1. Bottom-up and top-down programming:
Towards a strategy of parallel tracking.
Glenn Laverack

2. Health Promotion
Health promotion is a set of principles centered on empowering people to take control of their lives and health.
Health promotion is a practice that encompasses a range of communication, capacity building and politically orientated approaches set within a programme context.

3. Empowerment
Individual
Organisational
Family
Community

4. Empowerment: The Means to Attaining Power
Community empowerment is (David Werner, 1988):
‘a process by which disadvantaged people work together to increase control over events that influence their lives’.
Social change exerts influence over the nature of social behaviour or relations within society (Values and behaviours).
Political change exerts influence over the actions of civic organizations and institutions in society (Policy and legislation).

5. Health Promotion in Germany
BZgA (Federal Center for Health Education) largely responsible at the national level.
Coordinating structure at the state and national levels for health promotion with socially disadvantaged groups.
Empowerment is included as part of the 12 Good Practice Criteria for health promotion in socially disadvantaged groups.
The challenge is how to operationalize empowerment within the context of an elaborated German social welfare structure.

6. Socially disadvantaged groups
Migrants (legal and illegal workers)
Turks / Muslim
Russian
East European
Romany
Others by disability, age, economic status etc.

7. Two Types of Programming
‘Top down’
Agency/professionally managed (pre-packaged).
Goals identified by agent. By far the most common form of programming.
Lifestyle and behavioural.
Short time-frame.
Targets change at the individual level.
‘Bottom up’
Goals chosen on basis of unmet community needs.
Longer time-frame.
Focus on capacity building, participation and empowerment.
Targets change at the collective and structural levels.
A review of papers.
Labonte, R. (1998) A Community Development Approach to Health Promotion: A Background Paper on Practice Tensions, Strategic Models and Accountability Requirements for Health Authority Work on the Broad Determinants of Health. Edinburgh. Health Education Board for Scotland.
Interviewed 1000 HPs.
Canadian Public Health Association (1996) "Action Statement for Health Promotion in Canada" available at
These 2 studies found that almost all HP goals were disease prevention and lifestyle and behavioural and fell into a top-down style of programming.

8. Top-down and bottom-up health agendas
Obesity (Exercise & Diet).
Cancers.
Violence & Injury
(Domestic violence/ abuse).
Dangerous Consumptions (Gambling, Alcohol, Drugs, smoking).
National Security.
(Wanless report, 2002)
‘Bottom up’
Community safety.
Anti-social behaviours.
Shabby environment.
Unemployment/low income.
(Liew, 2007).
Public transport.
Housing stds & Heating.
Social exclusion.
A review of papers.
Labonte, R. (1998) A Community Development Approach to Health Promotion: A Background Paper on Practice Tensions, Strategic Models and Accountability Requirements for Health Authority Work on the Broad Determinants of Health. Edinburgh. Health Education Board for Scotland.
Interviewed 1000 HPs.
Canadian Public Health Association (1996) "Action Statement for Health Promotion in Canada" available at
These 2 studies found that almost all HP goals were disease prevention and lifestyle and behavioural and fell into a top-down style of programming.

9. The Top-Down - Bottom-Up Tension
State Agenda
Civil Society Agenda

10. The Saskatoon ‘In Motion’ Programme
A 3-5 year plan to increase physical activity in urban and rural communities in Saskatchewan, Canada.
Used public awareness, education and motivational strategies targeting individuals for behaviour change.
Agency/professionally managed (pre-packaged) including goal identification and implementation.

11. The Saskatoon ‘In Motion’ Programme
In Saskatoon 57% people surveyed said that they had seen, heard or read about the ‘in motion’ programme.
18% surveyed said that the ‘in motion’ messages had led to them definitely thinking more about physical activity.
30% said they had become more active. However, overall 49% had no change in physical activity and 14% had become less active & 7% unsure (SRHA, 2005).
No influence on socially disadvantaged groups such as low socio-economic, adolescents, indigenous people and ethnic minorities.

12. 1. Parallel-Tracking
‘Bottom-up’ approaches can be deliberately accommodated within ‘top-down’ programmes.
The programme becomes the means to an end to increase capacity building.
Parallel-tracking is a planning tool.
Parallel-tracking is ready to be introduced into pilot programmes.
Why build community capacity?
Towards improving skills, knowledge and competencies for community action and further towards broader community empowerment.
Especially important around the determinants of health ie. Unemployment, stress, transport, food etc.

13. Parallel-Tracking Blurring the boundaries
Civil society
Agenda
Govt Agenda
1. Programme design phase: Identification of issues, appraisal and approval stage.
Chronic Disease Prevention track
(Top-down) Obesity (Exercise - Diet)
Bottom-up track: Engaging and enabling Muslim people to take control of their lives and health.
2. Programme Objectives.
Reduction in the levels of morbidity and mortality in the population.
2. Bottom-up Objectives.
Increased level of control over health and life decisions by Muslim people.
Blurring the boundaries
There are HP programmes that already combine both top-down and bottom-up elements in their design. For example, the ‘like minds, like mine’ national project to counter stigma and discrimination associated with mental illness in NZ. Uses a combination of top-down mass media and community education, building community leadership and participation, developing infrastructure and culturally specific approaches. 3 year project. (MoH, 2003)
But this is not an either or situation.
Top-down programming will continue to be the most dominant style of programming in HP. HPs need to think creatively about how they can accommodate build bottom-up approaches within top-down programming.
3. Strategic approach.
Approaches employing social marketing, health education and behavioural interventions.
3. Strategic approach.
Program addresses local Muslim issues and builds community capacity.
4. Management
Muslims involved in the delivery of specific aspects of the programme
4. Management.
Pre-packaged and controlled by an outside agent.
5. Evaluation
Epidemiological data to demonstrate objectives.
5. Evaluation
The programme uses participatory evaluation techniques. 13

14. Accommodating top down and bottom up programming
Engage with civil society to share priorities.
Create a common point of entry.
Have flexible funding criteria.
Use parallel-tracking.
Measure the process as well as outcomes.
Build on successful initiatives.
What works- Recent research in the UK:
Exceptional people (local leaders) with a shared commitment to public involvement were necessary to motivate others and develop partnerships.
Bridging state and civil society
2. Local people were drawn into the process and with increased confidence (and capacity) became powerful advocates for their community.
Creative methods are necessary to involve people and a proper balance between professional inputs and lay people is necessary.
Important because conflict is common often over lack of clarity of who has decision making influence (control). (see- Anderson, E. et al (2006).

15. Creating a point of entry
Mapping to identify concerns.
Prioritise to set a local profile.
Share priorities.
Build community capacity and empowerment.

16. Flexible Funding Thinking outside the ‘health box’.
Using a broader base for health criteria.
Using funding in creative ways to engage people and to build community capacity and empowerment.
Thinking of creative funding partnerships.
The Health Park concept (UK) is a joint venture of government, private and public interests. ‘Health Parks’ partnerships have an emphasis on public involvement in deprived areas (Anderson et al 2006).
Partnerships such as the national lottery (UK) can also be a means to promote flexible funding.
But does seed funding work?
Joan Wharf Higgins et al (2007) in BC, Canada looked at 12 regional seed funded (short-term grants up to $4500) projects for HP for sustainable chronic disease initiatives. Found those with most capacity had better chance of success especially if resources could be found for longer term as seed funding was too short a timeframe to allow organic growth of the organisation. 10 out of the 11 continued – yes it can work.

17. 2. Building community empowerment
Community participation.
Problem assessment capacities.
Local leadership.
Resource mobilisation.
Organisational structures.
Links to other organisations and people.
Ability to ‘ask why’ (critical consciousness).
Community control over programme management.
Equitable relationship with outside agents.
(Laverack, 2009, p. 67).

18. The Methodology Participatory- workshop approach-4 phases.
Preparation (the development of a working definition & pre-testing the domains).
Assessment of each domain.
Strategic planning for each domain.
The follow-up (re-assessment and comparison of progress).

19. The Matrix

20. The Descriptors for each Domain
Five Qualitative statements.
Least to most capacity building.
Separate sheet and not numbered.
Participants select/adapt one statement.

21. Ranking the Assessment
Selected statements ranked 1 to 5.
Numerical value placed into graph.
Graph provides visual representation.
Graph should be culturally applicable.

22. Visual Representation
Spider web configuration.
Comparison between domains.
Comparison overtime.
Comparison between communities.

24. 1st and 2nd measurements

25. Outcomes By-Law for land ownership for eco-tourism.
Policy on housing standards & design.
Community action on sustainable livelihoods.
Policy on greater participation of socially disadvantaged groups in setting health priorities.

26. Research and Development
PEOPLE
PRACTITIONERS
POLICY MAKERS
Effective approaches to engage with disadvantaged groups in society.
Professional competencies to facilitate the empowerment of people at all levels.
Piloting (at state level) to replicate successful empowerment approaches.
Evidence of the link between empowerment and health promotion outcomes.

27. grlavera@hotmail.com www.conrad-verlag.de