Midwifery Today Issue Number 89 (Spring 2009) Midwifery Knowledge from around the
World International Midwifery, Back Issues
Theme: Midwifery Knowledge from around the World
When we came up with this theme, we anticipated being able to share a variety of midwifery knowledge from around the world. While a number of articles addressed that, one thing that soon became clear is that midwifery knowledge is beginning to be lost or fall into disuse around the world, as the medicalized version of childbirth continues to gain ground. This issue contains a mix of midwifery knowledge as well as discussion of the adverse effects of this medicalization of birth.
Articles include:
* Marion's Message: Does it Matter How We Are Born?, by Marion Toepke McLean. The author argues that midwives need to be aware that it does matter what happens during our birth so they can do the best job possible.
* The Life and Work of a Rope Midwife in Darfur, by Ramona Denk. This fictional composite is an account of the life and work of an imaginary traditional midwife in a Darfur village. It is based on multiple sources of information, including direct experience, observation, personal interviews and the research of others.
* The Emotional Impact of Cesareans, by Pamela Udy. This is part two of a two-part series by the President of the International Cesarean Awareness Network (ICAN), discussing the postpartum impact of cesareans on women and their families. This should be must-reading for all women who are considering a cesarean.
* Enoch's Waterbirth after Four C-sections, by April Bailey. A midwife in Hawaii tells the birth story of aVBAC waterbirth after four cesareans.
* Meeting by Chance with a Modern Day Che (A Fireside Chat with a Cuban Obstetrician, 2007), by Ruby Weldon. We often hear conflicting reports on the situation in Cuba. This article highlights the current status of birthing in that country, from the mouth of a Cuban obstetrician.
* The Influence of Birth Experience on Postpartum Depression, by Michelle Bland. It seems obvious that homebirth moms would experience a lower rate of postpartum depression than women with institutional births. Michelle Bland shares her research in this article, which showed that the participants in the homebirth group had the lowest rates of depression, felt the most control over their birth experiences and were the most satisfied.
* The Good Guys: Michael C. Klein, by Judy Slome Cohain. Another chapter in our ongoing feature on "good guy" obstetricians.
* Keeping the Midwifery Legacy Alive, by Nell Tharpe. The author creates a roadmap for keeping the traditions of midwifery alive.
* The Midwife, by Jacqueline Cuthbertson. A lovely piece on the midwife and the current state of midwifery.
* Husband-assisted Homebirth, by John Paul. A couple chooses to go it alone for the birth of their daughter.
* Birthing in South Africa, by Linda B. Jenkins. This short piece contrasts current birth practices in South Africa in a variety of settings.
* Why Music Matters in Childbirth, by Taz Tagore. Music has a central place in the lives of many of us, and it is an essential part of some birth plans. The author discusses the research and her experiences of music and birth, along with some helpful suggestions.
* Brona, by Darjee Sahala. This story of a stillborn baby, and the unexpected repercussions for his midwife mother, will evoke both sadness and anger in readers.
* Tradition, Birth and the Kitchen to Cook It All In, by Naoli Vinaver. The author, a Mexican midwife, laments the loss of birth knowledge that had been passed through generations of women like a family recipe. She also gives pointers on how to have the best experience when going to a developing country to learn midwifery skills or assist birthing women.
* Informed Consent, reprinted from AIMS Journal. This is a parody of a consent form that hospitals would require if they were really being honest about their childbirth practices.
* The Nuchal Cord at Birth: What Do Midwives Think and Do?, by Elaine Jefford, Kathleen Fahy and Deborah Sundin. Routinely checking for the nuchal cord is a common medical intervention in birth. Some evidence shows damage to the baby and mother. Results from the authors' study reflect the training midwives have received and their current practices in relation to a possible nuchal cord at birth.
* Traditional Mentoring, by Maryl Smith. A great article for all aspiring or practicing midwives, providing important advice on mentoring.
* Traditional Midwives and Maternal Morbidity and Mortality in Countries with Low Resources, by Kezaabu Edwidge. A discussion of the current policy direction regarding traditional midwives as providers of childbirth services in Uganda and other countries with low resources.
© 1987-2010 Midwifery Today, Inc. All Rights Reserved.
Wednesday, March 31, 2010
Promoting Community Partnership and Involvement under limited resources: Opportunities/Gains and challenges
URL http://www.the-networktufh.org/conference/previousconferences.asp
By Edwidge Kezaabu Lugemwa
From the VVOB Skills Lab Project -
Kigali Health Institute(KHI) – Rwanda.
AIM: To share ideas of the concept of community partnership and involvement in the promotion
of health in limited resources , opportunities and challenges.
Specific Objectives: By the end of the session participants should be able to:
1. Discuss the rationale of community partnership and involvement in the promotion of
health in limited resources.
2. Share their experiences in community partnership and involvement with evidence
based and best practices.
3. Share ideas related to opportunities and challenges in community partnership and
involvement in the promotion of health.
The process: Presentation, small group discussions, presentations in plenary, general
discussions and conclusion.
CONTENT
Introduction
The key words
What is a community?
The concept of community partnership
Community Empowerment
Community Participation
Community Involvement
Effective Community Communication
Rationale of community partnership in healthy care
Opportunities/Gains
Challenges
Conclusion
Acknowledgement
References
INTRODUCTION:
The vision ‘health people in health communities’ involves broad based preventive efforts and moves beyond what happens in physicians’ offices, clinics and hospitals, beyond the traditional medical care system to the neighborhoods, schools, workplaces and families in which people live their daily lives. These are the areas where a large proportion of prevention and rehabilitation occurs. Considering the emerging public health concerns, objectives that accurately reflect data can be developed, revised and re revised. The set objectives to address health concerns should be used with potential data source and when revised they should reflect the most current science. Achievement of such objectives towards health promotion in low resource environments can be attained fully with increased Community Partnership and involvement towards best practices.
KEY WORDS
Health, Health promotion, Evidence based and Best practices, Community Partnership.
* Health, defined as the state of complete physical, mental and social well being and not merely the absence of disease or infirmity,(’WHO)’ is also described as ‘a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life’. It is further described by medical scientists as a level of functional and/or metabolic efficiency of an organism at both the micro (cellular) and macro (social) level to restore and sustain a ‘state of balance’ known as homeostasis.
Health Promotion, according to the Ottawa charter of health promotion,1996, is a set of activities designed to achieve optimal health for all by maintaining and enhancing the health of everyone and facilitating individual and communities to increase control over factors that influence their health /determinants of health, and thereby improve their own health’
‘’Best practice in health promotion’are those sets of processes and activities that are
consistent with health promotion values/goals/ethics/beliefs, evidence, and understanding of the environment and which are most likely to achieve health promotion goals in a given situation, (Best practice in health promotion, Kahan & Goodstadt,IDM Manual,April 2002’’).
Evidence Based Practice is an approach to care where health professionals use the most current and appropriate information available to make decisions related to clients’/patients’ care.
EBP therefore promotes the collection, interpretation and integration of valid, important and applicable client/patient – reported, provider – observed and research derived evidence, Mitchell, G.J.(1999).
WHAT IS A COMMUNITY?
Ferdinand Tonnies in 1887 argued over the word community (Gemeinschaft) differitiating it from society (Gesellschaft). Community is perceived to be a tighter and more cohesive social entity within the context of the larger society due to the presence of a ‘unity of will’ or sense of the community one is identified with.
A Community is defined as a social group of organisms sharing an environment, and normally with shared interests. In the human communities, intent, belief, resources, preferences, needs, risks, common leadership and a number of other conditions may be present and common affecting the identity of the participants or the particular members of a community and their degree of cohesiveness. Membership, Influence, Integration, fulfillment of needs and shared emotional connection are elements of a community identified by Mcmillan and Chavis in a study they carried out in 1986.
THE CONCEPT OF COMMUNITY PARTNERSHIP IN HEALTH CARE
A partner has been defined by the oxford English Dictionary as a sharer. This implies that, the health care practitioners should be able to share knowledge, expertise, skills, beliefs, values and decision making with the clients in a one to one basis, with family or community as groups and to accept what they offer in these areas as both valid and respected, even when it differs fundamentally from their views. As a partner, the practioner should refrain from making judgments about the individuals, families or communities but should be able to share perspectives on an equal footing, and with their participation where possible, Ashworth et al. (1992).
It is important to note here that participation with others presupposes that each person is receptive to others’ contributions, and that each is able to assume the receptiveness of the others. But partnership goes beyond participation although both participation and empowerment are sometimes equated to partnership.
In partnership for health care, the aim is to promote health with the people, and not just to provide medical care for the people. In this case, partnership acts as a multiplier whereby individuals or members of the community become the agents of change, taking new health patterns and new ideas to other individuals, families and communities. Community partnership at first may seem to be a slow process but later this multiplier effect causes a rapid increase in growth, promoting health even in very low resources environments. The community members, with a great store of knowledge and skills reinforced with further training where possible can provide more and yet appropriate primary health care because they understand their local health concerns and needs more than anyone else outside their social interaction circles within their communities.
COMMUNITY EMPOWERMENT
Partnership is only in words without empowerment. Empowerment is a social process of recognizing, promoting and enhancing people’s abilities to meet their own needs, solve their own problems and mobilize the necessary resources in order to feel in control of their own lives, Gibson (1999). Community empowerment therefore occurs by empowering individuals first so as to make up empowered communities. Formal and informal education, the former being promoted through the bottom - up approach and community involvement are some of the strategies to empower individuals and communities. Through partnership, individuals and communities can be empowered but lack of empowerment means that people perceive themselves as powerless and not in control of their own lives or conditions which determine their health and
Empowerment is a multidimensional, social process, It occurs at various levels that is; at individual level, group or community level. It is a social process that fosters power ( that is, the capacity to implement) in people, for use in their own lives, their communities and in their societies, by acting on issues that they define are important, Bailey (1992). But it is not possible to offer people power so as to make them empowered, the focus is on the connection between individual actions to community action, encouraging individual change by supporting participants’ efforts towards community change.
COMMUNITY PARTICIPATION
Involvement of the people to solve their own problems is termed as participation although people cannot be forced to participate there should be all possible opportunities for them to participate in matters related to their health. Participation is held to be a basic human right and a fundamental principle to democracy (Goyet, 1999).
According to Goyet, participation does not occur automatically, it is initiated and goes through a process. In his guide towards participation, it is seen that it goes through four stages; initiation, preparation, participation and continuation. Participation can take place during any of the following activities; needs assessment, Planning, Mobilizing, Training, Implementing, monitoring and evaluation.
Understanding participation involves understanding power as well (the ability of different interests to achieve what they want). Power depends on who has the information, confidence and skills among other things. The reason why most community initiative programmes do not allow full participation of the local people is the fear that they will lose control of the assumed power. In participation there are incentives and disincentives and effective participation is most likely when the different interests involved are satisfied with the level at which they are involved.
Levels of participation
This guide supported by the Joseph Row tree Foundation and written by David Wilcox proposes a five-rung ladder of participation which relates to the stance an organization promoting participation may take.
Information: merely telling people what is planned.
Consultation: offering some options, listening to feedback, but not allowing new ideas.
Deciding together: encouraging additional options and ideas, and providing opportunities for joint decision-making.
Acting together: not only do different interests decide together on what is best, they form a partnership to carry it out.
Supporting independent community interests: local groups or organisations are offered funds, advice or other support to develop their own agendas within guidelines.
COMMUNITY INVOLVEMENT
Community involvement goes beyond community members checking whether they are happy with the services being provided. It is a more radical approach which sees community members involved in decision making during community programme design and management. This approach requires many people to completely change the way they approach their work.
The different ways of community involvement can be classified according to how much power is given to community members. The table below may help you decide at which level you would like to involve community members, and note here that in community partnership and involvement all parties are involved.
Self help
Community members take the initiative to take action on their own. If they get assistance from authorities it will only be for advice or resources, which they will control.
Partnership
Community members and outside experts plan design and take decisions together.
Consultation
Committee members are consulted by the outside authorities who listen to their views. The outside experts then decide what the problem is and how it should be solved. All decisions are made by the outsiders.
Information giving
Local people participate only by being told what is going to happen or has already happened. It is an announcement by e.g the project management without listening to people’s responses.
Adopted from Arnstein (1999)
EFFECTIVE COMMUNITY COMMUNICATION
Effective Community Communication is key to successful Community Partnership. Open, positive and respectful communication helps build commitment and trust in a community, leading to increased interest, support and involvement in community life. It is usually very difficult for community members to get involved when they do not know what’s going on. Whether it is at the community level or one to one, communication is most effective when it is two way; At the community level, this involves giving information and asking for feedback. Once information is exchanged, citizen involvement in local activities will increase and resources will be developed. A clearly established communication network is key to successful partnership.
RATIONALE OF COMMUNITY PARTNERSHIP IN HEALTH CARE
o The partial success of some models of health care to offer the basic health services to the poor.
o In Successful scaling up of the interventions related to health needs identifying ways in which services can be added to the already existing services
o Shifting successfully to community based and patient centered (Individual) – paradigms of care for the proper management of chronic diseases that include HIV/AIDS and cancer has given way to interventions that necessitate community partnership.
o To preserve health in conflict and post conflict areas so as promote health of the marginalized, the hard to reach and to address the unmet needs.
o To promote health of the vulnerable eg the children, the women, people with disabilities (PWDs), the elderly, the adolescents, and the incarcerated.
o Other special groups of people like the prostitutes, substance and drug abusers, the sexually abused, the mentally ill and those with other risky behaviors / behavioral disorders
o Deploying towards a continuum of care - One of the core competencies for long term care is partnering. .
o Provision of community mental health services relies heavily on effective educational outreach programmes .
o Studies show that there is an ever inceasing decline in the total resources towards the health sector in most of the low developed countries that include the human resource for health care services (C.H Wood et al,2001).
o Shortage of health workers as a constraint to achieving the three health related MDGs , that is , reducing childhood illnesses, improving maternal health and combating HIV/AIDS and other diseases such as Tuberculosis and Malaria.
o Simplification and delegation of tasks to less skilled colleagues, this was done in the global polio eradication initiaves and is still being well implemented in promoting oral rehydration therapy and home based management of malaria.( The World Health Report,2006)
o The gap between the haves and the have nots is becoming wider within countries where leadership is lacking at certain levels to support the rights of the underprivileged and if at all it is supported it is not with similar strength as compared to the support given to the beneficiaries of privatization.
o The problem is not the know how because lists of human resource for health are being released and the number of graduates in the medical fields would be just enough, the problem is the number of patients accessing services is increasing as compared to the resources to meet their needs.
o Health care eventually returns to the community with reference to clinics or hospitals when necessary.
o Although there has been increasing technology and new drugs , the concern is on the extent to which health services provide coverage to the communities they serve. Still the poor are not reached and even when health services are accessed individuals, families and communities should are seen as just consumers but not active partners in all matters related to their health needs and concerns.
o Questionnaire surveys, action research, extractive research are being superseded by investigation and analysis by local people themselves. Methods and approaches to research are not only used for the local people to inform outsiders, but also for peoples own analysis of their own health needs, conditions, and concerns (Chambers, R. ,PRA Methods and Tools,1992).
o The determinants of health, eg poverty ,gender inequality, social capital, income inequalities, cultural values, employment/working conditions etc, have been seen as having great influence to the well being of individuals, families and communities. Recent findings and analysis of emerging issues brings to light of the concern that goes beyond mere biomedical and behavioural risks ( The Ottawa charter for health promotion,1996)
o As health progresses from traditional to scientific, it must combine the best features from both in a radical community based model.
o The emerging public health concerns and that infectious diseases are spreading faster geographically ( WHO report,2007) , making all populations vulnerable.
o At Local level, communities have responded to disasters faster before government interventions.
o PLWHAs have proved to be a valuable educational resource to support the training of health workers.
o Adressing diversity and socio – cultural and demographic characteristics of populations.
OPPORTUNITIES/GAINS
* Since the Alma Ata Conference of 1978, a primary health system with full involvement of the people has been seen as the key to bringing about health for all..
* Current and realized transformation are that partnership is increasingly mandated and employed as a vehicle for health education , promotion of health and prevention of diseases, this was shown in programmes such as that for safe motherhood, Integrated management of early childhood illnesess, and Roll back malaria
* The Millennium development goals (MDG) agreed at the United Nations Millenium Summit in September 2000 where nearly 190 countries have subsequently signed upon them.The MDGs are the wold’s time bound and quantified targets for addressing extreme poverty(the number one cause of poor health) in its many dimensions. They are to address human rights – the rights of each person on the planet to health,education,shelter, and security. The road map towards the implementation of the MDGs realized the progress made in the prevention and treatment of diseases ( UN Secretary General report,2002).
* The roles demonstrated by the health sector as Leaders, Influencers, communicators and knowledge brokers.
* Collaboration towards multisectoral approaches of addressing issues, that is ,putting in place desks to address health related concerns and the decentralization process.
* Some communities have experienced a fast growing and sustainable partnership because of collaboration and flexibility in governance and leadership as the most recognized strength in community partnership.
* Practice – based teaching and problem – based learning : Institutions benefit from collaboration with community partners by developing research initiatives in the area of Public health practice and enhancing their practice based curriculum with practice to prepare students and Communities and agencies benefit from specific projects and research initiatives that promote public health.
* Patient focused interventions which recognizes the role of patients as active participants in the process of effective, safe and responsive health care. As individuals or family members patients can play a distinct role in their own care by diagnosing and treating conditions, by preventing occurrence or reoccurrence of diseases or harm , by selecting the most appropriate follow ups with the health professionals for more serious illness, and by actively managing long term conditions. Recognizing such interventions that strengthen them is seen as fundamental to securing a more patient – centered approach to health care delivery.
* Community partnership has actively managed the HIV/AIDS Care and Anti retro viral therapy in treatment support, keeping the drug regimen (adherence) through simple monitoring.
* Volunteers at village levels have proved to be an untrapped and yet potentially valuable resource. When identified and trained, volunteers have succeeded in certain communities to identify, refer and follow up people in their villages.
* An approach to community Based Participatory Research actively involves the community studied in the research through partnership.
* The presence of community Based Organisations such as churches and church members, community residents and other social organizations.
* Concepts, theories and models have shown evidence that partnership is still the only possible way to promote health with best practice, eg the Interactive domain model by Kahan & Goodstadt , April, 2002.
CHALLENGES
* A lack of political leaders to remove bureaucratic controls and free communities to take more responsibility for their own health. Much has been done in the name of decentralization and district focus but there is little real empowerment of communities to enable them to identify their health needs, choose priorities, design and implement interventions and monitor and evaluate the impact of those choosen interventions with the central government doing supervision and possible funding.
* The current policies that are developed only focus highly on Institutions based clinical service which has brought about severe cutbacks on the promotive, preventive and outreach services.
* The success will also depend largely on communities demonstrating worldwide that they can bring about effective and sustainable improvements in a cost effective manner.
* Corruption and its consequences.
* Progress towards the achievement of the MDGs is far from uniform across the goals with sub sahara Africa being in the epicenter of the crisis with continuing food insecurity, a rise of extreme poverty, stunningly high child and maternal mortality, a large number of people living in the slums and a widespread shortfall for most of the MDGs.
* Despite clear evidence that the social determinants of health affect health and illness, the health sector is still reluctant to champion policies that improve social conditions because areas of social and economic policy largely fall outside of the health department’s jurisdiction (Browne G. Nov;2002)
* Despite the increasing popularity and potential, there exists limited evidence of the effectiveness of partnership in achieving the desired outcomes. The measurements and indicators of public health changes as a result of partnership work , the quality of partnership processes and outcomes are failing to be measured effectively. The critical limitations of the existing research that constrain the way we think about and build evidence base for partnership work.
* While measuring functioning and the impact of partnership work over time is ideal, longitudinal designs are not always practical in community settings given limitations in time, funds and rewards of academics for collaborating in community work.
* Qualitative work related to the effects of partnership is not well published in journals, and although it is , findings of multiple studies are not well synthesized that the data and methodology are accessible to practioners and policy makers (Grammer , Sharpe, El Ansari et al.)
* Globalization that fosters the moving of people (labor) across borders and therefore the resurfacing of infectious diseases.
* Targets cannot be met if the resource estimates are not met,( Benjamin Johns et al in resource estimates for global maternal and newborn health services).
* Lack of incentives for communities to get involved in partnership, eg training, skill building and development, funding etc
* The need to increase incentives for universities and research organizations to conduct Community Based Participatory Research, carry out needs assessment to seek partnership
* Lack of trust by the communities highly embedded in social cultural ties.
* The bureaucratic power held by providers as owners of the knowledge related to health although they do not own those whose health needs is addressed to.
CONCLUSION
Partnership will not just happen if we arrange just a few meetings and keep hoping for the best. The ability to bring about participation has to be learnt and practiced; At the beginning many of the poorest and most exploited communities may not grasp the idea at all, nor show any interest. By making our aims clear, have community attachment through listening and respect for community members, and making the people realize that we are not merely providers, then their participation will be genuine. Avoiding professional biases that misguide real practice and aiming to bridge between academic work and practice.
Acknowledgement
VVOB / KHI Project - Rwanda
Kigali Health Institute – Rwanda
The Embassy of the Republic of Uganda in Rwanda.
TUFH Conference Secretariat 2007, Kampala – Uganda Conference.
Makerere University conference organizers.
Bank of Africa – Uganda.
References
Browne G. (2002). Presentation at The social Determinants of Health Across the Life – Span Conference, Toronto, November 2002.
EL Ansari W. Collaborative research partnership with disadvantaged communities: Challenges and potential solutions.Public Health 2005, 119:758 -770.
Granner ML and Sharpe PA. Evaluating community coalition characteristics and functioning: A summary of measurement tools.Health Educ Res 2004 19:514 – 32 ( Full text)
Israel BA,,Schulz AJ, Parker EA,,Berker AB. Review of community-based research:Assessing partnership approaches to improve public health.Annu Rev Public Healh 1998 19:173-202.
Kahan & Goodstadt, IDM Manual, April 2002
Kenneth William Musgrave Fulford, Steven Ersser, R.A Hope, Essential Practice in Patient – Centered Care , 2007.
Krueter MW, Lezin NA, Young la.Evaluating community – based collaborative mechanisms: Implications for practitioners.Health Promot Pract 2000 27: 49 – 91 ( Medline)
Linda Kehart, The Decatur Community Partneship, 2007, Decatur,USA
P Gilles . Health Education Authority, Hamilton House, Mabledon Place, London WC1 9TX, UK
Participation: The new Tyranny? Bill Cooke and Uma Kothari (eds), 2001, Zed London.
Participatory Rural Appraisal, from the World Bank Source book on participation
Paul Skidmore, Kirsten Bound and Hannah Lownsbroughw .Community Participation: Who benefits ? Joseph Rowntree Foundation
2007.
Roussos ST and Fawcett SB. A review of collaborative Partnership as a strategy for improving community health. Annu Rev Public Health 2000 21 : 369 – 402
Shortell SM, Zukoski AP, Alexander JA, et al . Evaluating partnership for community health improvements: tracking the footprints.J Health Polit Policy Law 2002 27: 49 – 91
The Millenium Development Goals, Targets and Indicators,United Nations Development Programme, 2005.
WHO Annual Report,2007.
W.K. Kellogg Foundation and The Robert Wood Johnson Foundation , W.K. Kellogg Foundation Logic model & Turning point Initiative Collaborative.
www.ahrg.gov
www.ahrg.gov/research/cbprrole.htm
http:www.bestpractice-healthpromotion.com/id12.html
http://www.depts.washington.educ/ccph/pdf
http://www.extension.unh.edu/pubs
www.futurehealth.ucsf.edu/ccph/commbas.html
www.idmbestpractice.ca/idm.php
http://www.phac-aspc.gc.ca/ph-sp/phdd/overview_implications/01_overview.html
www.sph.umich.edu/cbph
http://www.worldbank.org/wbi/sourcebook/sba104.htm
URL http://www.the-networktufh.org/conference/previousconferences.asp
By Edwidge Kezaabu Lugemwa
From the VVOB Skills Lab Project -
Kigali Health Institute(KHI) – Rwanda.
AIM: To share ideas of the concept of community partnership and involvement in the promotion
of health in limited resources , opportunities and challenges.
Specific Objectives: By the end of the session participants should be able to:
1. Discuss the rationale of community partnership and involvement in the promotion of
health in limited resources.
2. Share their experiences in community partnership and involvement with evidence
based and best practices.
3. Share ideas related to opportunities and challenges in community partnership and
involvement in the promotion of health.
The process: Presentation, small group discussions, presentations in plenary, general
discussions and conclusion.
CONTENT
Introduction
The key words
What is a community?
The concept of community partnership
Community Empowerment
Community Participation
Community Involvement
Effective Community Communication
Rationale of community partnership in healthy care
Opportunities/Gains
Challenges
Conclusion
Acknowledgement
References
INTRODUCTION:
The vision ‘health people in health communities’ involves broad based preventive efforts and moves beyond what happens in physicians’ offices, clinics and hospitals, beyond the traditional medical care system to the neighborhoods, schools, workplaces and families in which people live their daily lives. These are the areas where a large proportion of prevention and rehabilitation occurs. Considering the emerging public health concerns, objectives that accurately reflect data can be developed, revised and re revised. The set objectives to address health concerns should be used with potential data source and when revised they should reflect the most current science. Achievement of such objectives towards health promotion in low resource environments can be attained fully with increased Community Partnership and involvement towards best practices.
KEY WORDS
Health, Health promotion, Evidence based and Best practices, Community Partnership.
* Health, defined as the state of complete physical, mental and social well being and not merely the absence of disease or infirmity,(’WHO)’ is also described as ‘a process of continuous adjustment to the changing demands of living and of the changing meanings we give to life’. It is further described by medical scientists as a level of functional and/or metabolic efficiency of an organism at both the micro (cellular) and macro (social) level to restore and sustain a ‘state of balance’ known as homeostasis.
Health Promotion, according to the Ottawa charter of health promotion,1996, is a set of activities designed to achieve optimal health for all by maintaining and enhancing the health of everyone and facilitating individual and communities to increase control over factors that influence their health /determinants of health, and thereby improve their own health’
‘’Best practice in health promotion’are those sets of processes and activities that are
consistent with health promotion values/goals/ethics/beliefs, evidence, and understanding of the environment and which are most likely to achieve health promotion goals in a given situation, (Best practice in health promotion, Kahan & Goodstadt,IDM Manual,April 2002’’).
Evidence Based Practice is an approach to care where health professionals use the most current and appropriate information available to make decisions related to clients’/patients’ care.
EBP therefore promotes the collection, interpretation and integration of valid, important and applicable client/patient – reported, provider – observed and research derived evidence, Mitchell, G.J.(1999).
WHAT IS A COMMUNITY?
Ferdinand Tonnies in 1887 argued over the word community (Gemeinschaft) differitiating it from society (Gesellschaft). Community is perceived to be a tighter and more cohesive social entity within the context of the larger society due to the presence of a ‘unity of will’ or sense of the community one is identified with.
A Community is defined as a social group of organisms sharing an environment, and normally with shared interests. In the human communities, intent, belief, resources, preferences, needs, risks, common leadership and a number of other conditions may be present and common affecting the identity of the participants or the particular members of a community and their degree of cohesiveness. Membership, Influence, Integration, fulfillment of needs and shared emotional connection are elements of a community identified by Mcmillan and Chavis in a study they carried out in 1986.
THE CONCEPT OF COMMUNITY PARTNERSHIP IN HEALTH CARE
A partner has been defined by the oxford English Dictionary as a sharer. This implies that, the health care practitioners should be able to share knowledge, expertise, skills, beliefs, values and decision making with the clients in a one to one basis, with family or community as groups and to accept what they offer in these areas as both valid and respected, even when it differs fundamentally from their views. As a partner, the practioner should refrain from making judgments about the individuals, families or communities but should be able to share perspectives on an equal footing, and with their participation where possible, Ashworth et al. (1992).
It is important to note here that participation with others presupposes that each person is receptive to others’ contributions, and that each is able to assume the receptiveness of the others. But partnership goes beyond participation although both participation and empowerment are sometimes equated to partnership.
In partnership for health care, the aim is to promote health with the people, and not just to provide medical care for the people. In this case, partnership acts as a multiplier whereby individuals or members of the community become the agents of change, taking new health patterns and new ideas to other individuals, families and communities. Community partnership at first may seem to be a slow process but later this multiplier effect causes a rapid increase in growth, promoting health even in very low resources environments. The community members, with a great store of knowledge and skills reinforced with further training where possible can provide more and yet appropriate primary health care because they understand their local health concerns and needs more than anyone else outside their social interaction circles within their communities.
COMMUNITY EMPOWERMENT
Partnership is only in words without empowerment. Empowerment is a social process of recognizing, promoting and enhancing people’s abilities to meet their own needs, solve their own problems and mobilize the necessary resources in order to feel in control of their own lives, Gibson (1999). Community empowerment therefore occurs by empowering individuals first so as to make up empowered communities. Formal and informal education, the former being promoted through the bottom - up approach and community involvement are some of the strategies to empower individuals and communities. Through partnership, individuals and communities can be empowered but lack of empowerment means that people perceive themselves as powerless and not in control of their own lives or conditions which determine their health and
Empowerment is a multidimensional, social process, It occurs at various levels that is; at individual level, group or community level. It is a social process that fosters power ( that is, the capacity to implement) in people, for use in their own lives, their communities and in their societies, by acting on issues that they define are important, Bailey (1992). But it is not possible to offer people power so as to make them empowered, the focus is on the connection between individual actions to community action, encouraging individual change by supporting participants’ efforts towards community change.
COMMUNITY PARTICIPATION
Involvement of the people to solve their own problems is termed as participation although people cannot be forced to participate there should be all possible opportunities for them to participate in matters related to their health. Participation is held to be a basic human right and a fundamental principle to democracy (Goyet, 1999).
According to Goyet, participation does not occur automatically, it is initiated and goes through a process. In his guide towards participation, it is seen that it goes through four stages; initiation, preparation, participation and continuation. Participation can take place during any of the following activities; needs assessment, Planning, Mobilizing, Training, Implementing, monitoring and evaluation.
Understanding participation involves understanding power as well (the ability of different interests to achieve what they want). Power depends on who has the information, confidence and skills among other things. The reason why most community initiative programmes do not allow full participation of the local people is the fear that they will lose control of the assumed power. In participation there are incentives and disincentives and effective participation is most likely when the different interests involved are satisfied with the level at which they are involved.
Levels of participation
This guide supported by the Joseph Row tree Foundation and written by David Wilcox proposes a five-rung ladder of participation which relates to the stance an organization promoting participation may take.
Information: merely telling people what is planned.
Consultation: offering some options, listening to feedback, but not allowing new ideas.
Deciding together: encouraging additional options and ideas, and providing opportunities for joint decision-making.
Acting together: not only do different interests decide together on what is best, they form a partnership to carry it out.
Supporting independent community interests: local groups or organisations are offered funds, advice or other support to develop their own agendas within guidelines.
COMMUNITY INVOLVEMENT
Community involvement goes beyond community members checking whether they are happy with the services being provided. It is a more radical approach which sees community members involved in decision making during community programme design and management. This approach requires many people to completely change the way they approach their work.
The different ways of community involvement can be classified according to how much power is given to community members. The table below may help you decide at which level you would like to involve community members, and note here that in community partnership and involvement all parties are involved.
Self help
Community members take the initiative to take action on their own. If they get assistance from authorities it will only be for advice or resources, which they will control.
Partnership
Community members and outside experts plan design and take decisions together.
Consultation
Committee members are consulted by the outside authorities who listen to their views. The outside experts then decide what the problem is and how it should be solved. All decisions are made by the outsiders.
Information giving
Local people participate only by being told what is going to happen or has already happened. It is an announcement by e.g the project management without listening to people’s responses.
Adopted from Arnstein (1999)
EFFECTIVE COMMUNITY COMMUNICATION
Effective Community Communication is key to successful Community Partnership. Open, positive and respectful communication helps build commitment and trust in a community, leading to increased interest, support and involvement in community life. It is usually very difficult for community members to get involved when they do not know what’s going on. Whether it is at the community level or one to one, communication is most effective when it is two way; At the community level, this involves giving information and asking for feedback. Once information is exchanged, citizen involvement in local activities will increase and resources will be developed. A clearly established communication network is key to successful partnership.
RATIONALE OF COMMUNITY PARTNERSHIP IN HEALTH CARE
o The partial success of some models of health care to offer the basic health services to the poor.
o In Successful scaling up of the interventions related to health needs identifying ways in which services can be added to the already existing services
o Shifting successfully to community based and patient centered (Individual) – paradigms of care for the proper management of chronic diseases that include HIV/AIDS and cancer has given way to interventions that necessitate community partnership.
o To preserve health in conflict and post conflict areas so as promote health of the marginalized, the hard to reach and to address the unmet needs.
o To promote health of the vulnerable eg the children, the women, people with disabilities (PWDs), the elderly, the adolescents, and the incarcerated.
o Other special groups of people like the prostitutes, substance and drug abusers, the sexually abused, the mentally ill and those with other risky behaviors / behavioral disorders
o Deploying towards a continuum of care - One of the core competencies for long term care is partnering. .
o Provision of community mental health services relies heavily on effective educational outreach programmes .
o Studies show that there is an ever inceasing decline in the total resources towards the health sector in most of the low developed countries that include the human resource for health care services (C.H Wood et al,2001).
o Shortage of health workers as a constraint to achieving the three health related MDGs , that is , reducing childhood illnesses, improving maternal health and combating HIV/AIDS and other diseases such as Tuberculosis and Malaria.
o Simplification and delegation of tasks to less skilled colleagues, this was done in the global polio eradication initiaves and is still being well implemented in promoting oral rehydration therapy and home based management of malaria.( The World Health Report,2006)
o The gap between the haves and the have nots is becoming wider within countries where leadership is lacking at certain levels to support the rights of the underprivileged and if at all it is supported it is not with similar strength as compared to the support given to the beneficiaries of privatization.
o The problem is not the know how because lists of human resource for health are being released and the number of graduates in the medical fields would be just enough, the problem is the number of patients accessing services is increasing as compared to the resources to meet their needs.
o Health care eventually returns to the community with reference to clinics or hospitals when necessary.
o Although there has been increasing technology and new drugs , the concern is on the extent to which health services provide coverage to the communities they serve. Still the poor are not reached and even when health services are accessed individuals, families and communities should are seen as just consumers but not active partners in all matters related to their health needs and concerns.
o Questionnaire surveys, action research, extractive research are being superseded by investigation and analysis by local people themselves. Methods and approaches to research are not only used for the local people to inform outsiders, but also for peoples own analysis of their own health needs, conditions, and concerns (Chambers, R. ,PRA Methods and Tools,1992).
o The determinants of health, eg poverty ,gender inequality, social capital, income inequalities, cultural values, employment/working conditions etc, have been seen as having great influence to the well being of individuals, families and communities. Recent findings and analysis of emerging issues brings to light of the concern that goes beyond mere biomedical and behavioural risks ( The Ottawa charter for health promotion,1996)
o As health progresses from traditional to scientific, it must combine the best features from both in a radical community based model.
o The emerging public health concerns and that infectious diseases are spreading faster geographically ( WHO report,2007) , making all populations vulnerable.
o At Local level, communities have responded to disasters faster before government interventions.
o PLWHAs have proved to be a valuable educational resource to support the training of health workers.
o Adressing diversity and socio – cultural and demographic characteristics of populations.
OPPORTUNITIES/GAINS
* Since the Alma Ata Conference of 1978, a primary health system with full involvement of the people has been seen as the key to bringing about health for all..
* Current and realized transformation are that partnership is increasingly mandated and employed as a vehicle for health education , promotion of health and prevention of diseases, this was shown in programmes such as that for safe motherhood, Integrated management of early childhood illnesess, and Roll back malaria
* The Millennium development goals (MDG) agreed at the United Nations Millenium Summit in September 2000 where nearly 190 countries have subsequently signed upon them.The MDGs are the wold’s time bound and quantified targets for addressing extreme poverty(the number one cause of poor health) in its many dimensions. They are to address human rights – the rights of each person on the planet to health,education,shelter, and security. The road map towards the implementation of the MDGs realized the progress made in the prevention and treatment of diseases ( UN Secretary General report,2002).
* The roles demonstrated by the health sector as Leaders, Influencers, communicators and knowledge brokers.
* Collaboration towards multisectoral approaches of addressing issues, that is ,putting in place desks to address health related concerns and the decentralization process.
* Some communities have experienced a fast growing and sustainable partnership because of collaboration and flexibility in governance and leadership as the most recognized strength in community partnership.
* Practice – based teaching and problem – based learning : Institutions benefit from collaboration with community partners by developing research initiatives in the area of Public health practice and enhancing their practice based curriculum with practice to prepare students and Communities and agencies benefit from specific projects and research initiatives that promote public health.
* Patient focused interventions which recognizes the role of patients as active participants in the process of effective, safe and responsive health care. As individuals or family members patients can play a distinct role in their own care by diagnosing and treating conditions, by preventing occurrence or reoccurrence of diseases or harm , by selecting the most appropriate follow ups with the health professionals for more serious illness, and by actively managing long term conditions. Recognizing such interventions that strengthen them is seen as fundamental to securing a more patient – centered approach to health care delivery.
* Community partnership has actively managed the HIV/AIDS Care and Anti retro viral therapy in treatment support, keeping the drug regimen (adherence) through simple monitoring.
* Volunteers at village levels have proved to be an untrapped and yet potentially valuable resource. When identified and trained, volunteers have succeeded in certain communities to identify, refer and follow up people in their villages.
* An approach to community Based Participatory Research actively involves the community studied in the research through partnership.
* The presence of community Based Organisations such as churches and church members, community residents and other social organizations.
* Concepts, theories and models have shown evidence that partnership is still the only possible way to promote health with best practice, eg the Interactive domain model by Kahan & Goodstadt , April, 2002.
CHALLENGES
* A lack of political leaders to remove bureaucratic controls and free communities to take more responsibility for their own health. Much has been done in the name of decentralization and district focus but there is little real empowerment of communities to enable them to identify their health needs, choose priorities, design and implement interventions and monitor and evaluate the impact of those choosen interventions with the central government doing supervision and possible funding.
* The current policies that are developed only focus highly on Institutions based clinical service which has brought about severe cutbacks on the promotive, preventive and outreach services.
* The success will also depend largely on communities demonstrating worldwide that they can bring about effective and sustainable improvements in a cost effective manner.
* Corruption and its consequences.
* Progress towards the achievement of the MDGs is far from uniform across the goals with sub sahara Africa being in the epicenter of the crisis with continuing food insecurity, a rise of extreme poverty, stunningly high child and maternal mortality, a large number of people living in the slums and a widespread shortfall for most of the MDGs.
* Despite clear evidence that the social determinants of health affect health and illness, the health sector is still reluctant to champion policies that improve social conditions because areas of social and economic policy largely fall outside of the health department’s jurisdiction (Browne G. Nov;2002)
* Despite the increasing popularity and potential, there exists limited evidence of the effectiveness of partnership in achieving the desired outcomes. The measurements and indicators of public health changes as a result of partnership work , the quality of partnership processes and outcomes are failing to be measured effectively. The critical limitations of the existing research that constrain the way we think about and build evidence base for partnership work.
* While measuring functioning and the impact of partnership work over time is ideal, longitudinal designs are not always practical in community settings given limitations in time, funds and rewards of academics for collaborating in community work.
* Qualitative work related to the effects of partnership is not well published in journals, and although it is , findings of multiple studies are not well synthesized that the data and methodology are accessible to practioners and policy makers (Grammer , Sharpe, El Ansari et al.)
* Globalization that fosters the moving of people (labor) across borders and therefore the resurfacing of infectious diseases.
* Targets cannot be met if the resource estimates are not met,( Benjamin Johns et al in resource estimates for global maternal and newborn health services).
* Lack of incentives for communities to get involved in partnership, eg training, skill building and development, funding etc
* The need to increase incentives for universities and research organizations to conduct Community Based Participatory Research, carry out needs assessment to seek partnership
* Lack of trust by the communities highly embedded in social cultural ties.
* The bureaucratic power held by providers as owners of the knowledge related to health although they do not own those whose health needs is addressed to.
CONCLUSION
Partnership will not just happen if we arrange just a few meetings and keep hoping for the best. The ability to bring about participation has to be learnt and practiced; At the beginning many of the poorest and most exploited communities may not grasp the idea at all, nor show any interest. By making our aims clear, have community attachment through listening and respect for community members, and making the people realize that we are not merely providers, then their participation will be genuine. Avoiding professional biases that misguide real practice and aiming to bridge between academic work and practice.
Acknowledgement
VVOB / KHI Project - Rwanda
Kigali Health Institute – Rwanda
The Embassy of the Republic of Uganda in Rwanda.
TUFH Conference Secretariat 2007, Kampala – Uganda Conference.
Makerere University conference organizers.
Bank of Africa – Uganda.
References
Browne G. (2002). Presentation at The social Determinants of Health Across the Life – Span Conference, Toronto, November 2002.
EL Ansari W. Collaborative research partnership with disadvantaged communities: Challenges and potential solutions.Public Health 2005, 119:758 -770.
Granner ML and Sharpe PA. Evaluating community coalition characteristics and functioning: A summary of measurement tools.Health Educ Res 2004 19:514 – 32 ( Full text)
Israel BA,,Schulz AJ, Parker EA,,Berker AB. Review of community-based research:Assessing partnership approaches to improve public health.Annu Rev Public Healh 1998 19:173-202.
Kahan & Goodstadt, IDM Manual, April 2002
Kenneth William Musgrave Fulford, Steven Ersser, R.A Hope, Essential Practice in Patient – Centered Care , 2007.
Krueter MW, Lezin NA, Young la.Evaluating community – based collaborative mechanisms: Implications for practitioners.Health Promot Pract 2000 27: 49 – 91 ( Medline)
Linda Kehart, The Decatur Community Partneship, 2007, Decatur,USA
P Gilles . Health Education Authority, Hamilton House, Mabledon Place, London WC1 9TX, UK
Participation: The new Tyranny? Bill Cooke and Uma Kothari (eds), 2001, Zed London.
Participatory Rural Appraisal, from the World Bank Source book on participation
Paul Skidmore, Kirsten Bound and Hannah Lownsbroughw .Community Participation: Who benefits ? Joseph Rowntree Foundation
2007.
Roussos ST and Fawcett SB. A review of collaborative Partnership as a strategy for improving community health. Annu Rev Public Health 2000 21 : 369 – 402
Shortell SM, Zukoski AP, Alexander JA, et al . Evaluating partnership for community health improvements: tracking the footprints.J Health Polit Policy Law 2002 27: 49 – 91
The Millenium Development Goals, Targets and Indicators,United Nations Development Programme, 2005.
WHO Annual Report,2007.
W.K. Kellogg Foundation and The Robert Wood Johnson Foundation , W.K. Kellogg Foundation Logic model & Turning point Initiative Collaborative.
www.ahrg.gov
www.ahrg.gov/research/cbprrole.htm
http:www.bestpractice-healthpromotion.com/id12.html
http://www.depts.washington.educ/ccph/pdf
http://www.extension.unh.edu/pubs
www.futurehealth.ucsf.edu/ccph/commbas.html
www.idmbestpractice.ca/idm.php
http://www.phac-aspc.gc.ca/ph-sp/phdd/overview_implications/01_overview.html
www.sph.umich.edu/cbph
http://www.worldbank.org/wbi/sourcebook/sba104.htm
Tuesday, March 30, 2010
Culture an important aspect in human development
What is culture?
How does culture affect our day today lives/
and where is culture not applicable?
Does culture correspond to other environmental factors like geographical location, weather or even health ?
We need answers from you ?
Thank you for contributing to our Blog
Edwidge
How does culture affect our day today lives/
and where is culture not applicable?
Does culture correspond to other environmental factors like geographical location, weather or even health ?
We need answers from you ?
Thank you for contributing to our Blog
Edwidge
Thursday, March 25, 2010
Community Partnership
Community Partnership involves working with the Community in all matters related to the peoples' needs.
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