LEENA EKLUND From Citizen Participation Towards Community Empowerment An analysis on health promotion from citizen perspective ACADEMIC DISSERTATION To be presented, with the permission of the Faculty of Medicine of the University of Tampere, for public discussion in the auditorium of the School of Public Health, Medisiinarinkatu 3, Tampere, on November 26th, 1999 at 12 o’clock. University of Tampere Tampere 1999 LEENA EKLUND From Citizen Participation Towards Community Empowerment University of Tampere Tampere 1999 From Citizen Participation Towards Community Empowerment Acta Electronica Universitatis Tamperensis 4 ACADEMIC DISSERTATION University of Tampere, School of Public Health, Finland The Nordic School of Public Health, Göteborg, Sweden ISBN 951-44-4701-8 ISSN 1456-954X Contents ACKNOWLEDGEMENTS SUMMARY I INTRODUCTION ........................................................... 1 1 Background ...................................................................... 2 2 Aims and purpose of the study ................................................. 3 3 Health for all 2000 in Finland – from policy to action in health promotion ................................................................. 6 3.1 The development of health legislation behind primary health care and health promotion ....................................... 6 3.2 The main strategies in the Finnish health policy ...................... 8 3.3 The roles of state, professionals, NGOs, and citizens in health promotion ............................................. 12 3.4 Earlier community programmes ........................................ 14 II THEORETICAL PART – Elaboration of the empowerment approach ......................... 31 4 Introduction ..................................................................... 32 4.1 Participation .............................................................. 32 4.1.1 Defining participation ......................................... 32 4.1.2 Measuring participation in earlier studies ................... 37 4.2 Empowerment ............................................................ 39 4.2.1 Early practices of empowerment development ............. 40 4.2.2 Defining the concept of empowerment ...................... 41 4.2.3 Theories of empowerment as a process ..................... 45 4.3 Community organizing and community development ............... 48 4.4 Power, powerlessness, and human liberation ........................ 55 4.5 Summary and concluding remarks ..................................... 57 III EMPIRICAL PART – The assessment of empowerment in local settings ............... 61 5 Theoretical and methodological framework of the Somero-Järvenpää programmes ............................................... 62 5.1 The paradigms behind the study ....................................... 62 5.2 Strategies of inquiry ..................................................... 68 5.2.1 Action research ................................................ 68 5.2.1.1 The Somero-Järvenpää Programme in action research framework ................................ 69 5.2.1.2 The intervention approach ......................... 72 5.2.2 Evaluation ...................................................... 75 5.2.3 Operationalization and indicators ............................ 76 5.3 Study design, data collection and analysis methods ................. 79 5.3.1 Study design ................................................... 79 5.3.2 Implementation and organization of the Programmes ..... 81 5.3.3 Materials ........................................................ 88 5.3.4 Analysis methods .............................................. 91 5.4 Summary of the theoretical and methodological approaches in the Somero-Järvenpää Programme ................................. 94 6 Results ........................................................................... 96 6.1 Participation .............................................................. 96 6.1.1 Participants and activists of the Programme ............... 96 6.1.2 Participation in training ....................................... 97 6.1.3 Use of time ..................................................... 99 6.1.4 The "core group" and the permanence of theme groups .. 99 6.1.5 Motivation ...................................................... 100 6.1.6 Perceptions of the meaning of "participation" .............. 103 6.1.7 Perceptions about the purpose of the Programme ......... 109 6.1.8 What the participants had learned ............................ 111 6.1.9 Perceptions about the tasks of different actors in the development process .......................................... 114 6.2 Empowerment ............................................................ 118 6.2.1 Psychological empowerment ................................. 118 6.2.2 Community empowerment ................................... 123 6.3 Perceptions about what is Health ...................................... 133 IV DISCUSSION AND CONCLUSIONS ................................ 135 7 Research strategy, validity and instrument elaboration ..................... 136 7.1 Research strategy ........................................................ 136 7.2 Validity and reliability ................................................... 138 7.3 Instrument elaboration ................................................... 142 7.4 ATLAS.ti as a tool in qualitative research ............................. 146 8 From citizen participation towards community empowerment ............. 148 9 The Model of Reasoned Empowerment Action .............................. 156 10 Ideas for future research and development ................................... 158 References ....................................................................... 160 Annex 1. The scale of the types and approaches of the community programmes ......................................... 173 Annex 2. Appendix tables ................................................... 174 Acknowledgements The intention of the Healthy Somero and Järvenpää Programme was to be a new type of community programme adopting its principles from the health promotion ideologywhere ordinary citizens would have a major role. I wish to express my sincere gratitude to the citizens of Somero and Järvenpää who participated the programme and interviews and through this enabled me to produce an academic dissertation. The intervention project was initiated and run by the Finnish Centre for Health Promotion where I worked as a Project Manager from 1991 to 1994. I owe my warmest thanks to the staff of the Centre and particularly to Matti Rajala, the Executive Director of those days, with whom we were surfing between the county councils and municipalities in order to find the communities willing to participate. The crystallization of the health promotion principles applied in the project were developed in brainstorming together with Professor Matti Rimpelä and Matti Rajala. The academic part of the present study was carried out at the Nordic School of Public Health, Göteborg, Sweden and at the Tampere School of Public Health, University of Tampere, Finland. I sincerely thank my supervisors Professor Arja Rimpelä from the Tampere School of Public Health and Professor Matti Rimpelä from STAKES, Helsinki for their scientific visions during the stages of work as well as their support. I was honoured to have a world famous expert in health promotion, Professor Maurice Mittelmark from the University of Bergen, Norway, as one of my official reviewers. I wish to express my warmest thanks for his constructive and careful review of my thesis. My second official reviewer was Professor Marja-Liisa Honkasalo from the University of Helsinki. I would like to thank her for her valuable comments and advice in the field of qualitative methodology that markedly improved the structure and quality of my work, as well as for her role in strengthening my “girl power”. The chairperson of the expert group “Health for All by the Year 2000” of the Finnish Centre for Health Promotion Per-Erik Isaksson supported me to proceed to an academic career for which I wish to thank him sincerely. The present Executive Director of the Finnish Centre for Health Promotion Harri Vertio gave me valuable support during the process. Ms. Ritva Koivunen and Leena Åhman transcribed the interviews. For all of them I would like to express my warmest gratitude. The Project Secretaries Tarja Bersgström, Terttu Aaltonen, and Pirkko Sassi I would like to thank warmly for nice team working and support. Special thanks to Pirjo Koskinen-Ollonqvist for those moments we were brainstorming and producing wild frame-works for my study. The former Dean of the Nordic School, Professor Lennart Köhler and the present Dean professor Gudjon Magnusson created supportive environments for my research at the Nordic School of Public Health, for which I would like to express them my warmest thanks. I wish to express my gratitude to my colleagues Margaretha Strandmark for her valuable advice on qualitative methods, John Øvretveit for the advice on the evaluation questions, Göran Löfroth on helping with the references and Bengt Lindström and Vinod Diwan for supporting and inspiring me during the process, as well as all the library and other colleagues and service personnel at the Nordic School of Public Health. This study had never come true without the support from NEDIS Research Group of the Tampere School of Public Health as well as its secretarial and data management support by Margareta Ekman, Ville Autio and Marita Hallila.