HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 1 © Oxford University Press 2004. All rights reserved doi: 10.

1093/heapro/dah107 Printed in Great

Issues of participation, ownership and empowerment in a

Britain​

community development programme: tackling smoking in a

low-income area in Scotland
DEBORAH RITCHIE​1​, ODETTE PARRY​2​, WENDY GNICH​2 ​and STEVE PLATT​2

Department of Sociology, Queen Margaret University College, Edinburgh, UK and 2​​ Research Unit in Health,
1​
​
Behaviour and Change, University of Edinburgh, UK
SUMMARY ​Founded on community development principles and
held by those implementing the intervention. The paper practice, the ‘Breathing Space’ initiative aimed to produce
examines the principles that underpin health promotion a significant shift in community norms towards non-
in the community setting, particularly the concepts of toleration and non-practice of smoking in a low-income
ownership, empowerment and participation, and their area in Edinburgh, Scotland. The effectiveness of
differential interpretation and employment by participants. Breathing Space was evaluated using a quasi-experimental
The data illustrate how these varied understandings had design, which incorporated a process evaluation in order
implications for the joint planning and implementation to provide a description of the development and imple-
of Breathing Space objectives. In addition, the different mentation of the intervention. Drawing on qualitative data
understandings raise questions about the appropriateness from the process evaluation, this paper explores the varied
and viability of utilizing community development approaches and sometimes competing understandings of the endeavour
in this context.
Key words​: community development; empowerment; process evaluation; smoking
INTRODUCTION
Current health promotion policy and practice places a high value on community development work (Robinson and
Elliott, 2000) because it aims to enable communities to identify problems, develop solutions and facilitate change
(Blackburn, 2000). The overt ideological agenda of community development is to remedy inequalities and to achieve
better and fairer distribution of resources for communities (Tones and Tilford, 2001). This is achieved ideally through
participatory processes and bottom-up planning (Bracht and Tsouros, 1990; Bernstein ​et al​., 1994; Israel ​et al​., 1994;
Labonte, 1994; Robertson and Minkler, 1994; Robinson and Elliott, 2000; Smith ​et al​., 2001).

51 Empowering
​ communities to have more say in the shaping of policies influencing health represents a break with
earlier traditions of public health associated with top-down social engineering (Beresford and Croft, 1993; Petersen and
Lupton, 1996). However, community develop- ment means different things to different people and, as we shall see, can
operate on different levels (Arnstein, 1971; Brager and Specht, 1973; Tones and Tilford, 2001). Community develop-
ment has, for example, been linked to community organization, community-based initiatives, com- munity
mobilization, community capacity build- ing and citizen participation. There is, however, a common understanding of
core principles, which inform community development work (Bracht and Tsouros, 1990; Robinson and Elliott, 2000;
52 ​D. Ritchie ​et al. has proven difficult (Zakus and Lysack, 1998). For example, when
formal health services adopt an empowerment framework, their formal
Smith ​et al​., 2001), two of which are participation and empowerment.
structures are not nec- essarily conducive to participation. (Rifkin,
These principles can and are, however, operationalized differentially in
1990; Labonte, 1998; Zakus and Lysack, 1998). Although it is
different types of community development work. The concept of
commonly agreed that appropriate leadership and effective
community participation has proved to be more complex than was
organizational structures are crucial to successful community
originally envisaged by the early World Health Organization (WHO)
participation (Laverack and Wallerstein, 2001), this requires a political
health promotion strategies (WHO, 1978; Rifkin, 1986; WHO, 1986;
climate that nurtures and facilitates the approach (Labonte, 1998; Zakus
Rifkin ​et al.​ , 1988; Rifkin, 1995; Labonte, 1998; Zakus and Lysack,
and Lysack, 1998).
1998; Laverack and Wallerstein, 2001). Despite consensus that
Tensions can also occur where community participation is engaged
community participation should engender active processes involving
for disease prevention purposes rather than following a bottom-up,
choice, and the potential for implementing that choice, implementation
community-defined agenda (Rifkin, 1990; Asthana and Oostvogels,
 1996; Labonte, 1998; Zakus and Lysack, 1998). It has been 94; Wallerstein
argued, and Bernstein, 1994). To this end we draw on the
however, that these approaches are not neces- sarily incompatible
aluation andof Breathing Space, a community-based smoking
that both positions can be accommodated (Rifkin, 1990). If,
ervention
it is sug-in an area of low income. The paper examines the
gested, community participation is seen as a process rather
velopment
than anand execution of the Breathing Space programme through
intervention this will affect the value placed on different
rticipants’
types ofunderstandings about community development and the
outcomes (Rifkin, 1995; Labonte, 1998; Laverack and Wallerstein,
nslation of these understandings into health promotion practice.
2001). THODS
However, there are many different levels at which the community
may participate and at one extreme this may amount to littleindependently
more than funded study was undertaken to evaluate the
athing
tokenism (Labonte, 1994; Petersen and Lupton, 1996). Moreover, Space’ initiative using a quasi-experimental research design.
communities do not have the same access as local authority ddition to before and after surveys, a thorough qualitative process
organizations and government agencies to those resources uation was carried out which aimed to document development and
enabling
them to define and set the agendas and participate on an equal footing of the intervention and to assess threats to the validity
lementation
(Labonte, 1994; Wallerstein and Bernstein, 1994; Blackburn,he2000).
research design. This paper draws upon in-depth interviews
The concept of ‘empowerment’ has also assumed differentertaken as part of the study’s process evaluation.
meanings
within the context of community-based health promotion work (Israel
et al​., 1994; Labonte, 1994; Robertson and Minkler, 1994; Laverack, interviews ​Fifty-six semi-structured in-depth interviews were
2001; Smith ​et al.​ , 2001). For example, empowerment may be at either ducted with programme participants. These comprised eight
or both the individual and community level (Bracht and Tsouros, 1990; rviews with managers from the three main partner organizations,
Bernstein ​et al.​ , 1994; Israel ​et al​., 1994; Labonte, 1994; Robertsonnand
with the project coordinators, 28 with intervention team
Minkler, 1994; Robinson and Elliott, 2000; Smith ​et al.​ , 2001), and
mbers, 11 with subgroup members and two with community
tension may exist within community development practice between the
elopment workers, with responsibility for smoking cessation
two levels (Robertson and Minkler, 1994; Wallerstein and Bernstein, ices, employed by one of the partnership organizations. The
1994). Whereas individual empowerment might be concerned rviews, with which were recorded, were held at key points across the
individuals gaining mastery over their lives, community empowerment rse of the project (audit and planning, project design and
focuses on ‘the social contexts where empowerment takes place’ elopment, and implementation stages). They explored respondents’
[(Wallerstein and Bernstein, 1994), p. 142]. While it has been suggested erstandings and experiences of intervention programmes at different
that the two levels are interdependent, the aims of each may differ ls (overall programme organization and structure, individual
(Robertson and Minkler, 1994) and this may impede practice (Laverack ects, and personal roles and responsibilities).
and Wallerstein, 2001).
Community development has been used in several major UK
lysis ​The interviews were transcribed and analysed thematically
heart-health initiatives, reflecting the centrality of the approach within
h the assistance of qualitative software (NUD*IST). Three members
the New Public Health strategy (Robinson and Elliott, 2000). There is,
he research team developed a detailed coding scheme. Some of the
however, limited evi- dence of its overall success (Farquhar ​et al​., 1990;
mes/categories agreed by the team related directly to the aims of the
Luepker ​et al.​, 1994; Carleton ​et al.​ , 1995; COMMIT Research Group,
- uation and were identified before the interviews, while others
1995; Goodman ​et al​., 1995; Shelley ​et al.​, 1995; Brownson ​et al.​ ,
rged through exploration of the interview data. The robustness of
1996; Baxter ​et al​., 1997; Secker-Walker ​et al​., 2000; Hancock ​et al​.,
he cate- gories was tested by reference to the individ- ual cases, the
2001). A major difficulty in assessing effectiveness of different pro-
ditions and contexts of which were compared and contrasted. All
grammes arises because communities utilizing this approach tend to
e researchers were involved in coding the data. In order to ensure
interpret and implement aspects of community development deemed
gruence between coding styles, different researchers coded a
most appropriate to their specific needs (Buchanan, 1994; Robinson and
dom selection of transcripts, discrepancies were reviewed and
Elliott, 2000). Because community development programmes are not
ement of the final coding scheme was negotiated.
operationalized in a consistent way it is difficult to compare ‘like with
Empowerment issues in com
like’.
In order to understand better how these programmes perform,
ct identifiers ​In the Results section, extracts from the data
it is necessary to examine in depth how the community development buted to representatives from the different respondent
approach is rolled out within the local context (Robertson and Minkler,
ntifying numbers for each extract are prefixed by a letter
which can be interpreted as follows: ‘M’ indicates managers, ‘I’
indicates intervention team mem- bers, ‘YS’ indicates those working at Participation and ownership ​Respondents felt that each of the
subgroup level in the ‘Young Persons’ setting, ‘C’ identifies those in Breathing Space partners should have a different yet equal role to play
the ‘Community Setting’ and ‘PC’ identifies those in the ‘Primary in the development and execution of the programme. The role of
Care’ setting. Wester Hailes Urban Regeneration Partnership (WHURP), for example,
was described by a (WHURP) manager as: ‘... facilitating and taking
forward some of the actual interventions in specific settings where
The origins of Breathing Space ​Prior to Breathing Space there were
there’s a health promotion specialist (health board employee) working’,
two national anti-smoking initiatives supporting smaller scale projects
whereas the role of the health agency was described as ‘taking forward
using the community development ethos and approach in Scotland.
the community’s aspects, making sure that the project is in line with
These were the Women, Low Income and Smoking Initiative and the
community defined needs’ (M5).
Tobacco and Inequalities Project (Amos ​et al​., 1999; Barlow ​et al​.,
1999; Gaunt- Richardson ​et al.​ , 1999; McKie ​et al​., 1999). Breathing In practice, parity of participation was an issue for many
Space, however, was the first community-wide development respondents. Hence, the manager quoted above said ‘It can’t just be [us]
programme on smoking in Scotland. providing the support and doing the work’ (M5). Most concern about
parity of input, however, centred upon Lothian Health Board (LHB),
Breathing Space was a community health promotion
which was singled out by many respondents as being too prominent in
initiative, which aimed to produce a significant shift in community
both the development and the implementation of Breathing Space. The
norms towards non-smoking in a low-income area in Edinburgh. The
pro- portion of health board representatives (nine out of 12 at one point)
community (Wester Hailes) was unusual in that local community
on the intervention team and the heightened profile of health board
groups had identified smoking as a priority health concern, which they
workers throughout the project contributed to the view of some
had begun to address through the implemen- tation of no-smoking
respondents that the programme was ‘developed effectively by one
policies and the provision of support for smokers who wanted to quit.
organization’ (I8).
The Breathing Space programme was initiated by the local health
policy group—the health subgroup of an Urban Regeneration Concern about the over-representation of the health board was
Partnership—which approached their local health board for help in matched by at least equal, if not greater concern about a perceived
tackling the high prevalence of smoking in Wester Hailes. The aim of under- representation of the local community organizations:
the programme was to capitalize on local knowledge and encourage
I can remember one meeting where a senior member of health board staff was
local involvement in the development of a programme of activities that
talking about ‘we need to get the community involved, the community
would create a supportive environment to enable local people to make involved’, but
healthy choices. Although focusing on four main health promotion hat she was talking about were health visitors: the pharmacists, the local
settings (community, primary care, youth and schools, and workplace), ops—that is not a community. (I8)
Breathing Space set out to bridge these settings and create a health
promoting environment across the wider community. ence, although Breathing Space was conceived as a community
Breathing Space was organized on three levels. On velopment project, there was a lack of agreement among the partners
level one, an intervention team, comprising representatives from the out what community participation meant and who should be involved.
partner organizations, Participation and ownership were not only issues at an
54 ​D. Ritchie ​et al. ganizational/agency level, but also at the level of their membership.
ommitment held by managers did not necessarily reflect the
was set up to oversee planning and imple- mentation. This allianceof members. The heightened presence of health board
mmitment
formed a steering com- mittee, which supported settings-based
orkers did not appear to arise from any intention on their behalf to
subgroups (level two), whose remit it was to take project objectives
minate the Breathing Space programme. Indeed, a senior manager
forward. Subgroup membership included the main intervention team
om the health board described the initial ambivalence of some health
and other community workers with particular expertise or interest in
ard workers as a function of their lack of involve- ment in the early
that setting. The third level comprised others who worked or lived in
ages of the project:
the community, and who were involved in the implementation of
specific intervention activities. start with there wasn’t real ownership, there was a lot of ‘phew, I’ve got to
this now’—whereas now ‘this is a piece of work and its going forward and
m a bit concerned about how I’m going to fit it in’. (M1)
DISCUSSION OF FINDINGS
 (I5, health board). These respondents also tended to talk
Because some programme workers were not privy to the initial he health of the local community’ (I10) rather than the
decision-making processes through which the programme evolved,dividuals.
the I2, from the health board intervention team, for
level of enthusiasm or perceived ownership associated with successful
escribed her understanding of the programme thus:
community development work was forfeited.
idea of it was to look at smoking in a community and in a wider
opposed to] ... the usual sort of health prepared stuff which is about
Smoking as a priority ​Many respondents felt that Breathing Spaceehaviour
was and so on. (I2)
not a community venture and, related to this, that smoking was not a
community-defined priority. Views on this issue differed according to Most respondents acknowledged that smoking
the organization that respondents represented and the role they played
workinis traditionally focused at the individual level. Indeed,
the initiation of the programme. Representatives of the community ‘one to one’ was a way of working with which they were
health agency felt that the community had identified smoking as a iar and felt most comfortable. PS4, a health care professional
priority because smoking had been central to the community-based ary care setting, for example, described the programme work
work from which Breathing Space had evolved:

We were the core of the project before Breathing Space came into being. Itilarly,
was YS2, a youth agency worker, felt that smoking was not high
built on the work that we and the health project did. The whole thing evolved
he agenda of young people:
out of our work. (I8)
nk in a lot of ways it’s an adult issue. You know what I mean? It’s coming
Respondents, such as I1 from the Health Board, who were key players adults it’s not coming from young people ... I don’t think they see it as a
in the initiation and early issue. (YS2)
Empowerment issues in community development 5​ 5
Some respondents felt that the focus on smoking was
development of the programme, also felt that Breathing Space had cally problematic. For example, I13 (an intervention team member
evolved in line with the principles of community development, health board worker) felt that targeting smoking contributed further
describing smoking as: people’s already disadvantaged lives. She described smokers as
ple who maybe have lots of needs, have complex needs’ and
... located in the specific heart of the community. It’s certainly located in the
king as ‘their little bit of pleasure’ (I13).
structure of the partnership. I’m aware that it comes from the bottom up. (I1)
Some respondents reported difficulties in selling the
In contrast, those respondents who did not represent gramme to community gatekeepers. I16, when describing the
blems
community groups, and were not privy to the early discussions from she encountered when trying to get general practitioners on
which Breathing Space evolved, were less certain that smoking rd, said:
constituted a community-defined priority. From the perspective of a
WHURP representative, for example, other issues were described’sasnot a particularly nice feeling to be having to work so hard to sell
ething ... You get home and say to yourself ‘I’m not peddling drugs here,
more pressing: ‘It’s always been drugs and alcohol that have been its
trying to do something good’. (I6)
primary issues’ (I8). The health board workers drew on their the different channels with people who are identified as smoking if
experiences of working in the area to identify issues they saw ting as to either stop smoking or to reduce their smoking habits. (PS4)
important. For example, a health board young person specialist said:
individual smoking behaviour was not necessarily seen as
... we’re supposed to be talking about smoking in the 3rd year, and some of le thewith the aims of community development work. Some, for
girls start slagging another girl off about having had sex for the first time the
elt that increasing access to cessation materials and support
night before. And I would say that is a bigger issue as far as they are concerned
ultimately to a change in ‘perceptions on smoking in [the
than smoking. (I5)
3) and help ‘overall to reduce the number of people that
Empowerment and service delivery ​Respondents’ opinions differed
3).
as to whether Breathing Space should focus upon broad health issues or
more specifically upon smoking behaviour. Those taking the broader The programme was also affected by institutional
view talked, for example ‘about looking at the underlying issues and experienced by those working within the different partner
realising that smoking in a lot of cases is a symptom rather than the tions. Some implementers felt they were expected to
e the type of tangible outcomes associated with direct action
about smoking targeted at the individual level. For example, the d we are very much on the practical ... side here’ (I9).
Breathing Space coordinator said: Secondly, even where workers were knowl- edgeable about,
gained familiarity with these precepts, they did not find it easy to
As time has gone on there’s been a certain amount of pressure to do
nslate this knowledge into practice. Ways of working asso- ciated
things—practical things. And they tended to be about smoking, directly about
th the different partner organizations/ agencies were understood by
smoking. (R14)
spondents to be fundamentally incompatible:
Given the types of outcomes traditionally expected of health promotion,
... there are tensions in doing community development if you are a
the community
tutory organization ... it doesn’t quite fit, because on one level it’s home
56 ​D. Ritchie ​et al.
own, it’s grass roots development, it’s power is located in the community and
n you are there as a totally different, like well quite a powerful structure with
development approach presented some difficulties for respondents.
rtain ways of working. (I1)
Some, for example, were uncomfortable with, and resistant to, the idea
of project objectives that were shaped by the community agenda and
nsurprisingly, respondents representing the health agency described
that could evolve over time. A health board worker involved in the con-
emselves as more appropriately placed and better qualified to support
ception of the programme described the dilemma this posed for some
community-based approach:
workers:
we have a lot more facilities and support services to offer ... It’s not saying we
People are probably more used to working in a way that’sbetter, erm—you
we’ve just got more on offer in terms of alternatives and stuff than
know—you do this and then you do this and then you do this. Whereas whatand
y the GPs we the practice nurses. (CS1)
are trying to do is to allow a process to emerge...and what people are finding
difficult is being diffuse...very difficult, the anxiety is enormous. (I1)
ONCLUSION
RI1 felt, however, that workers who persevered despite reservations
could reach a better under- standing of the enterprise, over time: ndings from the process evaluation indicated a disjunction between
spondents’ conceptions of Breathing Space as a community develop-
You know, it’s working quite slowly for people ... , really itsent likeprogramme,
pennies and the translation of the pro- gramme into actual
beginning to drop, and people realising yes that’s what it is about. (I1)
actice. The data suggest this is a function of a combination of factors,
which participation, ownership and empow- erment play major roles.
Others, such as I2, a health board employee, described her uncertainty
That the partner organizations were felt to be represented
about the unfolding nature of the endeavour:
equally left many respon- dents, particularly those from the
mmunity
It’s very amorphous because it’s a developmental project. That’s the nature of agencies, feeling disempowered. While the community
the beast ... I’m not very confident about doing this. It’s not knowing soentitled to programme ownership, in that Breathing Space
rtners felt
shapeless—and what’s going to happen and then it comes together?as seen as developing out of their previous work on smoking in
ester Hailes, the health board was seen as the dominating and ‘more
In addition, although those representing the community based agencies
werful’ partner.
were more likely to be familiar with community development work,This not was perceived as particularly problematic, as of all the
all of their members were similarly experi- enced. For example, I12, a
rtnership groups, the health board was understood to be the least
recently recruited health agency employee, expressed a fixed
mpathetic or amenable to the aims of community development and
understanding that Breathing Space aimed to ‘Get mainlye youngsters least able to accommodate ways of
and teenagers to stop smoking ... to improve their health’ (I12). rationalizing the programme necessary for its success. In particular,
This raises two important points. First, not everybody, rrow focusandof the health board on the health of individuals and on
particularly those working within the statutory agency, were kingfamiliar
behaviour per se was, given the community development aims,
and/or comfortable taking a community development approach. to I5, for inappropriate expectations and constraints upon
place
example, said ‘Well to start with I didn’t have a clue what the principles
gramme outcomes.
were’ (I5). Equally, those working at the community level wereThe not different approaches, which appeared to index the
necessarily familiar with the theoretical principles underpinning their
ective positions of the community organizations and the health
work: ‘[It’s] certainly difficult because there is an awful lot more
rd, reflected two separate discourses operating within the
theoretical discussion around, gramme simultaneously. The first favoured the concept of
 community development and empowerment, while the second favoured hey have ownership of the programme. The study has
prevention of unhealthy lifestyles (and to a lesser extent the promotion
not only the importance of community ownership, but also
of individual empow- erment). That these discourses were seenance as of ensuring that members of organizations signed up to
mutually reinforcing rather than incompatible by many respondents, mme are involved at an early stage of the programme’s
reinforces a sense of their reluctance to grasp wholeheartedly nt. the
‘radical’ agenda and modus operandi of community development work.
At an even more fundamental level, the perceived low level
of input from actual community members, and a lack of consensus
WLEDGEMENTS
about what constituted the community, raised a question mark over
whether or not smoking was a community-defined priority in Wester
tion research on which this paper draws was funded by the
Hailes. Whereas those who were involved in the develop- ment of tthe of Health. The Research Unit in Health, Behaviour and
programme and/or had experience of community-based no-smoking ointly funded by the Scottish Executive Health Department
health promotion work saw smoking as a community issue, others did alth Education Board for Scotland. All opinions expressed in
not. While White Papers on tobacco and public health (Secretary are of those of the authors and not necessarily those of the
State for Health, 1999; Secretary of State for Scotland, 1999)
demonstrate government identification of smoking as an important
contributor to social inequalities in health (Graham, 1998), this may correspondence:
not ​ eborah Ritchie Department of
D
necessarily be reflected at a community level. Reticence expressedueen by Margaret University College Clerwood
some Breathing Space workers towards the issue of smoking reflected
burgh EH12 8TS UK​E-mail:
their concern that other problems experienced by the community were
more pressing. These views resonate with a body of sociological uc.ac.uk
findings, which indicate how the social circumstances of disadvantaged 58 ​D. Ritchie et al.
lives play an important part in sustaining smoking (Laurier ​et al​., 2000).
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