Narrowing the gap between academic professional wisdom and ...

Public Health (2002) 116, 151–159 ß R.I.P.H. 2002 www.nature.com/ph

Narrowing the gap between academic professional wisdom and community lay knowledge: perceptions from partnerships W El Ansari1*, CJ Phillips2 and AB Zwi3 1

Public and Community Health Department, School of Health Care, Oxford Brookes University, Oxford, UK; 2Centre for Health Economics and Policy Studies, School of Health Science, University of Wales, Swansea, UK; and 3Health Policy Unit, London School of Hygiene and Tropical Medicine, London, UK

Community involvement in health through community partnerships (CPs) has been widely advocated. Putting CPs into practice is complex and represents a challenge for all the stakeholders involved in the change process. Employing data from five CPs aiming to bring together communities, academics and health service providers in South Africa, this paper aims to examine and compare the views of the health care professionals with those of the community members with respect to each other’s skills and abilities. Five domains of expertise in partnership working are examined: educational competencies; partnership fostering skills; community involvement expertise; change agents proficiencies; and strategic and management capacities. The findings suggest that the community recognizes the expertise and abilities brought by the professional staff to the CPs. Community members have a positive view of the capabilities of the professionals, in particular their abilities as resource persons in the areas of budget management, policy formulation and the introduction and management of change. The professionals, on the other hand, are cautious regarding the level of skill and capability in communities. The limited appreciation of community skills by the professionals covered all the five domains of expertise examined. The findings suggest that if joint working is to survive, the professionals will need to increase their valuation of the indigenous proficiencies inherent in their community partners. We conclude that programme models need to consciously incorporate in their design and implementation, capacity building, skills transfer and empowerment strategies. Public Health (2002) 116, 151–159. doi:10.1038=sj.ph.1900839 Keywords: partnerships; community involvement; citizen participation; lay perspectives; joint working; evaluation

Introduction The prevention of ill health, and the maintenance and promotion of good health, cannot be realised through the services delivered by the health sector alone. Even within the health sector, collaboration between a variety of health practitioners, including nurses, nurse practitioners, physician assistants, dentists, managers, and others1 may not be sufficient. An essential component is the participatory approach which recognises the recipient and user of services, rather than the provider, as the central figure in the process. Consequently, multisectoral approaches to health recognize the key importance and the role of the user in planning and evaluating health care. As health care professionals focus on involving communities and individuals, they need to adapt approaches that emphasize the role of *Correspondence: W El Ansari, Public and Community Health Department, School of Health Care, Oxford Brookes University, Heritage Gate, Sandringham House, Sandy Lane West, Oxford OX4 6LB, UK. E-mail: [email protected] Accepted 20 February 2002

negotiation, compromise, advocacy and teaching.2 These considerations formed the underpinnings of the project discussed here. A partnership is a group of organisations and individuals who share some interests and are working toward one or more common goals while maintaining their own agendas.3 The Community Partnership (CP) approach has the potential for a synergistic maximisation of impact, and a means to increase citizen participation and community ownership.4 – 7 Despite the popular appeal and theoretical promise of this approach, the skills required by communities to implement complex partnership models remain unclear.8,9 The effective implementation and maintenance of a coalition not only requires motivated and involved members, but also the skills or ‘capacity to participate’ in order to operate an effective partnership.10,11 Demonstration projects initially rely heavily on the external skills of university personnel in collaboration with community assets.12 As these skills diffuse through the community, a better balance of external versus internal resources is achieved. Hence, the building of community capacity through participation is a central concern of many implementing and development agencies.13 – 15

Academic professional wisdom and community lay knowledge W El Ansari et al

152

However, the participatory approaches in health arenas recognise the impediments of entrenched medical dominance and inhibitory professional paradigms.16 The professionals’ role needs to shift from prime planners to resource persons.17 If community health promotion projects are to be successfully planned and implemented, a transfer of professional expertise to community members may be necessary through mentoring and other training approaches.18 This is because people and power are at the heart of CPs. When one party has unchallenged power and influence, collaboration does not make sense.19 Policy analysts20 and political scientists have viewed decision making as determined by how power is structured.21,22 Power, of course, can take many forms: accessing and utilising data and information (information power), resources and funds (economic power) as well as the competencies, capacities and proficiencies of the stakeholders (technical power). Discrepancies in this latter technical power is the focus of this paper. Conceptual framework Collaboration is a multi-faceted endeavour where a partnership’s membership is its primary asset.23,24 Personnel factors that are important to success include expertise and skills in partnership work, where members of the collective action contribute different sets of resources and skills for the task of partnership advancement.25,26 Operations need to be developed among community agencies, and programme strategies must be co-ordinated and implemented.27 A citizenry in possession of sufficient knowledge and skills in social organisation and related issues is thus imperative.28,29 Multi-dimensional team building, planning and scenario-mapping skills, involvement competencies and technology skills are similarly important, while introducing and managing change is another valued competency. This study focuses on five domains of stakeholder expertise that are critical to the effectiveness of collaborative projects. The aim of the study was to quantitatively compare how professional staff and community members working together in a collaborative ‘empowering’ mode appreciated each other’s: (1) educational competencies; (2) partnership fostering expertise; (3) community involvement skills; (4) change agents proficiencies; and (5) strategic and management capacities. Collectively, 11 variables mobilised these five domains of expertise. The South African CPs Since 1992 seven South African CPs were initiated as joint ventures between the local and regional health service providers and the academic training institutions on the one hand, and the beneficiary communities on the other. The vision was to train health professionals in a more community-oriented and community-based fashion. The Public Health

same donor funded the seven partnerships that operated with similar mandates and missions, and employed multipronged approaches of interdisciplinary community-based education for the health and allied health professions, along with a host of community development programmes that address the wider determinants of health. The study was undertaken directly after the first democratic elections in South Africa in 1994, and between 1995 and September 1996, five of the seven CPs were examined. Each had been running for 3 – 4 y, and all the CPs were established in previously underserved localities, dispersed across rough and rugged terrain, mostly lacking running water and electricity and away from the tarred roads. Within the localities, a health centre/post was sometimes available, while in others it was more than an hour’s drive to the nearest hospital. In all cases, it was envisaged that these partnerships would promote improved health care and health status of disadvantaged communities through developing a model of community-based health care.

Study design, subjects and methods The study is a cross-sectional multi-site survey. The questionnaire30 was adapted from published surveys that were developed, validated and employed in examining coalitions in the USA.31 – 34 At each of the five CPs participating in the study, the professional staff and community members were asked to rate themselves in relation to their own abilities and then to similarly rate their partners in terms of the same set of skills and abilities. ‘Professionals’ were defined as those trained in the health and allied health professions, while ‘Community’ members were defined as lay people who contributed to the variety of programmes and activities that the CPs were implementing. The data collection instrument employed in this study has been detailed elsewhere.30,35 Eleven variables examined the five domains of partnership expertise under investigation. Two questions inquired about the general expertise of implementing educational activities and maintaining the partnership; three variables covered proficiencies in working with and organising community groups and target populations; a further three queried the participant’s abilities as change agents; and, the final three questions elicited information on strategic and management capacities, eg policy formulation, planning and budget management. All the questions were scored on a 7-point Likert scale (1 ¼ ‘Low Ability’ and 7 ¼ ‘High Ability’) (copies of the questionnaire can be obtained from the first author). For respondents to be included in the survey they had to have attended at least one partnership-related meeting. This liberal criterion opened a wide window of eligibility, and after verbal consent, informants were included in the survey if they wished and carefully followed up. Data from the five CPs was pooled together, and the whole sample (n ¼ 668) was categorised into two groups


153

according to whether participants represented the professional side of the partnership (health services and academic training institutions, n ¼ 301), or alternatively, the community side (n ¼ 367). The statistical analysis was undertaken using the statistical package SPSS for Windows.36 For all the questions, the mean scores of the professionals and the community members were compared using independent t-tests for equality of means. To assess the stability of the scales,37 – 40 internal reliability alpha coefficient41 was reported for each of the comparison groups to indicate the degree of internal consistency within the multi-item measures, where values > 0.7 were taken as reliable.42 Significant differences in the groups’ views were indicated, and the corresponding P values were displayed (Figures 1 and 2).

Results In relation to the response rate, one assumption was that within any academic or health department participating in the CPs, not all the people in that department would be actively involved. In most instances of collective action, only a fraction of people or organisations with shared interests became involved in the effort,25,43 many at a relatively minor level, such as simply belonging to an

Figure 1

organisation.44 Usually one or two representatives of a department were actively participating in the CPs’ meetings/activities. Given the voluntary nature of CPs, there was some uncertainty regarding the denominator of how many people were actually ‘involved’. Eligible informants were carefully followed up and a ‘snowballing’ technique was employed. The response rate of potential participants who were approached to participate was around 90%. There was no apparent patterning or systematic difference between those who did or did not return the questionnaires based on the knowledge of age and background of nonreturnees. As regards reliability, the standardised alpha coefficient (Cronbach’s Alpha) for the multi-item measures indicated excellent reliability for the professionals’ ratings of their own expertise (n ¼ 260, a ¼ 0.92) and that of the community (n ¼ 237, a ¼ 0.91), and similarly for the community ratings of their own expertise (n ¼ 311, a ¼ 0.87) and that of professionals (n ¼ 303, a ¼ 0.91). Table 1 shows the respondents’ profiles. There were no age or past experience differences between the partner groups, neither were there differences in how the partners viewed the representativeness of their CPs. Similarly, there were no differences either in the percentages of those who reported to be moderately or very involved in their CPs, or in the number of times they served as the partnership’s spokespersons or representatives. However, the

Ratings of abilities of professional staff. Public Health


154

Figure 2 Ratings of abilities of community members.

professional partner comprised more females compared to the community group, reflecting the female nurses recruited in the health sector. The professionals had also participated in the CPs for slightly longer, probably reflecting their initial involvement in the early ‘negotiations’ or ‘preformation’ phase of the partnerships’ inception.45,46 Although the community members recruited more members to the partnerships it was the professionals who participated more in implementing partnership sponsored activities.

Skills, abilities and expertise The radar graphs (Figures 1 and 2) demonstrate the respondent groups’ views of each other’s abilities in relation to the five domains of partnership skills under study. While Figure 1 depicted the views of both professionals and community members as regards the skills of the professional staff, Figure 2 showed the same groups’ views in relation to the capacities of the community members. In both figures, the radii of the web represent the 11 skills described above, while the two webs represent the groups’ mean scores. The further out to the periphery the web is, ie the wider its radii are, the greater the perceived ability of that particular group. Public Health

Professional staff abilities For about half of the variables examined, both groups agreed in their ratings of the abilities of the professional staff, with the means of both groups ranging from 4.7 to 5.2 (on a 7point scale). However, educational policy, budget issues, and bringing about change in the health department were perceived by professionals to be significantly better among themselves (P ¼ 0.005; P < 0.05; P < 0.001, respectively). Conversely, when rating the professionals’ proficiencies in working with community groups and reaching target populations or designing educational activities, the community members significantly downrated the professionals’ expertise (P < 0.05; P < 0.05; P < 0.001, respectively). In Figure 1 the two webs are much closer to each other indicating that the two groups generally agreed as regards the perceived level of skills of the professionals. Nevertheless, significant differences were found in six ( 54%) areas of expertise. These were related to designing educational activities/policy abilities as well as change agents skills, effectively reaching target populations and working with community groups, and finally budget management. This empirical finding suggested that in general, the community members valued the abilities of the professionals and particularly their expertise as resource persons in the areas of budget management, policy formulation and introducing and managing change. On the other hand,


155

Table 1 Stakeholder profile comparisons Professionals (n ¼ 301)

Stakeholder composition

Service providers

Academic institutions

Community (n ¼ 367)

Mainly nurses of all categories and administrative strata (about 80%). The rest were hospital administrators, physicians, dentists, Department of Health representatives, environmental officers and co-ordinators

University/College faculty of various teaching/ administrative levels, many with nursing/ medical background. This group represented many academic departments: physiotherapy, nursing, medicine, primary health care, pediatrics, occupational therapy and public health

Community members comprised a myriad of participants: civic organisations, church and youth groups, teacher’s associations, community leaders, businessmen, a priest, cre`che and playgroup leaders, school teachers, tribal representatives, individuals from the lay community in general 40 NS 57.9*** 11.8 NS 21*

Age in years (M) % Females % With past partnership experience Duration in this partnership (Months) % Moderately/very involved in partnership Times recruited new members (M) Times served as partnership spokesperson (M) Times implemented partnership activities (M) Times served as partnership representative (M) How representative is the partnership (M)

41 71.5 9.1 24 75

67.5 NS

6.7 11.4

12** 9.5 NS

16.1

6.9***

9.2

6.7 NS

4.6

4.8 NS

*P < 0.05; **P < 0.005; ***P 0.001; NS, non-significant.

community members perceived that the professionals could benefit from more expertise in both the design of relevant educational activities as well as working with community groups and underserved populations.

0.08 and 0.06, respectively), the professionals nevertheless still rated the community lower than community members rated themselves. Taken together, these findings suggested that the professional staff were substantially more cautious than the community members when assessing the levels of expertise and abilities that are present in the community.

Community member’s abilities When both groups reported their perceptions of the abilities and skills that were available in the community, Figure 2 suggested a different picture. For all except two ( 80%) areas of enquiry, the professionals significantly (P < 0.001 for more than 50% of the questions) and considerably (mean difference in groups’ scores when rating community capacities ¼ 0.56 as opposed to a mean difference of 0.02 when rating the professionals’ skills) downrated the community abilities. This was indicated by the much narrower diameter (and smaller perimeter) of the professionals’ web as compared to that of the community members. With respect to the two questions (working with community groups and community organising) where the groups’ differences were close to statistical significance (P ¼

Discussion Many current health promotion initiatives require CPs in order to build effective community-based efforts that bring together all capacities and skills to bear upon health problems. However, the philosophy of community involvement and ownership, a major plank in the CP approach, demands the stakeholders’ appreciation of each other’s assets and skills. Without this mutual recognition of capacities and worth, frustration about unfulfilled expectations may impede commitment and stall the progress of collaborative efforts. Thus, the initial bursts of enthusiasm to Public Health


156

implement programmes may wither and be replaced by a perception that the CP is another professionally engineered ‘top-down’ institutional approach. This study provided several key insights about the views of diverse partner groups who traditionally did not communicate with each other. The community recognised and valued the expertise that the professionals brought to the CPs. Community members had a generally positive view of the professionals’ skills with the exception of their capabilities of working with, organising and reaching community groups and target beneficiaries. The professionals, however, were less generous in their assessment of the skills and capacities of the communities. The more modest rating of community members’ skills by the professionals stretched across all the five spheres of expertise: educational and partnership fostering skills; community involvement capacities; change agents proficiencies; and, strategic and management abilities. Similar findings have been reported in a survey of tobacco control coalitions in the USA,31 where, as in this study, community members and professional staff rated equally the staff expertise, but the professionals significantly underrated the community expertise. Participation is about moving away from a ‘them and us’ mentality towards a partnership of mutual benefits.47 To achieve a sense of ‘we’,48 collective ownership that dispels the marginalisation of peoples’ knowledge and narrows the distance between the university and the community is required.7,49,50 The significance of lay knowledge has often been established, but may often be accorded inferior status.51 However, the division between people and professional is not a rigid one, as while each health worker may be an expert in their own area, they are just one of the people when faced with challenges outside their expertise.52 Consequently, there is need to embrace lay knowledge and indigenous theory,7 but to take secular knowledge seriously implies a shift of the ownership and control away from the professional experts. Joint working has to build nurturing relationships, where the professional knowledge is fused with community wisdom and experience.53 Professionals and frontline lay people working ‘on the ground’ need to connect science with service, share skills and information in an empowering fashion,54 while dispelling any disconnections that might represent missed opportunities and compromise the effectiveness of both groups. Valuing each other’s contributions is at the core of collaborative efforts, and for successful community involvement, CPs need to build on identified strengths and assets.55,56 Communities should not be viewed as a set of needs and deficiencies while overlooking their gifts and capacities,57,58 as each partner brings strengths and assets to the initiative.59 The failure of many community development programmes can be traced to neglecting to use local skills, experience and expertise of local communities.60 Often overlooked are the finer underpinnings linking together a community — the gifts and capacities of individuals, citizen associations, and local institutions.59,61,62 By ignoring Public Health

the understanding that frontline workers bring to partnerships serving high-risk populations, useful information necessary to improve programmes may be lost.53 Hence Minkler63 has advised an empowering approach: ‘walk with the community in its journey’ rather than ‘making the path or leading the group.’ Empowering organisations can foster participation,64 and empowerment strategies increase people’s participation in health activities.65 Empowerment is not a zero-sum game,66 and by working together, the power of both groups can be enhanced. Power disparities pose real obstacles to collaboration. Pre-existing historical and ideological tensions19 may be exacerbated by an emphasis on community participation.28 Given the adversarial interactions of the apartheid history of South Africa, for this cluster of CPs, the ambitious task of community organisation and building community’s capacity will involve meeting the interrelated challenges of the past.67,68 There is need for change in the culture and attitudes of professional staff and their managers to enable them to work with as well as for the people.69 The main distinction between professional knowledge and popular knowledge is that the latter is more experiential, and includes judgement and common sense which has been acquired with experience.52 A synthesis of the partner’s understandings, values, knowledge is inescapable,70 where peoples’ power is assisted by professional authority to maximise the impact of collaborative undertakings. This necessitates a combination of constant contact and numerous discussions and training.71 It is essential that health care professionals invest in the success of the community by thoughtful technology transfer, and enhance community capacity to institutionalise interventions.72 As community empowerment and managing primary heath care effectively requires distinct sets of knowledge and skills,9 ‘midwifing’ rather than directing change, is one of the most effective roles that health care professionals can play in communities.1 In this study, the findings suggested that the professionals needed to place greater value on the skills of the community. In situations where the perceptions of community abilities are low, then additional investments to facilitate greater understanding, trust and respect between groups, or to ensure community skills development, is clearly necessary. In parallel, engagement with, and empowerment of, the community necessitates the removal of the barriers of occupational knowledge, non-appreciation and fear that come between professionals and the community.73

Conclusions ‘What lies behind us and What lies before us are Small Matters compared to What lies within us’ Emerson 1803 – 1882


157

The 1990s witnessed a marked shift in the commitment of professional organisations and funders to collaborative lay involvement in community-based approaches to health problems.7 Community organisations have the capacity to reach difficult-to-reach populations, but collaboration is more than a means for academics to get input, advice, and access to hard-to-reach citizenries. Conversely, academics have technical expertise, but these skills cannot be applied effectively in the community context without the input and support of community-based organisations.74 The aim of collaboration is shared goal setting, decision making, and the processing of information operationalised through ongoing exchanges among those involved.70 Bringing together communities and professionals is not an easy process. Health services interventions that ignore the capacity of local communities to solve problems consequently exacerbate the problem by focusing on providing services, rather than strengthening community capacity.75 In the South African context, the CPs were themselves experimental as there were no local models to draw upon.76,77 There are no blueprints for partnerships and there is no ‘right way’ to work together.78 One critical guideline is that health administrators and practitioners need to acknowledge the indigenous capacities of the communities and to aid in their empowerment process. From the community’s side, capacity building and the transfer of much needed skills, building on their indigenous expertise, may assist in analysing and addressing the root causes of their situation. The aim is the development of ‘community scholars’ who have the skills to assess their own interests and priorities, and are aware of sources of information they can use to advocate for improvements.7,79 On the other hand, from the professionals side, educating the professional groups on dialogue, building trust and rapport, empowering strategies and mechanisms for capitalising on and furthering community strengths could prove useful. The professionals are required to focus on the riches, strengths and capacities of the communities. Thus, promoting linkages between the partners, and facilitating mutual respect between the two groups are prerequisites. Programmes need to incorporate in their design and delivery flexible negotiation techniques, mutual recognition, and asset-building strategies that aim to decrease the power inequalities for the disfranchised populations. Empowerment is transformative, is labour intensive and has no ‘short course’.80 Supportive reciprocal relationships of resource persons and structures within the community remains a challenge for this cluster of CPs. Bridging the cultures of the professionals and the cultures of communities to blend professional expertise with community experience and advocacy, is difficult but worth seeking to achieve.81 Empowerment of the communities is a learning process, development is a lengthy cause and the inclusion of the relevant parties is usually built on incrementalism and gradualism. If a better balance of external versus internal resources is to be

realised,12 then the mutual recognition of skills is a prerequisite. Groups that are working together need to communicate to identify mutual abilities and capacities that can address the existing shortfalls. When there are perceived to be big differences in how the groups see the way forward, then the success of such collaborative endeavours may rely heavily on the professionals’ abilities to interface effectively with the community, its capacities and its health.

Acknowledgements This research would not have been possible without the active involvement of the five South African Community Partnerships. We extend our appreciation and thanks to all those who contributed: directors, chairpersons and project management staff; health service personnel; academics from a range of disciplines; and, community leaders, workers and members who participated in this study.

References 1 Eng E, Salmon ME, Mullan F. Community empowerment: the critical base for primary health care. Fam Community Health 1992; 15: 1 – 2. 2 Hildebrandt E. A model for community involvement in health (CIH) program. Soc Sci Med 1994; 39: 247 – 254. 3 Staggenborg S. Coalition work in the pro-choice movement: organisational and environmental opportunities and obstacles. Soc Probl 1986; 33: 374 – 390. 4 Chavis D, Florin P. Community Development, Participation and Substance Abuse Prevention. Department of Health, County of Santa Clara: San Jose, CA, 1990. 5 Fawcett SB, Paine AL, Francisco VT, Vliet M. Promoting health through community development. In: Glenwick D, Jason LA (eds). Promoting Health and Mental Health Behavioural Approaches to Prevention. Haworth Press: Binghamton, NY, 1993, pp 233 – 255. 6 Fawcett SB, Paine-Andrews A, Francisco VT, Schutlz JA, Richter KP, Lewis RK, Harris KJ, Williams EL, Berkley JY, Lopez CM, Fisher JL. Empowering community health initiatives through evaluation. In: Fetterman DM, Kaftarian SJ, Wandersman A (eds). Empowerment Evaluation: Knowledge and Tools for Self-Assessment and Accountability. Sage: Thousand Oaks, CA, 1996, pp 161 – 187. 7 Schensul JJ. Organizing community research partnerships in the struggle against AIDS. Health Educ and Behav 1999; 26: 266 – 283. 8 Steward K, Klitzner M. Alcohol and other Drug Problem Prevention from a Public Health Perspective. Pacific Institute for Research and Evaluation: Bethesda, MD, 1992. 9 Carlson CL, El Ansari W. Squaring the circle: developing public health competencies in primary care. Nurs Times Res 2000; 5: 2 – 14. 10 Gray B. Conditions facilitating interorganisational collaboration. Hum Relat 1985; 38: 911 – 936. Public Health


158

11 Balcazar FE, Seekins T, Fawcett SB, Hopkins BL. Empowering people with physical disabilities through advocacy skills training. Am J Community Psychol 1990; 18: 281 – 296. 12 Bracht N, Finnegan JR Jr, Rissel C, Weisbrod R, Gleason J, Corbett J, Veblen-Morteson S. Community ownership and program continuation following a health demonstration project. Health Educ Res 1994; 9: 243 – 255. 13 Sashkin M, Burke WW. Organisation development in the 1980’s. J Mngt 1987; 13: 393 – 417. 14 Kaluzny AD. Managing a Health Care Alliance: Improving Community Cancer Care. Jossey-Bass: San Francisco, CA, 1996. 15 Clark NM, McLeroy KR. Creating capacity: establishing a health education research agenda. Health Educ Q 1995; 22: 270 – 272. 16 Brownlea A. Participation: myths, realities and prognosis. Soc Sci Med 1987; 25: 605 – 614. 17 Freyens P, Mbakuliyemo N, Martin M. How do health workers see community participation? World Health Forum 1993; 14: 253 – 257. 18 Goodman RM, Steckler A, Hoover S, Schwartz R. A Critique of contemporary community health promotion approaches: based on a qualitative review of six programs in Maine. Am J Health Promot 1993; 7: 208 – 220. 19 Gray B. Collaborating. Finding Common Ground for Multiparty Problems. Jossey-Bass: San Francisco, CA, 1989. 20 Brugha R, Varvasovszky Z. Stakeholder analysis: a review. Health Policy Plann 2000; 15: 239 – 246. 21 Lindblom CE. The science of muddling through. Public Admin Rev 1959; 19: 78 – 88. 22 Dahl R, Lindblom CE. Politics, Economics and Welfare, 2nd edn. Harpers: New York, NY, 1976. 23 Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for prevention and health promotion. Health Educ Res: Theory Pract 1993; 8: 315 – 330. 24 El Ansari W. Partnerships in health: the pressing challenges. Public Health Forum 1998; 2: 5. 25 McCarthy JD, Zald MN. Resource mobilization and social movements: a partial theory. Am J Sociol 1977; 82: 601 – 610. 26 Jenkins CJ. Resource mobilization theory and the study social movements. Ann Rev Sociol 1983; 9: 527 – 553. 27 Florin PR, Mitchell R, Stevenson J. Identifying training and technical assistance needs in community coalitions: a developmental approach. Health Educ Res: Theory Pract 1993; 8: 417 – 432. 28 Zakus JD, Lysack CL. Revisiting community participation. Health Policy Plann 1998; 13: 1 – 12. 29 El Ansari W. Partnerships and new ways of learning: a second opinion. Nat Health Serv Mag 1998; 15: 21. 30 El Ansari W. A study of the characteristics, participant perceptions and predictors of effectiveness in community partnerships in health personnel education: the case of South Africa. Unpublished Doctoral thesis. University of Wales College Newport, UK, 1999. 31 Rogers T, Howard-Pitney B, Fieghery EC, Altman DG, Endres JM, Roeseler AG Characteristics and participation perceptions of tobacco control coalitions in California. Health Educ Res: Theory Pract 1993; 8: 345 – 357. 32 Gottlieb NH, Brink SG, Gingiss PL. Correlates of coalition effectiveness the Smoke Free Class of 2000 Program. Health Educ Res: Theory Pract 1993; 8: 375 – 384.

Public Health

33 Minnesota Department of Health. A Self-assessment form for use by a community health committee. Community Health Services Administration Group Draft Interim Report. Minnesota Department of Health: Minneapolis, MN, 1990. 34 Prestby JE, Wandersman A, Florin P, Rich R, Chavis, D. Benefits, costs, incentive management and participation in voluntary organisations: a means to understanding and promoting empowerment. Am J Community Psychol 1990; 18: 117 – 149. 35 El Ansari W, Phillips CJ. Altogether better health personnel education? Findings from three community partnerships in health in South Africa. In: Conway J, Fisher R, SheridanBurns L, Ryan G (eds). Research and Development in Problem Based Learning. Integrity, Innovation, Integration, Volume 4. The Australian Problem Based Learning Network: NewCastle, Australia, 1997, pp 127 – 138. 36 Norusis MJ. SPSS for Windows Advanced Statistics Release 6.0. SPSS Inc.: Chicago, IL, 1990. 37 Politi PL, Piccinelli M, Wilkinson G. Reliability, validity and factor structure of the 12-item General Health Questionnaire among young males in Italy. Acta Psychiatr Scand 1994; 90: 432 – 437. 38 Eisen SV, Dill DL, Grob MC. Reliability and validity of a brief patient-report instrument for psychiatric outcome evaluation. Hosp Community Psychiatry 1994; 45: 242 – 247. 39 Pomerleau CS, Carton SM, Lutzke ML, Flessland KA, Pomerleau OF. Reliability of the Fagerstrom Tolerance Questionnaire and the Fagerstrom Test for nicotine dependence. Addicit Behav 1994; 19: 33 – 39. 40 Pomerleau CS, Pomerleau OF, Majchrzak MJ, Kloska DD, Malakuti R. Relationship between Nicotine Tolerance Questionnaire scores and plasma cotinine. Addicit Behav 1990; 15: 73 – 80. 41 Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrica 1951; 16: 297 – 334. 42 Nunnally J. Psychometric Theory, 2nd edn. McGraw-Hill: New York, NY, 1978. 43 Olson M. The Logic of Collective Action: Public Goods and the Theory of Groups. University Press: Cambridge, MA, 1965. 44 Rothenberg LS. Linking Citizens to Government — Interest Group Politics at Common Cause. Cambridge University Press: New York, NY, 1992. 45 Kreuter MW, Lezin NA, Young LA. Evaluating communitybased collaborative mechanisms: implications for practitioners. Health Promot Pract 2000; 1: 49 – 63. 46 Lexau C, Kingsbury L, Lenz B, Nelson C, Voehl S. A community-wide approach for promoting farming health and safety. AAOHN J 1993; 41: 440 – 449. 47 Pietroni P, Chase HD. Partners or partisans? Patient participation at Marylebone health centre. Br J Gen Pract 1993; 43: 341 – 344. 48 Hord SM. A synthesis of research on organisational collaboration. Educ Leadership 1986; 43: 22 – 26. 49 El Ansari W. Health Improvement Programmes — The Future: Partnerships for Better Health. Report to The Scarman Trust. The Scarman Trust: Birmingham, 2000. 50 El Ansari W. Community partnerships in health; critical lessons learned from a case study of the Hillbrow Primary Health Care Project, Johannesburg, South Africa. Unpublished MSc Thesis. London School of Hygiene and Tropical Medicine, London, 1994.


159

51 Popay J, Williams G. Public health research and lay knowledge. Soc Sci Med 1996; 42: 759 – 768. 52 Stacey M. The power of lay knowledge. A personal view. In: Popay J, Williams G (eds). Researching the People’s Health. Routledge: London, 1994, pp 85 – 98. 53 Sanstad KH, Stall R, Goldstein E, Everett W, Brousseau R. Collaborative community research consortium: a model for HIV prevention. Health Educ Behav 1999; 26: 171 – 184. 54 Fawcett S, Paine-Andrews A, Francisco V et al. Using empowerment theory in collaborative partnerships for community health and development. Am J Community Psychol 1995; 23: 677 – 697. 55 Maurana CA, Beck B, Newton GL. How principles of partnership are applied to the development of a community – campus partnership. In: Connors K, Seifer SD (eds). Partnership Perspectives, Volume 1, Issue 1. Community – Campus Partnerships for Health: San Francisco, CA, 1998, pp 47 – 53. 56 El Ansari W, Phillips CJ. Partnerships, community participation and intersectoral collaboration in South Africa. J Interprofess Care 2001; 15: 119 – 132. 57 Seifer SD, Maurana CA. Health professions education, civic responsibility and the overall health of communities – campus partnerships. J Interprofess Care 1998; 12: 253 – 257. 58 El Ansari W. Narrowing the health gap? Partnerships: problems and possibilities. In: Turpin A, Battel-Kirk B (eds). Narrowing the Health Gap. Health Promotion Working for Social Inclusion. Society of Health Education & Health Promotion Specialists (SHEPS): Glasgow, UK, 2000, pp 47 – 51. 59 Connors K, Prelip M. Principle 3: the partnership builds upon identified strengths and assets, but also addresses areas that need improvement. In: Connors K, Seifer SD (eds). Partnership Perspectives, Volume I, Issue II. Community – Campus Partnerships for Health: San Francisco, CA, 2000, pp 27 – 32. 60 Phillimore P, Moffatt S. Discounted knowledge. Local experience, environmental pollution and health. In: Popay J, Williams G (eds). Researching the People’s Health. Routledge: London, 1994, pp 134 – 153. 61 El Ansari W. Critical components of successful partnerships across countries. Partnerships Child Welfare 1999; 6: 3, 10 – 11. 62 El Ansari W, Phillips CJ, Hammick M. Collaboration and partnerships: developing the evidence base. Health Soc Care Community 2001; 9: 215 – 227. 63 Minkler M. Community Organizing and Community Building for Health. Rutgers University Press: Piscataway, NJ, 1997. 64 Kumpfer KL, Turner C, Hopkins R, Librett, J. Leadership and team effectiveness in community coalitions for the prevention of alcohol and other drug abuse. Health Educ Res: Theory Pract 1993; 8: 359 – 374. 65 Pilusk M, Parks S, Kelly J, Turner E. The helping network approach: community promotion of mental health. J Primary Prev 1982; 3: 116 – 132. 66 Wallerstein N, Bernstein E. Introduction to community empowerment, participatory education, and health. Health Educ Q 1994; 21: 141 – 148.

67 MUCPP (Mangaung-University of the Orange Free State Community Partnership Project) Building our Nation Together. Report of the Mangaung-University of the Orange Free State Community Partnership Project: Bloemfontien, South Africa, undated, circa 1997. 68 El Ansari W, Phillips CJ. Community development for a changing world? Innovative joint working in health care — a South African partnership model. Int J Public Private Partnerships 2001; 3: P269 – 275. 69 Taylor P. Supporting community involvement: the organisational challenges. In: Burton P, Harrison L (eds). Identifying Local Health Needs. New Community Based Approaches. The Policy Press: Bristol, 1996, pp 15 – 19. 70 Klein D, Williams D, Witbrodt J. The collaboration process in HIV prevention and evaluation in an urban American Indian clinic for women. Health Educ Behav 1999; 26: 239 – 249. 71 Harper GW, Carver LJ. ‘Out-of-the-Mainstream’ youth as partners in collaborative research: exploring the benefits and challenges. Health Educ Behav 1999; 26: 250 – 265. 72 Stevenson H, White J. AIDS prevention struggles in ethnocultural neighborhoods: why research partnerships with community based organizations can’t wait. AIDS Educ Prev 1994; 6: 126 – 140. 73 El Ansari W, Phillips CJ. Empowering health care workers in Africa: partnerships in health — beyond the rhetoric towards a model. Crit Public Health 2001; 11: 231 – 252. 74 Grinstead OA, Zack B, Faigeles B. Collaborative research to prevent HIV among male prison inmates and their female partners. Health Educ Behav 1999; 26: 225 – 238. 75 McLeroy KR, Kegler M, Steckler A. Editorial. Health Educ Res 1993; 8: 1 – 11. 76 El Ansari W, Phillips CJ. Partnerships in health? A case study of an urban community partnership in South Africa. Proceedings of the Ninth International Congress on Women’s Health Issues, June 22, 1998. Faculty of Nursing, University of Alexandria: Egypt, 1998. 77 El Ansari W, Phillips CJ. Interprofessional collaboration: A stakeholder approach to evaluation of voluntary participation in community partnerships. J Interprofess Care 2001; 15: 351 – 368. 78 Gomez CA, Hernandez M, Faigeles B. Sex in the new world: an empowerment model for HIV prevention in Latina immigrant women. Health Educ Behav 1999; 26: 200 – 212. 79 Gomez CA, Goldstein E. The HIV prevention evaluation initiative. In: Fetterman DM, Kaftarian SJ, Wandersman A (eds). Empowerment Evaluation: Knowledge and Tools for Self-Assessment & Accountability. Sage: Thousand Oaks, CA, 1995, pp 100 – 122. 80 Kieffer CH. Citizen empowerment: a developmental perspective. Prev Hum Serv 1984; 3: 9 – 36. 81 El Ansari W. Community development and professional education in South Africa. In: Mitchell S (ed). Effective Educational Partnerships: Experts, Advocates, and Scouts. Praeger: Westport, CT, 2002, pp 217 – 236.

Public Health