Participation and democracy in health promotion

1. Participation and democracy in health promotion 9 June 2007, Vancouver Goof Buijs, the Netherlands gbuijs@nigz.nl based on the work of Bjarne Bruun Jensen, Denmark bjbj@dou.dk

2. contents • 2 paradigms?! • key concepts: participation and action • the IVAC approach • conclusion and challenges

3. Different paradigms? PREVENTION HEALTH PROMOTION • 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

4. 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

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

6. 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)

7. 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.

8. 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

9. Therefore.. • 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

10. 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

11. Participation - in relation to what and how?

12. Different forms of actions

13. Components of action competence • Knowledge/Insight • Commitment • Visions • Action experiences • Critical thinking • …

14. Four dimensions of knowledge

15. traditional ”knowledge landscape”

16. Action-oriented knowledge landscape

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. ”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%

24. The ”IVAC” approach Investigation • 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 Visions • 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?

25. 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

26. 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.

27. 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

28. 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?

29. 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

30. 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)