Contents2. Approaches to Health Promotion
Examples of approaches to health promotion (Ewles & Simnet, 1995)
1. Health awareness goal
2. Changing attitudes and behaviour
3. Improving knowledge
3. Policy Environment
Helping to strengthen community action in various settings
Comprehensive approaches to health development are the most effective
Participation is essential to sustain efforts
4. Community Development Approaches to Health Promotion
4.2 What is Community Development?
4.3 What are Community Development Approaches to Health Promotion? (Literature Abstracts)
However, developing communities brings its own problems; problems of definition; and tensions between the various agenda setters
Northern Ireland is one area where Community Development Approaches have been adopted strongly
Insufficiency of education alone
Community development and health
Community Development Issues
In this literature review, it has become apparent that there are problems with definitions at every turn. What is Health Promotion? What is community? What is Community Development? What are community development approaches to health promotion?
It is also clear that the policy environment has progressively moved, both nationally and internationally, towards a policy of community development approaches – accelerated since the adoption of the Ottawa Charter (and its 5 Principles) in 1986.
However, the translation of policy into practice has proved problematic, and solutions to these problems are still in development.
The first part of this review attempts to extract some definitions which can set the way to understanding this process, and briefly visits the policy environment.
The second part lifts abstracts from the literature in order to address the questions of community development approaches to health promotion, the need and barriers, looks at the problems of defining effectiveness or success of interventions, suggests requisites necessary in designing or implementing any community development approach, and finally briefly discussing the issues of empowerment and partnership.
It must be emphasised that these are weighty issues, and the time allocated has not allowed for detailed analysis. Rather, the abstracts, sometimes repetitive, have been extracted and placed in an order that can begin to make some sense although this process is in no way complete.
1. What is Health Promotion? Page 1
2. Approaches to Health Promotion – Page 3
3. Policy Environment – Page 6
4. Community Development Approaches to Health Promotion – Page 7
4.1 What is Community? – Page 8
4.2 What is Community Development? – Page 8
4.3 What are Community Development Approaches to Health Promotion? (Literature Abstracts) – Page 9
4.4 Lack of Evidence re Community Development Intervention Outcomes – Page 14
4.5 Difficulties in defining success or effectiveness – Page 16
4.6 Some examples of Community Development Approaches to Health Promotion – Page 17
5. Any Community Development Approaches to Health Promotion must have the following elements - Page 29
6. Questions of Community Empowerment & Partnership – Page 40
1. What is Health Promotion?
“McKinlay tells the story: He was sitting by the river one nice sunny day when he heard a shout and saw someone in the middle of the river clearly struggling to stay afloat. He dived in and rescued them . they had taken in a fair bit of water so required resuscitation, which he duly performed. Just as that person was ok, he heard another shout and lo and behold another person was in trouble. Of course he dived in and rescued that person too. Just as they were coming around, another shout! A third person had to be rescued. This went on for some time until he became exhausted and started to think about what was going on upstream that was causing all these people to end up in the river in such distress. So he headed up for a look. This is, in essence, what health promotion is. Of course people need to be rescued and brought back to full health BUT someone also needs to go upstream and figure out why there are so many people needing to be rescued.” 
Health Promotion occurs upstream with the aim of preventing people falling in or being pushed. Downstream we have secondary (aim to detect disease early so that treatment can be started before irreversible damage occurs e.g. screening), and tertiary prevention and health care (management of established disease e.g. to minimise disability and prevent complications e.g. foot care for people with diabetes). Mid-stream we have primary prevention and health care, usually individual, for example attempts to reduce risk of contracting disease (educating smokers, vaccinating). And upstream we have health promotion including social policies and health promotion programmes, such as taxes on tobacco, smoke free legislation and advertising bans. This may include health education, which aims to reduce ill-health and increase positive health influencing people’s beliefs, attitudes and behaviour. Health Promotion has a dual role to prevent ill health and promote positive health. [25, 32]
“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 well-being, an individual or group must be able to identify and to realize 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 emphasizing 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.” [Ottawa Charter for Health Promotion, First International Conference on Health Promotion, Ottawa, 21 November 1986 - WHO/HPR/HEP/95.1] 
A refined definition might be, "health promotion is the process of enabling individuals and communities to increase control over the determinants of health and thereby to improve their health." Among other things, this definition suggests that in our efforts to evaluate health promotion efforts, we should obtain evidence on process as well as outcome, on the empowerment of individuals and communities, on the interventions directed at the "determinants of health" and on positive health outcomes as well as the prevention of negative ones. It also implies that we might consider using the evaluation process itself as a means to improve the capacities of individuals and communities to increase control over the determinants of health. 
Another refining definition, “health promotion is about helping people to have more control over their lives, and thereby improve their health. It occurs through processes of enabling people, advocacy, and by mediating among sectors. In essence, health promotion action involves helping people to develop personal skills, creating supportive environments, strengthening communities, influencing governments to enact healthy public policies, and reorientating and improving health services.” 
Put another way:
• aims to gain effective public participation
Three words describe the role of practitioners involved in integrated health promotion programs:
• Enable: Integrated health promotion focuses on achieving equity in health. A major aspect of the work of integrated health promotion is to provide the opportunities and resources that enable people to increase control over and improve their health. This includes developing appropriate health resources in the community and helping people to increase their health knowledge and skills, to identify the determinants of their own health, to identify actions by themselves and others, including those in power, that could increase health, and to demand and use health resources in the community.
• Advocate: Action for health often requires health workers to speak out publicly or write on behalf of others, calling for changes in resources, policies and procedures. The Cancer Council lobbying for a ban on smoking in all enclosed spaces is an example, as is a local community health worker writing letters to the local paper calling on the council to improve facilities for physical activity for older people.
• Mediate: Many sectors of the community, such as government departments, industry, non-government organisations, volunteer organisations, local government and the media take action that has an impact on people’s health, sometimes acting to support one another, sometimes disagreeing about what should be done. Health workers play a role in mediating between these different groups in the pursuit of health outcomes for the community, or in mediating between the health requests of different sectors of the community. 
How can one go about "doing" health promotion?
The following strategies, which are often combined, are commonly used:
Integrated health promotion service delivery can be organised from one or more different angles, depending on the key priorities identified and the problem definition, including:
The key requirement for quality practice is how programs are planned, delivered and evaluated. By definition, quality practice is:
In 1979, the thirty-second World Health Assembly launched the Global Strategy for health for all the year 2000 thereby endorsing the Report and Declaration of the International Conference on Primary Health care, held in Alma-Ata, USSR in 1978. The commitment to the achievement of "Health for All by the Year 2000" was accepted by the 150 member states and became the basis of all the WHO - related new developments in the field of health care in the world. A modern movement termed Health Promotion emerged out of the historical need for a fundamental change in strategy to achieve and maintain health. The Health Promotion Programme at the regional office for Europe of World Health Organisation (WHO) was established in 1984 bringing to fruition the objectives outlined in the policy documents that the Regional Office for Europe had developed over the previous five years.
The first International Conference on Health Promotion met in 1986 in Ottawa to present a charter for action in order to work towards the achievement of Health for All by the Year 2000 and beyond. The action plan of the 1986 Ottawa Charter advises that health promotion strategies and programmes should be adapted to the local needs and possibilities of individual countries and regions to take account of differing social, cultural, political and economic systems. The declaration and programme for action is predicated upon the fundamental prerequisites for health i.e. peace, shelter, education, food, income, sustainable resources, a stable ecosystem, social justice and equity. At the heart of this health promotion action programme lies the key concerns with advocacy, enablement and mediation.
Identification of priority issues is only one dimension of the Ottawa Action plan. The role of those engaged in health promotion is to put into effect, within an integrated philosophy, these following aspects of the health promotion action programme:
i) Endeavouring to build a healthy public policy
ii) Working to create supportive environments
iv) Striving to develop personal skills
v) Working together to re-orientate Health Services 
Ottawa Charters Five strategies
The 1997 World Health Organisation (WHO) Jakarta Declaration on Health Promotion into the 21st Century explicitly acknowledges the demonstrated effectiveness of health promotion in the following statement: 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. There is now clear evidence that:
^ - those which use combinations of the Ottawa Charter's five strategies are more effective than single track approaches.
Settings offer practical opportunities for the implementation of comprehensive strategies - these include mega-cities, islands, cities, municipalities, and local communities, their markets, schools, workplaces, and health care facilities.
^ people have to be at the centre of health promotion action and decision- making processes for it to be effective.
Health learning fosters participation - access to education and information is essential to achieving effective participation and the empowerment of people and communities.
These strategies are core elements of health promotion and are relevant for all countries (WHO, 1997). 
The theoretical drive for WHO's action programme is based upon a shift in emphasis from issues to settings. The shift has been from infectious diseases to behavioural diseases and risk factors followed by an increasing emphasis on the environmental factors that create and maintain health. The aim now is to influence the context of health actions and make the social and physical environment supportive to health and to provide individuals with strategies of health improvement and maintenance that can be integrated with meaning into a person's overall life pattern. 
Improving health and reducing health inequalities are now cross-cutting UK Government priorities, with national targets agreed by various departments (public service agreements), as part of the Government Intervention in Deprived Areas (GIDA). There are now unprecedented national policy drivers to involve communities in local decision-making across sectors. 
1999 Saving Lives: Our Healthier Nation is a comprehensive government-wide public health strategy for England. Its goals are to improve health and to reduce the health gap (health inequalities). The strategy aims to prevent up to 300,000 untimely and unnecessary deaths by the year 2010. Targets, including health inequalities, will be tailored to local needs through needs assessments in association with local authorities.
2004 Choosing Health: Making healthy choices easier is a government white paper, which sets out the key principles for supporting the public to make healthier and more informed choices in relation to their health. 
4.1 What is Community?
The US Government 2010 Healthy People report defines community as a specific group of people, often living in a defined geographical area, who share a common culture, values and norms, and who are arranged in a social structure according to relationships the community has developed over a period of time (World Health Organization, 1998; US Department of Health and Human Services, 2000). 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. [1, 28]
Community development seeks to empower individuals and groups of people, with the skills they need to advocate on their own behalf, improve their lives, and provide communities with access to resources. 
Or put another way….
Community development, in very simple terms, is the process of developing social capital. It is a process that emphasises the importance of working with people as they define their own goals, mobilise resources, and develop action plans for addressing problems they have collectively identified. 
Definition of social capital (Putnam 1993): The community cohesion resulting from high levels of civic identity and the associated phenomenon of trust, reciprocity and civic engagement. Four characteristics: the existence of community networks, formal or informal, civic engagement (particularly in networks), local identity and a sense of solidarity and equality with other community networks, and norms of trust and reciprocal help and support. 
Social capital and community development:
Participating in social and civic activities, such as community group meetings, child care arrangements with neighbours, neighbourhood watch schemes and voting, all work to produce a resource called social capital. Social capital is critical to the health, wealth and wellbeing of populations.33 It is a key indicator of the building of healthy communities through collective and mutually beneficial interaction and accomplishments.34 Recent research has linked these types of activities to improved health outcomes.35, 36, 37, 38 
[33. Putnam, R. (1993), Making Democracy Work, Princeton University Press, Princeton, New Jersey.
34. Baum, F., Palmer, C., Modra, C., Murray, C. and Bush, R. (2000), ‘Families, social capital and health’, in Winter, I. (ed.), Social Capital and Public Policy in Australia, Australian Institute of Family Studies, Melbourne.
35. Berkman, L. and Syme, S. (1979), ‘Social networks, host resistance, and mortality: A nine-year follow-up study of Alameda County residents’, American Journal of Epidemiology, vol. 109, no. 2, pp. 186–203.
36. Kawachi, I., Kennedy, B., Lochner, K. and Prothrow-Smith, D. (1997), ‘Social capital, income inequality, and mortality’, American Journal of Public Health, vol. 87, no. 9, pp. 1491–8.
37. Baum, Palmer, Modra, Murray and Bush, op. cit.
38. Kawachi, I., Colditz, G., Ascherio, A., Rimm, E., Giovannucci, E., Stampfer, M. and Willet (1996), ‘A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA’, Journal of Epidemiology and Community Health, vol. 50, pp. 245–51.]
The notion of social capital represents a way of thinking about the broader determinants of health and about how to influence them through community-based approaches to reduce inequalities in health and wellbeing.39 A focus on social capital supports a balance of strategies that address behaviour and those that focus on the settings in which people live, work and play. The implication for integrated health promotion is that more emphasis is needed on efforts to strengthen the mechanisms by which people come together, interact and, in some cases, take action to promote health. Simple measures, such as providing space for people to meet, may be as health promoting as providing health information in an effort to change behaviour. 
[39. Gillies, P. (1998), ‘Effectiveness of alliances and partnership for health promotion’, Health Promotion International, vol. 13, no. 2.]
Service providers can also enhance the social capital within a community by supporting community projects that bring neighbours together to achieve a mutually beneficial goal, such as beautifying the environment of a public housing estate, establishing a community fruit and vegetable garden or working with the local sporting club to encourage all parts of the community to participate in sporting activities. 
The evidence suggests that there has been a shift to looking at the social, economic, political, and environmental determinants of health because other methods of ill-health reduction have failed.
Therefore, the argument goes, it is necessary to develop communities themselves to take control of their own health agenda to tackle these health issues from the source.
The suggestion is, in much of the literature, although not clearly proven, that the only way left to go forward is community development, and some writers suggest that partnerships can be and need to be forged between communities, health service providers, and academics.
Below are some abstracts from the literature review, theorising about community development approaches and its barriers. This is followed by a discussion on the lack of comparable evidence and the difficulty in defining effectiveness or success in looking at interventions; some examples of specific interventions; a discussion of what community development approaches should or must include; and finally some notes on empowerment and partnership.
Again there is a problem of definition:
^ : the process by which a community identifies its needs, develops an agenda with goals and objectives, then builds the capacity to plan and take action to address these needs and enhance community well-being.
Community Organisation: the process of involving and mobilising major agencies, institutions and groups in a community to work together to coordinate services and create programmes for the united purpose of improving the health of the community:
Community-based: the process of agency development of solutions for health problems which incorporate community consultation and input thus allowing adaptation of the implementation to suit local needs/circumstances. 
A Community Development approach to health … is a process by which a community defines its own health needs to bring about change. The emphasis is on collective action to redress inequalities in health and enhance access to health care.
(Community Development and Health Network, Northern Ireland) 
Social, political, economic and environmental determinants of health
“Recent epidemiological analysis of health, disease and disability in the populations of most developed countries confirms the role of social, economic and environmental factors in determining increased risk of disease and adverse outcomes from disease. 
Health status is influenced by individual characteristics and behavioural patterns (lifestyles) but continues to be significantly determined by the different social, economic and environmental circumstances of individuals and populations. 
Through the Charter, health promotion has come to be understood as public health action which is directed towards improving people's control over all modifiable determinants of health. This includes not only personal behaviours, but also the public policy, and living and working conditions which influence behaviour indirectly, and have an independent influence on health. 
(This more sophisticated approach to public health action is reinforced by accumulated evidence concerning the inadequacy of overly simplistic interventions of the past. To take a concrete example, efforts to communicate to people the benefits of not smoking, in the absence of a wider set of measures to reinforce and sustain this healthy lifestyle choice, are doomed to failure. A more comprehensive approach is required which explicitly acknowledges social and environmental influences on lifestyle choices and addresses such influences alongside efforts to communicate with people. Thus, more comprehensive approaches to tobacco control are now adopted around the world. Alongside efforts to communicate the risks to health of tobacco use, these also include strategies to reduce demand through restrictions on promotion and increases in price, to reduce supply by restrictions on access (especially to minors), and to reflect social unacceptability through environmental bans. This more comprehensive approach is not only addressing the individual behaviour, but also some of the underlying social and environmental determinants of that behaviour.) 
It is now well understood from experiences in addressing specific public health problems of tobacco control, injury prevention and prevention of illicit drug use, and the more general challenge of achieving greater equity in health, that education alone is generally insufficient to achieve major public health goals. 
“More recently, researchers have called for a renewed focus on an ecological approach that recognises that individuals are embedded within social, political and economic systems that shape behaviors and access to resources necessary to maintain health. 
Such an approach corresponds with increased interest in understanding the complex issues that compromise the health of people living in marginalized communities. Emphasis has also been placed on the need for expanded use of both qualitative and quantitative research methods (e.g. Israel et al); greater focus on health and quality of life; and more translation and integration of basic, intervention, and applied research. 
Greater community involvement in processes that shape research and intervention approaches, e.g., through partnerships between academic, health services and community-based organisations is one means towards these ends. 
“Essentially, community development work acknowledges that health is as affected by the social conditions of people’s lives such as damp housing, unemployment, or poor access to facilities, as it was by lifestyle choices. Major policy documents including Towards a Healthier Scotland (1999) and Our National Health (2000) highlight the importance of considering life circumstances alongside lifestyle choices and disease in promoting health and wellbeing. 
A World Health Organisation (WHO) position paper (1991) directly linked community participation to empowerment as a means in itself of promoting healthier individuals and environments. Furthermore, research has recognised the significance of powerlessness and empowerment to the health of individuals and communities (Wallerstein 1993). The concept of healthy communities as developed by the WHO regards active community participation as essential to creating healthy communities:
“The formation of local social capital can thus lead to the promotion of shared values and a common vision, integrated planning and resource utilization, and ultimately to systemic change.” (Murray, 2000, p101) 
There is a growing body of literature showing that being part of a social network of contacts is protective for health (Fisher 2001). The effects derive from improved self-esteem, trust and increased feelings of being in control. 
“Current health promotion policy and practice places a high value on community development work because it aims to enable communities to identify problems, develop solutions and facilitate change. 
The overt ideological agenda of community development is to remedy inequalities and to achieve better and fairer distribution of resources for communities. This is achieved ideally through participatory processes and bottom-up planning. Empowering communities to have more say in the shaping of policies influencing health represents a break with earlier traditions of public health associated with top-down social engineering. 
However, community development means different things to different people and can operate on different levels (See Arnstein’s ladder, 1971). Community development has, for example, been linked to community organisation, community-based initiatives, community mobilisation, community capacity building and citizen participation. 
There is, however, a common understanding of core principles, which inform community development work, two of which are participation and empowerment. These principles can and are, however, operationalised differentially in different types of community development work. 
Despite consensus that community participation should engender active processes involving choice, and the potential for implementing that choice, implementation has proven difficult. For example, when formal health services adopt an empowerment framework, their formal structures are not necessarily conducive to participation. 
Although it is commonly agreed that appropriate leadership and effective organisational structures are crucial to successful community participation, this requires a political climate that nurtures and facilitates the approach. 
“Community development uses a variety of methods and activities such as self help work, outreach, local action groups, lobbying, peer work, festivals and events, information, advocacy, group work, network building and pump priming community initiatives with small grants. 
The key characteristic of community development is that it starts from the experiences and perspectives of communities. In terms of health, local people need to be enabled or supported to identify the factors that impinge on their health and the solutions. It is argued that genuine participation is only possible when there is involvement in decision-making and evaluation. 
Community development approaches challenge the definition of health as an individual problem for which there are individual solutions, and health care systems that treat the symptoms and not the root causes of ill health. Instead, such approaches emphasise the knowledge and expertise of individuals and communities living through an experience and the centrality of drawing on this source of expertise to define problems and solutions and ultimately to design more effective services. The main benefits of community development approaches have been summarised as:
• Improving networks in a community, which has been shown to have a protective effect on health.
• Identifying health needs from users’ point of view, in particular disadvantaged and socially excluded groups.
• Change and influence, as it enhances local planning and delivery of services.
• Developing local services and structures that act as a resource.
• Improving self-esteem and learning new skills that can aid employment.
• Widening the boundaries of the health care debate by involving people in defining their views on health and local services.
• Tackling underlying causes of ill health and disadvantage. 
There is increasing empirical evidence that a complex set of contextual factors (including social, economic and physical environmental factors, such as poverty, air pollution, racism, inadequate housing, and income inequalities) play a significant role in determining health status. These factors contribute to the disproportionate burden of disease experienced by marginalised communities. There is also considerable evidence suggesting that numerous resources, strengths and skills exist within communities (e.g. supportive interpersonal relationships, community-based organisations) that can be engaged in addressing problems and promoting health and well-being. This understanding of the factors associated with health and disease has contributed to calls for more comprehensive and participatory approaches to public health research and practice, and a rise in partnership approaches, variously referred to as ``participatory action research’ ’, ``participatory research’ ’, ``action research’ ’, and ``community-based research’ ’. Policy changes at the organizational, community and national levels are needed to help address barriers and challenges to the adoption of such approaches and to support their increasing use. 
The community development approach encounters particular challenges in the context of health care. While support for the idea of extending community development approaches into mainstream health services and other public services has grown, in reality organisations are not always receptive to the idea of a longer term ongoing dialogue which might lead to major changes within the organisation or into areas that the organisation had not previously considered. The conclusion of a DHSS (Northern Ireland) (1999) document was that community development is still at a relatively early stage of development within mainstream agencies. It found most NHS Trusts and Boards did not have a stated policy for a community development approach, and there was a lack of focus for this work and few instances of training for staff in this area. 
The way of working with and not just on behalf of individuals and communities that is central to the community development approach, sits uneasily with traditional western medicine and the ‘medical model’ in which professionals know what the problem is as well as the solution. The challenge is not to the value of medical expertise per se, but rather to its dominance in respect of health knowledge and the allocation of resources. 
Few health service professionals are fluent with community development approaches and ways of working with, rather than on behalf of, people. In describing a public health programme set up to link new mothers with experienced mothers and Public Health Nurses in Ireland during the 1980s, Johnstone (1993) concluded: “Familiarisation of all health care workers with changes in policy and the background of research and development and aims of policy would eliminate some of the frustrations and create a more supportive environment...The community based approach has proved more effective in achieving change where this is indicated and is likely to be a more useful model for empowerment and self-care then the traditional type of health care approach.” (p255) Subsequently, Johnstone (1993) advocated that the education and training of health care workers should include the possibility of working in partnership with people rather than for people. Community and user groups and health and social services professionals need to perceive each other interacting in different sets of roles and relationships. McKnight (2001) also highlighted core differences between the shape and function of communities and service systems: communities were based around individuals and families, informal relationships, as well as formal groups, and relationships defined by choice. Service systems on the other hand, had hierarchical structures designed to ensure “a few people could control a lot of people” to produce goods or services. Such structures ensured uniformity and that goods and services met the same standards. Each kind of structure has its own (very different) rationale, ways of working and communicating, and the two kinds of system therefore often find it very difficult to engage constructively together. The central concern identified by McKnight (2001) was that of ensuring people were at the centre and influencing what happens. 
"Although there is general agreement about the complex interplay among individual-, family-, organizational-, and community-level factors as they influence health outcomes, there is still a gap between health promotion research and practice. The authors suggest that a disjuncture exists between the multiple theories and models of health promotion and the practitioner's need for a more unified set of guidelines for comprehensive planning of programs. 
"For the purposes of this review, researchers defined an intervention as an organized and planned effort to change individual behavior, community norms or practices, organizational structure or policies, or environmental conditions." 
“Despite the fact that community development approaches have been used by several of the major community-based heart health initiatives, evidence of their use and usefulness remains sparse.” 
“The health effects of social interventions have rarely been assessed and are poorly understood. Studies are required to identify the possible positive or negative health impacts and the mechanisms for these health impacts. The assessment of indirect health effects of social interventions draws attention to competing values of health and social justice” 
“The Working Group also debated what is meant by "evidence" in the context of health promotion, with several members arguing that the concept of "evidence" may in fact be an inappropriate one in this context. One of the key arguments for this position is that the concept of "rules of evidence" in science tends to be related to particular disciplines, and since health promotion is by nature "multi-disciplinary," it is not clear whose rules of evidence it should follow. However, most members of the group felt that it was impractical to take this stance given the fact that relevant policymakers, including members of the World Health Assembly, were demanding "evidence-based" health promotion. Several members suggested that it would be prudent if, at least for the time being, we accept the use of the term "evidence" within health promotion. As suggested by Keith Tones, perhaps the best way to think of it is within a judicial paradigm: "We should assemble evidence of success using a kind of 'judicial principle' - by which I mean providing evidence which leads to a jury committing [itself] to take action even when 100% proof is not available." This approach has several advantages: it is a concept of "evidence" which most people can understand, it provides scope for considering a broad range of sources and types of evidence, it implies that evidence differs in quality and it implies that one must take the "weight of evidence" into account. However, this approach does not give us any guidance regarding what evidence is needed in the context of health promotion." 
“Health outcomes in populations are the product of three factors: (1) the size of effect of the intervention; (2) the reach or penetration of an intervention into a population and (3) the sustainability of the effect.(4). There are few written accounts of the adoption of community development approaches within the fields of statutory health care, while there is a thriving literature about the community development approach to health (Jones, 1998). This picture is bound to change as the emphasis on adopting community development approaches increases.” 
“There is a well recognised gap between research findings and the implementation of evidence based prevention strategies in community settings (McGinnis and Foege, 2000). Research should inform community leaders or facilitate using proven intervention strategies in community environments. However, community leaders and health promotion experts suggest that a barrier to the adoption of research-based, efficacious interventions is that these strategies may not meet community needs (Green and Mercer, 2001). Interventions may be too complex, difficult or costly to integrate with existing activities. Part of the problem may be researchers’ attempts to find the most efficacious program rather than a program that could be implemented and delivered with limited resources to many people.” 
“The low level of individual participation rates in studies that recruited from a representative targeted population raises questions about generalisability.” 
“Despite a comprehensive search for literature relating to the effectiveness of policy interventions implemented through sporting organisations for promoting healthy behaviour change, no evidence in the form of well-designed and evaluated interventions was found. The ability to provide clear directions or strategies for future health promotion interventions is therefore limited. It is likely that these types of interventions are rarely evaluated or published, or that such evaluations are only available through contacting each sporting club, sporting association, health promotion agency or other agencies with a remit for sport (e.g. local councils). An internet search identified a number of case studies in this area. These included post-data only, and evidence on outcomes was typically anecdotal. It is essential that sporting or health promotion agencies that conduct such interventions evaluate the interventions, publish the results and disseminate them widely. This will enable practitioners to more readily and the available evidence, and consequently, to implement effective interventions. In future, funding for evaluation should be built into sporting programs. However, as noted in the review by Payne (Payne 2003) there is a limited capacity to carry out evaluation in sporting organisations. Payne suggests that academic-based researchers should work in partnership with the sport and recreation industry to ensure that sporting programs are evaluated in a useful way. This may simply involve the introduction of data collection tools/databases in order to evaluate programs in a quasi-experimental manner. Practitioners therefore need to form relationships with the tertiary education sector.” 
“It is important to recognise that these conclusions are drawn from a wide range of research across many different issues. Establishing evidence for the effectiveness of interventions dealing with specific issues, however, can be more problematic in some cases than for others, particularly in areas such as nutritional status and obesity which have complex and multifactorial etiologies and which require long time frames for measurable changes to occur. This must be taken into account in considering the material provided in this report.” 
Findings: This synthesis identified good quality systematic reviews that covered mental health, aggressive behaviour, healthy eating, physical activity, substance use and misuse, driver education, and peer approaches. Reviews of programmes that promoted mental health in schools (including preventing violence and aggression) show these programmes to be among the most effective ones in promoting health. Of these programmes, the ones that were most effective were of long duration and high intensity, and involved the whole school. New reviews that focused on promoting healthy eating and physical activity confirmed an earlier review, which found that multifactorial interventions, particularly those involving changes to the school environment, were effective. Four new reviews of programmes that focused on promoting the prevention of substance use confirmed previous findings that these programmes are relatively ineffective. Also, programmes on preventing suicide reduced suicide potential, depression, stress and anger, but less rigorous studies suggested a potential harmful effect in young males. In some (but not all) studies, peer-delivered health promotion was found to be effective, compared with teacher-led interventions, and this approach was highly valued by the young people involved. The systematic review, which evaluated health outcomes of programmes that used elements of the health promoting schools approach, included small studies of variable quality. It found apparent benefits to the social and physical environment of the school, and some studies found the programmes benefited health-related behaviour (dietary intake and physical fitness). No reviews evaluated the cost–effectiveness of the programmes or interventions.” 
There is a clear lack of comparative data in measuring effectiveness of different approaches to health promotion.
Definition of goals of intervention (what to measure)
“Reach is defined as the percent of potentially eligible individuals who participate in the intervention study, and how representative they are of the target population from which they are drawn. Efficacy/effectiveness is the intended positive impact of the intervention and its possible unintended consequences on quality of life and related factors. Reach and efficacy/effectiveness operate at the individual level. Adoption is the percent of potential settings and intervention agents that participate in a study and how representative they are of targeted settings/agents. Implementation refers to the quantity and quality of delivery of the intervention’s various components. Adoption and implementation are setting-level dimensions. Finally, the maintenance dimension includes individual- and setting-level indices. At the individual level, maintenance is defined as the longer-term efficacy/effectiveness of an intervention. Outcomes at 6 months post-intervention contact reflect longer-term individual maintenance. The setting level definition of maintenance refers to the institutionalisation of a program and is assessed according to the percent of settings that continue the intervention program, in part or in whole, beyond the study duration (Glasgow et al., 1999; Glasgow et al., 2001).” 
"There is increasing evidence emerging regarding the effectiveness of community-based injury prevention programmes. The use of multiple interventions implemented over a period of time can allow injury prevention messages to be repeated in different forms and contexts and can begin to develop a culture of safety within a community. Important elements of community-based programmes are a long-term strategy, effective and focused leadership, multi-agency collaboration, the use of local surveillance to develop locally appropriate interventions and tailoring interventions to the needs of the community. Time is also needed to coordinate existing networks, and to develop new ones. However, a positive and sustained impact of community-based programmes on injury rates has not yet been demonstrated conclusively. There is a need to develop valid and reliable indicators of impact and outcome appropriate to community studies. Where proxy measures are used for injury outcomes, it is important that there is clear evidence of the association between the proxy (e.g. hazard removal, knowledge gain or behaviour change) and injury risk (Towner et al., 1996Go). There is also an urgent need to develop and monitor indicators to assess and monitor a culture of safety, programme sustainability and long-term community involvement. Community-based injury prevention programmes have been hampered by the lack of resources allocated to both their programme development, and appropriate and rigorous evaluation." 
“Health promoting schools and health promotion in schools: two systematic reviews
# Ensure that process evaluation which describes the way in which programmes have been implemented is undertaken and reported in all studies of health promotion in schools.
# Develop valid and reliable measures for evaluating the outcome of the health promoting school initiatives, particularly those measuring mental and social well-being for children and adults. Incorporate these in all studies of health promotion in schools." 
1. Community development, user involvement, and primary health care
Community development recognises the social, economic, and environmental causes of ill health and links user involvement and commissioning to improve health and reduce inequalities. Communities can be geographical—such as particular housing estates—or communities of interest, such as user groups. Trained community development workers bring local people together to:
* identify and support existing community networks, thus improving health;
* identify health needs, in particular those of marginalised groups and those suffering inequality;
* work with other relevant agencies, including community groups, to tackle identified needs;
* encourage dialogue with commissioners to develop more accessible and appropriate services.
Many examples of these activities exist. Studies show that community support through social networks is protective of people’s health. High levels of trust and density of group membership are associated with reduced mortality. Conversely, lack of control, lack of self esteem, and poor social support contribute to increased morbidity.
Needs assessment that is focused on communities can identify solutions as well as problems. Results of such initiatives include a new post of youth health adviser to support youth centred health activities across practices in Lewisham, which has led to improved learning about contraception and sexual health, improved liaison with practices, and changes in practice provision to make services more appropriate for the young people they serve. In St Peter’s Ward, a deprived area of Plymouth, a community development approach has resulted in free pregnancy testing in a local community project, the setting up of a “parentwise” project that draws on resources within the community, changes in health visitors’ working, and the provision of more acceptable antenatal classes. The more involved the community is in needs assessment, the more likely changes are to ensue. These assessments can provide representative views, particularly if quantitative approaches are used to triangulate these views, and there is little evidence that patients make unreasonable demands.
Community development can also lessen the impact of poverty on health. In Torquay concern about nutrition has led to the setting up of a food cooperative managed by local people that makes available cheap, healthy food. Community development can reduce social exclusion by ensuring that marginalised groups influence health services. In Bradford such an approach increased the uptake of cervical and breast screening among women from ethnic minorities. Minority ethnic communities, disabled people, adolescents, and elderly people have all been involved in the commissioning process in Newcastle, where a community development worker, accountable to the community, brings together community groups with purchasers and providers to implement change.
Examples of community development interagency activity include the work of a safety group in Torquay which resulted in policy changes within the housing department, play areas, and other borough and police services. While health professionals prescribed drugs to patients in their hilly area in Lewisham, a community development solution was found through a new bus service. By involving the local authority, it was possible, in a single intervention, to respond in a practical way to issues of loneliness, isolation, and problems of exercise tolerance." 
Improved Research Quality Outcomes
When the EPC researchers looked at the influence of community involvement on the quality of interventional studies, they discovered 11 of the 12 completed intervention studies had reported enhanced intervention quality. Just two studies reported improved outcomes, while eight noted enhanced recruitment efforts, four reported improved research methods and dissemination, and three described improved descriptive measures. Very little evidence of diminished research quality resulting from CBPR was reported.
Of the 60 studies reviewed, 47 reported improved community involvement, including additional grant funding and job creation, as an outcome associated with the study. The authors—typically academics—generally focused on the increased capacity of the participant community, rather than that of the research community.
Among the 12 studies evaluating completed interventions that play a role in health outcomes, two dealt with physiologic health outcomes, three with cancer screening behavior, and four addressed other behavioral changes (including alcohol consumption, immunization rates, and safer sex behavior). Finally, three studies measured the impact of the intervention on emotional support, empowerment, and employee well-being.
Given the highly varied health outcomes, measurement strategies, and intervention approaches used, the EPC researchers were unable to perform a direct comparison of studies and their relative impact on health outcomes. Moreover, an absence of cost-effectiveness data precluded any comparison of outcomes from CBPR studies and those of more traditional research studies.
Community involvement varied in different stages of the research. There was strong involvement in recruiting study participants, designing and implementing the intervention, and interpreting findings. Many authors argued that community involvement (especially in theses areas) leads to:
The disadvantages of community involvement were not frequently reported, but they may include:
From mid July 1998 to the end of May 1999, Auseinet provided seed funding and intensive support to eight agencies that provided services to children and young people to reorient an aspect of their service to an early intervention approach to mental health. The aim was to give the agencies the opportunity to build their capacity by developing a range of tailored, potentially sustainable strategies.
All agencies made workforce development the foundation of their reorientation process. As most of the agencies were not primarily mental health focused, enhancing the mental health literacy of staff was a vital first step in reorientation. They informed staff about the mental health issues faced by the young people who used their service, gave them the skills to recognise risk factors and early warning signs, and established procedures for appropriate referral. The training programs were documented to guide future training needs and to provide resources for staff.
All of the projects showed evidence of organisational development. Management support was demonstrated by the formation of steering committees, reference groups and umbrella groups. Policy development occurred within as well as between agencies. One project developed an early intervention policy outlining referral and support mechanisms and others developed recommendations for incorporating early intervention into new policies. Two projects developed formal interagency agreements and policies. The development of