art & science sexual healthUsing peer education projects t.docx

art & science sexual health
Using peer education projects to
prevent HIV/AIDS in young people
Campbell S (2005) Using peer education projects to prevent
HIV/AIDS in young people. Nursing
Standard. 20,10, 50-55. Date of acceptance: December 6 2004.
SummarY
This article discusses the use of peer education to reduce
sexually
transmitted infections, including human immunodeficiency
virus/acquired immunodeficiency syndrome, in young people. I
t
describes experiences gained from a peer education project for
young people in Uganda,
Author
Sue Campbell is a freelance writer in Kampala, Uganda,
Email: Masc(@)utlonline.co,ug
AIDS; Health education; Peer education
These keywords are based on the subject headings from the
British
Nursing Index, This article has been subject to double-blind
review.
For related articles and author guidelines visit our online
archive at
www.nursing-standard.co.uk and search using the keywords.

MORE THAN half of people newly infected with
the human immunodeficiency virus (HIV)
worldwide are aged 15-24 years (United Nations
Children's Fund (UNICEF) etal 2002).
Empowering young people with the basic human
right of reproductive choice is, therefore,
critically important.
Over the past decade there has been a growing
interest in involving young people as peer
educators in health education in the UK,
particularly in the area of sexual health (Health
Education Board for Scotland (HEBS) 2003),
Peer education approaches offer the possibility
of changing behaviour and increasing knowledge
to prevent HIV, This article explains what a peer
education approach is and gives guidance on
how to develop a project focused on young
people. Although the author's experience of
developing peer education projects in Uganda for
HIV prevention is discussed, some of the
principles can be transferred to working with
young people in the UK,
Young people are at the centre of the global
HIV and acquired immunodeficiency syndrome
(AIDS) pandemic. They are also a key human
resource for the future wellbeing of communities.
Each day nearly 6,000 young people aged from
5 0 november 16 :: vol 20 no 10 :: 2005
15-24 years become infected with HIV (UNICEF
etal2002). Educating young people about HIV,
and teaching them skills in negotiation, conflict
resolution, critical thinking, decision-making and

communication improve their self-confidence
and ability to make informed choices, for
example, postponing sex until they are mature
enough to protect themselves from HIV, other
sexually transmitted infections (STIs) and
unwanted pregnancies (UNICEF ef a/2002).
In 2003, an estimated 4,1 per cent of adults in
Uganda and 0,2 per cent in the UK were living
with HIV/AIDS (Joint United Nations
Programme on HIV/AIDS (UNAIDS) 1999,
UNAIDSAJNICEFAVorld Health Organization
(WHO) 2004), Factors that encourage the spread
of HIV/AIDS among young people in Uganda
include (Government of Uganda 1999):
• Sociocultural issues, including attitudes among
peer groups about early and risky sexual
behaviour, and service providers' attitudes
about adolescents' sexuality,
• Practical issues, such as the availability of
condoms and information,
• Economic factors that encourage young people
to engage in sexual practices that put them at
risk of developing an infection,
To be most effective, prevention approaches
should be tailored to the needs of particular
groups, such as young people, and address
predisposing factors to the spread of HIV/AIDS,
such as the lack of condom use.
Peer education

Peer refers to a person of the same age, status or
ability as another specified person (Pearsall
1999), Peer education is a popular concept that
implies an approach, a communication channel,
methodology, philosophy and strategy. In
practice, peer education has encompassed a range
of definitions and interpretations about who is a
peer and what is education, for example,
advocacy, counselling, drama, lecturing,
NURSING STANDARD
distributing materials, making referrals to
services or providing support (UNAIDS 1999),
The theoretical base of peer education is
behavioural theory, assuming that people make
change based on progressive steps of
understanding and internalising the relevance to
their own situation (0stergaard 2003), Peer
education typically involves training and
supporting members of a given group to effect
change among members of the same group.
These can be changes in knowledge, attitudes,
beliefs and behaviour at an individual level, and
stimulating collective action that can bring about
change at a policy and programme level.
The Baaba project - a Baaba is a respected
elder sibling in the local Luganda dialect - is a
peer-led HIV/AIDS prevention programme for
street children in Uganda, It is facilitated by
GOAL, an international non-governmental
organisation (NGO), Street children as a group

are generally vulnerable and difficult to reach.
An estimated 4,000 young people live on the
streets of Kampala and are the most visible of
Uganda's marginalised youth. Social breakdown
and poverty resulting from the HIV/AIDS
epidemic have contributed to the existence of
street children in Uganda, Urbanisation, conflict
and the breakdown of traditional family
structures are also responsible (Ministry of
Gender, Labour and Social Development 1999),
Other health problems include skin infections,
respiratory infections, diarrhoeal diseases and
malaria (GOAL Uganda 2001),
The Baaba project seeks to integrate
HIV/AIDS prevention into mainstream
interventions for street children, such as provision
of shelter, food and basic education and health
care, and into the activities of other agencies that
influence the health and welfare of street children
and young people. The project involves a life skills
approach to tackle HIV/AIDS prevention and
issues such as drug misuse and rape. It is based on
social learning theory (Bandura 1986), which
emphasises self-efficacy - belief in the ability to
change behaviour - and beliefs about the outcome
of changing behaviour, for example, the belief
that using condoms will prevent HIV,
The aim ofthe peer education approach is to
develop the confidence, capacities and leadership
skills of the young people who are trained as peer
educators. This can be achieved by running
project activities, training to be trainers, project
planning and management training, occupying
respected and responsible positions among their

peers, and working as information providers on
sexual and reproductive health issues.
Peer education can take place individually or in
small groups in a variety of settings, including
schools, clubs, religious settings, workplaces, on
the street or in a shelter, or wherever young people
gather. It can be used with a variety of populations
and age groups. In the past decade, peer education
has been used extensively in HIV/AIDS prevention
and reproductive health programmes around the
world (Population Services International (PSI)
2000, Neukom and Ashford 2003),
Benefits
Studies show that young people frequently turn
to their peers for information and advice. These
interactions tend to be more frequent, intense
and diverse than those with other people, and
they also provide an arena for support and
modelling (HEBS 2003), The peer education
approach is culturally appropriate, community-
based, accepted by the target audiences and can
also be economical (Family Health
International/AIDS Control and Prevention
Project (FHI/AIDSCAP) 1996),
Peer education has the advantage of perceived
credibility of peer educators in the eyes of their
target group. Young people exposed to peer
education often praise this approach because it is
reached through a shared background between
the educator and his or her audience. Themes of
interest for students, team members and others

might include: musical tastes, popular celebrities,
use of language and family themes - such as the
struggle for independence and fitting into
culturally accepted norms and values. Another
advantage of peer education is that young peer
educators are less likely to be seen as authority
figures preaching about how others should
behave. Rather, peer education is perceived more
like receiving advice from a friend who is 'in the
know', A successful peer educator is viewed by
his or her peers as someone who has similar
concerns, is trying to help out, and has an
understanding of what it is like to be a young
person (Stakic et al 2003),
Peer education advocates the right of young
people to participate in processes that affect them
and to access the information and services they
require to protect their health. Young people
represent a key resource in mobilising an
expanded and effective response to the
HIV/AIDS epidemic. Their energy, charisma,
creativity and urge to learn and adopt new ways
can bring insight and inspiration to programmes
that listen to what they say.
Projects
Peer education can be a useful and productive
approach to health promotion. However, it is not
appropriate in all situations. It can be useful in
targeting groups that are traditionally hard to
reach, such as those who are alcohol and/or
substance misusers and street children. It is also
NURSING STANDARD november 16 :: vol 20 no 10 :: 2005 51

art & science sexual health Recruitment and selection
useful in reaching other marginalised groups,
such as homosexuals or commercial sex workers.
It can reach those who are in or out of school,
college or university. It can work in projects to
address bullying in school or assist in promoting
sexual health. Peer education can also be used
with information and communication
technologies, such as internet-based counselling
services or telephone help lines.
The identification of target groups should
always be based on the identification of the
specific needs of young people, preferably
through baseline surveys and needs assessment
studies in the proposed project sites (International
Planned Parenthood Federation (IPPF) 2001), It is
essential to make enquiries about the profile of
the intended health education audience before
deciding whether to deploy peer educators. There
are a number of questions that should be
addressed in a needs assessment (Box 1),
Questions to ask in a needs assessment of a proposed
project site
• What are the goals of the project?
• Who is the target audience?
• Are there people in the target group who have the time,
interest and ability to work as peer educators?

• What will the peer educators need to do?
• What resources will the peer educators need to conduct these
activities?
• Can the project provide these resources?
• How large is the target group?
• How many peer educators are required to reach this group?
• Can the project train and support that many peer educators?
• Will the peer educators need incentives and, if so, what? Can
the project provide them?
• Can the peer educators be supported with supervision,
refresher training and incentives over the long term? Is there a
budget for this?
• How many staff members will be required to support the
project?
• What other activities will the peer education strategy
complement?
* Have there been or are there any other similar projects going
on
in your area? This is important to avoid duplication and
confusion.
(Adapted from FHI/AIDSCAP 1996)
52 november 16 :: vol 20 no 10 :: 2005

The recruitment and selection of peer educators
should not be the responsibility of project
managers only. The selection process should
involve the relevant stakeholders to increase the
acceptability of peer educators either in schools
or the community (IPPF 2001), There are certain
qualities to look for when selecting peer
educators (Box 2), Another way to identify
candidates for peer educators is to observe a
group's behaviour and then identify its natural
opinion leaders (FHI/AIDSCAP 1996),
The Baaba project involves 170 trained peer
educators, or Baabas, who plan and implement
HIV/AIDS prevention activities with partner
NGOs, on the streets and in surrounding
communities. There are currently 12 NGOs
participating in the Baaba project across Uganda,
Partner NGOs provide activities for street
children and are trained by GOAL to work on the
Baaba project. Other organisations can become
partners in the Baaba project if they (GOAL
Uganda 2003):
• Work to meet the short and long-term needs of
street children and youth,
• Are committed to the long-term development
and rehabilitation of street children and youth,
• Recognise that street children and youth are at
risk of contracting HIV/AIDS,
• Currently lack the capacity to confront
HIV/AIDS issues for street children and youth.

Ten to 20 young people are elected as Baabas by
their peers. The N G O director appoints a link
staff member to supervise the Baabas and act as a
link between them and GOAL, At project level,
activities are co-ordinated and facilitated by a
GOAL team, comprising a manager, three peer
trainers/counsellors and two volunteers. The
team provides capacity building and ongoing
supervision support, organises inter-NGO events
and co-ordinates advocacy activities.
Training topics and activities
Initial training, of seven to ten days and focusing
on theoretical and practical issues, is an
important element of a successful peer education
programme. The initial training is important to
equip them with the necessary skills, knowledge
and motivation (IPPF 2001), The choice of
training will depend on the objectives and
activities of the project and the results of the
needs assessments. Peer educators may:
• Provide one-to-one counselling or
information, either formally or informally,
î URSING STANDARD
• Provide formal or informal information or
counselling in a group setting,
• Facilitate outreach programmes for target
audiences in the general population,

• Reach audiences through a variety of
interactive strategies, such as small group
presentations, role play or games,
• Staff outreach offices, telephone help lines and
resource centres to provide peer educators
with health information and take part in
self-assessments,
• Act in drama groups with role model
problem-solving skills woven into scenarios
that are recognisable as actual health risks to
peers (HEBS 2003),
• Refer to service providers.
Experience in counselling young people has
shown that information alone does not lead to a
change in behaviour and, increasingly, there is
recognition that young people should be
equipped with the necessary skills to sustain
behaviour change. Learning life skills, such as
conflict resolution and negotiation, helps young
people to relate to one another as equals, work in
groups, build self-esteem, resolve disagreements
peacefully and resist both peer and adult pressure
to take unnecessary risks (UNICEF etal 2002),
Thus training in life skills is important in all peer
education programmes.
Frequent additional training and refresher
courses in sexual and reproductive health and
communication are necessary to ensure quality in
peer educators' work and keep them motivated
and committed (IPPF 2001), Training should use
as many different participatory techniques as

necessary, for example, group discussions, role
play, music, dance and drama and puppetry to
increase understanding.
In the Baaba project, training and peer
education activities are based on participatory
learning tools,Objectives ofthe peer education
and life skills component ofthe project are:
• Increased knowledge and skills of Baabas in
promoting the sexual and reproductive health
of street children and young people in and
outside NGOs,
• Street children and young people accessing
'street friendly' sexual and reproductive health
services, counselling, prophylaxis and
protection through an effective N G O , Baaba
network and referral system,
• Increased knowledge of sexual and
reproductive health among street children and
young people,
NURSING STANDARD
Activities run by the Baaba project include:
• Prevention clubs - focusing on information,
education and communication activities to
prevent HIV - seminars, sport and street
outreach run by Baabas,
• Referral systems established through 'street-
friendly' service providers,

• Counselling,
• Condom distribution by Baabas and GOAL,
• Puppetry and drama.
Trainers include nominated teachers to assist with
the school-based clubs and other community
members. Links are made with the various clubs by
displaying pertinent information on notice boards
and through end of year festivals, when all the
partner organisations get together and put on a
joint concert. Encouragement is given for people
living with HIV/AIDS to meet staff and members of
the AIDS awareness clubs to share information and
answer questions, AIDS awareness clubs develop
their own topics for discussion and examples
include: family life education, training in life skills,
risk reduction, sexual and reproductive health
rights, condom negotiation and distribution,
coping with AIDS in the home, running a club, and
music, dance and drama training, A manual was
developed with the participation of the clubs.
Condoms are available through the clubs.
Qualities to look for in potential peer educators for a sexual
health project
• Ability to communicate clearly and persuasively with peers.
• Good interpersonal skills, including listening skills,
• A sociocultural background similar to that of the target
audience - may include age, sex and social class.
• Accepted and respected by their peers.

• A non-judgemental attitude.
• Strong motivation to work towards human
immunodeficiency virus (HIV) risk reduction.
• Care, compassion and respect for people affected by HIV and
acquired immunodeficiency syndrome (AIDS).
• Self-confidence and potential for leadership.
• Pass a practical, knowledge-based exam at the end of training.
• Time and energy to devote to this work.
• Potential to be a safer-sex role model for their peers.
• Able to get to the location of the target audience.
• Able to work irregular hours.
(FHI/AIDSCAP 1996)
november 16 :: vol 20 no 10 :: 2005 53
art & science sexual health
Supervision and support
Support for peer educators includes (GOAL
Uganda 2003):
• Regular in-service meetings,

• Additional educational materials for peer
educators' own use, for example, a handbook
or manual,
• Information, education and communication
materials and condoms for distribution to peers,
• Certificates, badges, T-shirts, bags or hats to
identify them as trained peer educators and
acknowledge their contribution to the project,
• Supervisor availability to help peer educators
deal with discouraging or difficult experiences,
• Information booklets that provide answers to
commonly asked questions,
V Special activities just for fun,
• Links with other community groups,
• Referral book that allows educators to send
peers to other available resources,
• Opportunities for established peer educators
to teach and mentor new peer educators.
Supervision helps to ensure that the peer
educators are doing a good job and there are
various ways to supervise peer educators.
Monitoring and evaluation
The monitoring and evaluation of peer education
projects should be carefully planned.
Monitoring This should include field visits,

activity reports, regular meetings, focus group
discussions and qualitative surveys with young
people and peer educators to assess progress and
what needs to be done to improve the project
(IPPF 2001), Peer education can include various
activities and there appears to be no systematic
evaluation ofthe effects of each ofthe activities
(HEBS 2003), Consequently, there is little
detailed understanding ofthe processes involved
in such interventions and a lack of evidence
about their effectiveness. Therefore, when setting
up a peer education programme there is no clear
guidance about issues, such as timing,
recruitment, nature ofthe targeted behaviour,
status of peers, effects on participants, social
contexts and social processes.
Evaluation This must be tailored to the realities
ofthe time that is available. As with other health
54 november 16 :: vol 20 no 10 :: 2005
education activities, outcomes may vary
depending on the timing ofthe assessment. With
peer education it is also possible that the
motivation ofthe peer educators may vary over
time, depending in part on changes in their own
life circumstances (HEBS 2003), The length of
each project will vary depending on its target
group and the objectives but often youth projects
require long-term commitments. As the peer
educators get older they will inevitably drop out
ofthe project and others will have to be brought
in to replace them. Often the targeted 'problem'
will not disappear and will affect the next age
group of children.

The Baaba project has used regular reviews of
project, NGO staff and Baabas and their peers to
evaluate its activities. The project also conducted a
knowledge, attitudes and practice survey of street
children as part ofthe baseline needs assessment
and after two years of project implementation.
These all demonstrated improvement and led to the
development of a second phase of the project.
Participation
True participation is a partnership in which young
people and adults have agreed responsibilities.
Energetic, enthusiastic and creative young people
are a tremendous resource in all areas of HIV
prevention and care. Their input is invaluable to
programme design and outreach, ensuring that
prevention and care efforts are meaningful to
young people, that information is communicated
through effective channels and that the messages
conveyed are relevant to their everyday lives
(UNICEF efa/2002).
Involving young people in prevention efforts
not only educates them about HIV but also
gives them a sense of responsibility and pride.
Participation of peer educators and other
young people in the planning process and
development of action plans is essential for
successful programme implementation, A
weekly or monthly activity plan, as well as
clearly defined targets, are key elements to
ensure that peer educators know what is
expected of them (IPPF 2001),
Adults should ensure that young people are

informed, trained, motivated and supported in all
of their HI V prevention efforts, according to their
ability and as the project evolves. Young people
should demonstrate commitment, be reliable and
active contributors. It is also important when
working with young people that they are regarded
as part of the solution and not the problem.
Limitations
There is a lack of research, particularly in the UK,
that evaluates the various components of peer
NURSING STANDARD
education projects. The inherent difficulties with
evaluation of such projects remain challenging.
Projects do not exist in isolation so it is difficult to
identify the impact of the project and to
demonstrate that a specific intervention resulted
in behaviour change because there are other
influences in the environment or possible
contributing factors. Although an increase in
knowledge is often used as a measure of impact,
the objective of behaviour change is more difficult
to measure, and an increase in knowledge does
not necessarily lead to a change in behaviour.
A high attrition rate of peer educators can be a
positive result because it may mean that the peer
educators have left their previous negative
behaviours such as substance misuse and are now
concentrating on their academic career. It should
also be noted than no single intervention is likely

to bring about sustained behaviour change (Berlin
and Hornbeck 2003).
In formulating youth programmes, the peer
education component has to be integrated with
other aspects of a youth project, and be part of an
overall project philosophy. A single theatre
performance may motivate a teenager or pre-teen
to consider or adopt safer sexual options, but it
cannot ensure that that this will be sustained.
Parental, school and community involvement are
crucial to sustain behaviour change (Berlin and
Hornbeck 2003).
Working in an established system can also have
limitations, such as having to fit your activities into
a structured school curriculum. A peer education
project requires a dynamic staff member to work
with the young people and ensure that they remain
motivated. A project should also be long term
because many ofthe attributes required, such as
self-esteem, take time to develop. Other difficulties
encountered may have no right or wrong answers.
References
and need to be discussed with colleagues and the
project participants to consider what is appropriate
for a particular setting. This includes issues such as:
• Should the peer educators be paid?
• Should the peer educators only provide
information, leaving the counselling and
support activities to professional staff?

• Should the peer education project be linked
formally with other health projects?
Because peer educators often receive little or no
pay, the Baaba project had to find ways of ensuring
the commitment of the Baabas. Various incentives
have been used, such as designing and printing T-
shirts and bags for the peer educators, regular
supervision and support with refresher training,
inter-club competitions and festivals. Peer
educators are supplied with adequate educational
materials and tools, for example, samples of
contraceptives or flipcharts. Training the trainers
has also been initiated to increase the number of
peer educators and to compensate for those who
drop out. The development of a manual will help
to ensure that training of trainers and support and
follow-up are of high quality.
Conclusion
Peer education can be a useful approach when
working with young people. With a thorough
needs assessment and the participation ofthe
young people, an effective project to change
negative behaviour or maintain positive behaviour
can be developed and implemented, provided this
is integrated with other activities. Adequate
monitoring and evaluation should be included
from the start of the project to help avoid
difficulties at a later stage NS
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NURSING STANDARD november 16 :: vol 20 no 10 ;: 2005 55
SOCIAL DETERMINANTS OF HEALTH INEQUITIES
Integrating Social Theory Into Public Health Practice
The innovative practice
that resulted from the Ot-
tawa Charter challenges pub-
lic health knowledge about
programming and evalua-
tion. Specifically, there is a
need to formulate program
theory that embraces social
determinants of health and
local actors' mobilization for
social change. Likewise, it is
imperative to develop a the-
ory of evaluation that fosters
reflexive understanding of
public health programs en-

gaged in social change.
We believe advances in
contemporary social theory
that are founded on a cri-
tique of modernity and that
articulate a coherent theory
of practice should be con-
sidered when addressing
these critical challenges.
{Am J Public Health. 2005;
95:591-595. doi:10.2105/
AJPH.2004.048017)
Louise Potvin, PhD, Sylvie Gendron, PhD, Angele Bilodeau,
PhD, and Patrick Chabot, PhD
DURING THE LAST DECADE,
there has been an acute need for
theoretical innovation in the
fields of population and public
health. Although the crucial
question about the social deter-
minants of health have led to sig-
nificant theoretical contribu-
tions,' the innovative public
health practices prompted by the
Ottawa Charter for Health Pro-
motion are still undertheorized,
because they cannot be ap-
praised through the traditional
scientific bases of public hesilth.̂
For example, if we accept that
health is a resource at the core of
everyday life,'' we need concep-

tual tools that allow us to have
an in-depth understanding of
everyday life.
Subsequently, public health
action has evolved from a bio-
medical orientation to a social
orientation that assumes the in-
volvement of multiple actors.
Public health practice is largely
supported by progressive policy,
and it has shifted toward the de-
velopment of alliances with an
increasingly broad range of so-
cial actors. This is seen in the
growing number of reports about
overlapping actions and integra-
dve programs.''
Because the theoretical foun-
dations of public health have
been based, since the beginning
of the 20th century, largely on
behavioral psychology, biomed-
iccil science, and public adminis-
tration,^ our capacity to under-
stand and form theories about
the complex interactions in-
volved in these programs is lim-
ited. This, in turn, constrains our
ability to further direct innova-
tion and transform practice. We
argue for a renewal of the knowl-
edge base that drives public
health practice so that develop-

ments in contemporary social
theory can be integrated into
public health practice.
INCOMPLETE
KNOWLEDGE BASE FOR
PUBLIC HEALTH POLICY
AND PRACTICE
The Ottawa Charter has Ccilled
for and promoted new forms of
intervention that are guided by
values of empowerment and
community participation and that
imply health is produced into the
core of social life—how people
live and organize their lives be-
cause of their social conditions.̂ '̂
Unfortunately, these values are
all too often juxtaposed on ex-
pert models within which stan-
dardized activities are prescribed
as a set of bodily or behavioral
practices that reduce the preva-
lence of individual risk factors
among the population. This
leaves practitioners with very few
relevant instruments and models
for implementing the basic prin-
ciples of the Ottawa Charter^ and
the evolving policy discourse. In
fact, there is little theory for in-
voking, and reflecting upon, the
social and relational dimensions
of public health practice.

Innovative public health prac-
tice is increasingly understood to
be the permeation of health is-
sues into the social realm, where
a growing number of situations
traditionally regarded as social
problems are reinterpreted
within a health framework. Illicit
drug use is an example where, in
many jurisdictions, policy is shift-
ing from a socio-judicial ap-
proach to a harm-reduction
model that includes access to
psychosocial rehabilitation ser-
vices and low-threshold drug
substitution treatments in super-
vised injection sites. Another ex-
ample is the intense support in-
tervention through front-line
health services involvement in in-
tegrative social-development ac-
tions that responds to the needs
of vulnerable young children and
their adolescent parents. In our
opinion, this "healthification" of
social issues,̂ which justifies the
overlapping actions for social
change repeatedly called for by
current public health policy, is an
important way of incorporating
contemporary social theory into
the theoretical foundations of
We defined contemporary so-

cial theory by referring to 2 large
bodies of social sciences work
undertaken since the 1960s that
refiect on and critique the condi-
tions of modernity. The theories
in the first body of work reject
both the determinism of a purely
structuralist perspective and the
idealism of a entirely voluntaryist
conception of human action.
Contemporary social theorists
such as Pierre Bourdieu and An-
thony Giddens believe human
subjects are actors whose
agency—or capacity to act delib-
erately or to exercise willful
power—is constrained by—yet re-
produces and transforms—the so-
cial structure through a dialecti-
cal relationship. The second
body of work includes theories
that explore and critique the role
of reason and rationality in the
regulation of human practice and
April 2005, Vol 95, No. 4 ] American Journal of Public Health
Potvin et al. Peer Reviewed | Social Determinants of Heaith
Inequities | 591
in contemporary society, such as
the work of Jurgen Habermas,
Michel Foucault, Ulrich Beck,
Anthony Giddens, Michel Callon,
Bruno Latour, and others.

Therefore, our underlying as-
sumptions are (1) there is a con-
flict between the innovative prac-
tices emerging in public health
and public health's scientific
base, and (2) we must integrate
relevant social theory into the
theoretical foundations that in-
form—and potentially transform-
contemporary public health prac-
tice. We present 2 challenges to
this integration of social theory
that refer to the interrelated—and
fundamental—processes of public
health programming and evalua-
tion. We also present some pro-
posals taken from advances in
contemporary social theory that
set the stage for a reconsidera-
tion of both the nature of public
health practice and the epistemo-
logical position from which to
evaluate and further develop
TWO CURRENT
CHALLENGES FOR PUBLIC
HEALTH
Iiblic health interventions are
often grouped into a limited
number of core functions. In
many jurisdictions, these func-
tions are related to health protec-
tion; mortality, morbidity, and

risk factor surveillance; disease
prevention; and health promo-
tion. Cutting across these func-
tions are the 2 fundamental find
interrelated processes of pro-
gramming and evaluation. They
are the prism through which we
have identified 2 crucial chal-
lenges for contemporary public
health theory and practice:
(1) formulating program theory
that takes into account the social
determinants of health and the
mobilization of diverse actors for
social change, and (2) developing
evaluation theory that fosters a
reflexive understanding of the in-
tegrative public health programs
engaged in social change. Al-
though these challenges have
been independently addressed
by other researchers,'"'" it is our
contention that they are closely
interrelated and that, taken to-
gether, they critically call into
question the bureaucratic/struc-
tural model upon which public
health practice has been tradi-
tionally based.
The bureaucratic/structural
model is a decontextualized in-
terpretation of scientific knowl-
edge by experts, e.g., pharmaceu-
tical drug development models,'^

and a bureaucratic, vertical, top-
down approach to programming
and evaluation." We maintain
that this approach does not pro-
vide adequate conceptual instru-
ments to reflect upon and repro-
duce the innovative practices that
are being implemented by the
most innovative public health
practitioners when addressing
the social determinants of health.
We need programs that build on
broad partnerships in which vari-
ous types of knowledge are
brought together to illuminate an
issue, i.e., relevant actors must be
mobilized to create local solu-
tions. A prerequisite for such pro-
grams is horizontal relationships
between the various partners
through a democratic participa-
tory process.
Formulating a Program
Theory
The first challenge is to formu-
late program theory that takes
into account the social determi-
nants of health and the mobiliza-
tion of diverse actors for social
change. Social epidemiology
studies have shown that health
and diseases are affected not
only by the conditions in which

individuals live but also by socie-
tal organization." These forms of
organization, which are reflected
in the different social strata that
shape our societies, mold our
connection with the world and
have an effect on health. Socio-
economic factors,'*'^ race/
ethnicity," gender,'* and stages
of life'** refiect our social stratifi-
cation. This stratification is asso-
ciated with the social determi-
nants of heeilth that, according to
Link and Pheelan,^" represent
fundamental causes of popula-
tion health. Social organization,
as defined by relationships cre-
ated among and between various
strata, thus forms the framework
upon which health and disease
phenomena develop.
Numerous studies have shown
the existence of spatial configura-
tions in the distribution of health
and disease, which suggests that
living environments vary accord-
ing to the degree they facilitate
or impede population health.^'
However, the abundance of re-
sults that establish an empirical
link between health and place is
not refiected on a conceptual
level.'" Although we agree with
Macintyre's call to better concep-
tualize the social aspects of

health, we further argue that
such theoretical knowledge must
be linked with, and even emerge
from, the various social change
programs that are experimented
with by numerous organizations
when attempting to address
health inequalities. It is this form
of public health programming, in
which health penetrates the so-
cial realm, that requires strong
theories to support further inno-
vative public health practice.
There is increasing support for
social-change programs at all lev-
els of the health system's deci-
sionmaking bodies, when a dis-
course promoting practice that
fosters integrative approaches on
the basis of partnerships among
all relevant actors is articulated.
For example, the World Health
Organization has made intersec-
toral action a key intervention
strategy.̂ ^ In a recent document.
Health Canada stated that an in-
tegrated health promotion and
prevention strategy should em-
ploy a "setting approach" on the
basis of intersectoral partnerships
that bring together a multiplicity
of actors from both social institu-
tions and civil society. '̂' Simi-
larly, Sweden's "Health on Equal

Terms" policy is the result of an
exercise that involved all sectors
of society.̂ "'
In response to these and other
repeated recommendations for
developing and implementing
social-change programs on the
basis of broad reciprocal partner-
ships, many examples of innova-
tive practices are appearing in
the literature. In essence, practi-
tioners develop alliances and
share resources v«th concerned
groups and create local solutions.
Such practices are not just a mat-
ter of bringing individuals to-
gether under the umbrella of a
program planned and imple-
mented by public health profes-
sionals. The purpose is to estab-
lish enduring partnerships with
all actors in a community who
are concerned with issues that af-
fect health.^^ Moreover, these
projects cover a vast spectrum of
the social and life sciences and
promote the exchange of rele-
vant knowledge between both
professional and lay individuals.
Such broad dialogues, carried
out in a nonhierarchical mode,
can create knowledge essential in
which readily available solutions
cannot be implemented.^^ These
interventions developed with—

592 I Social Determinants of Health Inequities | Peer Reviewed
| Potvin et al. American Journal of Public Health | April 2005,
Vol 95, No. 4
rather than applied to—communi-
ties call for a change in program
planning paradigms. A general-
ized paradigm shift would help
move planning and partnership
practices from the mere creation
of consultative processes to coap-
propriation of programs by, and
empowerment of, mobilized ac-
tors from the community.
Numerous innovative interven-
tions reported in the literature
have illustrated how the evolu-
tion of practice opens up new di-
rections for theoretical work that
we think ought to be grounded
in emergent practices. Unfortu-
nately, current thinking about
public health program develop-
ment, as exemplified by models
such as PRECEDE/PROCEED,
fosters a rationality that gives pri-
ority to the identification of pub-
lic health priorities through ob-
jective means. In the case of
PRECEDE/PROCEED " those
objective means are a sequence
of social, epidemiological, and

educational diagnostics estab-
lished at the beginning of the
planning process. Thus, the first
challenge facing public health is
to organize and integrate knowl-
edge about social determinants
of health and innovative partner-
ship practices to support the de-
velopment of theory that is suit-
able for social-change programs
in public health.
Developing a Theory About
Evaluation
The second challenge is to de-
velop a theory about evaluation
that fosters refiexive understand-
ing of public health programs en-
gaged in social change. There is
a lively debate about what con-
stitutes appropriate approaches
and methodologies for evaluating
and drawing valid scientific
knowledge from the innovative
public health practices already
We are very fa-
miliar with the abundant litera-
ture on evidence-based practices
and the numerous attempts to
adapt this discourse to the evalu-
ation of new public health prac-
tices.^" However, we believe that
the parameters defining opposite
opinions in this debate do not

allow for the proposal of proper
conceptual and methodological
tools.
The 2 extreme positions in
this debate illustrate the age-old
opposition that has existed be-
tween positive science and rela-
tivist approaches to knowledge.
The former provides generaliz-
able and context-free results that,
in principle, allow the elaboration
of evidence-based programs to
solve objectively defined prob-
lems; the latter proposes a con-
textualized interpretation on the
basis of a consensus that brings
together the points of view of all
relevant actors and thus bears
strong potential to improve local
practices. We believe that pre-
senting the dilemma around
these 2 paradigms only serves to
create an impasse." In our view,
consensus is not possible or de-
sirable, because it masks power
struggles and it restricts the de-
velopment of innovative solutions
through informed dialogue and
compromise. Moreover, profes-
sionals and practitioners who try
to implement social-change pro-
grams rarely find conceptual
tools pertinent to their practice in
the evidence-based discourse.^^
They rightly argue that generaliz-

able estimates of effects consti-
tute only 1 of mciny indicators
that reflect on their practice.
These indicators are not very
useful because they are synthetic,
distal, and do not provide infor-
mation on the dynamics of
change. Additionally, when used
at the exclusion of other types of
indicators, they may be blind to
some of the other, and possibly
more effective, mechanisms trig-
gered by the program. As we will
show, theoretical propositions of
contemporary social theory jus-
tify this unease. The problem is
not that practitioners have under-
standably become somewhat
reluctant to participate in evalua-
tion; rather, it is that the per-
ceived relevance of such an exer-
cise is low. Thus, the current
challenge is to develop a relevant
framework that v«ll foster a sys-
tematic reflection of practices in-
volved in social-change programs
so that the programs can be repli-
cated and refined. To do this, we
must go beyond the parameters
of the "paradigmatic" discourse.
THEORETICAL MARKERS
FOR ADVANCING PUBLIC
HEALTH PRACTICE

Our examination of the
post-Ottawa Charter public
health practice challenges mir-
rors 3 theoretical bodies of
work by contemporary social
theorists that refiect on the con-
ditions of modernity; (1) the
unintended consequences inher-
ent to human activity in com-
plex systems, (2) the critique of
the bureaucratic/structural plan-
ning model, and (3) a reflexive
epistemology to overcome the
objectivist/subjectivist dilemma.
The first marker stems from
the work of German sociologist
Ulrich Beck, who hypothesized
that risk is a by-product of
techno-sciendfic activity that has
been directing developments in
most fields of human action.
Beck argues that because risk is
situated in the future and in the
realm of the possible, rather than
that of the empirical, positive sci-
ences are blind to their exis-
tence. Consequently, techno-
scientific solutions are bound to
induce unforeseeable conse-
quences that institutional science
is incapable of anticipating, thus
laying the foundations for more
complex problems to materialize
in the future. '̂'

More than 30 years ago,
IUich '̂' identified varied iatro-
genic unintended effects inherent
to techno-scientific medical activ-
ity. In the field of public health,
improving population health indi-
cators goes together with the un-
desirable effect of increasing
health inequalities. In Western
societies, significant efforts to
construct and consolidate mod-
em health systems, including
public health, during the last dec-
ades are associated with spectac-
ular gains for a vnde range of
health indicators.''^ A growing
ntimber of studies, however,
show that these gains have not
benefited everyone equally,
which suggests that an increase
in health inequalities is an unin-
tended consequence of such im-
provements. For example, today
the number of smokers is 4
times higher among individuals
who have not completed high
school than among university
graduates''®; infectious diseases
that were thought to be under
control, such as tuberculosis,
have a higher incidence among
poor neighborhoods in large
North American cities^'; and,
studies have shown that even in
systems where universal access is

guaranteed, health service utiliza-
tion^* and survival rates among
individuals from more privileged
socioeconomic classes are higher
than among persons from disad-
vantaged groups.''^ The differ-
ences observed in the results of
health interventions according to
social class suggest that our inter-
ventions might contribute to
widening the gap in morbidity
April 2005, Vol 95, No. 4 I American Journal of Public Health
Potvin et ai. Peer Reviewed | Social Determinants of Health
Inequities | 593
UWi.
and mortality between the rich
and the poor."""'
The second marker is the
critique of the bureaucratic/
structural model at the root of
vertical programs designed in
top-down systems, which is
founded on the administrative
systems described by Max
Weber.''̂ These systems can be
recognized by the preponderance
of institutionalized rules and pro-
cedures that map out courses of
action. They leave little room for
contextual elements and con-

cerns or any contribution of non-
institutional actors. Their struc-
ture is such that power and
decisions are based on expertise
and authority. In this model, pro-
gram development is presented
as a strict sequence of hierarchi-
cal steps that proceed from
planning to implementation to
evaluation and, eventually, to
sustainability/institutionalization
on the basis of results from the
previous steps.̂ ^ The decision to
proceed to the next step is con-
ceived as a discrete event that is
justified by evidence-based data.
Recent publications have shed
light on a number of shortcom-
ings to this model. Empirical ob-
servations have shown that sev-
eral events that characterize
program implementation and
sustainability occur concur-
rently.'*'' A literature review of
program longevity shows that al-
though evaluation results con-
tribute to decisions about the fu-
ture of programs, the processes
that lead to these decisions begin
well before evaluation results are
available and are based on much
more comprehensive informa-
tion.''' Several programs can
readily be conceptualized as rep-
resentative of another model. In

opposition to an essentially rules-
and-procedures model, this other
model implies dynamic configu-
rations that are founded on
strategic objectives defined by all
relevant actors, whose goals and
purposes also depend on context,
knowledge, and interactions with
other systems of action.®
The third marker is derived
from the theoretical work of
Pierre Bourdieu, who hypothe-
sized that a theory of practice
can only be suitably developed
by transcending the opposition
between subjective and objective
knowledge and by situating prac-
tice itself as the very subject of
research. According to Bourdieu,
an objective stance assumes that
the nature of the social world is
given and predetermined cind,
therefore, the representations
that shape our practices can only
be elaborated at the expense of a
rupture between rationality and
experiential knowledge.'*'' Other-
wise, a subjective stance prevents
the consideration of the objective
relational systems that shape our
practices. To get beyond the in-
evitable character of such a di-
chotomy between subjective and
objective approaches to knowl-

edge of practices, Bourdieu sug-
gests a reflexive approach, where
the object of knowledge is not
limited to a system of objective
relationships between events,
which is the case in program
logic models that are based on
scientific knowledge.
For Bourdieu, knowledge of
practice, or practical knowledge,
can only be reflexive and dia-
logic. This means that practical
knowledge can only result from
the confrontation between the
objective systems of relation-
ships that structure practice and
the subjective experience of
social actors whose practices re-
produce and transform the struc-
ture. The results of this con-
frontation are then introduced
into the knowledge-production
process itself Thus, the reflexive
knowledge that is required for
planning, implementing, and
evaluating social-change pro-
grams also includes a dialectical
relationship between these 3 ele-
ments; an objective representa-
tion of the social world, a subjec-
tive system of knowledge, and
the structural conditions in
which they take place and that
tend to reproduce them.''''''^ A

reflexive approach to knowledge
requires a double movement of
objectification of the social
world and integration of objec-
tive knowledge into the struc-
turation of the subjective experi-
ence. Therefore, a reflexive
action is always an action that is
perpetually moving to position it-
self in space and time so that no
point of view is completely inter-
nal (subjectivist approach) or ex-
ternal (objectivist approach).
Hence, any reflexive practice is
situated within a space that
transforms itself continually with
social interactions. Such dynamic
processes of program implemen-
tation and evaluation have been
described in relationship with
participatory approaches to in-
terventions that are derived from
broad partnerships.^
CONCLUSION
The challenges of elaborating
program and evaluation theory
that takes social change into ac-
count highlight the limits of prac-
tice models that are based on
dissemination of expert knowl-
edge to practitioners. Because
these models leave little room
for local actors' knowledge in
the face of standardized expert

solutions, they do not explain
the mechanisms through which
programs are adapted and trans-
formed and then alter the local
environment. To resolve the
challenges associated with emer-
gent and innovative practice,
public hecilth must renew its
own theoretical foundations. In
fact, because it presents pro-
grams as objects that are more
or less independent of their con-
texts, and because it overshad-
ows the network of actors who
uphold them, the scientific basis
that underlies public health ig-
nores a substantial part of the
dynamic and social nature of
public health programs, i.e., their
capacity to adapt, innovate, and
propose pertinent, effective, and
transformative actions in re-
sponse to local dilemmas.
We maintain that the knowl-
edge base that should enable the
reproduction and transformation
of practice in alignment with the
principles of the Ottawa Charter
and the emerging progressive
policy is the result of translating
a dialectical link between these
innovative programs and their
evaluation. Public health pro-
grams cannot be reduced to a hi-

erarchical sequence of proce-
dures; rather, they function as
systems of action designed to
transform social reality. As such,
we believe that the knowledge
base of public health should be
situated more coherently within
a theoretical perspective that
seeks to understand and gtiide
our contemporary world. It is
time to consider social theory as
a way of reconciling public
health practitioners, decisionmak-
ers, and researchers. •
About the Authors
Louise Potvin, Syivie Gendron, and Angele
Bilodeau are with the Lea-Roback Centre
for Research on Social Health Inequalities
of Montreal, Quebec. Louise Potvin and
Angele Bilodeau also are with the Depart-
ment of Social and Preventive Medicine,
University of Montreal. Angele Bilodeau is
also with the Public Health Directorate,
Montreal Agency for Health and Social
Services. Syivie Gendron is also with the
594 I Social Determinants of Health Inequities | Peer Reviewed
| Potvin et al. American Journal of Public Health | April 2005,
Vol 95, No. 4
School of Nursing, University of Montreal.
Patrick Chabot is with the Groupe de
Recherchi sur les Aspects Sodaux de la

Prevention, University of Montreal.
Requests for reprints should be sent to
Louise Potvin, PhD, Social and Preventive
Medicine, University of Montreal, PO Box
6128, Station Centre-ville, Montreal, QC
H3C 3/7 Canada (e-mail: [email protected]
umontreal.ca).
This article was accepted November
13, 2004.
Contributors
L. Potvin originated the content and
wrote the article. S. Gendron and A.
Bilodeau contributed to the develop-
ment of the content, provided public
health practice insight, and assisted with
rewriting the final draft. S. Gendron also
was responsible for final language edit-
ing. P. Ghabot contributed to the original
development of the bureaucratic model
of programming critique.
Acknowledgments
Louise Potvin holds the Chair on Com-
munity Approaches and Health Inequali-
ties funded by the Canadian Health Ser-
vices Research Foundation and the
Canadian Institute for Health Research
(CHSRF-CIHR #CPI-022605). Sylvie
Gendron was lunded by a joint Canadian
Institute for Health Research, Sodal Sci-
ences and Humanities Research Council,
and National Health Research and De-
velopment Program postdoctoral fellow-

ship awaixi (CIHR/SSHRC/NHRDP
#765-2000-0092).
Human Participant Protection
No protocol approval was needed for
this study.
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The challenge of diversity in the delivery of women's health
careBallem, Penny J.
Canadian Medical Association. Journal: CMAJ;
Ottawa Vol. 159, Iss. 4, (Aug 25, 1998): 336-8.
Full textFull text - PDFAbstract/Details
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FromArabic
Chinese (Simplified)
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German
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Over the last 8 years at BC Women's Hospital and Health Centre
(now part of the Children's & Women's Health Centre of BC) we

have had the opportunity to develop holistic programming in a
number of challenging areas to respond to the diversity of the
community we serve. We have come to appreciate that when
working with groups that have been underserved or
marginalized by the health care system, an essential first step is
to establish a trusting relationship based on mutual respect. This
can take longer to achieve than one might expect. It involves
creating an environment in which the community involved feels
safe examining its vulnerability with respect to health care
issues. Humility on the part of the professionals involved,
together with a willingness to learn about different perspectives
on health, sickness and wellness are key ingredients. In our
experience, it has been very important to include not only
physicians and nurses but also professionals in other
disciplines.
We have been fortunate that our government colleagues have
supported a responsive approach that encourages communities
to set their own health care agendas. Over time, opportunities
have arisen to put cervical cancer on the table for discussion.
After nearly 4 years, we have co-sponsored women's health
workshops and conferences in various communities, framing the
issues from an aboriginal perspective. For many communities,
this was the first occasion when priorities in women's health
had been examined and discussed. As a result of this partnering,
BC Women's has developed training programs to address the
specific needs of nurses and community educators from
aboriginal communities with respect to women's health issues.
Five communities are now providing their own women's
wellness services, staffed by aboriginal nurses who received
training through our program. Along the way, a number of
resources have been developed that look at women's health
issues from an aboriginal perspective, and strong partnerships
have been developed with other agencies and organizations who
are also working to better meet the needs of aboriginal

communities.
Dr. Ballem is Vice-President of Women's and Family Health,
British Columbia's Women's Hospital and Health Centre
(Children's & Women's Health Centre of British Columbia),
Vancouver, BC.
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To understand the perspectives of the many diverse groups in
our population and to respond effectively to their particular
health care needs is a monumental challenge. Diversity
encompasses many things -- ethnicity, culture, geography,
sexuality, disability, race, age and socioeconomic status, among
other descriptors - any of which can present a barrier to our
delivery of high-quality health care. Moreover, diversity is a
matrix in which every facet intersects with all the others. It is
impossible to anticipate every nuance of diversity as we plan
and deliver health care, but there are fundamental principles
that we should apply as we try to make those services truly
accessible.
To be genuinely accessible, health care services must be
responsive and intelligible; from the patient's point of view,
accessibility also implies safety, respect, comfort and
empowerment. If all of our health care services met these
criteria, most women would find their interactions with health
care professionals positive and productive.

Active listening
Over the last 8 years at BC Women's Hospital and Health Centre
(now part of the Children's & Women's Health Centre of BC) we
have had the opportunity to develop holistic programming in a
number of challenging areas to respond to the diversity of the
community we serve. We have come to appreciate that when
working with groups that have been underserved or
marginalized by the health care system, an essential first step is
to establish a trusting relationship based on mutual respect. This
can take longer to achieve than one might expect. It involves
creating an environment in which the community involved feels
safe examining its vulnerability with respect to health care
issues. Humility on the part of the professionals involved,
together with a willingness to learn about different perspectives
on health, sickness and wellness are key ingredients. In our
experience, it has been very important to include not only
physicians and nurses but also professionals in other
disciplines.
As health care professionals, many of us feel that we have a
good sense of sociocultural barriers to health care delivery and
how to address them. However, to proceed on the basis of this
assumption may be to miss the target. BC Women's Breast
Implant Centre provides a good example. Although the link
between silicone breast implants and recognized systemic
diseases is still unclear, a significant number of women in
Canada have both local and systemic signs and symptoms that
may be related to their breast implants. In BC a strong
community voice has emerged advocating services for women
with health issues related to breast implants. BC Women's was
asked by the provincial Ministry of Health to establish a
program for affected women. We thought we had a fairly clear

idea of what these women would want: a multidisciplinary
clinic providing medical consultation to complement the role of
the family physician, a pain management program and a peer-
support program. We were proven wrong.
Through our "listening and learning" activities we received a
clear message that these services were not of primary
importance to our clients. They wanted a centre that would
legitimize this health issue and provide a safe place to share
concerns and experiences. They wanted a centre where women
would be treated with respect and receive support from staff as
well as their peers, where scientific information could be
demystified and shared with women and health care providers,
and where physicians and other professionals could come
together to exchange information. Finally, they wanted research
to be done. As a result, the emphasis and format of the program
that evolved was radically different from what we would have
developed on the basis of our own intuition.
Setting priorities
Large national, provincial and institutional health databases in
this country provide a rich source of information on the health
status of Canadians. The welcome move toward evidence-based
decision-making has encouraged the use of such information in
establishing population health goals and program initiatives.
However, the priorities of health care planners and providers
and those of the population they serve are often far from
congruent with one another. This is particularly true in the field
of women's health, where there appears to be a significant gap
between health status data on the one hand and, on the other,
women's perceptions of their own health and their priorities
with regard to health care. In practice, it is difficult to engage a

community in addressing a given health issue if they do not
perceive it as a priority.
The BC Women's Aboriginal Health Program was funded by the
provincial Ministry of Health to address the inordinately high
rates of invasive cervical cancer among aboriginal women in
BC. Research and a demonstration project undertaken by the BC
Cancer Agency provided a clear description of the most likely
reasons for this: low uptake of cervical screening because of
lack of awareness of its importance, difficulty of access,
feelings of vulnerability with regard to pelvic exams and other
sociocultural barriers. We were given a mandate to work with
communities on Vancouver Island, where the data pointed to
particularly high incidence rates of advanced cervical cancer.
Our program coordinator has strong community connections,
and expectations were high. My colleagues in the government
who were responsible for funding the project reminded me that
outcomes could be readily monitored. We anticipated that by
helping to establish community-based women's wellness clinics
or even mobile clinics for cervical screening we would achieve
a dramatic increase in the number of women living on reserves
who would undergo screening for cervical cancer by the end of
2 years.
However, it quickly became apparent as we began to work with
women in a number of communities that, in spite of compelling
data on the high rate of cervical cancer, this health issue was
either absent from or very low on their list of priorities. With
respect to concern with women's health issues in general, each
community was somewhere along a continuum. At one end were
communities in which women had never had the opportunity to
articulate their thoughts about health issues affecting them. At
the other end were communities that had, through their own
health planning process, paved the way for the establishment of

women's wellness services and were therefore very receptive to
having us train their community nurses to provide screening. In
the middle were communities where other concerns such as
violence and teen suicide were more pressing. Needless to say,
at the 2-year mark, if our funding model had been based on the
number of Papanicolaou smears taken, we would have been in
serious difficulty.
However, we have been fortunate that our government
colleagues have supported a responsive approach that
encourages communities to set their own health care agendas.
Over time, opportunities have arisen to put cervical cancer on
the table for discussion. After nearly 4 years, we have co-
sponsored women's health workshops and conferences in
various communities, framing the issues from an aboriginal
perspective. For many communities, this was the first occasion
when priorities in women's health had been examined and
discussed. As a result of this partnering, BC Women's has
developed training programs to address the specific needs of
nurses and community educators from aboriginal communities
with respect to women's health issues. Five communities are
now providing their own women's wellness services, staffed by
aboriginal nurses who received training through our program.
Along the way, a number of resources have been developed that
look at women's health issues from an aboriginal perspective,
and strong partnerships have been developed with other
agencies and organizations who are also working to better meet
the needs of aboriginal communities.
Expectations and outcomes
As we learned in the Aboriginal Health Program, working in
collaboration with a community to establish a service requires

more time than conventional approaches. Moreover, output and
outcome are more difficult to measure, a fact that speaks to the
need to develop indicators that more adequately measure our
progress in addressing the concerns of difficult-to-serve
populations. Measuring patient visits or looking for shifts in
incidence rates or other health status indicators are of little use,
especially in the early years of programs such as this. As Dr.
Lorna Sent and colleagues describe in this issue (page 350), the
Asian Women's Health Clinic in Vancouver will not by itself
make a significant impact on the number of cases of invasive
cervical cancer in immigrant Chinese women even after 4 years
of activity. However, in both of these programs we are
attempting to track such variables as changes in practice
patterns, level of community interest in women's wellness as a
whole, and awareness of the importance of screening programs.
At the beginning of such initiatives, it is important to establish
indicators of success that are innovative and will help us
understand how programs such as these affect health-promoting
behaviours and health service delivery as well as health status.
Advocacy
Achieving the best possible outcome in our health care services
for diverse communities often requires a crosssectoral approach.
The Sexual Assault Service at BC Women's provides urgent
medical care, counselling and forensic evidence collection for
survivors of sexual assault- who often become isolated after
such an event and among whom street women and teens at risk
are overrepresented. The program relies on close partnerships
with the police, crown counsel, community rape crisis services,
victims services, physicians, nurses, counsellors and social
workers.

Women who have survived a sexual assault present many
challenges to physicians. We have learned that within 48 hours
of the assault most survivors cannot be contacted and want to
have no further interaction with the health care system.
Furthermore, many want to avoid interaction with the legal
system because of their perception that they will be
revictimized in the process. The goal of our program is to
provide women with excellent supportive health care, legal
issues being secondary. To return to our fundamental criteria of
safety, respect, comfort and empowerment, women who have
been assaulted have a right to health care that allows them
choice and informed consent. Therefore we do not collect
forensic evidence under any circumstance without a woman's
consent, nor do we requisition drug testing unless the woman
herself requests it. Our health-based framework is sometimes at
odds with the legal framework, which has as its goal the
arraignment of the perpetrator. Thus, tension sometimes arises
in our relationships with our colleagues in the police force and
the crown counsel's office with respect to issues such as the
collection of evidence from an unconscious woman or the
routine ordering of drug screening for survivors.
To ensure that our health services remain safe, respectfill,
supportive and responsive, we have spent a significant amount
of time in challenging discussions with our lawenforcement and
legal colleagues. We have come to a better understanding of one
another's paradigms and goals, but the Sexual Assault Service
has stood firm on its basic premise that each woman has the
right to choose how her case is handled. Our community
partners working in rape crisis centres are giving us a clear
message that we are on the right track.
Hidden dynamics

Over the last few years our understanding of the barriers to
access to health care has improved considerably. Language,
culture, geography, family responsibilities, inflexibility in the
workplace and poverty are frequently cited as factors that can
impede access. But there are other, more subtle, dynamics that
are important to understand. Some of these issues may come to
light through focus groups or other informal exchanges with
groups of women in the community; others are stumbled upon
by accident.
In our Aboriginal Health Program we found that a number of
women resisted the idea of a women's wellness clinic. On
further investigation, it appeared that their male partners
perceived the cervical screening program as equivalent to the
STD clinic. Because contact tracing is mandatory in the
province for STDs, the men were reluctant to allow their
partners to access the program. Although the solutions to this
problem are complex, understanding the dynamics at work has
been an important first step.
The broad diversity of our population presents many challenges
to physicians who strive to provide inclusive, respectful and
effective health care services. At BC Women's we have learned
many powerful lessons over the last few years that will inform
our future endeavours. Our hope is that the outcome will be
health care that is truly accessible to the diverse groups of
women that we serve.
AuthorAffiliation

Dr. Ballem is Vice-President of Women's and Family Health,
British Columbia's Women's Hospital and Health Centre
(Children's & Women's Health Centre of British Columbia),
Vancouver, BC.
AuthorAffiliation
Reprint requests to: Dr. Penny Ba/lem, Women's and Family
Health Program, BC Women's Hospital and Health Centre,
D213-4500 Oak St., Vancouver BC V6H 2N1
Word count: 2116
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