PARTICIPATION IN COMMUNITY HEALTH PLANNING

The health of a community depends on many factors, including the health protection and promotion activities of local government agencies (e.g., public health, transportation, public works, parks and recreation), not-for-profit agencies (e.g., Red Cross, American Cancer Society, YMCA/YWCA) and private sector organizations (e.g., plastic recycling firms). Because the determinants of health lie, to a great extent, outside the health sector (including socioeconomic, cultural, and working conditions), involving citizens in making decisions on issues that affect their health has long been supported by public health. Theory and practice in community health suggests that planning is best done by those individuals who will be the recipients of, or will be affected by, the resulting programs, policies, or services. Efforts to get people to change their lifestyle behaviors, their worksites (e.g., to implement a no smoking policy), or their schools (e.g., to adopt a healthier lunch menu), will be most successful if those asked to make such changes are included in the planning process. In addition to engendering positive program outcomes, participation is also thought to:

• Empower individual participants by increasing their knowledge and skill levels, their feelings of control and competence to make a difference, and their sense of self-worth and dignity.
• Nurture local planning skills and abilities.
• Build community capacity to tackle future health issues.
• Foster the overall health of the community by strengthening citizens' trust in each other and their connectedness to the community.

Opportunities for citizens to participate in health planning has often been hindered or blocked, however, by resistance from the state and from the professions, precluding citizens from making decisions and shaping policy about their own lives. Participation can be, and often is, tokenistic or consultative rather than meaningful. While it remains an attractive concept, it is one that has been realized only in a limited sense.

Community participation is often narrowly defined as simply asking community members about their health needs. Opinions are often confined to prepackaged formulas, and delegating the actual planning, implementation, and evaluation of programs is left to professional practitioners. While needs assessments and pretesting programs are crucial components of planning, participation needs to go beyond responding to surveys or opinion polls, with people actively involved in defining the issues and in all subsequent phases of the process.

It is often difficult to attract participants that reflect the diversity of a community. The participation process itself can discriminate against those in the community who are not well-educated, well-spoken, or well-off. Committee meetings and public forums can be inconvenient, inaccessible, and intimidating to all but the few who possess the requisite professional experience and educational and discretionary resources to attend. In addition to meetings being convenient and welcoming, citizens must be able to see some reflection of themselves in the participatory endeavor in order to trust the process and become involved. In the absence of broad-based participation, particularly when economy of time and problems of scale restrict participation by all, experiential participation may be a step toward achieving better representation of diverse perspectives.

Experiential participation abandons the "meeting mindset." Participation takes place in schools, worksites, churches, street corners, and coffee houses, and engages citizens in a planning process that reflects their life experiences. It also demands acknowledging and respecting the diverse and nontraditional contributions and strengths of different groups of citizens. Meaningful participation may constitute sharing experiences as recipients of services, providing input about the delivery and quality of health programs, as well as chairing meetings, interpreting statistics, and penning community health plans. A final challenge lies in maintaining the momentum of, and interest in, participatory initiatives when much of the work relies on lay volunteers with busy lives.

Examples of successful initiatives in community health planning where citizens have shared in the responsibility and decision making include the Healthy Cities/Healthy Communities projects in Europe and North America, the Planned Approach to Community Health (PATCH) programs in the United States and Canada, and the Canadian Active Living Movement. Common to these experiences were generous timelines for accomplishing tasks; involving citizens early on in the planning process and allowing participants, rather than professionals, to define the health issues and propose solutions; participatory techniques that accommodated for and respected participants' diverse skills and contributions; and local intersectoral (e.g., education, transportation, environment, recreation) representation and collaboration on the issue.

Joan Wharf Higgins

(see also: Citizens Advisory Boards; Community Health; Community Organization; Decentralization and Community Health; Health Promotion and Education; Healthy Communities; Nongovernmental Organizations, United States; Planned Approach to Community Health [PATCH]; Politics of Public Health; Social Assessment in Health Promotion Planning )

Bibliography

Arnstein, S. (1969). "A Ladder of Citizen Participation." American Institute of Planners Journal (July):216–224.

Green, L. W., and Ottoson, J. (1999). Community and Population Health. Boston: McGraw-Hill.

Marmot, M., and Wilkinson, R. (1999). Social Determinants of Health. London: Oxford University Press.

Prior, D.; Stewart, J.; and Walsh, K. (1995). Citizenship: Rights, Community and Participation. London: Pittman Publishing.

Putnam, R. D. (2000). Bowling Alone, The Collapse and Revival of American Community. New York: Simon & Schuster.

Quinney, H. A.; Gauvin, L.; and Wall, A. E. T. (1994). Toward Active Living. Champaign, IL: Human Kinetics.

Wharf Higgins, J. (1992). "The Healthy Communities Movement in Canada." In Communities and Social Policy in Canada, ed. B. Wharf. Toronto: McClelland and Stewart.

—— (1999). "Closer to Home: The Case for Experiential Participation in Health Reform." Canadian Journal of Public Health 90(1):30–34.

U.S. Department of Health and Human Services (1996). Planned Approach to Community Health: Guide for the Local Coordinator. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion.