3. Conceptual framework - III
Conceptual framework for Mujer Sana - Comunidad Sana
Lay healthy promotion
Lay health promotion is not a new concept. People all over the world always have helped each other to keep healthy. Families, friends and neighbours share information about what to do when someone is sick; how to avoid illness; or where to go for help when hurt. The lay (non-professional) people to whom others frequently turn when they need advice, assistance, or support can be described as 'natural' or 'peer' helpers. These community members are respected, trusted, compassionate, and responsive to others' needs. Their role is especially important in communities that are marginalized, and that experience barriers accessing information, assistance, or support. Lay health promotion interventions try to build on these informal community-based lay helping systems. The principle behind lay health promotion is that health can be improved by identifying, training, and supporting these natural helpers. In contrast to health promoters, doctors, or nurses with formal health education, lay health promoters are chosen for their role and abilities as natural helpers and leaders in their own community.
Lay health promotion projects exist all over the world, including Latin America, Africa, and the United States, where there are many millions of people without access to medical care. Lay health promotion projects frequently target people with few economic resources, newcomers, and those who are marginalized. Helpers who share the language, beliefs, social or cultural characteristics of a minority community often act as 'cultural brokers'. They provide a bridge between marginalized populations and formal systems of care. 2, 3, 4 Training and support empowers natural helpers, and, as 'lay health promoters', they become better able to help isolated people develop social networks. They negotiate services for people in need, and they organize community groups to improve services.
In Canada, they provide a culturally appropriate method of health promotion that is complementary to, not a replacement for, 'mainstream' health promotion and care.
Participatory action research
Participatory research emphasizes valuing people's knowledge of their own situation; and assumes that adults are capable of learning, changing, acting to transform their own reality. Participatory action research also aims to improve the lives of those involved in the research process. 5 A well-known educator of this approach is Paulo Freire, 6 who emphasized the importance of providing communities with the tools necessary to make social change. Participatory action research (PAR) is widely used in Latin America to empower disenfranchised communities and support their change efforts. 7, 8, 9, 10, 11, Many feminist researchers also have embraced participatory research methods, which are guided by equality principles consistent with feminism. 12 In PAR, researchers are responsible to ensure the well-being of the participants beyond the research moment. For instance, if an interview raises issues that require follow-up in terms of needed resources, or emotional crisis, the researcher is expected to provide information and referral or support to the participant. 13, 14,
The Mujer Sana - Comunidad Sana project used a participatory action research framework of 'health promotion for social change'. As with most projects that use a PAR approach, we applied mixed research methods to answer many different questions of interest to different participants in the project. The community was involved in all aspects, including design, data collection, and analysis. The conceptual framework, design, and methods were periodically reviewed with community participation. Hispanic women were supported to analyse their own situation, so that they could decide what was best for their own health. Women participating in the research were empowered to make changes in their situation, and that of their community. They were supported to find ways to respond to community needs collectively. Since the researchers were also community members, there was less power imbalance between those who create and have access to knowledge, and those who are the 'sample' or research 'subjects'. 15 Community members were not treated as passive recipients of health information, but became actively involved in its production and use, ensuring the research benefited the participants, who were members of the community. 16, 17,
Community capacity building
To understand what might happen at the level of communities and organizations, in the process of working towards improving health with, and for, Hispanic women, we used Moyer et al's 18 Community Capacity Building (CCB) model. This model describes four stages through which organizations progress as they develop effective and sustainable working relationships and address health promotion issues in a community. Stage 1 is the Entry phase, in which organizations start to learn about one another, and initiate first contact. Mobilizing (Stage 2) is achieved when communication channels begin to form, roles and relationships start to be defined, and possibilities for working together on the health promotion issues are explored. In Stage 3 (Joint Activity), at least two organizations in the community have begun to work together on a concrete project; effective communication channels have been established, and project leadership (champions) are present. Stage 4 is Sustainability, in which working relationships between and among organizations continue, and the project is integrated into the organizational structures to be maintained over time.
Trans-theoretical model
Individual-level behavioural change (in breast and cervical cancer screening behaviour) was an important component of the demonstration project. The Trans-theoretical Model (TTM) 19, 20 suggests that people progress through a number of stages in the process of behavioural change: Precontemplation (not thinking about adopting a specific behaviour in the near future); Contemplation (considering adopting a specific behaviour in the near future); Preparation (intending to adopt a specific behaviour immediately); Action (implementing the specific behaviour); and Maintenance (consolidating the behaviour and using strategies to continue and prevent slips). This model has been used to explain individual health behaviour change in problem areas such as smoking cessation and HIV prevention, as well as mammography and cervical screening. 21 TTM models have been successfully used to inform, as well as document the impact, of interventions aimed at the individual level, including message tailoring and reinforcement over time, based on assessment of stage of TTM behavioural change.
Feminism and anti-racism
As expected in a participatory action research project, periodic review of the conceptual framework led us to revise the concepts and approaches we were using, once the project got under way. We found we needed to clearly describe two other pieces of the conceptual framework: a feminist approach, and anti-racism. Our feminist approach to research is guided by feminist political and social concerns: addressing the power imbalance between the 'researcher' and the 'researched'; focusing on action to reduce social inequalities; and beginning with the standpoint, experiences, and ideas of women. An anti-racism approach implies a particular understanding of how society is constructed, what racism is, and how racism can be fought; an understanding of racism as a social relation, and of 'race' as a social construct. Applying an anti-racism approach in a project that involves training requires "critical pedagogy: it demands cooperation, participation, respect, critical thinking, honesty, creativity and commitment". 22
Integration of frameworks
The various frameworks interacted with each other in many complex ways, as we implemented, revised, and tried to understand the effect
of the project.
For example, we expected that lay health promotion and participatory research would complement each other well. Lay health
promoters/participatory researchers (LHP/PRs), who were also 'natural helpers' and community leaders, might be able to assess community
needs and ensure the project was responsive to these as they emerged. At the same time, they would be able to give back to the community
information about health issues and services, and strengthen their ability to act as community advocates. This two-way process was expected
to benefit both the lay health promoters/participatory researchers and other community members. As another example, Centretown Community
Health Centre (CCHC) was not only a site for the case study in organizational change, but also an active 'institutional' participant.
We anticipated that its experience and expertise in health promotion and community development would support and greatly enhance the goals
of lay health promotion and community capacity building, as well as provide access to screening services through primary care.
We also wanted to explore how the 'stages of change' could apply to an organization: would CCHC move from contemplation to action in
removing organizational barriers, or get involved with the community in anti-racist social change?
The following table shows some other possible links among the frameworks and approaches used, it is a 'work in progress' (see key findings). For example, would we reach 'Action' , 'Removal of Barriers', 'Working Together' and 'Empowerment' at the same time?
Interaction of Transtheoretical Model and Community Capacity Building,
and addition of a feminist/anti-racist approach
|
