HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 1 © Oxford University Press 2004.
All rights reserved
doi: 10.1093/heapro/dah107
10.1093/heapro/
Issues of participation, ownership
dap054 and empowerment
in a community development programme: tackling
smoking in a low-income area in Scotland
DEBORAH RITCHIE1, ODETTE PARRY2, WENDY GNICH2
and STEVE PLATT2
1
Department of Sociology, Queen Margaret University College, Edinburgh, UK and 2Research Unit in
Health, Behaviour and Change, University of Edinburgh, UK
SUMMARY
Founded on community development principles and
practice, the ‘Breathing Space’ initiative aimed to produce
a significant shift in community norms towards non-
toleration and non-practice of smoking in a low-income
area in Edinburgh, Scotland. The effectiveness of
Breathing Space was evaluated using a quasi-experimental
design, which incorporated a process evaluation in order
to provide a description of the development and imple-
mentation of the intervention. Drawing on qualitative data
from the process evaluation, this paper explores the varied
and sometimes competing understandings of the endeavour
Key words: community development; empowerment; process evaluation; smoking
INTRODUCTION
Current health promotion policy and practice
places a high value on community development
work (Robinson and Elliott, 2000) because it
aims to enable communities to identify problems,
develop solutions and facilitate change
(Blackburn, 2000). The overt ideological agenda
of community development is to remedy
inequalities and to achieve better and fairer
distribution of resources for communities (Tones
and Tilford, 2001). This is achieved ideally
through participatory processes and bottom-up
planning (Bracht and Tsouros, 1990; Bernstein
et al., 1994; Israel et al., 1994; Labonte, 1994;
Robertson and Minkler, 1994; Robinson and
Elliott, 2000; Smith et al., 2001).
Printed in Great Britain
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
held by those implementing the intervention. The paper
examines the principles that underpin health promotion
in the community setting, particularly the concepts of
ownership, empowerment and participation, and their
differential interpretation and employment by participants.
The data illustrate how these varied understandings had
implications for the joint planning and implementation
of Breathing Space objectives. In addition, the different
understandings raise questions about the appropriateness
and viability of utilizing community development approaches
in this context.
Empowering communities to have more say in
the shaping of policies influencing health
represents a break with earlier traditions of
public health associated with top-down social
engineering (Beresford and Croft, 1993; Petersen
and Lupton, 1996). However, community develop-
ment means different things to different people
and, as we shall see, can operate on different
levels (Arnstein, 1971; Brager and Specht, 1973;
Tones and Tilford, 2001). Community develop-
ment has, for example, been linked to community
organization, community-based initiatives, com-
munity mobilization, community capacity build-
ing and citizen participation. There is, however, a
common understanding of core principles, which
inform community development work (Bracht
and Tsouros, 1990; Robinson and Elliott, 2000;
51
52 D. Ritchie et al.
Smith et al., 2001), two of which are participation
and empowerment. These principles can and are,
however, operationalized differentially in
different types of community development work.
The concept of community participation has
proved to be more complex than was originally
envisaged by the early World Health Organization
(WHO) health promotion strategies (WHO,
1978; Rifkin, 1986; WHO, 1986; Rifkin et al.,
1988; Rifkin, 1995; Labonte, 1998; Zakus and
Lysack, 1998; Laverack and Wallerstein, 2001).
Despite consensus that community participation
should engender active processes involving
choice, and the potential for implementing that
choice, implementation has proven difficult
(Zakus and Lysack, 1998). For example, when
formal health services adopt an empowerment
framework, their formal structures are not nec-
essarily conducive to participation. (Rifkin,
1990; Labonte, 1998; Zakus and Lysack, 1998).
Although it is commonly agreed that appropriate
leadership and effective organizational structures
are crucial to successful community participation
(Laverack and Wallerstein, 2001), this requires a
political climate that nurtures and facilitates the
approach (Labonte, 1998; Zakus and Lysack,
1998).
Tensions can also occur where community
participation is engaged for disease prevention
purposes rather than following a bottom-up,
community-defined agenda (Rifkin, 1990;
Asthana and Oostvogels, 1996; Labonte, 1998;
Zakus and Lysack, 1998). It has been argued,
however, that these approaches are not neces-
sarily incompatible and that both positions can
be accommodated (Rifkin, 1990). If, it is sug-
gested, community participation is seen as a
process rather than an intervention this will
affect the value placed on different types of
outcomes (Rifkin, 1995; Labonte, 1998; Laverack
and Wallerstein, 2001).
However, there are many different levels at
which the community may participate and at one
extreme this may amount to little more than
tokenism (Labonte, 1994; Petersen and Lupton,
1996). Moreover, communities do not have the
same access as local authority organizations and
government agencies to those resources enabling
them to define and set the agendas and participate
on an equal footing (Labonte, 1994; Wallerstein
and Bernstein, 1994; Blackburn, 2000).
The concept of ‘empowerment’ has also
assumed different meanings within the context of
community-based health promotion work (Israel
et al., 1994; Labonte, 1994; Robertson and
Minkler, 1994; Laverack, 2001; Smith et al.,
2001). For example, empowerment may be at
either or both the individual and community
level (Bracht and Tsouros, 1990; Bernstein et al.,
1994; Israel et al., 1994; Labonte, 1994; Robertson
and Minkler, 1994; Robinson and Elliott, 2000;
Smith et al., 2001), and tension may exist within
community development practice between the
two levels (Robertson and Minkler, 1994;
Wallerstein and Bernstein, 1994). Whereas
individual empowerment might be concerned
with individuals gaining mastery over their lives,
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
community empowerment focuses on ‘the social
contexts where empowerment takes place’
[(Wallerstein and Bernstein, 1994), p. 142]. While
it has been suggested that the two levels are
interdependent, the aims of each may differ
(Robertson and Minkler, 1994) and this may
impede practice (Laverack and Wallerstein,
2001).
Community development has been used in
several major UK heart-health initiatives,
reflecting the centrality of the approach within
the New Public Health strategy (Robinson and
Elliott, 2000). There is, however, limited evi-
dence of its overall success (Farquhar et al., 1990;
Luepker et al., 1994; Carleton et al., 1995;
COMMIT Research Group, 1995; Goodman
et al., 1995; Shelley et al., 1995; Brownson et al.,
1996; Baxter et al., 1997; Secker-Walker et al.,
2000; Hancock et al., 2001). A major difficulty
in assessing effectiveness of different pro-
grammes arises because communities utilizing
this approach tend to interpret and implement
aspects of community development deemed most
appropriate to their specific needs (Buchanan,
1994; Robinson and Elliott, 2000). Because
community development programmes are not
operationalized in a consistent way it is difficult
to compare ‘like with like’.
In order to understand better how these
programmes perform, it is necessary to examine in
depth how the community development approach
is rolled out within the local context (Robertson
and Minkler, 1994; Wallerstein and Bernstein,
1994). To this end we draw on the evaluation of
Breathing Space, a community-based smoking
intervention in an area of low income. The paper
examines the development and execution of the
Breathing Space programme through participants’
understandings about community development
and the translation of these understandings into
health promotion practice.

METHODS
An independently funded study was undertaken
to evaluate the ‘Breathing Space’ initiative using
a quasi-experimental research design. In addition
to before and after surveys, a thorough qualitative
process evaluation was carried out which aimed
to document development and implementation of
the intervention and to assess threats to the
validity of the research design. This paper draws
upon in-depth interviews undertaken as part of
the study’s process evaluation.
The interviews
Fifty-six semi-structured in-depth interviews
were conducted with programme participants.
These comprised eight interviews with managers
from the three main partner organizations, seven
with the project coordinators, 28 with intervention
team members, 11 with subgroup members and
two with community development workers, with
responsibility for smoking cessation services,
employed by one of the partnership organizations.
The interviews, which were recorded, were held at
key points across the course of the project (audit
and planning, project design and development,
and implementation stages). They explored
respondents’ understandings and experiences of
intervention programmes at different levels
(overall programme organization and structure,
individual projects, and personal roles and
responsibilities).
Analysis
The interviews were transcribed and analysed
thematically with the assistance of qualitative
software (NUD*IST). Three members of the
research team developed a detailed coding
scheme. Some of the themes/categories agreed by
the team related directly to the aims of the eval-
uation and were identified before the interviews,
while others emerged through exploration of
the interview data. The robustness of all the cate-
gories was tested by reference to the individ-
ual cases, the conditions and contexts of
which were compared and contrasted. All three
researchers were involved in coding the data.
In order to ensure congruence between coding
styles, different researchers coded a random
selection of transcripts, discrepancies were
reviewed and agreement of the final coding
scheme was negotiated.
Empowerment issues in community development 53
Data extract identifiers
In the Results section, extracts from the data can
be attributed to representatives from the
different respondent groups. Identifying
numbers for each extract are prefixed by a letter
which can be interpreted as follows: ‘M’ indicates
managers, ‘I’ indicates intervention team mem-
bers, ‘YS’ indicates those working at subgroup
level in the ‘Young Persons’ setting, ‘C’ identifies
those in the ‘Community Setting’ and ‘PC’
identifies those in the ‘Primary Care’ setting.
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
The origins of Breathing Space
Prior to Breathing Space there were two national
anti-smoking initiatives supporting smaller scale
projects using the community development
ethos and approach in Scotland. These were the
Women, Low Income and Smoking Initiative
and the Tobacco and Inequalities Project
(Amos et al., 1999; Barlow et al., 1999; Gaunt-
Richardson et al., 1999; McKie et al., 1999).
Breathing Space, however, was the first
community-wide development programme on
smoking in Scotland.
Breathing Space was a community health
promotion initiative, which aimed to produce a
significant shift in community norms towards
non-smoking in a low-income area in Edinburgh.
The community (Wester Hailes) was unusual in
that local community groups had identified
smoking as a priority health concern, which they
had begun to address through the implemen-
tation of no-smoking policies and the provision
of support for smokers who wanted to quit. The
Breathing Space programme was initiated by the
local health policy group—the health subgroup
of an Urban Regeneration Partnership—which
approached their local health board for help in
tackling the high prevalence of smoking in
Wester Hailes. The aim of the programme was to
capitalize on local knowledge and encourage
local involvement in the development of a
programme of activities that would create a
supportive environment to enable local people to
make healthy choices. Although focusing on four
main health promotion settings (community,
primary care, youth and schools, and workplace),
Breathing Space set out to bridge these settings
and create a health promoting environment
across the wider community.
Breathing Space was organized on three levels.
On level one, an intervention team, comprising
representatives from the partner organizations,
54 D. Ritchie et al.
was set up to oversee planning and imple-
mentation. This alliance formed a steering com-
mittee, which supported settings-based subgroups
(level two), whose remit it was to take project
objectives forward. Subgroup membership
included the main intervention team and other
community workers with particular expertise or
interest in that setting. The third level comprised
others who worked or lived in the community, and
who were involved in the implementation of
specific intervention activities.
DISCUSSION OF FINDINGS
Participation and ownership
Respondents felt that each of the Breathing
Space partners should have a different yet equal
role to play in the development and execution of
the programme. The role of Wester Hailes Urban
Regeneration Partnership (WHURP), for
example, was described by a (WHURP) manager
as: ‘… facilitating and taking forward some of the
actual interventions in specific settings where
there’s a health promotion specialist (health
board employee) working’, whereas the role of
the health agency was described as ‘taking
forward the community’s aspects, making sure
that the project is in line with community defined
needs’ (M5).
In practice, parity of participation was an issue
for many respondents. Hence, the manager
quoted above said ‘It can’t just be [us] providing
the support and doing the work’ (M5). Most
concern about parity of input, however, centred
upon Lothian Health Board (LHB), which was
singled out by many respondents as being too
prominent in both the development and the
implementation of Breathing Space. The pro-
portion of health board representatives (nine out
of 12 at one point) on the intervention team and
the heightened profile of health board workers
throughout the project contributed to the view of
some respondents that the programme was
‘developed effectively by one organization’ (I8).
Concern about the over-representation of the
health board was matched by at least equal, if
not greater concern about a perceived under-
representation of the local community
organizations:
I can remember one meeting where a senior member
of health board staff was talking about ‘we need to get
the community involved, the community involved’, but
what she was talking about were health visitors:
the pharmacists, the local shops—that is not a
community. (I8)
Hence, although Breathing Space was conceived
as a community development project, there was a
lack of agreement among the partners about
what community participation meant and who
should be involved.
Participation and ownership were not only
issues at an organizational/agency level, but also
at the level of their membership. Commitment
held by managers did not necessarily reflect the
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
commitment of members. The heightened
presence of health board workers did not appear
to arise from any intention on their behalf to
dominate the Breathing Space programme.
Indeed, a senior manager from the health board
described the initial ambivalence of some health
board workers as a function of their lack of involve-
ment in the early stages of the project:
To start with there wasn’t real ownership, there was a
lot of ‘phew, I’ve got to do this now’—whereas now
‘this is a piece of work and its going forward and I’m a
bit concerned about how I’m going to fit it in’. (M1)
Because some programme workers were not
privy to the initial decision-making processes
through which the programme evolved, the level
of enthusiasm or perceived ownership associated
with successful community development work
was forfeited.
Smoking as a priority
Many respondents felt that Breathing Space was
not a community venture and, related to this, that
smoking was not a community-defined priority.
Views on this issue differed according to the
organization that respondents represented and
the role they played in the initiation of the
programme. Representatives of the community
health agency felt that the community had
identified smoking as a priority because smoking
had been central to the community-based work
from which Breathing Space had evolved:
We were the core of the project before Breathing
Space came into being. It was built on the work that we
and the health project did. The whole thing evolved
out of our work. (I8)
Respondents, such as I1 from the Health Board,
who were key players in the initiation and early

development of the programme, also felt
that Breathing Space had evolved in line with
the principles of community development,
describing smoking as:
… located in the specific heart of the community. It’s
certainly located in the structure of the partnership.
I’m aware that it comes from the bottom up. (I1)
In contrast, those respondents who did not
represent community groups, and were not privy
to the early discussions from which Breathing
Space evolved, were less certain that smoking
constituted a community-defined priority. From
the perspective of a WHURP representative, for
example, other issues were described as more
pressing: ‘It’s always been drugs and alcohol that
have been its primary issues’ (I8). The health
board workers drew on their experiences of
working in the area to identify issues they saw as
important. For example, a health board young
person specialist said:
… we’re supposed to be talking about smoking in the
3rd year, and some of the girls start slagging another
girl off about having had sex for the first time the night
before. And I would say that is a bigger issue as far as
they are concerned than smoking. (I5)
Similarly, YS2, a youth agency worker, felt that
smoking was not high on the agenda of young
people:
I think in a lot of ways it’s an adult issue. You know
what I mean? It’s coming from adults it’s not coming
from young people … I don’t think they see it as a
huge issue. (YS2)
Some respondents felt that the focus on smoking
was ethically problematic. For example, I13 (an
intervention team member and health board
worker) felt that targeting smoking contributed
further to people’s already disadvantaged lives.
She described smokers as ‘people who maybe have
lots of needs, have complex needs’ and smoking as
‘their little bit of pleasure’ (I13).
Some respondents reported difficulties in selling
the programme to community gatekeepers. I16,
when describing the problems she encountered
when trying to get general practitioners on board,
said:
… it’s not a particularly nice feeling to be having to
work so hard to sell something … You get home and
say to yourself ‘I’m not peddling drugs here, I’m trying
to do something good’. (I6)
Empowerment issues in community development 55
Empowerment and service delivery
Respondents’ opinions differed as to whether
Breathing Space should focus upon broad health
issues or more specifically upon smoking
behaviour. Those taking the broader view talked,
for example ‘about looking at the underlying
issues and realising that smoking in a lot of cases
is a symptom rather than the issue itself’ (I5,
health board). These respondents also tended to
talk about the ‘the health of the local community’
(I10) rather than the health of individuals. I2,
from the health board intervention team, for
example, described her understanding of the
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
programme thus:
… the main idea of it was to look at smoking in a
community and in a wider context [as opposed
to] … the usual sort of health prepared stuff which is
about individual behaviour and so on. (I2)
Most respondents acknowledged that smoking
cessation work is traditionally focused at the
individual level. Indeed, for many, ‘one to one’
was a way of working with which they were most
familiar and felt most comfortable. PS4, a health
care professional in the primary care setting, for
example, described the programme work as:
going down the different channels with people who are
identified as smoking if they are wanting to either stop
smoking or to reduce their smoking habits. (PS4)
Targeting individual smoking behaviour was not
necessarily seen as incompatible with the aims of
community development work. Some, for
example, felt that increasing access to cessation
materials and support would lead ultimately to a
change in ‘perceptions on smoking in [the area]’
(PS3) and help ‘overall to reduce the number of
people that smoke’ (I13).
The programme was also affected by
institutional constraints experienced by those
working within the different partner organi-
zations. Some implementers felt they were
expected to demonstrate the type of tangible
outcomes associated with direct action about
smoking targeted at the individual level. For
example, the Breathing Space coordinator said:
As time has gone on there’s been a certain amount of
pressure to do things—practical things. And they tended
to be about smoking, directly about smoking. (R14)
Given the types of outcomes traditionally
expected of health promotion, the community
56 D. Ritchie et al.
development approach presented some
difficulties for respondents. Some, for example,
were uncomfortable with, and resistant to, the
idea of project objectives that were shaped by the
community agenda and that could evolve over
time. A health board worker involved in the con-
ception of the programme described the dilemma
this posed for some workers:
People are probably more used to working in a way
that’s erm—you know—you do this and then you do
this and then you do this. Whereas what we are trying
to do is to allow a process to emerge … and what
people are finding difficult is being diffuse … very
difficult, the anxiety is enormous. (I1)
RI1 felt, however, that workers who persevered
despite reservations could reach a better under-
standing of the enterprise, over time:
You know, it’s working quite slowly for people … ,
really its like pennies beginning to drop, and people
realising yes that’s what it is about. (I1)
Others, such as I2, a health board employee,
described her uncertainty about the unfolding
nature of the endeavour:
It’s very amorphous because it’s a developmental
project. That’s the nature of the beast … I’m not very
confident about doing this. It’s not knowing so
shapeless—and what’s going to happen and then it
comes together?
In addition, although those representing the
community based agencies were more likely to
be familiar with community development work,
not all of their members were similarly experi-
enced. For example, I12, a recently recruited
health agency employee, expressed a fixed
understanding that Breathing Space aimed to
‘Get mainly youngsters and teenagers to stop
smoking … to improve their health’ (I12).
This raises two important points. First, not
everybody, and particularly those working within
the statutory agency, were familiar and/or
comfortable taking a community development
approach. I5, for example, said ‘Well to start
with I didn’t have a clue what the principles
were’ (I5). Equally, those working at the
community level were not necessarily familiar
with the theoretical principles underpinning their
work: ‘[It’s] certainly difficult because there is
an awful lot more theoretical discussion around,
and we are very much on the practical … side
here’ (I9).
Secondly, even where workers were knowl-
edgeable about, or gained familiarity with these
precepts, they did not find it easy to translate this
knowledge into practice. Ways of working asso-
ciated with the different partner organizations/
agencies were understood by respondents to be
fundamentally incompatible:
… there are tensions in doing community
development if you are a statutory organization … it
doesn’t quite fit, because on one level it’s home grown,
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
it’s grass roots development, it’s power is located in the
community and then you are there as a totally
different, like well quite a powerful structure with
certain ways of working. (I1)
Unsurprisingly, respondents representing the
health agency described themselves as more
appropriately placed and better qualified to
support a community-based approach:
… we have a lot more facilities and support services to
offer … It’s not saying we are better, we’ve just got
more on offer in terms of alternatives and stuff than
say the GPs and the practice nurses. (CS1)
CONCLUSION
Findings from the process evaluation indicated
a disjunction between respondents’ conceptions
of Breathing Space as a community develop-
ment programme, and the translation of the pro-
gramme into actual practice. The data suggest
this is a function of a combination of factors, in
which participation, ownership and empow-
erment play major roles.
That the partner organizations were felt
to be represented unequally left many respon-
dents, particularly those from the community
agencies, feeling disempowered. While the
community partners felt entitled to programme
ownership, in that Breathing Space was seen
as developing out of their previous work on
smoking in Wester Hailes, the health board was
seen as the dominating and ‘more powerful’
partner.
This was perceived as particularly problematic,
as of all the partnership groups, the health board
was understood to be the least sympathetic or
amenable to the aims of community development
and the least able to accommodate ways of

operationalizing the programme necessary for its
success. In particular, a narrow focus of the health
board on the health of individuals and on smoking
behaviour per se was, given the community
development aims, felt to place inappropriate
expectations and constraints upon programme
outcomes.
The different approaches, which appeared to
index the respective positions of the community
organizations and the health board, reflected two
separate discourses operating within the
programme simultaneously. The first favoured
the concept of community development and
empowerment, while the second favoured
prevention of unhealthy lifestyles (and to a lesser
extent the promotion of individual empow-
erment). That these discourses were seen as
mutually reinforcing rather than incompatible by
many respondents, reinforces a sense of their
reluctance to grasp wholeheartedly the ‘radical’
agenda and modus operandi of community
development work.
At an even more fundamental level, the
perceived low level of input from actual
community members, and a lack of consensus
about what constituted the community, raised a
question mark over whether or not smoking was a
community-defined priority in Wester Hailes.
Whereas those who were involved in the develop-
ment of the programme and/or had experience of
community-based no-smoking health promotion
work saw smoking as a community issue, others
did not. While White Papers on tobacco and public
health (Secretary of State for Health, 1999;
Secretary of State for Scotland, 1999) demonstrate
government identification of smoking as an
important contributor to social inequalities in
health (Graham, 1998), this may not necessarily be
reflected at a community level. Reticence expressed
by some Breathing Space workers towards the issue
of smoking reflected their concern that other
problems experienced by the community were
more pressing. These views resonate with a body of
sociological findings, which indicate how the social
circumstances of disadvantaged lives play an
important part in sustaining smoking (Laurier
et al., 2000). That is, smoking is portrayed as one
mechanism that smokers use to cope with living
and caring in disadvantaged circumstances
(Graham, 1987, 1993; Gaunt-Richardson et al.,
1999). However, it is important to note that neither
the views of the community organizations nor the
health board can be seen as reflecting the position
Empowerment issues in community development 57
of community members, because of the very
minimal presence of this group in the Breathing
Space programme.
In conclusion, although current policy may
celebrate rhetoric of community development and
partnership, the data illustrate how the reality may
be difficult to deliver, especially for those working
in the statutory sector. This is a finding supported
in the literature (Robertson and Minkler, 1994).
Our findings also illustrate the importance of
clarifying the respective roles and inputs of
organizations/agencies involved in partnership
working. In particular, it is crucial to recognize
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
that not all partners will have equal input into the
programme and that the nature of that input will
be quite different. For example, community-based
agencies might usefully focus upon their own role
in engaging with the own local community and
then communicating effectively within the actual
structures of decision making. It is very impor-
tant for the success of programmes that the
relationships between partnership organizations,
and the structures and processes of decision
making, are explicitly acknowledged. Certainly,
this is crucial for ensuring that respective
organizations and agencies feel that they have
ownership of the programme. The study has
highlighted not only the importance of community
ownership, but also the importance of ensuring
that members of organizations signed up to the
programme are involved at an early stage of the
programme’s development.
ACKNOWLEDGEMENTS
The evaluation research on which this paper
draws was funded by the Department of Health.
The Research Unit in Health, Behaviour and
Change is jointly funded by the Scottish
Executive Health Department and the Health
Education Board for Scotland. All opinions
expressed in the article are those of the authors
and not necessarily those of the funders.
Address for correspondence:
Deborah Ritchie
Department of Sociology
Queen Margaret University College
Clerwood Terrace
Edinburgh EH12 8TS
UK
E-mail: dritchie@qmuc.ac.uk
58 D. Ritchie et al.
REFERENCES
Amos, A. Gaunt-Richardson, P., McKie, L. and Barlow, J.
(1999) Addressing smoking and health among women
living on low income 111. Ayr Barnados Homelessness
Service and Dundee Women’s Aid. Health Education
Journal, 58, 329–340.
Arnstein, S. R. (1971) Eight rungs on the ladder of citizen
participation. In Cahn, S. E. and Passett, B. A. (eds)
Citizen Participation: Effecting Community Change.
Praeger Publications, New York.
Asthana, S. and Oostvogels, R. (1996) Community
participation in HIV prevention problems and prospects
for community based strategies among female sex
workers in Madras. Social Science and Medicine, 45,
133–148.
Barlow, J., Gaunt-Richardson, P., Amos, A. and Mckie, L.
(1999) Addressing smoking and health among women
living on low income 11. TAPS Tiree: a dance and drama
group for rural community development. Health
Education Journal, 58, 321–328.
Baxter, A., Milner, P., Wilson, K., Leaf, M., Nicholl, J.,
Freeman, J. et al. (1997). A cost effective, community
based heart health promotion project in England:
prospective comparative study. British Medical Journal,
315, 582–585.
Beresford, P. and Croft, S. (1993) Citizen Involvement: a
Practical Guide for Change. Macmillan, Basingstoke.
Bernstein, E., Wallerstein, N., Braithwaite, R., Gutierrez, L.,
Labonte, R. and Zimmerman, A. (1994) Empowerment
forum: a dialogue between guest Editorial Board
members. Health Education Quarterly, 21, 281–294.
Blackburn, J. (2000) Understanding Paulo Freire: reflec-
tions on the origins, concepts and possible pitfalls of his
educational approach. Community Development Journal,
35, 3–15.
Bracht, N. and Tsouros, A. (1990) Principles and strategies
of effective community participation. Health Promotion
International, 5, 199–208.
Brager, C. and Specht, H. (1973) Community Organising.
Columbia University Press, New York.
Brownson, R. C., Smith, C. A., Pratt, M., Mack, N. E.,
Jackson-Thompson, J., Dean, C. G. et al. (1996)
Preventing cardiovascular disease through community-
based risk reduction: The Bootheel Heart Health Project.
American Journal of Public Health, 86, 206–213.
Buchannan, D. R. (1994) Reflections on the relationship
between theory and practice. Health Education Research
Theory and Practice, 19, 273–284.
Carleton, R. A., Lasater, T. M., Assaf, A. R., Feldman, H. A.,
McKinlay, S. and Pawtucket Heart Health Program
Writing Group (1995) The Pawtucket Heart Health
Program: community changes in cardiovascular risk
factors and projected disease risk. American Journal of
Public Health, 85, 777–785.
COMMIT Research Group (1995) Community intervention
trial for smoking cessation (COMMIT): I. Cohort results
from a four-year community intervention. American
Journal of Public Health, 85, 183–192.
Farquhar, J. W., Fortmann, S. P., Flora, J. A., Barr Taylor, C.,
Haskell, W. L., Williams, P. T. et al. (1990) Effects of
communitywide education on cardiovascular disease risk
factors: The Stanford Five-City Project. Journal of the
American Medical Association, 264, 359–365.
Gaunt-Richardson, P., Amos, A. and Moore, M. (1999)
Women, low income and smoking: developing
community-based initiatives. Health Education Journal,
57, 303–312.
Goodman, R. M., Wheeler, F. C. and Lee, P. R. (1995)
Evaluation of the Heart to Heart Project: lessons from a
community-based chronic disease prevention project.
American Journal of Health Promotion, 9, 443–455.
Graham, H. (1987) Women’s smoking and family health.
Social Science and Medicine, 25, 47–56.
Graham, H. (1993) When Life’s a Drag: Women, Smoking
and Disadvantage. HMSO, London.
Graham, H. (1998) Promoting health against inequality:
using research to identify targets for intervention—a
case study of women and smoking. Health Education
Journal, 57, 292–302.
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
Hancock, L., Sanson-Fisher, R., Clin, M., Perkins, J.,
McClintock, A., Howley, P. et al. (2001) Effect of a
community action program on adult quit smoking rates in
rural Australian towns: The CART project. Preventive
Medicine, 32, 118–127.
Israel, B., Checkoway, B., Schulz, A. and Zimmerman, M.
(1994) Health education and community empowerment:
conceptualizing and measuring perceptions of individual,
organizational and community control. Health Education
Quarterly, 21, 149–170.
Labonte, R. (1994) Health Promotion and Empowerment:
reflections on professional practice. Health Education
Quarterly, 21, 253–268.
Labonte, R. (1998) A Community Development Approach
to Health Promotion: a Background Paper on Practice
Tensions, Strategic Models and Accountability
Requirements for Health Authority Work on the Broad
Determinants of Health. Health Education Board of
Scotland and Research Unit in Health, Behaviour and
Change, University of Edinburgh.
Laurier, E., McKie, L. and Goodwin, N. (2000) Daily and
lifecourse contexts of smoking. Sociology of Health and
Illness, 22, 289–309.
Laverack, G. (2001) An identification and interpretation of
the organizational aspects of community empowerment.
Community Development Journal, 36, 134–145.
Laverack, G. and Wallerstein, N. (2001) Measuring
community empowerment: a fresh look at organizational
domains. Health Promotion International, 16, 179–185.
Luepker, R. V., Murray, D. M., Jacobs, D. R., Mittlemark, M. B.,
Bracht, N., Carlaw, R. et al. (1994). Community education
for cardiovascular disease prevention: risk factor changes
in the Minnesota Heart Health Program. American
Journal of Public Health, 84, 1383–1393.
McKie, L., Gaunt-Richardson, P., Barlow, J. and Amos, A.
(1999)Addressing smoking and health among women
living on low income 1. Dean’s Community Club: a mental-
health project. Health Education Journal, 58, 311–320.
Petersen, A. and Lupton, D. (1996) The New Public Health:
Health and Self in the Age of Risk. Sage, London.
Rifkin, S. (1986) Lessons from community participation in
health programmes. Health Policy and Planning, 1, 240–249.
Rifkin, S. B. (1990) Community Participation in Maternal
and Child Health/Family Planning Programmes. World
Health Organization, Geneva.
Rifkin, S. (1995) Paradigms Lost: Toward a new
understanding of community participation in health
programmes. Acta Tropica, 61, 72–92.

Rifkin, A. B., Muller, F. and Bichmann, W. (1988) Primary
health care: on measuring participation Social Science
and Medicine, 9, 931–940.
Robertson, A. and Minkler, M. (1994) New health promotion
movement. Health Education Quarterly, 21, 295–312.
Robinson, K. L and Elliott, S. J. (2000) The practice of
community development approaches in heart health
promotion Health Education Research Theory and
Practice, 15, 219–231.
Secker-Walker, R. H., Flynn, B. S., Solomon, L. J., Skelly, J. M.,
Dorwaldt, A. L. and Ashikaga, T. (2000) Helping
women quit smoking: results of a community
intervention program. American Journal of Public
Health, 90, 940–946.
Secretary of State for Health (1999) Smoking Kills. The
Stationery Office, London.
Secretary of State for Scotland (1999) Towards a Healthier
Scotland. The Stationery Office, Edinburgh.
Shelley, E., Daly, L., Collins, C., Christie, M., Conroy, R.,
Gibney, N. et al. (1995) Cardiovascular risk factor
Empowerment issues in community development 59
changes in the Kilkenny Health Project: a community
health promotion programme. European Heart Journal,
16, 752–760.
Smith, N., Littlejohns, L. B. and Thompson, D. (2001)
Shaking out the cobwebs: insights into community
capacity and its relation to health outcomes. Community
Development Journal, 36, 30–41.
Tones, K. and Tilford, S. ( 2001) Health Promotion:
Effectiveness, Efficiency and Equity. Nelson Thornes Ltd,
Cheltenham, UK.
Wallerstein, N. and Bernstein, E. (1994) Introduction
to community empowerment, participatory educa-
tion and health. Health Education Quarterly, 21,
141–148.
WHO (1978) Alma Ata Declaration. WHO, Geneva.
WHO (1986) Ottawa Charter for Health Promotion.
Downloaded from http://heapro.oxfordjournals.org/ at University of Sydney Library on May 3, 2015
Journal of Health Promotion, 1, 4.
Zakus, J. D. L. and Lysack, C. L. (1998) Revisiting
community participation Health Policy Planning, 13,
1–12.