Community action success in public health: are we using a ruler to measure a sphere?

The Community Action and Public Health study explored how Ontario public health practitioners interpret and implement guidance in community action. In-depth interviews were conducted with 107 public health professionals and community members in 6 Ontario health units. This report briefly describes the study methods and presents results pertaining to the measurement of success based on interviews with 67 public health professionals. Data substantiate the view that evaluation methodologies employing quantitative measures of epidemiological outcomes inadequately capture "success" in community action, possibly attributable to an unproductive dichotomization of "process" and "outcome". Results suggest two kinds of "success": a) changes related to stated goals and targets; and b) more iterative and process-oriented changes, including necessary but often undocumented shifts in relationships, structures, social conditions and processes. In order to legitimize and validate results that might otherwise pass unrecognized, we suggest a methodology that records project "milestones" as successes in their own right.

Heterogeneity among smokers and non-smokers in attitudes and behaviour regarding smoking and smoking restrictions.

OBJECTIVE: To determine if smokers and non-smokers cluster into meaningful, discrete subgroups with distinguishable attitudes and behaviours regarding smoking and smoking restrictions. DESIGN: Qualitative research with 45 smokers guided development of questionnaire items applied in a population based telephone survey of 432 current smokers and 1332 non-smokers in Ontario, Canada. METHODS: Cluster analysis of questionnaire items used to categorise adult smokers and non-smokers; comparison of clusters on sociodemographic characteristics and composite knowledge and attitude scores. RESULTS: Smokers clustered in three groups. "Reluctant" smokers (16%) show more concern about other people discovering that they smoke, but parallel "easygoing" smokers (42%) in supporting restrictions on smoking and not smoking around others. "Adamant" smokers (42%) feel restrictions have gone too far, and are less likely to accommodate non-smokers. Significant gradients across categories in the expected direction were observed with respect to smoking status, stage of change, knowledge, and attitude scores, and predicted compliance with restrictions, validating the proposed typology. Non-smokers also clustered into three groups, of which the "adamant" non-smokers (45%) are the least favourably disposed to smoking. "Unempowered" non-smokers (34%) also oppose smoking, but tend not to act on it. "Laissez-faire" non-smokers (21%) are less opposed to smoking in both attitude and behaviour. A significant gradient across categories in the expected direction was observed with respect to composite scores regarding knowledge of the health effects of active and passive smoking and a composite score on support for restrictions on smoking in public places. CONCLUSION: Recognition and consideration of the types of smokers and non-smokers in the population and their distinguishing characteristics could inform the development of tobacco control policies and programmes and suggest strategies to assist implementation.

The 'considerate' smoker in public space: the micro-politics and political economy of 'doing the right thing'.

This paper examines the discourse of 'interactions' as applied to the interpersonal management of smoking in public places (and to accounts thereof). Empirical data from a qualitative study of smokers and non-smokers in metropolitan Toronto, Ontario (Canada) are used to illustrate how smokers and non-smokers define and claim to operationalize 'consideration' in their daily lives. Drawing on the work of Foucault, Rose, Castel, and Bourdieu, the paper explores the possible significance of 'consideration' as a discourse of risk management masked as 'common sense', as a marker of social competence. In particular, parallels with emergent forms of governmentality embedded in community participation and individual self-monitoring and self-restraint are noted. Further, the social control implications of 'consideration' as moral discourse are examined with respect to Bourdieu's analysis of class struggles for (social) distinction. In this light, it is suggested that legitimate health concerns raised by tobacco control advocates cannot be divorced from other implicit social agendas which also fuel the drive for the 'purification of public space'.

Interactions between smokers and non-smokers in public places: a qualitative study.

Few studies have employed a qualitative approach to better understand how both smokers and non-smokers experience and make sense of no-smoking restrictions in their daily lives. We describe qualitative research involving an examination of self-reported interpersonal interactions between smokers and non-smokers in public places regarding exposure to environmental tobacco smoke (ETS). Five focus group discussions and twenty individual in-depth interviews were conducted with smokers and non-smokers in the Metropolitan Toronto region as a complement to a quantitative survey of the adult population of Ontario. Strategies used by non-smokers in responding to ETS exposures included verbal confrontations, non-verbal cues, use of a third party, and moving away. The perceived consequences of such actions, as described by both smokers and non-smokers, are discussed, together with implications for tobacco control policy and practice.

Learning to 'walk our talk': the implications of sociological theory for research methodologies in health promotion.

In recent formulations of the concept of health promotion, such as Achieving Health for All and the Ottawa Charter, emphasis is clearly placed on comprehensivity and the integration of individual and social determinants of health, broadly defined. This paper is premised on the observation that despite evidence of a paradigm shift in the way we talk about health promotion at a conceptual level, we have yet to properly articulate a 'new' research methodology to accompany the 'new' health promotion. The paper has three main sections. First, some of the limitations and contradictions that separate the rhetoric of health promotion from its current operationalization in research practice are discussed. In asserting the inherent links between theory, methodology and method, the need for a new research paradigm is demonstrated. In the second section, seven key issues derived from the literature on sociological theory are identified and discussed in terms of their implications for choosing a new research methodology for health promotion. In the third section it is suggested that using these issue areas as a 'decision map' leads to the selection of a preferred strategy which brings together both interpretive and critical perspectives to bear on our understanding of social reality as it affects health. Elements of both of these approaches and the nature of their potential complimentarity are considered. Throughout these deliberations the reader is encouraged to consider the potentially conservative or activist orientations that alternate methodologies imply, and to critically evaluate how these mesh with the emerging rhetoric of fostering empowerment that is the cornerstone of the 'new' health promotion.

Reported versus recorded health service utilization in Grenada, West Indies.

Calls for household surveys to provide information on service utilization in less developed countries raise questions regarding the accuracy and reliability of reporting. This paper compares reported to recorded health service utilization for diarrhoea and any other morbidity over a 2-week and 3-month period for information obtained from a household survey in Grenada, West Indies. A sensitivity analysis is used to derive minimum and maximum estimates of the accuracy of reported utilization. Over-reporting utilization was found to be between 33 and 62% for diarrhoea and 49 and 81% for any other morbidity. Under-reporting of all utilization was estimated to be between 47 and 65%. These results cast doubt on the utility of household surveys as a reliable source of information regarding service utilization.

The ecology of health services utilization in Grenada, West Indies.

Few empirical investigations into the nature of health services utilization fully acknowledge that the home environment may act as a socio-geographic focus of both disease transmission and of learned health behavior. This paper examines the role of the home environment, as well as of personal characteristics and accessibility, in the utilization of health services in Grenada, West Indies. Bivariate and logit analyses of household survey data are employed to identify markers of high user individuals and households. Aspects of each domain of the home environment (physical and behavioral environment, demographics, and residential mobility) emerge as contributors to the utilization phenomenon in the study communities. Both etiological and socio-economic linkages are postulated to underlie the observed relationships. The implications of this work for health planning in developing countries is discussed.