The effectiveness of community development in health is enhanced by partnerships between health and other sectors such as education, housing, arts or sport, or in programs such as community building and neighborhood renewal. Community development approaches to health promotion are generally poorly identified in planning and practice. Concepts such as empowerment, community engagement and participation are commonly referred to as either processes or out- comes, but often given token effort and paid only lip service. Community development is not a single track in health promotion programs. Health promotion practice entails the planning and implementation of interventions which may take many forms. Evidence about the effectiveness of health promotion demonstrates that one-off programs at a single level of intervention have little value, and that multi-level approaches delivered intensively over longer periods of time are much more likely to create sustainable change. The Framework for Health Promotion Action (Murphy, 2004) illustrates the different levels of health pro- motion interventions and shows where community/health development is situated in relation to other interventions.

Community participation, engagement, empowerment and action Consumer participation in health service development has been built into the planning of health services for at least 20 years, and there is a substantial body of literature about strategies which are designed to improve health services through consumer participation. There are many excellent resources such as kits, fact sheets and reviews to assist health services with community participation strategies and consultation processes. However, there are challenges in achieving effective consumer participation strategies. Token or symbolic community representation on advisory groups can allow health services to 'tick the box' those consumers have been consulted, based on the erroneous belief that one or two selected (rather than elected) people can genuinely represent the diversity and complexity of consumers in any community.

Further, organizations are not usually provided with adequate resources to undertake consultation with the communities they are supposed to represent. Genuine participation actually involves more than token consultation with one, or even a few, people from the community. Another criticism of consumer participation is that its strategies are much more likely to give voice to people who are already empowered by education and who are in relatively comfortable circumstances. There also appears to be very little evaluation available of consumer participation activities or strategies.

Health Promotion Strategies Related to "Income and Social Status"

Consumer engagement is a term that is somewhat more in its infancy (Bush, 2002) than consumer participation. Consumer engagement is emerging in relation to health promotion as a strategy to improve the use of, and access to, services. In this context, consumer engagement seeks to increase the uptake of health services by a more diverse range of consumers, particularly vulnerable population groups including those experiencing disadvantage and/or social exclusion.

The processes and philosophy of consumer engagement include the enhancement of services so that they are more likely to be used or taken up by those consumers. Through engagement with consumers and their subsequent participation, enhancement and quality improvement of services is more likely to occur. Thus community engagement is also about issues of reach as well as shared power and shared decision-making.

A theory of motivation that may be used to change behaviors towards health promotion actions related to "Income and Social status"

When members of a community are engaged with an issue of concern to them-that is, an issue that they have defined as being a determinant of their health-more effective engagement with the processes of community action are likely to result. For example, communities feeling threatened by plans to locate a facility that will have a negative impact on their locale (e.g. A toxic waste facility) often show remarkable capacities to organize and resource themselves in order to mount a campaign to oppose the planning scheme. They will often demonstrate a sophisticated understanding of the problem-for example that a toxic waste facility needs to be located away from sensitive environmental areas, from waterways and agricultural land because contamination will pose threats to the health of people or native habitat that may come into contact with toxic waste. Such communities become empowered by this theory of motivation.

Brief Overview of the Theory

A different example is when a health practitioner has developed a program that he/she then attempts to implement in a community setting. For example, a diabetes / healthy lifestyles education program that has been developed on the basis of staff, consumer and key service provider consultation will have limited appeal to marginalized groups.

Explain Your Rationale for Choosing This Theory

The program will have greater success in reaching people whose first language is English, who have access to transport, and who are...

The program is not likely to reach other cultural groups such as CALD populations or people living on low incomes, both of whom have a high incidence of diabetes mellitus (type 2 diabetes). In order to reach these groups, a community development approach needs to be taken to ensure the program is able to meet needs, is culturally relevant, and is specific to the population group of interest.'
Consultation with recognized community leaders and people they nominate is absolutely necessary, as is shared decision-making over the program outline and content. Developmental approaches and engagement are necessary to ensure outcomes such as a good attendance and high completion rate, which themselves constitute indicators that the program was relevant, appropriate and wanted. Diabetes management programs designed on the single intervention of health education are less likely to be effective than those that use multiple-level interventions. Thus, when community engagement is combined with health education and organizational change in health services to ensure they are culturally sensitive and appropriate, much greater success is achieved over time than with single-level, one-off programs. Further, participants are likely to feel more empowered to manage their illness.

An Example From the Literature That Demonstrates Successful Application of Health Promotion Strategies on Income and Social Status

Empowerment often arises in the language of community development and of health promotion. Yeo (1993) explains empowerment as an ethic that arises from the Ottawa Charter concept of 'enabling'. Therefore, if community development is a strategy to counter poverty and other determinants of health, then community development programs need to be concerned with social and economic regeneration and addressing social exclusion. Consumer engagement needs to be active in order to achieve the enabling that heightens critical consciousness about issues.

Empowerment should always result from engagement.

Your Suggestions / Recommendations for Health Promotion on Income and Social Status

Green and Kreuter (2005) make the point that programs not conceived and developed from the spirit and day-to-day workings of a community are, by definition, outside that community; typically in such cases, when the initial resources dry up or the intervention period comes to an end, the program is not only over, it is gone! In other words, a program that been generated from outside the community generates no sense of community ownership, and so has little or no chance of becoming a permanent part of the fabric of that community. To obtain lasting effects and to achieve positive shifts in a community's health, genuine community participation and commitment are essential. In summary, engagement and participation are strategies of community development in health that are about finding ways for citizens to respond to issues collectively. The goal of community developers is to enable people to identify their own problems and the determinants of those problems. Outcomes are more likely to be effective if they result in social change, including healthier policies, organizational change or legislative change-all of which are upstream actions that help to produce sustainable outcomes.