for All Children: Report of the Third Joint Working Party on Child Health Surveillance, 4th edn, Oxford University Press, Oxford Health Screening in Central Australia 1997, Central Australian Rural Practitioners Association, [Alice Springs] Mak DB, McDermott R, Plant AJ & Scrimgeour D 1998, The contribution of community health surveys to Aboriginal health in the 1990s, Australian and New Zealand Journal of Public Health, vol 22(6), pp 645-647 National Health and Medical Research Council 2002, Review of Child Health Screening and Surveillance: a Critical Review of the Evidence, National Health and Medical Research Council, [Canberra]. Download at: www.nhmrc.gov.au/publications/_files/ch42.pdf Pencheon D, Guest C, Melzer D, Muir Gray J 2001, Oxford Book of Public Health Practice, Oxford University Press, Oxford 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 About this chapter .......................................................................................... 151 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 Before proceeding ..................................................................................... 174 Relationship between the goal, objectives and strategies .......................... 174 Step 6: develop the action plan ..................................................................... 176 Questions to help identify resources .......................................................... 177 Before proceeding ..................................................................................... 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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: http://www.nt.gov.au/health/healthdev/health_promotion/promotion_contacts.shtml 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 184 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 186 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 1986:4 188 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project (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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project • • • • • 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 (How to achieve Objective 1) Actions/Activities (Tasks to do) Resources required (Who will do it? What is needed?) Time frame (When will it be done by?) Evaluation (How will the team know how it is going? What will be measured?) 209 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 (How to achieve Objective 2) Actions/Activities (Tasks to do) Resources required Time frame (Who will do it? What is needed?) (When will it be done by?) Evaluation (How will the team know how it is going? measured?) What will be 210 Chapter 5 – Planning and Evaluation a Health Promotion Project Useful websites http://www.nt.gov.au/health/healthdev/health_promotion/promotion_contacts.shtml ‘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 Abbott D 1990, How to Evaluate Your Community Health Programs, Research and Evaluation in Community Health Series Paper, 2, rev B Craig (1994), South Australian Community Health Research Unit, Adelaide. 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. Bear-Wingfield R 1996, Sharing Good Tucker Stories: A Guide for Aboriginal and Torres Strait Islander Communities, eds C Dignan & R Sharp, Commonwealth Department of Health and Family Services, Canberra. Central Sydney Area Health Service and NSW Health 1994, Program Management Guidelines for Health Promotion, CSAHS & NSW Health, Sydney. 211 Chapter 5 – Planning and Evaluation a Health Promotion Project 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. Ewles L & Simnett I 2003, Promoting Health: A Practical Guide to Health Education, 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. Feuerstein M 1986, Partners in Evaluation: Evaluating Development and Community Programmes with Participants, Macmillan, London. 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. Hawe P, Degeling D & Hall J 1990, Evaluating Health Promotion: A Health Worker’s 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. 212 Chapter 5 – Planning and Evaluation a Health Promotion Project 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 Australian Community Health Research Unit, Adelaide. 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 Unit, Adelaide. 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 National Health and Medical Research Council 2003 Guidelines on Ethical Matters in Aboriginal and Torres Strait Islander Health Research Commonwealth of Australia, Canberra O’Connor ML & Parker E 2001, Health Promotion: Principles and Practice in the Australian Context, 2nd Edition, Allen & Unwin, St Leonards, NSW. Owen JM 1999, Program Evaluation: Forms and Approaches, 2nd Edition, Allen & Unwin, St Leonards, NSW. Patton MQ 2002, Qualitative Evaluation and Research Methods, 3rd Edition, Sage Publications, Newbury Park, California. 213 Chapter 5 – Planning and Evaluation a Health Promotion Project 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. Sinatra J & Murphy P 1997, Landscape for Health: Settlement Planning and Development for Better Health in Rural and Remote Indigenous Australia, RMIT Outreach Australia Program, Melbourne. Smith D, Wununmurra P, Bamundurruwuy D, Nyomba H, Nalpinya L, Edmond K, Ruben A 2002, Community Action to Promote Child Growth in Gapuwiyak: Final report on a participatory action research project, Cooperative Research Centre for Aboriginal Health, Darwin Southern Community Health Research Unit 1991, Planning Healthy Communities: A Guide to Doing Community Needs Assessment, Southern Community Health Research Unit, Adelaide. Wadsworth Y 1997, Everyday Evaluation on the Run, 2nd Edition, Action Research Issues Association, Melbourne. Wadsworth Y 1997, Do It Yourself Social Research, 2nd edn, Allen & Unwin, St Leonards, NSW. Wass A 2000, Promoting Health: The Primary Health Care Approach, 2nd Edition, Harcourt Brace, Sydney. Weaver B 2003, Catch the Wave, How to find good information on the internet- fast, RMIT University Press, Victoria, Australia 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 Chapter 6 – A Health Promoting Health Centre • 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 Chapter 6 – A Health Promoting Health Centre • 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 http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/parta.pdf 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre • 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre (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 Chapter 6 – A Health Promoting Health Centre • 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre • 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre • 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 For a copy contact: 8999 2660 NT Domestic and Family Violence Strategies 2002-2007 For a copy contact: 8999 3785 NT Food and Nutrition Policy 1995-2000, Nutrition and Physical Activity Action Plans 2001-2006 For a copy contact: 8999 2424 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 For a copy contact: 8999 2707 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre 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 Chapter 6 – A Health Promoting Health Centre Information provided by Kerry Taylor, Centre for Remote Health, Alice Springs Websites listed in this chapter http://www.infoprivacyhealth.nt.gov.au http://www.nt.gov.au/health/comm_health/abhealth_strategy/apact/parta.pdf 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 Bibliography Australian Medical Association (WA Branch) 1998, A Medical Practitioner’s Guide to Aboriginal Health, AMA and Healthway, Nedlands, WA. Bartlett B 1995, An Aboriginal Health Workers’ Guide to Family, Community and Public Health, Central Australian Aboriginal Congress, Alice Springs. Butler P & Cass S (eds) 1993, Case Studies of Community Development in Health, Centre for Development and Innovation in Health, [Northcote, Victoria]. Butler P, Legge D, Wilson G & Wright M 1995, Towards Best Practice in Primary Health Care, A working paper of the Best Practice in Primary Health Care Project, Centre for Development and Innovation in Health, [Northcote, Victoria]. Couzos S & Murray R 2003, Aboriginal Primary Health Care: An Evidence-Based Approach, 2nd Edition Oxford University Press, Melbourne. Craig JV & Smyth RL (et al) (ed) 2002, The Evidence Based Practice Manual for Nurses, Churchill Livingstone, Edinburgh 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 1992, Aboriginal Health Worker Project: Why Don’t They Stay?, NT Department of Health and Community Services, Alice Springs. 252 Chapter 6 – A Health Promoting Health Centre 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 the Territory Health Services by the WHO Regional Training Centre for Health Development, University of New South Wales, Sydney. Johnson A & Paton K 2007, Health Promotion and Health Services : Management for Change, Oxford University Press, Melbourne Josif P & Elderton C 1992, Working Together? A Review of Aboriginal Health Workers: Recruitment and Retention in the Northern Territory’s “Top End”, Department of Health and Community Services, Darwin. Kennedy K (comp) 1997, Quality Discharge Planning: Doing it Better for the Bush, Territory Health Services, Darwin. Lankester T, Campbell ID & Rader AD 2002, Setting Up Community Health Programmes: A Practical Manual for Use in Developing Countries, 2nd ed’n Macmillan Education, London. Nathan P & Japanangka DL 1983, Health Business, Heinemann Educational Australia, Richmond, Victoria. National Health and Medical Research Council 1996, Promoting the Health of Australians: Case Studies of Achievements in Improving the Health of the Population, Commonwealth of Australia, Canberra. 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. Northern Territory Department of Health and Community Services 2005, Building healthier Communities: a Framework for health and Community Services 2004 – 2009, Northern Territory Department of Health and Community Services, Darwin. Northern Territory Department of Health and Community Services 1994, 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, Northern Territory Department of Health and Community Services, Darwin. Northern Territory Department of Health 1979, Northern Territory Bush Book: A Guide for Field Staff, 2nd edn, ed DS Jacobs, Northern Territory Department of Health, Darwin. Northern Territory Department of Health and Community Services 2006, Remote Health Branch Atlas, Northern Territory Department of Health and Community Services, Darwin Northern Territory Department of Health and Community Services, The Chronicle: Chronic Diseases Network Northern Territory, Vol 8/3, Dec 2004, Darwin 253 Chapter 6 – A Health Promoting Health Centre Palmer GR & Short SD 2000, Health Care & Public Policy: An Australian Analysis, 3rd edn, Macmillan Education, Melbourne. Reid J & Trompf P (eds) 1991, The Health of Aboriginal Australia, Harcourt Brace Jovanovich, Sydney. Roe M 1995, Working Together to Improve Health: A Team Handbook, Queensland Primary Health Care Reference Centre, University of Queensland, Brisbane. Ryan P 1992, Cases for Change: CHASP in Practice, Australian Community Health Association, Bondi Junction, NSW. Tarimo E 1991, Towards a Healthy District: Organizing and Managing District Health Systems Based on Primary Health Care, WHO, Geneva. Taylor K & James V 1998, Preparing for Practice: A Guide to Remote Area Nursing in Central Australia for Registered Nurses, Territory Health Services, Alice Springs. Tregenza J & Abbott K 1995, Rhetoric and Reality: Perceptions of the Roles of Aboriginal Health Workers in Central Australia, Central Australian Aboriginal Congress, Alice Springs. Wass A 2000, Promoting Health: The Primary Health Care Approach, 2nd edition Harcourt Brace, Sydney. 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. 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 Community participation Continuous quality improvement Contributing factor Cultural security Determinants of health Disease Disease prevention Early intervention Empowerment Environmental Health 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary • 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 Chapter 7 - Glossary 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). Community participation 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 Chapter 7 - Glossary 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 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary 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 Chapter 7 - Glossary Bibliography Abbott D 1990, How to Evaluate Your Community Health Programs, Research and Evaluation in Community Health Series Paper, 2, rev B Craig (1994), South Australian Community Health Research Unit, Adelaide. Anderson KN, Anderson LE & Glanze WD (eds) 1994, Mosby’s Medical, Nursing, and Allied Health Dictionary, 4th edn, Mosby, St Louis, Missouri. Baum F, Fry D & Lennie I (eds) 1992, Community Health: Policy and Practice in Australia, Pluto Press, Leichhardt, NSW in assoc with Australian Community Health Association, Bondi Junction, NSW. Department of Health and Aging 2002 Canberra, retrieved 5 May 2006 http://www.health.gov.au/pubhlth/about/whatis.htm Foundation for Integrated Health 2006 United Kingdom retrieved 8 December 2006 http://www.fih.org.uk/Resources/educationresource/furtherresources/Glossary.htm Freudenberg N 1984, Training health educators for social change, International Quarterly of Community Health Education, vol 5(1), pp37-52. Goodman RM, Speers MA, McLeroy K, Fawcett S, Kegler M, Parker E, Smith SR, Sterling TD & Wallerstein N 1998, Identifying and defining the dimensions of community capacity to provide a basis for measurement, Health Education and Behavior, vol 25(3), pp258-278. Green LW & Kreuter MW 1991, Health Promotion Planning: An Educational and Environmental Approach, 2nd edn, Mayfield, Mountain View, California. Hawe P, Degeling D & Hall J 1990, Evaluating Health Promotion: A Health Worker’s Guide, MacLennan & Petty, Sydney. Higgins-Biddle JC & Babor TF 1996, Reducing Risky Drinking: A Report on Early Identification and Management of Alcohol Problems Through Screening and Brief Intervention, Alcohol Research Center, University of Connecticut Health Center, Farmington, Connecticut. Institute of Medicine 1990, Broadening the Base of Treatment for Alcohol Problems: Report of a Study by a Committee of the Institute of Medicine Division of Mental Health and Behavioural Medicine, National Academy Press, Washington DC. 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. Kunitz SJ 1994, Disease and Social Diversity: The European Impact on the Health of Non-Europeans, Oxford University Press, New York. Last JM (ed) 1995, A Dictionary of Epidemiology, 3rd edn, Oxford University Press, New York. 269 Chapter 7 - Glossary Lawson JS 1991, Public Health Australia: An Introduction, McGraw-Hill, Sydney. The Macquarie Dictionary 1987, 2nd rev, Macquarie Library, Sydney. Miller WR & Rollnick S 1991, Motivational Interviewing: Preparing People to Change Addictive Behavior, Guilford Press, New York. Moodie R& Hulme A 2004, Hands On Health Promotion, IP Communications, Victoria 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. Nutbeam D 1986, Health promotion glossary, Health Promotion International, vol 1 (1), pp113-127. Palmer GR & Short SD 1994, 2nd Ed, Health Care and Public Policy: An Australian Analysis, McMillan Education, Melbourne. Pholeros P, Rainow S & Torzillo P 1993, Housing for Health: Towards a Healthy Living Environment for Aboriginal Australia, Healthabitat, Newport Beach, NSW. Public Health Agency of Canada, 2002 Population Health Approach, Ottawa. Retrieved 15 June 2006 http://www.phac-aspc.gc.ca/ph-sp/phdd/approach/approach.html#health) Reid J & Trompf P (eds) 1991, The Health of Aboriginal Australia, Harcourt Brace Jovanovich, Sydney. Territory Health Services 1998, Living With Alcohol: A Handbook for Community Health Teams, Living With Alcohol Program, Territory Health Services, Darwin. UK Commission on Environment and Health 18 March 1996, quoted in Environmental Health News, vol 11 (12), 22 March 1996. Western Australia, Department of Health 2004, Aboriginal Cultural Security: A Background paper, Government of Western Australia, Perth 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 1998, Health Promotion Glossary, WHO, Genev. World Health Organization 2001, Strengthening Mental Health Promotion, WHO Factsheet No 220, WHO, Geneva 270 Chapter 7 - Glossary World Health Organization 2003, Social Determinants of Health: The Solid Facts, 2nd Ed, WHO, Geneva World Health Organization 2004, Promoting Mental Health: Concepts, Emerging Evidence, Practice, Summary Report, WHO, Geneva World Health Organization 2005, The Bangkok Charter for Health Promotion in a Globalised World, WHO, Geneva 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. 272 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