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

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participation and democracy in health promotion

Participation and democracy in health promotion

9 June 2007, Vancouver

Goof Buijs, the Netherlands

based on the work of Bjarne Bruun Jensen, Denmark

  • 2 paradigms?!
  • key concepts: participation and action
  • the IVAC approach
  • conclusion and challenges
different paradigms
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
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
  • ….. That even the ”surgeon” has to be aware of supporting the patients’ own participation and actions
two paradigms
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)
two paradigms7
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.
barriers for changing paradigms
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
  • 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
the concept of participation
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
components of action competence
Components of action competence
  • Knowledge/Insight
  • Commitment
  • Visions
  • Action experiences
  • Critical thinking
experts versus target groups
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
health concept developments in health promoting schools
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
the participation concept
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
three principal lines
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

pupils visions 1800 13 y o
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
pupils commitment 1 800 13 y o
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

achieving influence is very easy 3 660 13 15 y o
”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%

the ivac approach
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?
a case from denmark i
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
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.
what helps to build ownership and action competence
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
challenges for schools
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?
professional competence
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
conclusions and future challenges
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)