2. Participation and democracy in health promotion 9 June 2007, Vancouver Goof Buijs, the Netherlands gbuijs@nigz.nl based on the work of Bjarne Bruun Jensen, Denmark bjbj@dou.dk

3. contents z2 paradigms?! z key concepts: participation and action z the IVAC approach conclusion and challenges

4. Different paradigms? PREVENTIONHEALTH PROMOTION TotalitarianDemocratic MoralizeParticipate Top-downBottom-up MonologueDialogue Individual Collective PrivationCommitment Driven by expertsDriven by participants Behaviour changeAction competence Health InformationHealth Pedagogy DiseaseQuality of life LifestyleLiving conditions Closed health concept Open health concept

5. Two different paradigms? Health promotion versus prevention and treatment? No- a false contrast Instead retrieves a dialogue-oriented versus a top down approach to: Health promotion,prevention and treatment

6. Meaning ….. ….. That even the surgeon has to be aware of supporting the patients own participation and actions

7. Two paradigms? l The work (with health promotion), is in short, based on visions and possibilities, driven by hope, dominated by a bottom up perspective…. l The work (with prevention), is in short, based on risk-thinking, driven by fear, dominated by experts and by a top down perspective (Jensen & Johnsen, 2000, s.7)

8. Two paradigms? l Health Promotion efforts are participatory, based on dialogue and can be targeted towards individuals as well as sections of populations (Danish National Board of Health 2005, p. 49). l In description of prevention nothing is mentioned about participation, dialogue, user-involvement ect.

9. Barriers for changing paradigms Basic training Professional terminology and language Historical background Afraid of loosing professionalism Expectations from target groups and collaborating partner Lack of time for dialogue with target groups Lack of tools for working in another paradigm Demand on documentation and evaluation

10. Therefore.. Health promotion/prevention have different goals, but are complementary – therefore they do not belong to different paradigms Starting point for sharing values is in the operationalisation of the key concepts (such as participation, action competence) in relation to the context/ setting

11. The concept of participation Participation – what is it about? Students need to be involved in decisions about content, process and outcome Participation – why is it important? ethical reasons learning efficiency creating ownership educating for democracy

12. Participation - in relation to what and how ?

13. Different forms of actions

14. Components of action competence Knowledge/Insight Commitment Visions Action experiences Critical thinking …

15. Four dimensions of knowledge

16. traditional knowledge landscape

17. Action-oriented knowledge landscape

18. experts versus target groups Top down approach – dominated by experts Bottom up approach – dominated by the target groups Dialogue approach – the content and the professional has an important role to play

19. Health concept: developments in health promoting schools From disease-oriented health concept healthy food = correct nutritional balance To wellbeing-dominated health concept e.g. healthy food = food which tastes good Or: health concept which includes quality of life, disease elements as well as its mutual links e.g. healthy food = nutritional, aesthetical, social and sustainable dimensions

20. The participation concept Criticism of top-down and bottom-up approach (top down, moralising, expert- dominated) Many projects had to begin with target- group dominated (professional was put on the sideline) Gradually self-determination became targetgroup-professional dialogue with professionalism back in the centre

21. Three principal lines 1. Towards a health concept that contains both disease and healthy life 2. Towards a participation concept, where the professional is placed centrally 3. Towards a setting perspective, where the framework and education are connected and related to education and health … competence development

22. Pupils Visions (1800, 13 y.o.) I have many ideas about how we can improve: - my daily life (a) - my school (b) the World (c) ANSWERS:abc Fully agree/Agree:49 4758 Does not agree or disagree:383932 Totally disagree/Disagree:121410

23. Pupils Commitment (1.800, 13 y.o) I would like to fight for improving: - my daily life (a) - my school (b) - the World (c) ANSWERS:abc Fully agree/Agree:73 6378 Does not agree or disagree:213019 Totally disagree/Disagree:673

24. Achieving influence is very easy (3.660, 13-15 y.o) The students were asked about four different settings Leisure activities36% Family44% School14% Society 6%

25. The IVAC approach Investigation why is it important to us do lifestyle and living conditions make an influence how was it in former times and how has it changed Visions what alternatives can we imagine? how are the conditions in other countries and cultures? what do we prefer and why? Actions & Change what changes will bring us closer to the visions? changes in our own life, in the class, in the society? what action possibilities exist in order to reach the changes? which actions will we carry out?

26. A case from Denmark - I Students actions: Applications sent to the local government's departments:18 Cleaning (gathering of litter from streets, beaches etc.):12 Articles in the local newspaper:10 Written petitions to private companies: 6 Embellishments (painting lamp-posts, stones etc.): 6 Written petitions to local village boards: 5 Establishment of compost containers: 5 Hanging up of posters regarding environmental issues: 5 Demonstration concerning traffic conditions (150 pupils): 1

27. A case from Denmark - II Changes due to students actions: City council set aside 130.000 for reorganising traffic in Lyngerup local area (roundabout etc.) Establishing Toronto-flash and zebra crossing near the school Reducing speed limit to 50 Km/h near the school Planting trees along cycle paths between two neighbourhoods Intensifying local media debate on traffic Extending playground and establishing basketball court Creating a meeting and activity place for adults and children Establishing children's village board as part of village board Establishing compost containers Painting lamp posts, putting up bird houses, planting shrubs and cleaning roadsides.

28. What helps to build ownership and action competence Genuine participation (but in a dialogue with a professional) Own actions (but as integrated elements) Barriers might help to increase motivation (but the role of the professional is crucial) All ages and all socio-economic groups benefit from an participatory and action-oriented approach

29. Challenges for Schools Actions often defined by external actors Economy used as external motivating factor Skills needed by teachers to integrate authentic actions and collaboration in education? How to prepare the community for acting pupils? Supporting structure needed?

30. Professional competence Clarification related to the health concept Action-oriented insight about health related conditions Feeling for - and insight in – dialogue with target group Insight in the targetgroups health understandings Insight in the active concept facets

31. Conclusions and future challenges Dialogue, instead of top-down bottom-up Towards genuine participation and action Focus on competence development Potential for schools needs more research and development (measure impact and effectiveness)