Promoting participation in health in the community using a health survey
Health promotion is an emerging discipline that seeks to enhance positive health and prevent ill health. This thesis is designed to inform practice in health promotion. It is based on an action research project that draws together interdisciplinary concepts of the measurement of health and community participation. In so doing it identifies the use of a survey, the Community Health Promotion Survey (CHPS). The thesis argues that when used creatively in this way a survey may simultaneously serve two purposes: first, measure health-related behaviour and, secondly, promote participation in health within a community. Thus, in this study, the survey process and its impact on the lay community were considered to be as important as the measurements of health-related behaviour obtained. Surveys to measure the health-related behaviour of whole populations have been well tested and standard methods were adopted. In this project two of the three local GP Practices gave permission for their FPC patients' lists to be used as a sampling frame which covered 75% of all Staveley's 13,420 adult patients. Lists were stratified by age and sex. A 20% systematic, random sample of 2,003 patients was drawn. The sample was shown to be representative by age and sex of the whole population. A postal survey of these patients, using two reminders, obtained a response of 59% after exclusions for non-delivery of 8%. Males and the elderly are under-represented in response. Teachers in all 3 local secondary schools agreed to administer the survey to their first and fourth year groups. Response from pupils attending school on the day on which the survey took place was 100%. Self-reported measurements of health-related behaviour were obtained, using reliable questions. For example, 23% of adult respondents were ex-smokers and 26% were daily cigarette smokers. 22% of respondents reported that they never drank alcohol and 18% of males had drunk more than 21 units of alcohol in the previous week. Analyses by chisquare and Mantel-Haenszel showed, generally, that the strongest influences on health-related behaviour were age and social class. For example, parental status was less strongly associated with levels of alcohol consumption than age. Re-administration of the adult survey to a matched sample identified changes in health-related behaviour, for example, there was a reduction in the frequency of egg consumption and younger people were more likely to have increased their frequency of drinking skimmed milk than older groups. The role of a survey in facilitating community participation is less well understood. Two crucial elements were therefore introduced and tested in the survey. These may be seen as early stages of community participation and contained key elements of "radical" survey methodology. First, the feasibility of surveying a range of non-representative "hard to reach" community groups was assessed. Of the 52 groups contacted 50 (96%) agreed to participate, with response being achieved from 47 (94%). Response rates from groups collectively was low (16%) but varied greatly between groups, reaching 86% in one instance. Groups producing the highest responses were social in nature, with a membership of 10 - 100. The study showed that many types of community groups will readily assist in the distribution and collection of questionnaires to group members. Secondly, extensive feedback from and about the survey to lay and professional individuals and groups was tested. Results showed that there was considerable lay interest in feedback. 62% of respondents selected, on average, three of the ten items offered. The summary of survey findings (38%) and healthy eating (36%) were of most interest, making up 40% of all feedback. Those often thought to be least interested in health, such as the unemployed, were just as likely to ask for information as others, although women requested 63% of all feedback. Information requested appeared to relate to the individual's circumstances with, for example, males in the "at risk" age group for heart disease asking for that leaflet. The impact of the CHPS on individual respondents and the lay community was measured. The study showed that awareness of the survey was raised amongst 40% of the community. Women (51%) were more likely to have heard about it than men (33%). The survey's ability to stimulate social networks was assessed. Friendships were shown to be the most important channels of information about the CHPS (37%). The family was of equal importance to posters (16%) in disseminating information about the survey. There was some evidence that, in a few groups, awareness of health issues had been raised and some activity had been generated. This appeared to be greater where contacts with a health promotion officer had been established. A surprising, and tentative, finding is that, in itself, the CHPS may have stimulated some change in a small number of individual respondents. Follow-through by professionals that builds on the surveying process and feedback may lead to more intensive levels of community participation. Practical opportunities for follow-through were identified, for example, systematic feedback about their own patients and school pupils to General Practitioners and teachers and feedback of a group's data to a participating community group. Response from health promotion professionals to follow-through opportunities were examined and found to be generally disappointing. The use of the method by policy makers, planners and practitioners was explored. Their dissemination of findings to other professionals and setting targets for changes in the population's health-related behaviour was similar to that observed elsewhere. However, practitioners' response to the implications of research for practice was negligible. It is recommended that health-related behaviour should continue to be seen as one limited but appropriate intermediate indicator for health promotion. The limitations of postal survey data need be recognised, for example, measurements often under-represent the health-related behaviour of some population groups, such as males and the elderly. Resulting bias in data are important considerations when using data in policy and planning, for example, setting targets for health promotion and monitoring population changes in health-related behaviour. Methods for increasing postal response from those known to be poorer responders are suggested, such as personalisation of postal contacts, telephone reminders and complementary data collection methods, including interviewing the elderly in their usual meeting places. It is recommended that, at a national level, reliable, standardised questions should be developed for use in postal surveys to facilitate comparison of data between populations. In terms of community participation in health it is proposed that, based on the CHPS experience, surveys in small areas to further examine their potential to promote participation in health should be carried out. Such studies should focus on examining ways in which surveys may activate social networks and innovative routes for feedback. Emphasis should be given to the use of data by practitioners and to identifying, carrying out and assessing the impact on the lay community of follow-through activities. It is recommended that training for health promotion staff in both research methods and community participation is required to underpin professional practice in community participation in health. The study demonstrated that a survey to measure health and, at the same time, promote participation in health was a feasible, coherent activity that was acceptable to the community. It may therefore be considered as one strategy by health promotion staff seeking economic and innovative methods for practice.