Founded on community development principles and practice, the ‘Breathing Space’ initiative aimed to produce a significant shift in community norms towards non-toleration and non-practice of smoking in a low-income area in Edinburgh, Scotland. The effectiveness of Breathing Space was evaluated using a quasi-experimental design, which incorporated a process evaluation in order to provide a description of the development and implementation of the intervention. Drawing on qualitative data from the process evaluation, this paper explores the varied and sometimes competing understandings of the endeavour held by those implementing the intervention. The paper examines the principles that underpin health promotion in the community setting, particularly the concepts of ownership, empowerment and participation, and their differential interpretation and employment by participants. The data illustrate how these varied understandings had implications for the joint planning and implementation of Breathing Space objectives. In addition, the different understandings raise questions about the appropriateness and viability of utilizing community development approaches in this context.
Current health promotion policy and practice places a high value on community development work (Robinson and Elliott, 2000) because it aims to enable communities to identify problems, develop solutions and facilitate change (Blackburn, 2000). The overt ideological agenda of community development is to remedy inequalities and to achieve better and fairer distribution of resources for communities (Tones and Tilford, 2001). This is achieved ideally through participatory processes and bottom-up planning (Bracht and Tsouros, 1990; Bernstein et al., 1994; Israel et al., 1994; Labonte, 1994; Robertson and Minkler, 1994; Robinson and Elliott, 2000; Smith et al., 2001).
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 (Beresford and Croft, 1993; Petersen and Lupton, 1996). However, community development means different things to different people and, as we shall see, can operate on different levels (Arnstein, 1971; Brager and Specht, 1973; Tones and Tilford, 2001). Community development has, for example, been linked to community organization, community-based initiatives, community mobilization, community capacity building and citizen participation. There is, however, a common understanding of core principles, which inform community development work (Bracht and Tsouros, 1990; Robinson and Elliott, 2000; Smith et al., 2001), two of which are participation and empowerment. These principles can and are, however, operationalized differentially in different types of community development work.
The concept of community participation has proved to be more complex than was originally envisaged by the early World Health Organization (WHO) health promotion strategies (WHO, 1978; Rifkin, 1986; WHO, 1986; Rifkin et al., 1988; Rifkin, 1995; Labonte, 1998; Zakus and Lysack, 1998; Laverack and Wallerstein, 2001). Despite consensus that community participation should engender active processes involving choice, and the potential for implementing that choice, implementation has proven difficult (Zakus and Lysack, 1998). For example, when formal health services adopt an empowerment framework, their formal structures are not necessarily conducive to participation. (Rifkin, 1990; Labonte, 1998; Zakus and Lysack, 1998). Although it is commonly agreed that appropriate leadership and effective organizational structures are crucial to successful community participation (Laverack and Wallerstein, 2001), this requires a political climate that nurtures and facilitates the approach (Labonte, 1998; Zakus and Lysack, 1998).
Tensions can also occur where community participation is engaged for disease prevention purposes rather than following a bottom-up, community-defined agenda (Rifkin, 1990; Asthana and Oostvogels, 1996; Labonte, 1998; Zakus and Lysack, 1998). It has been argued, however, that these approaches are not necessarily incompatible and that both positions can be accommodated (Rifkin, 1990). If, it is suggested, community participation is seen as a process rather than an intervention this will affect the value placed on different types of outcomes (Rifkin, 1995; Labonte, 1998; Laverack and Wallerstein, 2001).
However, there are many different levels at which the community may participate and at one extreme this may amount to little more than tokenism (Labonte, 1994; Petersen and Lupton, 1996). Moreover, communities do not have the same access as local authority organizations and government agencies to those resources enabling them to define and set the agendas and participate on an equal footing (Labonte, 1994; Wallerstein and Bernstein, 1994; Blackburn, 2000).
The concept of ‘empowerment’ has also assumed different meanings within the context of community-based health promotion work (Israel et al., 1994; Labonte, 1994; Robertson and Minkler, 1994; Laverack, 2001; Smith et al., 2001). For example, empowerment may be at either or both the individual and community level (Bracht and Tsouros, 1990; Bernstein et al., 1994; Israel et al., 1994; Labonte, 1994; Robertson and Minkler, 1994; Robinson and Elliott, 2000; Smith et al., 2001), and tension may exist within community development practice between the two levels (Robertson and Minkler, 1994; Wallerstein and Bernstein, 1994). Whereas individual empowerment might be concerned with individuals gaining mastery over their lives, community empowerment focuses on ‘the social contexts where empowerment takes place’ [(Wallerstein and Bernstein, 1994), p. 142]. While it has been suggested that the two levels are interdependent, the aims of each may differ (Robertson and Minkler, 1994) and this may impede practice (Laverack and Wallerstein, 2001).
Community development has been used in several major UK heart-health initiatives, reflecting the centrality of the approach within the New Public Health strategy (Robinson and Elliott, 2000). There is, however, limited evidence of its overall success (Farquhar et al., 1990; Luepker et al., 1994; Carleton et al., 1995; COMMIT Research Group, 1995; Goodman et al., 1995; Shelley et al., 1995; Brownson et al., 1996; Baxter et al., 1997; Secker-Walker et al., 2000; Hancock et al., 2001). A major difficulty in assessing effectiveness of different programmes arises because communities utilizing this approach tend to interpret and implement aspects of community development deemed most appropriate to their specific needs (Buchanan, 1994; Robinson and Elliott, 2000). Because community development programmes are not operationalized in a consistent way it is difficult to compare ‘like with like’.
In order to understand better how these programmes perform, it is necessary to examine in depth how the community development approach is rolled out within the local context (Robertson and Minkler, 1994; Wallerstein and Bernstein, 1994). To this end we draw on the evaluation of Breathing Space, a community-based smoking intervention in an area of low income. The paper examines the development and execution of the Breathing Space programme through participants' understandings about community development and the translation of these understandings into health promotion practice.
An independently funded study was undertaken to evaluate the ‘Breathing Space’ initiative using a quasi-experimental research design. In addition to before and after surveys, a thorough qualitative process evaluation was carried out which aimed to document development and implementation of the intervention and to assess threats to the validity of the research design. This paper draws upon in-depth interviews undertaken as part of the study's process evaluation.
Fifty-six semi-structured in-depth interviews were conducted with programme participants. These comprised eight interviews with managers from the three main partner organizations, seven with the project coordinators, 28 with intervention team members, 11 with subgroup members and two with community development workers, with responsibility for smoking cessation services, employed by one of the partnership organizations. The interviews, which were recorded, were held at key points across the course of the project (audit and planning, project design and development, and implementation stages). They explored respondents' understandings and experiences of intervention programmes at different levels (overall programme organization and structure, individual projects, and personal roles and responsibilities).
The interviews were transcribed and analysed thematically with the assistance of qualitative software (NUD*IST). Three members of the research team developed a detailed coding scheme. Some of the themes/categories agreed by the team related directly to the aims of the evaluation and were identified before the interviews, while others emerged through exploration of the interview data. The robustness of all the categories was tested by reference to the individual cases, the conditions and contexts of which were compared and contrasted. All three researchers were involved in coding the data. In order to ensure congruence between coding styles, different researchers coded a random selection of transcripts, discrepancies were reviewed and agreement of the final coding scheme was negotiated.
Data extract identifiers
In the Results section, extracts from the data can be attributed to representatives from the different respondent groups. Identifying numbers for each extract are prefixed by a letter which can be interpreted as follows: ‘M’ indicates managers, ‘I’ indicates intervention team members, ‘YS’ indicates those working at subgroup level in the ‘Young Persons’ setting, ‘C’ identifies those in the ‘Community Setting’ and ‘PC’ identifies those in the ‘Primary Care’ setting.
The origins of Breathing Space
Prior to Breathing Space there were two national anti-smoking initiatives supporting smaller scale projects using the community development ethos and approach in Scotland. These were the Women, Low Income and Smoking Initiative and the Tobacco and Inequalities Project (Amos et al., 1999; Barlow et al., 1999; Gaunt-Richardson et al., 1999; McKie et al., 1999). Breathing Space, however, was the first community-wide development programme on smoking in Scotland.
Breathing Space was a community health promotion initiative, which aimed to produce a significant shift in community norms towards non-smoking in a low-income area in Edinburgh. The community (Wester Hailes) was unusual in that local community groups had identified smoking as a priority health concern, which they had begun to address through the implementation of no-smoking policies and the provision of support for smokers who wanted to quit. The Breathing Space programme was initiated by the local health policy group — the health subgroup of an Urban Regeneration Partnership — which approached their local health board for help in tackling the high prevalence of smoking in Wester Hailes. The aim of the programme was to capitalize on local knowledge and encourage local involvement in the development of a programme of activities that would create a supportive environment to enable local people to make healthy choices. Although focusing on four main health promotion settings (community, primary care, youth and schools, and workplace), Breathing Space set out to bridge these settings and create a health promoting environment across the wider community.
Breathing Space was organized on three levels. On level one, an intervention team, comprising representatives from the partner organizations, was set up to oversee planning and implementation. This alliance formed a steering committee, which supported settings-based subgroups (level two), whose remit it was to take project objectives forward. Subgroup membership included the main intervention team and other community workers with particular expertise or interest in that setting. The third level comprised others who worked or lived in the community, and who were involved in the implementation of specific intervention activities.
DISCUSSION OF FINDINGS
Participation and ownership
Respondents felt that each of the Breathing Space partners should have a different yet equal role to play in the development and execution of the programme. The role of Wester Hailes Urban Regeneration Partnership (WHURP), for example, was described by a (WHURP) manager as: ‘… facilitating and taking forward some of the actual interventions in specific settings where there's a health promotion specialist (health board employee) working’, whereas the role of the health agency was described as ‘taking forward the community's aspects, making sure that the project is in line with community defined needs’ (M5).
In practice, parity of participation was an issue for many respondents. Hence, the manager quoted above said ‘It can't just be [us] providing the support and doing the work’ (M5). Most concern about parity of input, however, centred upon Lothian Health Board (LHB), which was singled out by many respondents as being too prominent in both the development and the implementation of Breathing Space. The proportion of health board representatives (nine out of 12 at one point) on the intervention team and the heightened profile of health board workers throughout the project contributed to the view of some respondents that the programme was ‘developed effectively by one organization’ (I8).
Concern about the over-representation of the health board was matched by at least equal, if not greater concern about a perceived under-representation of the local community organizations:
Hence, although Breathing Space was conceived as a community development project, there was a lack of agreement among the partners about what community participation meant and who should be involved.
I can remember one meeting where a senior member of health board staff was talking about ‘we need to get the community involved, the community involved’, but what she was talking about were health visitors: the pharmacists, the local shops — that is not a community. (I8)
Participation and ownership were not only issues at an organizational/agency level, but also at the level of their membership. Commitment held by managers did not necessarily reflect the commitment of members. The heightened presence of health board workers did not appear to arise from any intention on their behalf to dominate the Breathing Space programme. Indeed, a senior manager from the health board described the initial ambivalence of some health board worker as a function of their lack of involvement in the early stages of the project:
Because some programme workers were not privy to the initial decision-making processes through which the programme evolved, the level of enthusiasm or perceived ownership associated with successful community development work was forfeited.
To start with there wasn't real ownership, there was a lot of ‘phew, I've got to do this now’ — whereas now ‘this is a piece of work and its going forward and I'm a bit concerned about how I'm going to fit it in’. (M1)
Smoking as a priority
Many respondents felt that Breathing Space was not a community venture and, related to this, that smoking was not a community-defined priority. Views on this issue differed according to the organization that respondents represented and the role they played in the initiation of the programme. Representatives of the community health agency felt that the community had identified smoking as a priority because smoking had been central to the community-based work from which Breathing Space had evolved:
Respondents, such as I1 from the Health Board, who were key players in the initiation and early development of the programme, also felt that Breathing Space had evolved in line with the principles of community development, describing smoking as:
We were the core of the project before Breathing Space came into being. It was built on the work that we and the health project did. The whole thing evolved out of our work. (I8)
… located in the specific heart of the community. It's certainly located in the structure of the partnership. I'm aware that it comes from the bottom up. (I1)
In contrast, those respondents who did not represent community groups, and were not privy to the early discussions from which Breathing Space evolved, were less certain that smoking constituted a community-defined priority. From the perspective of a WHURP representative, for example, other issues were described as more pressing: ‘It's always been drugs and alcohol that have been its primary issues’ (I8). The health board workers drew on their experiences of working in the area to identify issues they saw as important. For example, a health board young person specialist said:
Similarly, YS2, a youth agency worker, felt that smoking was not high on the agenda of young people:
… we're supposed to be talking about smoking in the 3rd year, and some of the girls start slagging another girl off about having had sex for the first time the night before. And I would say that is a bigger issue as far as they are concerned than smoking. (I5)
I think in a lot of ways it's an adult issue. You know what I mean? It's coming from adults it's not coming from young people … I don't think they see it as a huge issue. (YS2)
Some respondents felt that the focus on smoking was ethically problematic. For example, I13 (an intervention team member and health board worker) felt that targeting smoking contributed further to people's already disadvantaged lives. She described smokers as ‘people who maybe have lots of needs, have complex needs’ and smoking as ‘their little bit of pleasure’ (I13).
Some respondents reported difficulties in selling the programme to community gatekeepers. I16, when describing the problems she encountered when trying to get general practitioners on board, said:
… it's not a particularly nice feeling to be having to work so hard to sell something … You get home and say to yourself ‘I'm not peddling drugs here, I'm trying to do something good’. (I6)
Empowerment and service delivery
Respondents' opinions differed as to whether Breathing Space should focus upon broad health issues or more specifically upon smoking behaviour. Those taking the broader view talked, for example ‘about looking at the underlying issues and realising that smoking in a lot of cases is a symptom rather than the issue itself’ (I5, health board). These respondents also tended to talk about the ‘the health of the local community’ (I10) rather than the health of individuals. I2, from the health board intervention team, for example, described her understanding of the programme thus:
… the main idea of it was to look at smoking in a community and in a wider context [as opposed to] … the usual sort of health prepared stuff which is about individual behaviour and so on. (I2)
Most respondents acknowledged that smoking cessation work is traditionally focused at the individual level. Indeed, for many, ‘one to one’ was a way of working with which they were most familiar and felt most comfortable. PS4, a health care professional in the primary care setting, for example, described the programme work as:
Targeting individual smoking behaviour was not necessarily seen as incompatible with the aims of community development work. Some, for example, felt that increasing access to cessation materials and support would lead ultimately to a change in ‘perceptions on smoking in [the area]’ (PS3) and help ‘overall to reduce the number of people that smoke’ (I13).
going down the different channels with people who are identified as smoking if they are wanting to either stop smoking or to reduce their smoking habits. (PS4)
The programme was also affected by institutional constraints experienced by those working within the different partner organizations. Some implementers felt they were expected to demonstrate the type of tangible outcomes associated with direct action about smoking targeted at the individual level. For example, the Breathing Space coordinator said:
Given the types of outcomes traditionally expected of health promotion, the community development approach presented some difficulties for respondents. Some, for example, were uncomfortable with, and resistant to, the idea of project objectives that were shaped by the community agenda and that could evolve over time. A health board worker involved in the conception of the programme described the dilemma this posed for some workers:
As time has gone on there's been a certain amount of pressure to do things — practical things. And they tended to be about smoking, directly about smoking. (R14)
RI1 felt, however, that workers who persevered despite reservations could reach a better understanding of the enterprise, over time:
People are probably more used to working in a way that's erm — you know — you do this and then you do this and then you do this. Whereas what we are trying to do is to allow a process to emerge … and what people are finding difficult is being diffuse … very difficult, the anxiety is enormous. (I1)
Others, such as I2, a health board employee, described her uncertainty about the unfolding nature of the endeavour:
You know, it's working quite slowly for people …, really its like pennies beginning to drop, and people realising yes that's what it is about. (I1)
In addition, although those representing the community based agencies were more likely to be familiar with community development work, not all of their members were similarly experienced. For example, I12, a recently recruited health agency employee, expressed a fixed understanding that Breathing Space aimed to ‘Get mainly youngsters and teenagers to stop smoking … to improve their health’ (I12).
It's very amorphous because it's a developmental project. That's the nature of the beast … I'm not very confident about doing this. It's not knowing so shapeless — and what's going to happen and then it comes together?
This raises two important points. First, not everybody, and particularly those working within the statutory agency, were familiar and/or comfortable taking a community development approach. I5, for example, said ‘Well to start with I didn't have a clue what the principles were’ (I5). Equally, those working at the community level were not necessarily familiar with the theoretical principles underpinning their work: ‘[It's] certainly difficult because there is an awful lot more theoretical discussion around, and we are very much on the practical … side here’ (I9).
Secondly, even where workers were knowledgeable about, or gained familiarity with these precepts, they did not find it easy to translate this knowledge into practice. Ways of working associated with the different partner organizations/agencies were understood by respondents to be fundamentally incompatible:
Unsurprisingly, respondents representing the health agency described themselves as more appropriately placed and better qualified to support a community-based approach:
… there are tensions in doing community development if you are a statutory organization … it doesn't quite fit, because on one level it's home grown, it's grass roots development, it's power is located in the community and then you are there as a totally different, like well quite a powerful structure with certain ways of working. (I1)
… we have a lot more facilities and support services to offer … It's not saying we are better, we've just got more on offer in terms of alternatives and stuff than say the GPs and the practice nurses. (CS1)
Findings from the process evaluation indicated a disjunction between respondents' conceptions of Breathing Space as a community development programme, and the translation of the programme into actual practice. The data suggest this is a function of a combination of factors, in which participation, ownership and empowerment play major roles.
That the partner organizations were felt to be represented unequally left many respondents, particularly those from the community agencies, feeling disempowered. While the community partners felt entitled to programme ownership, in that Breathing Space was seen as developing out of their previous work on smoking in Wester Hailes, the health board was seen as the dominating and ‘more powerful’ partner.
This was perceived as particularly problematic, as of all the partnership groups, the health board was understood to be the least sympathetic or amenable to the aims of community development and the least able to accommodate ways of operationalizing the programme necessary for its success. In particular, a narrow focus of the health board on the health of individuals and on smoking behaviour per se was, given the community development aims, felt to place inappropriate expectations and constraints upon programme outcomes.
The different approaches, which appeared to index the respective positions of the community organizations and the health board, reflected two separate discourses operating within the programme simultaneously. The first favoured the concept of community development and empowerment, while the second favoured prevention of unhealthy lifestyles (and to a lesser extent the promotion of individual empowerment). That these discourses were seen as mutually reinforcing rather than incompatible by many respondents, reinforces a sense of their reluctance to grasp wholeheartedly the ‘radical’ agenda and modus operandi of community development work.
At an even more fundamental level, the perceived low level of input from actual community members, and a lack of consensus about what constituted the community, raised a question mark over whether or not smoking was a community-defined priority in Wester Hailes. Whereas those who were involved in the development of the programme and/or had experience of community-based no-smoking health promotion work saw smoking as a community issue, others did not. While White Papers on tobacco and public health (Secretary of State for Health, 1999; Secretary of State for Scotland, 1999) demonstrate government identification of smoking as an important contributor to social inequalities in health (Graham, 1998), this may not necessarily be reflected at a community level. Reticence expressed by some Breathing Space workers towards the issue of smoking reflected their concern that other problems experienced by the community were more pressing. These views resonate with a body of sociological findings, which indicate how the social circumstances of disadvantaged lives play an important part in sustaining smoking (Laurier et al., 2000). That is, smoking is portrayed as one mechanism that smokers use to cope with living and caring in disadvantaged circumstances (Graham, 1987, 1993; Gaunt-Richardson et al., 1999). However, it is important to note that neither the views of the community organizations nor the health board can be seen as reflecting the position of community members, because of the very minimal presence of this group in the Breathing Space programme.
In conclusion, although current policy may celebrate rhetoric of community development and partnership, the data illustrate how the reality may be difficult to deliver, especially for those working in the statutory sector. This is a finding supported in the literature (Robertson and Minkler, 1994). Our findings also illustrate the importance of clarifying the respective roles and inputs of organizations/agencies involved in partnership working. In particular, it is crucial to recognize that not all partners will have equal input into the programme and that the nature of that input will be quite different. For example, community-based agencies might usefully focus upon their own role in engaging with the own local community and then communicating effectively within the actual structures of decision making. It is very important for the success of programmes that the relationships between partnership organizations, and the structures and processes of decision making, are explicitly acknowledged. Certainly, this is crucial for ensuring that respective organizations and agencies feel that they have ownership of the programme. The study has highlighted not only the importance of community ownership, but also the importance of ensuring that members of organizations signed up to the programme are involved at an early stage of the programme's development.
The evaluation research on which this paper draws was funded by the Department of Health. The Research Unit in Health, Behaviour and Change is jointly funded by the Scottish Executive Health Department and the Health Education Board for Scotland. All opinions expressed in the article are those of the authors and not necessarily those of the funders.
1Department of Sociology, Queen Margaret University College, Edinburgh, UK and 2Research Unit in Health, Behaviour and Change, University of Edinburgh, UK