Building Community Capacity Through Health Education at the Grassroots

Special Articles / Joy Penman / Community Work : Theories, Experiences & Challenges

Abstract
The University of South Australia at Whyalla has been involved in various community engagements, including health education sessions, which enable community members to build their self-management capacity and increase the human capital of the community.These educational sessions are conducted by staff and invited guest speakers, including this author who is an academic and also health director of a local church congregation.

For the past six years, this author has been conducting health education sessions,on a weekly basis where possible, as part of the church program.The main aim was to prevent or manage chronic medical conditions among church members.In addition, health seminars and screens have been arranged regularly to keep members up to date with the latest developments in health, conduct health checks, and encourage members to observe a healthy lifestyle.

This paper discusses the value of these health education sessions.Using a cross-sectional study design, a 12-item Likert-type evaluation questionnaire was administered to gain feedback on church members’perceptions of the sessions and their impact, and what they considered to be the best aspects and areas for improvement.

Of the 35 regular church attendees, 14 completed the questionnaire,representing a 40% response rate.The encouraging results showed that, as a consequence of hearing the health messages, the majority of the participants felt positive about maintaining good health and were practising good health habits.The best things about the sessions were the ‘clear and concise’, ‘relevant’, varied and detailed information provided; however, the participants wanted more information on particular topics such as junk food and caffeine, and a few more pictures, diagrams and DVDs to go with the presentations.More important, however, is their gaining in self-efficacy, empowerment and capacity to manage their own health.
Keywords: health education, health promotion, capacity building, faith community

Introduction
The Centre for Regional Engagement (CRE) of the University of South Australia (UniSA) is responsible for two regional university campuses, the largest of which is at Whyalla.It has sought to be responsive to the needs of its surrounding community through innovative ways of providing education (Penman & Ellis, 2004).The CRE has human resources that enrich community human and social capital connecting individuals and groups.In engaging with community members, the CRE contributes to the learning and capacity building of individuals and communities (Penman & Ellis, 2010; Penman, 2009).

The author of this chapter is one of the CRE Whyalla Nursing and Rural Health unit’s staff involved in delivering many community educational sessions.The central focus of the majority of the sessions conducted is health.Historically, health education and health promotion activities aimed at maintaining and promoting the health and well-being of the Whyalla community have been undertaken through public forums and health fairs (Penman, 2009).However, this community involvement has been extended to a local faith community in the last six years when this staff member took on the role of health director at the local Adventist Church. 

The value of faith communities, defined in this paper as churches or religious institutions of a particular faith, in health maintenance and promotion has been recognised in the past.Chatters, Levine and Ellison (1998) demonstrate the strong interconnections between public health, health education, and faith-based communities. Many studies support the close association between religious involvement and health (Alves, Alves, Barboza, & Souto, 2010; Campbell, Yoon,& Johnstone, 2010; Baetz& Bowen, 2008; Koenig, McCullough,& Larson, 2001).The growing public interest in faith communities lies in the view that faiths are a reservoir of resources important for building and strengthening of communities (Dinham, 2011). The same author explains that faiths have human and material assets which can be mobilised for the provision of welfare and social services, participative neighbourhood governance and initiatives for community cohesion (Dinham, 2011).In the same light, Smith (2002) describes the faith-based community work that is currently being undertaken in urban areas in England and concludes that faith communities have a role in community development. 

With these potential outcomes in mind, this health director has been engaging consistently with the faith community by conducting health-related activities targeting church attendees.The health-related activities consist of health talks (weekly for most weeks of the year), and annual health seminars and/or health fairs.The engagement with a faith community presents an exciting and unique opportunity for community outreach as free health education, health assessment, early detection of health problems, and increased awareness of the impact of lifestyle choices on health are provided.

Are these sessions helpful in promoting the health and well-being of a faith community? If yes, how are they helpful? This paper discusses the value of the conducting health education sessions for church members (referred to also as participants), highlighting their benefits and implications as well as determining how to optimise their use in learning and behaviour. While the health-related activities undertaken consisted of the health talks, health seminars and/or health fairs mentioned above, the focus of this paper is on only the weekly health education sessions which have been integrated into the church program.

Background
Australia’s health profile ranks amongst the best in the world in terms of life expectancy and infant mortality.Australia has the joint fourth-highest life expectancy (along with Switzerland) over the period 2005-10 for males (Australian Institute of Health and Welfare [AIHW], 2013), while it has the joint third-highest female life expectancy in the world.However, there are still pockets in society that have high risk factors predisposing some community members to ill health (Lee & Bishop, 2010).The reasons for poor health and/or deteriorating health for some communities are varied and complex.Among these are problems in accessing services, lack of services, poor English proficiency, variations in cultural health and illness beliefs and inappropriate and/or insensitive health services and programs.The reality of communities today is that some are better resourced than others (Ife, 2013), and so some communities may need more community work to develop into stronger and healthier communities.

Whyalla is the geographical location of this community capacity building initiative.The regional city is located in the Upper Spencer Gulf Region, about 400 kilometres north-west of Adelaide.It is the second-largest regional city in South Australia with a population of approximately 23,000.Of this population, according to the 2011 Australian Census, about 25.8 per cent were born outside Australia,4.2 per cent were of Aboriginal descent, and.6.0 per cent of residents of the Whyalla Local Government Area spoke a language other than English at home (Australian Bureau of Statistics, 2013).The majority of Whyalla residents receive some form of government financial support. One Steel-Arrium is Whyalla’s major employer.As well as the UniSA campus in Whyalla, there is a local TAFE SA campus.The most prevalent medical conditions in Whyalla include asthma, stroke, high blood pressure, high cholesterol, anxiety and depression, and diabetes (Dal Grande, Dempsey, Johnson,& Taylor, 2000).
The concept of community capacity building pertains to community members developing competence to function better and achieve goals, thus achieving a ‘sense of empowerment’ (Kenny, 2011, p. 193).Empowerment refers to ‘the ability of people to gain understanding and control over personal, social, economic and political forces in order to take action to improve their life situations’ (Israel, Checkoway et al., 1994, as cited in Baum, 2000, p. 352).Increasing capacity and becoming empowered involve changes in structures, resources, behaviour and skills in order to do certain tasks or activities, which in this case is to care and be responsible for one’s own health.

Capacity building is viewed in a variety of ways.It is a means to an end as in methodologies for the purpose of improving performance or it is an end in itself (Kenny, 2011; Eade, 1997).Another view of capacity building is stimulating and training by external agents who build capacity for communities, i.e. a deficit approach.The orientation of capacity building could be viewed top down or bottom up.The elements that constitute it include: ‘identifying and accessing opportunities; monitoring context; developing a strategy; drawing on existing experiences, skills and capacities, existing resources; providing knowledge, workshop and training; and developing and implementing strategies’ (Kenny, 2011, pp. 197-198).

Capacity building is also consistent with community development.One definition of community development that is pertinent to this topic on health education sessions is ‘a process in which a community grows or builds its capacity to protect and enhance the health and wellbeing of its members’ (Mitchell, 2000, p. 161).In other words, community development happens when the capacity of individuals is developed to determine their needs and priorities and act on these (Eade & Williams, 1995, p. 9, as cited in Eade, 1997, p. 23)

The capacity building approach taken by this educational initiative for church goers is asset-based (i.e.,focusing on the many strengths of the participants), as well as mutual (i.e., participants sharing the need to improve their capacities), and internal (i.e., the local church community does its own self-capacity building).The initiative involves educating and training participants on health maintenance and promotion, guided by Christian principles, using local individuals and resources, and sharing the need to improve certain aspects of health with the rest of the faith community.From a community development perspective, the capacity building principles relevant to this initiative include: making a positive difference to the community; community ownership; developing participants’capacities; and community self-determination (Kenny, 2011, p. 200).Some of these aspects are revealed in the recent evaluation of health education sessions.

Health Education Sessions
The motivations underpinning the conduct of the health education sessions are many, including a genuine interest in the health and well-being of the participants.Rural people are significantly disadvantaged in comparison to their urban counterparts (Baum, 2008).According to AIHW (2008, p. 80), ‘those who live in rural and remote areas generally have poorer health than their major city counterparts, reflected in their higher levels of mortality, disease and health risk factors’, irrespective of the great diversity represented by these areas away from large cities.The church members expressed the need to keep up to date with the developments in health as knowledge continuously increases.However, educational opportunities are limited in rural and regional areas for reasons relating to equity and access.

Providing education sessions is one way of bridging the gap in knowledge of health issues.The deficits in knowledge may be addressed by a local individual, this university academic/health director, for example, whom church members view as a resource and authority in the health field.More than credibility, there were years of relationship building involved, where respect, trust and positive regard have been established.Important to note also is the fact that the Seventh-day Adventist Church advocates wholeness and health.The church is known for presenting the so-called ‘health message’ that recommends vegetarianism, abstinence from certain foods, and emphasis on exercise, water, fresh air and temperate living, amongst others (General Conference of Seventh-day Adventists, 2013).As the physical body is seen as sacred, the church discourages its members from the use of alcohol, tobacco, caffeinated beverages or illegal drugs.

Much effort is devoted to the planning, implementing and evaluating of the health education sessions, which aim to share current information about health-related topics of interest to those attending church.The crucial steps undertaken include the planning and organisation of the health talks, including determining the content, teaching approach, time and duration.The content is categorised either as managing common medical conditions or health promotion.A typical session averages 20 minutes including a five to ten minute question and answer segment.Some topics covered have been suggested by church members; however, the majority of the topics are determined by the health director, guided by the most prevalent medical conditions in Australia, specifically in Whyalla, and the latest discoveries and developments in the health field that proved or disproved the health principles subscribed to by the church.The implementation phase includes the use of various teaching tools such as PowerPoint presentations, online and printed materials and equipment, pictures, posters, clips, diagnostic tests, role plays and demonstrations and return demonstrations1 (e.g. deep breathing, stretching exercises, hand massage).

The format in discussing common medical conditions typically has a number of components: the definition, cause/s of disease (if known), clinical manifestations (signs and symptoms of disease), and interventions and treatments (including complementary and alternative therapies).The format for conducting health promotion sessions relates to the Adventist lifestyle program which aims to prevent and reverse disease through natural methods (Weimar Institute, 2013.). The program uses the acronym NEWSTART, where N stands for good nutrition, E for exercise, W for sufficient water, S for sunlight, T for temperance, A for fresh air, R for rest and relaxation, and T for trust in God.The overall message is that the individual’s lifestyle choices do impact on health outcomes and that the individual is ultimately responsible for his/her health.In addition to the presentations, educational materials are sometimes distributed for reference. Individualised health education and follow-up consultations on various topics are also provided.Referrals to other health professionals and health services are made as appropriate.A walking group, an exercise class and a few healthy cooking lessons all under the title ‘Healthy mind, healthy body’ complement the educational sessions.

Evaluation Method
A cross-sectional study design, which is a type of observational study, was used to evaluate the participants’ experience with the health education sessions.In cross-sectional studies, the study factor (i.e., conduct of educational sessions) and the outcome (i.e., perceived impact of the sessions) are examined together in one sample and atone point of time (Buttner & Muller, 2011).All participants were invited to evaluate the initiative using a 12-item evaluation questionnaire.Feedback from participants is paramount in order to continue improving the initiative.It is also important to determine whether objectives are met, who actually benefited, the impact on the community, and specific areas for improvement.Before completing the questionnaire, they were informed about the voluntary nature of their participation in the evaluation and were assured of the confidentiality of information provided. Participation in the evaluation was taken as consent.

Using a Likert scale, participants were asked to tick the most appropriate response (Strongly disagree; Disagree; Neutral; Agree; Strongly agree) for each of the nine statements that reflected the outcomes of participating in the health education sessions. (See statements relating to session attendance listed in Table 1.)The participants also had the opportunity to: identify the best things about the health education sessions, make suggestions to improve future offerings, and record other comments they might have.(See Table 2.)

Results
Of the 35 regular church attendees, 14 completed and returned the questionnaire,representing a 40% response rate.Feedback from faith community members has been positive and satisfactory as summarised in the tables below:

Discussion
The results of the evaluations of the health initiatives were positive overall with participants showing a high degree of approval; additional comments were encouraging.The health education sessions were deemed a pleasant experience, which is important for learning to happen.However, while there were many learning opportunities, it is important to understand exactly how the participants were affected.The following discussion will focus on the impact of the sessions on the participants.

Better understanding of health concepts
The health education sessions afforded the participants a better understanding of common illnesses and the treatments involved in these.The sessions also were opportunities for participants to learn about the influences of lifestyle, diet, exercise, rest, smoking, and alcohol use on good health.They were assisted in understanding the link between lifestyle and diseases as well as health principles governing the human body and strategies for maintaining and promoting health.Knowledge discovery happened, as revealed in these comments by the participants who reflected on the best aspects of the sessions:

Understanding what and how much what we eat and drink, and that the choices we make every day do affect every part of our body

Showing how we can improve our lives by small changes in our diet, exercise etc.

An awareness of certain foods and the damage they can cause us.

While many participants were familiar with the link as they have been introduced to the health message in the past, they appreciated re-learning about it.They were pleased to note how recent scientific studies supported and confirmed their health beliefs and practices.One participant explained:

Using science to confirm what we have known all along, the natural stuff.It’s all back to basics – diet, exercise, sunshine, water, less stress and so forth, but we need to be reminded and these sessions achieve just that.

The majority of the participants held a positive regard for this educational initiative. Broderick (2013) noted that positive emotions help build resilience, which is crucial for health and well-being.Hence, the faith community has now adopted this health promotion activity as a part of its order of service.While the participants reported positive and satisfying experiences with increased understanding of health maintenance and promotion, other effects on the participants are now discussed.

The role of religion and spirituality
As alluded to earlier, religious involvement and health have been linked in the literature.Religion is rooted in a faith tradition and involves adherence to shared beliefs and practices associated with organised systems (Peach, 2003).Broader than religion, however, is the concept of spirituality.Spirituality has been defined as a search for greater meaning, purpose and direction in living (MacKinlay, 2006).Currently, the conceptual understanding of spirituality has expanded to include relationships and connections amongst human beings, nature and their God (Wiklund, 2008; Harrington, 2006; Peach, 2003).Traditionally, spirituality has been linked with religion.

Spirituality has relevance for the health outcomes revealed in this study.Spirituality facilitates psychosocial support, existential meaning, a sense of purpose, a coherent belief system and a clear moral code promoting health and well-being.This concept was demonstrated by the participant that remarked:

I feel very positive about God’s advice about health.I want to practise good health habits.I am encouraged to cut down meats, sugar and dairy products.

The relationships between spirituality and better clinical health outcomes may be explained through the impact of biological, bio-psychosocial and behavioural mechanisms.The plausible biological mechanisms relate to neurohormones and immune measures (Campbell, Yoon, & Johnstone, 2010; Ironson & Hayward, 2008).The interconnections of the mind, spirit and body become the focus of attention when explaining the relationship between spirituality and health, according to Clarke (2010); what affects the body impacts upon the mind and the spirit.Martinet al. (2010) promote the client’s view of God and spirituality on health, illness, healing and care-seeking behaviour.The personal resilience and connectedness are means by which individuals can claim a good quality of life despite life-threatening illnesses (Denz-Penhey& Murdoch, 2008).

Gaining self-efficacy
The health education sessions provided the participants access to needed knowledge about health from a resource person and other resources supplied by her.The participants gained self-efficacy and were empowered as they acquired knowledge, and developed further understanding and control over factors affecting health (Israel, Checkoway et al., 1994, as cited in Baum, 2000).More significant is taking action to improve their health status.A participant responded when asked for further comment:

It is empowering knowing we could do something to prevent diabetes, heart attacks and strokes, that it is not what just happens as a consequence of age.

The sessions focused on the inherent personal strengths of individuals in helping them make the necessary changes to achieve better health outcomes.These are referred to as strengths based practices (Pulla, 2012), which promote coping, empowerment and resilience.At the same time, however, the participants recognised their ultimate source of strength as God, hence, putting emphasis on faith-based practices as well.

The survey showed that the participants felt positive about maintaining good health. Many of them indicated that,as a result of the health education sessions,they were in fact practising healthy lifestyles.Below are reflections about the health education sessions:

The sessions made me realise that I should take my diet really seriously now.

Made us think more about what we eat and how we eat etc.

Through regular health education sessions emphasising health promotion, the participants were encouraged to take a proactive approach to health instead of a reactive one.They were encouraged to maintain a high-level of wellness and maintain and promote their health.A proactive approach empowers community members to be partners in managing their own health (Cavaye, 2007).The participants were empowered to take their learning further and gain control of their health.

I could change, though it may be hard and may take some time.I could unlearn some unhealthy habits and adopt new ones that have been shown to be helpful to good health2.

Enabling participants to acquire usable knowledge and information, act on their needs, and become confident in managing their health, may contribute to capacity building and improvement of quality of life.Lifestyle change incorporating self-care, for instance, is an example of what might be achieved following positive health behaviour change.

Capacity-building
The education sessions supported and facilitated the learning of participants on health matters, reframe health problems in ways that they can understand, help them promote their health, make lifestyle changes as necessary, find the resources that might help, and prevent health problems rather than simply respond to problems.In better understanding their bodies and medical conditions, participants were challenged to think strategically and reflectively, thus putting theory into practice and facilitating decision-making and capacity building.In short, at the most basic community level, the resources and skills transferred to the faith community during the health education sessions can be seen as building community capacity.A participant noted:

I learnt that there are these basic health principles of healthy living to prevent chronic conditions in the future.A simple physical exercise routine for example will help conditions like diabetes, hypertension and cholesterol.

A take-home message for me is to make an appointment to see my doctor even though I am not sick.Regular health checks could provide useful information about my health.

The participants have been able to apply the lessons of the education sessions to their everyday lives.They were able to identify, reflect and solve their own problems and minimise potential health risks and complications by initiating changes in their lifestyle.The sessions have clarified and resolved many conflicting ideas about some health issues, at the same time confirming some beliefs and practices observed by the participants.During the course of the sessions, the participants involved were able to establish links with health care services and health care professionals.They have been able to contribute topics of interest to be discussed during the sessions.Another church member was keen to assume the role of health director and volunteered to take a leadership and advocacy role as well.Moreover, the initiative has been able to engage the local media in promoting relevant health issues and has involved non-formal and informal health training of some participants through short courses and workshops resulting in further up-skilling of community members.Consequently, more organisational resources have been directed to the area of health in this faith community resulting in the conduct of annual community events.All these are indicators for capacity building; at least three participant responses attest to this as they determined how to improve the initiative:

Longer question and answer time
Have more seminars open to the public
Good to use local experts in the community

Future directions
The direction these health education sessions will take will be guided by the suggestions offered including continuing the beneficial sessions and having more health seminars opened to the wider community.Specific additional topics suggested for discussion will be considered in the future: ‘info about junk food’, ‘the effect of caffeine’, and ‘the effect of food – vegetables, fruits etc. on individual parts of our bodies’.Having a suggestion box has been highlighted, indicating a desire to contribute to the planning and implementation of the initiative.Some presentation suggestions have also been put forward: ‘More pictures and diagrams would be helpful’, ‘Show DVDs like “Forks over Knives”’ and sampling of healthy and ‘free food’.

The fact that people requested sessions on specific areas of education and training that they believed were needed was the key factor in the successful links with the participants.As Mitchell (2000) highlights, education and training benefit community members profoundly if they are spearheaded by the community.In most of these sessions participants’ knowledge about health matters has been developed, expanded and challenged.The capacity of participants to identify their health needs and care is encouraged through the process of study and reflection on the options available to them.

Conclusion
There were many benefits derived from implementing these health education sessions.Valuable learning occurred for the participants and organiser/facilitator involved.Short education sessions were found to be valuable when offered on an ongoing basis and in conjunction with services rendered by local health services.The findings of this initiative resonate with those conducted by the health director under the Centre Regional Engagement of the University of South Australia banner (Penman, 2009; Penman & Ellis, 2004, 2008, 2010).This initiative contributed to increased self-efficacy, empowerment and community capacity building.

The impact of the sessions includes: increased knowledge of health concepts and management strategies and links to health resources and key people; increased feelings of responsibility for participants’own health; being more proactive rather than reactive in health; change in cultural health beliefs and practices; and potentially improved health status of participants.The process of identifying needs, acquiring knowledge and skills, and determining resources to address the needs enables greater self-efficacy.The participants become empowered to find their own solutions to their health problems by applying their learning and using various alternatives and available resources via strengths and faith-based practices.Self-efficacy and empowerment contribute to capacity-building and community development, which in turn increases human capital in the wider community.

The limitations of the study include the absence of long-term evaluation of health outcomes with regard to sustained behavioural change in participants and the lack of pre- and post-intervention comparisons.However, the feedback received showed that it is important to continue the initiative and to expand it further to involve the general public.This endeavour clearly demonstrates that a local volunteer resource person can be a focus for health promotion and health education.

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