Best Practice in Health Promotion: the Sonagachi Project - Literature review Example

RUNNING HEAD: BEST PRACTICE IN HEALTH PROMOTION-THE SONAGACHI PROJECT Best Practice in Health Promotion: The Sonagachi Project Name: Course: Institution: Date: Best Practice in Health Promotion: The Sonagachi Project Introduction The Ottawa Charter for Health Promotion in 1986 defined health promotion as “the process of enabling people to exert control over the determinants of health and thereby improve their health (International Union for Health Promotion-IUHPE 2000, WHO 1986).” This reflects consensus that health promotion is a key strategy in improving health and quality of life. According to Nutbeam (1998) and Nutebeam et al (1990), health promotion is an activity which is directed towards enabling people to take action with a view to realising better health outcomes or improving their quality of life. What distinguishes health promotion interventions from other public health services is that health promotion embodies partnership with and participation of the target group rather than simply a vertical application of a particular program. Unlike other public health services which are offered to people to improve their health, health promotion activities are essentially designed to foster the involvement and participation of the individuals or groups being targeted by the promotion and typically constitute efforts to empower them or build their capacity towards improving their quality of life (Kelly and Vlaenderen 1996, Green and Kreuter 2004). The IUHPE (2000) defines this as strengthening the skills and capabilities of individuals to take action, and the capacity of groups or communities to act collectively to exert control over the determinants of health (IUHPE, 2000 p 2).. This essay will examine what constitutes, or the essential components, of good health promotion. The essay will review a health promotion initiative in India, The Sonagachi Project, and evaluate it in terms of established best practice health promotion principles. The essay will outline best practice principle as established by professional bodies such as the International Union for Health Promotion (2000) and compare and contrast these principles with those reflected in the Sonagachi Project. The essay will demonstrate the fundamental principles necessary for a successful health promotion initiative or intervention by highlighting some of the critical success factors in the design and implementation of the project and how the project has addressed social and cultural issues and determinants of health which had not been addressed in similar previous initiatives. What is Best-Practice in Health Promotion? A review of the literature on health promotion reveals several factors, determinants or principles of best-practice in health promotion. Thurston et al (2003), Ramaliu and Thurston (2003) and Kahan and Goodstadt (1998) define best practices in health promotion as “the set or sets of continually evolving actions and associated attitudes which are most likely to achieve health promotion goals in a given situation, and which are consistent with the values of health promotion." For instance, the International Union for Health Promotion (2000) published a report for the European Commission to provide evidence for effective health promotion. The IUHPE identifies several factors present in successful health promotion initiatives in what is essentially a best-practice manual in professional health promotion which highlighted some of the critical success factors. As pointed out by Thurston and Potvin(2003) and Nutbeam (1998, 1996, 1996a), best-practice in health promotion is a set of guiding principles to aid not only in the design and implementation of effective health promotion initiatives but also in their evaluation (Grol and Grimshaw 2003, Ramaliu and Thurston 2003). Best-practice didactically implies the use of best practices. Green and Kreuter (2004) define best practices in health as medical interventions that, under controlled, experimental conditions, have been shown to be effective across the human species. Best practices should also be effective regardless of context in terms of culture, socioeconomic condition, or historical precedent in social customs, laws, and policies (Green and Kreuter 2004). Therefore, best-practice in health promotion should yield replicable effective programs or identify conditions which if replicated can lead to successful programs and initiatives. The IUHPE outlines several best-practice principles that characterize effective health promotion based on factors such as the scope of health promotion approaches, the settings and the participation and involvement of the target individuals or groups. First, the IUHPE provides evidence that effective health promotion initiatives are based on comprehensive and multi-level approaches based on the five key strategies of health promotion identified in the Ottawa Charter- building healthy public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services (IUHPE 2000). Secondly, health promotion initiatives are most effective in certain community settings such as schools, workplaces and cities. Third, health promotion initiatives need to foster and encourage the participation of the people affected by health issues. The target individuals or groups should be at the heart of health promotion action programs and actively participate in decision making processes to guarantee the effectiveness of the programs. Fourth, it is vital for the program to provide real access to education and information for the target groups or individuals in appropriate language and styles. Lastly, health promotion should be a key investment or an essential element of social and economic development for the involved communities (IUHPE 2000). DeLeeuw (2007) and Green and Jones (1999) also identify several variables in the formulation of effective public health and healthy public policies which can also be applied to health promotion. Most importantly, such policies should be evidence-based and grounded in theory. Best-practice also dictates that the policy design behind the health promotion program include the range of stakeholders in public health such as public health officials, community representatives and local NGOs (De Leeuw 2007, WHO 1998). Kahan and Goodstadt (1998) have also outlined broad principles underlying best practice in health promotion. Best practices in health promotion: are based upon core values including equity and empowerment which should guide all aspects of health promotion practice, use processes that are consistent with health promotion values and are appropriate to achieving health promotion goals and outcomes, build upon and enhance knowledge regarding the appropriateness and effectiveness of health promotion, make effective use of available resources in achieving the goals of health promotion, reflect and contribute to a theoretical understanding of health, are aware of and sensitive to issues of power and strive to increase shared power and recognize, respect and include diversity in all its forms. Green and Kreuter (2004) also identify several elements of health promotion programs consistent with best-practice that resonate with those already discussed. These include respect for the people and context of health programs, the comprehensiveness of the social needs assessment prior to the implementation of the program and the flexibility and scalability of the program. The Sonagachi Project The Sonagachi Project is a multilevel HIV prevention intervention for sex workers in Calcutta, India. The Project was founded by Doctor Smarajit Jana and the All India Institute of Hygiene and Public Health (AIIHPH) on the advice of an Ethiopian public health worker (Jana et al 1994, 1994, 2004). The Sonagachi Project is acclaimed as a successful model of HIV intervention to which the lower prevalence rates of HIV among sex workers (or ‘prostitutes’) and higher levels of condom use in the red-light district of Sonagachi, Calcutta, can be attributed (Singh 1998, Cohen 2004). Unlike other HIV prevention programs, the Sonagachi Project has evolved and survived for over 12 years and has entailed comprehensive multifaceted and multilevel interventions which have addressed a range of issues related to the health and occupational safety from insisting on the use of condoms, provision of affordable STD treatment services for them and their children and provision of financial services in the form of facilitating loans and credit for their economic development (Bandyopadhyay and Banerjee 1999). The success of the project has been attributed to its innovative approach to health promotion consistent with best practices and innovative flexibility and adaptation (Swendeman et al 2009). The Sonagachi Project offers a practical demonstration of most of the principles identified as best practice in health promotion. Jana et al (2004) identifies four key components of the project at community level which can be used to evaluate its adoption of best practices. These are; redefining the problem in a way that does not stigmatize individuals, helping the community assume responsibility by highlighting ways in which the short- and long-term benefits of implementing safer acts are apparent both for the individual and the community, reducing environmental barriers to implement the Sonagachi Project and providing resources. The essay will discuss best practice in the four components by highlighting how they fit into or deviate from best practices as outlined in best practices literature. Best Practice and the Sonagachi Project According to Green and Kreuter (2005), a social assessment to determine the needs of the target individual, group or community is the first stage in planning an effective health promotion program. The Sonagachi Project was framed as an intervention aimed at improving the occupational safety and the health of commercial sex workers in Sonagachi (Nath 2000). The needs identified for sex workers included realization that they needed to have their fundamental rights protected such as their right to health, a safe work environment free from harassment, access to social services for them such as STD treatment, education and micro-financial services and integration into mainstream society (Jana et al 2004). These are some of the core values such as equity and empowerment identified by Kahan and Goodstadt (1998). However, according to Jana et al (2004), the Sonagachi Project significantly deviates from conventions of best practice as identified by Nutbeam (1998) and IUHPE (2000). The project is not based on well-articulated and accepted theoretical models but represents a form of situational innovation to adapt to the environment. The setting for the project, the red-light district of Sonagachi, also enhanced the effectiveness and practicability of the intervention consistent with best practices (Bandyopadhyay and Banerjee 1999). Nevertheless, it fits best practice in the form of adaptability and flexibility as outlined by Green and Kreuter (2005). The project also contributes significantly to a theoretical understanding of health by illuminating the critical success factors in community based HIV prevention programs through group level in addition to individual level changes (Jana et al 2004, Green and Tones 1999). Sonagachi has subsequently been used as a reference point and a replicable model for effective HIV prevention interventions in India and beyond (Basu et al 2008) Notwithstanding, the Sonagachi Project reflects another principle of best practice in successfully framing and redefining the problem of the intervention (De Leeuw 2007) as that of improving occupational safety for sex workers. In framing the problem, the project also addresses some of the shortcomings in HIV prevention interventions such as the focus on behavior change at an individual level rather than at a community level (Jana et al: Chakraborty et al 1994). The project also addresses more effective means to deliver the intervention such as the use of peer outreach workers (Jana et al 2004). The project also demonstrates a practical application of the principles of sensitivity to power (Kahan and Goodstadt 1998, Green and Kreuter 2005) and participation (Nutbeam 1998). According to Jana et al (2004), the Sonagachi Project identifies and respects the existing power structure and power brokers in Calcutta such as the police and landlords of the hostels and encourages their participation by appealing to their vested interests in promoting the health of sex workers in Sonagachi (Nath 2000). As Green and Kreuter 2005) point out, best practice is founded on a respect for the people and the context in an intervention. The Sonagachi Project acknowledges the existing power structure and fosters the participation of not just the sex workers but other related stakeholders in the intervention (Jana et al 2004). In addition, the project put in place measures to progressively transfer ownership of the project from its implementers to sex workers who were empowered to assume leadership roles as the project evolved (Jana et al 2004). The architects of the project also ensured that sex workers were treated with respect by adopting approaches that did not humiliate sex workers as previous interventions had through police enforced STD testing. Instead, the project used peer outreach workers who would relate better to sex workers and provided services without compulsion or coercion (Basu et al 2008). The staff members for the project were trained to develop respective attitudes towards sex workers and build on their self respect, self esteem and basic rights consistent with the principle of sensitivity to diversity (Jana et al 2004). Best practices demand the use of available resources in achieving the desired outcomes of an intervention (Thurston et al 2003, Kahan and Goodstadt 1998). By offering free condoms and STD medication to sex workers, the Sonagachi Project was able to make effective use of available financial resources. The project also makes extensive use of the available human resources in the form of both professional staff and peer outreach workers. The project was also able to elevate sex workers into positions of authority within the organization that would then ensure the continuity of the project (Cohen 2004). According to the IUHPEE (2000), best also practice dictates that health promotion activities include components to develop the personal skills of individuals to take action, and the capacity of groups or communities to act collectively to exert control over the determinants of health. The Sonagachi Project evolved into a co-operative for sex workers that among other things, secured access to credit through microfinance to help them address some of the determinants of their health such as poverty, illiteracy, sexual health and access to social services for themselves and their children (Singh 1998). For instance, micro-financial services in the form of small loans with low interest rates were availed to members of the project were able to use condom sales to generate revenue. The Sonagachi project also managed to spawn a quasi-trade union of sex workers to protect their rights and provide a support system (Jana et al 2004). Conclusion Best practices in health promotion can be considered as the set or sets of continually evolving actions and associated attitudes which are most likely to achieve health promotion goals in a given situation, and which are consistent with the values of health promotion. The Sonagachi Project offers a practical demonstration of most of the principles identified as best practice in health promotion through various actions undertaken in the project. These various actions can be categorized into the four components of the Sonagachi Project as argued by Jana et al (2004). First, the project was redefined in a way that did not stigmatize sex workers by outlining the purpose as that of improving their occupational safety, establishing and protecting their basic rights and training staff to develop professional positive attitudes towards sex workers. Secondly, in helping the community to understand how the program impacts them, the project’s architects were able to appeal to various stakeholders such as the police and landlords of the hostels in Sonagachi by demonstrating how facilitating the project would be in their best interests. The project also reduced environmental barriers and provided resources for implementation of the project through actions such as educating sex workers and their children and distribution of free condoms. References Basu, I., Jana, S., Rotheram-Borus, M.J., Swendeman, D., Lee, S.J., Newman, P. & Weiss, R. (2004). HIV prevention among sex workers in India. Journal of Acquired Immune Syndrome 36(3), 845-52. Bandyopadhyay, N. & Banerjee, B. (1999). Sex workers in Calcutta organize themselves to become agents for change. Sexual Health Exchange 1999 (2), 6-8. Cohen J. (2004). Sonagachi sex workers stymie HIV. Science 304 (5670), 506. 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