Community Action Success in Public Health: Are We Using a Ruler to Measure a Sphere?
Boutilier, Marie A, Rajkumar, Elizabeth, Poland, Blake D, Tobin, Stasey, Badgley, Robin F, Canadian Journal of Public Health
The Community Action and Public Health study (CAPHS)1 explored how Ontario public health practitioners interpret and implement the call to community action, and the community's response to their efforts. By `community action', we refer to actions undertaken by public health staff to work in collaboration with individuals and groups from the community to address community health issues, broadly defined. We use `community action' in a generic sense to cover the full range of approaches to working collaboratively with community. As such, it is meant to encompass such terms as `community development', `community organizing', `locality development', and `community mobilization'. Both the literature2-13 and the 1996 Action Statement on Health Promotion in Canada14 allude to the complexity of evaluating community action, and underline the need to develop methodologies capable of meeting the challenges. The World Health Organization's definition of health includes the capacity to act,15 yet the capacity to act itself has to be developed.16 Success indicators must thus recognize not only the multiple dimensions of health but also the contribution of community capacity-building to sustainable and meaningful health improvements.5,17 Since continued support for community action may rest on positive evaluations, it is crucial to capture the full range of success indicators in public health initiatives that fall under this rubric.
This paper describes the CAPHS, a qualitative case study capturing management, frontline and community perspectives. No other studies focus specifically on public health's experience in community action. This paper presents results pertaining to the measurement of success and discusses implications for future efforts to evaluate community action initiatives.
Our examination of how Ontario public health professionals view "success" in community action substantiates the view that evaluation methodologies that focus primarily on quantitative measures of epidemiological outcomes do not adequately capture what constitutes success in community action. Such methodologies, while indispensable to the public health toolkit, may produce incomplete (if not misleading) results for community action initiatives. This may in part be due to an unproductive dichotomization of "process" and "outcome".
Six health units across Ontario were selected for in-depth study using three criteria: 1) resources; 2) geographic region; and 3) serving urban or rural communities (Table I). Each health unit was asked to identify three exemplary "community action" projects, one in each of the following program areas: Healthy Growth and Development, Healthy Lifestyles, and Healthy Environments (Table II). Study interviewees (107 in all) were drawn from the 19 projects thus identified. Early in1997, in-depth face-to-face interviews were completed with these individuals (Table III). Interviews ranged from 20 to 175 minutes, were audiotaped, transcribed, and data were managed with NUD*IST software. Using an inductive approach, we coded data and reviewed text to conceptual categories. Emerging themes and trends were challenged and discussed via research team reviews and in meetings with public health colleagues who acted as advisory partners. Feedback on preliminary findings came from the broader public health community at annual OPHA and CPHA meetings.
Interviewees reflected on aspects of "success in community action": its meaning, the factors influencing it, and how they measured it. The questions included such probes as: "In what ways was the project a success?", "In what ways may it not have been a success?" and "What would indicate to you that this project was a success?" This paper explores some of the challenges involved in gauging success, as discussed by the 67 public health interviewees.
Across health units, management and staff expressed frustration about the unavailability of clear, comprehensive, appropriate and legitimized evaluation tools to assess the community impacts of public health participation in community action. …