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Participation and democracy in health promotion. 9 June 2007, Vancouver Goof Buijs, the Netherlands [email protected] based on the work of Bjarne Bruun Jensen, Denmark [email protected] contents. 2 paradigms?! key concepts: participation and action the IVAC approach

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Participation and democracy in health promotion l.jpg

Participation and democracy in health promotion

9 June 2007, Vancouver

Goof Buijs, the Netherlands

[email protected]

based on the work of Bjarne Bruun Jensen, Denmark

[email protected]

Contents l.jpg

  • 2 paradigms?!

  • key concepts: participation and action

  • the IVAC approach

  • conclusion and challenges

Different paradigms l.jpg
Different paradigms?


  • Totalitarian Democratic

  • Moralize Participate

  • Top-down Bottom-up

  • Monologue Dialogue

  • Individual Collective

  • Privation Commitment

  • Driven by experts Driven by participants

  • Behaviour change Action competence

  • Health Information Health Pedagogy

  • Disease Quality of life

  • Lifestyle Living conditions

  • Closed health concept Open health concept

Two different paradigms l.jpg
Two different paradigms?

  • Health promotion versus prevention and treatment?

  • No- a false contrast

  • Instead retrieves a ’dialogue-oriented’ versus a ’top down’ approach to:

  • Health promotion,prevention and treatment

Meaning l.jpg

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

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Two paradigms?

  • The work (with health promotion), is in short, based on visions and possibilities, driven by hope, dominated by a ”bottom up” perspective….

  • The work (with prevention), is in short, based on risk-thinking, driven by fear, dominated by experts and by a ”top down” perspective (Jensen & Johnsen, 2000, s.7)

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Two paradigms?

  • ”Health Promotion efforts are participatory, based on dialogue and can be targeted towards individuals as well as sections of populations” (Danish National Board of Health 2005, p. 49).

  • In description of prevention nothing is mentioned about participation, dialogue, user-involvement ect.

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Barriers for changing paradigms

  • Basic training

  • Professional terminology and language

  • Historical background

  • Afraid of loosing professionalism

  • Expectations from target groups and collaborating partner

  • Lack of time for dialogue with target groups

  • Lack of tools for working in another paradigm

  • Demand on documentation and evaluation

Therefore l.jpg

  • Health promotion/prevention have different goals, but are complementary – therefore they do not belong to different paradigms

  • Starting point for sharing values is in the operationalisation of the key concepts (such as participation, action competence) in relation to the context/ setting

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The concept of participation

  • Participation – what is it about?

    • Students need to be involved in decisions about content, process and outcome

  • Participation – why is it important?

    • ethical reasons

    • learning efficiency

    • creating ownership

    • educating for democracy

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Participation - in relation to what and how?

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Components of action competence

  • Knowledge/Insight

  • Commitment

  • Visions

  • Action experiences

  • Critical thinking

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traditional ”knowledge landscape”

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Action-oriented knowledge landscape

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experts versus target groups

  • ”Top down” approach – dominated by experts

  • ”Bottom up” approach – dominated by the target groups

  • Dialogue approach – the content and the professional has an important role to play

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Health concept:developments in health promoting schools

From disease-oriented health concept

  • healthy food = correct nutritional balance

    To wellbeing-dominated health concept

  • e.g. healthy food = food which tastes good

    Or: health concept which includes quality of life, disease elements as well as its mutual links

  • e.g. healthy food = nutritional, aesthetical, social and sustainable dimensions

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The participation concept

  • Criticism of top-down and bottom-up approach (top down, moralising, expert-dominated)

  • Many projects had to begin with ”target-group dominated” (professional was put on the sideline)

  • Gradually ”self-determination” became ”targetgroup-professional dialogue” with professionalism back in the centre

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Three principal lines

1. Towards a health concept that contains both disease and healthy life

2. Towards a participation concept, where the professional is placed centrally

3. Towards a ”setting” perspective, where the framework and education are connected and related to education and health … competence development

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Pupils’ Visions (1800, 13 y.o.)

  • I have many ideas about how we can improve:

  • - my daily life (a)

  • - my school (b)

  • the World (c)

  • ANSWERS: a b c

  • Fully agree/Agree: 49 47 58

  • Does not agree or disagree: 38 39 32

  • Totally disagree/Disagree: 12 14 10

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Pupils’ Commitment (1.800, 13 y.o)

I would like to fight for improving:

  • my daily life (a)

  • my school (b)

  • the World (c)

    ANSWERS: a b c

    Fully agree/Agree: 73 63 78

    Does not agree or disagree: 21 30 19

    Totally disagree/Disagree: 6 7 3

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”Achieving influence is very easy” (3.660, 13-15 y.o)

The students were asked about

four different settings

Leisure activities 36%

Family 44%

School 14%

Society 6%

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The ”IVAC” approach


  • why is it important to us

  • do lifestyle and living conditions make an influence

  • how was it in former times and how has it changed


  • what alternatives can we imagine?

  • how are the conditions in other countries and cultures?

  • what do we prefer and why?

    Actions & Change

  • what changes will bring us closer to the visions?

  • changes in our own life, in the class, in the society?

  • what action possibilities exist in order to reach the changes?

  • which actions will we carry out?

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A case from Denmark - I

Students’ actions:

  • Applications sent to the local government's departments: 18

  • Cleaning (gathering of litter from streets, beaches etc.): 12

  • Articles in the local newspaper: 10

  • Written petitions to private companies: 6

  • Embellishments (painting lamp-posts, stones etc.): 6

  • Written petitions to local village boards: 5

  • Establishment of compost containers: 5

  • Hanging up of posters regarding environmental issues: 5

  • Demonstration concerning traffic conditions (150 pupils): 1

A case from denmark ii l.jpg
A case from Denmark - II

Changes due to students’ actions:

  • City council set aside €130.000 for reorganising traffic in Lyngerup local area (roundabout etc.)

  • Establishing Toronto-flash and zebra crossing near the school

  • Reducing speed limit to 50 Km/h near the school

  • Planting trees along cycle paths between two neighbourhoods

  • Intensifying local media debate on traffic

  • Extending playground and establishing basketball court

  • Creating a meeting and activity place for adults and children

  • Establishing children's village board as part of village board

  • Establishing compost containers

  • Painting lamp posts, putting up bird houses, planting shrubs and cleaning roadsides.

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What helps to build ownership and action competence

  • Genuine participation (but in a dialogue with a professional)

  • Own actions (but as integrated elements)

  • Barriers might help to increase motivation (but the role of the professional is crucial)

  • All ages and all socio-economic groups benefit from an participatory and action-oriented approach

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Challenges for Schools

  • Actions often defined by external actors

  • Economy used as external motivating factor

  • Skills needed by teachers to integrate authentic actions and collaboration in education?

  • How to ‘prepare’ the community for ‘acting pupils’?

  • Supporting structure needed?

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Professional competence

  • Clarification related to the health concept

  • Action-oriented insight about health related conditions

  • Feeling for - and insight in – dialogue with target group

  • Insight in the targetgroup’s health understandings

  • Insight in the active concept facets

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Conclusions and future challenges

  • Dialogue, instead of top-down bottom-up

  • Towards genuine participation and action

  • Focus on competence development

  • Potential for schools needs more research and development (measure impact and effectiveness)