Recommendations to improve participation in health promotion program through the NICE Community

Engagement guidance

By Hiba Malek

Professor: Joan J. Paredes i Carbonell

Hiba Malek 1

Hiba Malek 2

MASTER OF PUBLIC HEALTH AND HEALTH MANAGEMENT

UNIVERSITY OF VALENCIA - SPAIN

MASTER THESIS 2014-2015

MASTER DE SALUD PÚBLICA Y GESTIÓN SANITARIA

DE LA UNIVERSITAT DE VALÈNCIA - ESPAÑA

TRABAJO FIN DE MASTER 2014-2015

Recycled paper

Hiba Malek 3

Hiba Malek 4

Acknowledgments

It would not have been possible to write this master thesis without the help and support

of the kind people around me, to only some of whom it is possible to give particular

mention here.

Above all, I would like to thank my principle supervisor, Prof. Joan J. Paredes i Carbonell

whom his help, patience and support helped me to finish this thesis, not to mention his

advice and unsurpassed knowledge and experience in the field of Community health. Also I

have to acknowledge the good support and cooperation of Pilar López Sánchez as the

impact of her participation helped me to move forward in this study.

Many thanks to my family oversees who are the reason of my achievement today. To

my parents with their unconditional love and unlimited support. They guided me through

every step in my life and yet not stopped. To my beloved sisters, for the joy of life and the

unequivocal support throughout.

Special thanks to my husband Nazir for his personal support and his great patience at all

times, thank you from my heart.

At the end, I would like to express my deepest appreciation to the University of Valencia

for giving me the chance to attend this master of Public Health and Health Management.

Also to the professors and my classmates during the master for their support and friendship

over this year. I know now that I have new friends for which I am grateful.

Hiba Malek 5

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Content

ABSTRACT AND KEY WORDS………………………………………………………….………………….……………10

RESUMEN Y PALABRAS CLAVE…………………………………………………………….………………………….11

1. INTRODUCTION……………………………………………………………………………………….………….12

1.1 Health for all…………………………………………………………………………………………..…….12

1.2 Health promotion and its implementation……………………………………………….…..14

1.3 Community engagement in health promotion programs and its importance…16

1.4 NICE guidance…………………………………………………………………………………………….…20

1.5 NICE Public Health guidance 9………………………………………………………………….…..21

1.6 Community Engagement guidance 2008………………………………………………….……22

1.7 Situation in Spain and the application of health promotion programs…………..25

1.8 Mihsalud program in Valencia city……………………………………………………………..…27

2. OBJECTIVES…………………………………………………………………………………………………….……28

3. METHODS………………………………………………………………………………………………………..….28

3.1 Study preparation and planning………………………………………………………………...…29

3.2 Elaboration of the “Draft List”……………………………………………………………………...29

3.3 Focus group preparation and implementation……………………………………….……..34

3.3.1 Participants recruitment…………………………………………………………………....34

3.3.2 The preparation………………………………………………………………………………….35

3.3.3 The implementation…………………………………………………………………………..36

3.3.4 Debriefing session………………………………………………………………………….…..38

3.4 Transcription of the recordings……………………………………………………………………..39

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3.5 Analysis…………………………………………………………………………………………………..……39

4. RESULTS…………………………………………………………………………………………………………...…44

4.1 Reviews of the team of mihsalud program…………………………………………………...44

4.2 Reviews of directors related to mihsalud program…………………………………..……53

4.3 Reviews of the program team and directors related to the program………..……63

4.4 The final report, the “Recommendations List”…………………………………………...…68

5. DISCUSSION…………………………………………………………………………………………………………71

5.1 Limitations……………………………………………………………………………………………..…….75

5.2 Applicability & future lines……………………………………………………………………………75

6. CONCLUSIONS……………………………………………………………………………………………………..76

7. REFRENCES………………………………………………………………………………………………………….78

8. GLOSSARY……………………………………………………………………………………………………………80

8.1 Wider social determinants of health……………………………………………………………..80

8.2 Governance………………………………………………………………………………………………….80

8.3 Health promotion…………………………………………………………………………………………80

8.4 Regeneration………………………………………………………………………………………………..80

8.5 Commissioners and providers……………………………………………………………………….80

8.6 Area-based initiatives……………………………………………………………………………………80

8.7 Neighborhood managers………………………………………………………………………………80

9. APPENDIX

Appendix 1. Draft List in English……………………………………………………………………………………..81

Appendix 2. Draft List in Spanish………………………………………………………………………………….…87

Appendix 3. Focus group discussion in English………………………………………………………………..94

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Appendix 4. Focus group discussion in Spanish……………………………………………………………….95

Appendix 5. Invitation e-mail………………………………………………………………………………………...96

Appendix 6. Meeting guide for the focus group………………………………………………………………98

Appendix 7. The presentation for the focus groups…………………………………………..…………102

Appendix 8. Consent form…………………………………………………………………………………………….108

Appendix 9. Debriefing session 1……………………………………………………………………………….…111

Appendix 10. Debriefing session 2…………………………………………………………………………………112

Appendix 11. Focus group transcription 1……………………………………………………………………..113

Appendix 12. Focus group transcription 2………………………………………………………………….….122

INDEX OF TABLES

Table 1. Sign-in Sheet……………………………………………………………………………………………..………36

Table 2. Profile of participants…………………………………………………………………………..……………38

Table 3. The aspects of these recommendations that are being applied to mihsalud

program………………………………………………………………………………………………………………………….39

Table 4. The aspects of these recommendations that are not being applied to mihsalud

program………………………………………………………………………………………………………………………….41

Table 5. Aspects that cannot be applied in the mihsalud program right now……………..……43

Table 6. The study applicability to other health program………………………….…………………….43

Table 7. Reviews of mihsalud team program on the implementation of the

recommendations of NICE guidance- Community Engagement 2008…………………………..….47

Table 8. Reviews of the mihsalud team program on the applicability of the

recommendations to other health promotion programs…………………………………………….…..53

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Table 9. Reviews of directors involved in mihsalud program on the implementation of the

recommendations of the NICE guidance- Community Engagement 2008…………………………56

Table 10. Reviews of the directors on the applicability of the recommendations to other

health promotion programs……………………………………………………………………………………….…..62

Table 11. Degree of compliance with the recommendations of the NICE guidance-

Community Engagement 2008, in the reviews of the program team and directors

involved………………………………………………………………………………………………………………………….65

FIGURES

Figure 1. The interaction determinants of health…………………………………………………………….13

Figure 2. Pathways from community participation, empowerment and control to health

improvement………………………………………………………………………………………………………….……..17

Figure 3. Logic model………………………………………………………………………………………………………19

Figure 4. Community engagement overview…………………………………………………………………..24

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Abstract

Objective: Elaborate the final report "Recommendations List" by integrating the

recommendations of NICE guidance- Community Engagement 2008 in mihsalud program in

the Public Health Center of Valencia. The list of recommendations will have effect on how to

increase the community participation in health promotion activities and make the program

ready for this change.

Methods: The design of the study arises as a qualitative descriptive study using content

analysis. The method that was applied is a focus group method. Two focus groups were

conducted, the first one with 6 health workers and the second with 6 directors related

directly and indirectly to mihsalud. The discussion was recorded, transcribed and then

analyzed according to 3 categories: recommendations that are incorporated to mihsalud,

are not incorporated or cannot be applied now. “Recommendations list” was elaborated to

increase community engagement.

Results: According to the opinions of the program team and directors in the two focus

groups we found that mihsalud follows NICE recommendations in most of its parts. In

infrastructure and approaches, the program is incorporating most of the recommendations.

In prerequisites for success and evaluation, the program needs improvements to be able to

meet the full recommendations. There is only one weakness in the program where it affects

its sustainability, is lacking of long-term investment. “Recommendations list” was

elaborated with 7 internal recommendations to enhance the structure of the program and 7

external recommendations to ensure sustainability and more spreading of the program.

Conclusion: The elaboration of the “Recommendations list” and implement it in the

mihsalud program will let the program reach more vulnerable population and increase

community engagement in the program.

Key words: Community engagement, community participation, health promotion, wellbeing

and participation.

Word count: 18409 words.

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Resumen

Objetivo: Elaborar el informe final "Lista de recomendaciones" mediante la integración de

las recomendaciones de la guía NICE de Participación Comunitaria de 2008 en el programa

mihsalud del Centro de Salud Pública de Valencia. La lista de recomendaciones tendrá un

efecto sobre la forma de aumentar la participación de la comunidad en las actividades de

promoción de la salud y hacer que el programa esté preparado para este cambio.

Métodos: Se plantea un estudio descriptivo cualitativo mediante análisis de contenido. El

método que se aplicó es un método de grupo focal. Se realizaron dos grupos focales, el

primero con 6 profesionales y la segunda con 6 directivos relacionados directa e

indirectamente con mihsalud. La discusión fue grabada, transcrita y analizada según 3

categorías: recomendaciones que se incorporan en el programa, no se incorporan o no se

puede aplicar ahora. Finalmente, se elaboró la “Lista de recomendaciones” para aumentar

la participación de la comunidad.

Resultados: De acuerdo con las opiniones del equipo del programa y los directores en los

dos grupos se encontró que mihsalud sigue las recomendaciones de la guía NICE en la gran

parte de sus apartados. En infraestructura y enfoques, el programa incorpora gran parte de

las recomendaciones. En pre-requisitos para el éxito y la evaluación, el programa necesita

mejoras para poder cumplir con todas las recomendaciones. Sólo hay una debilidad en el

programa que afecta a su sostenibilidad: la falta de inversión a largo plazo. "Lista de

recomendaciones" fue elaborado con 7 recomendaciones internas para mejorar la

estructura del programa y 7 recomendaciones externos para garantizar la sostenibilidad y

una alta difusión del programa.

Conclusión: Implementar la "Lista de recomendaciones" en el programa mihsalud permitirá

que el programa llegue a la población más vulnerable y aumentará la participación de la

comunidad en el programa.

Palabras clave: Compromiso comunitario, participación comunitaria, promoción de la salud,

el bienestar y la participación.

Recuento de palabras: 18409 palabras.

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1. Introduction

1.1 Health for all

The right to health as a basic human was first proclaimed in 1948 in the preamble of

World Health Organization (WHO) constitution. Therefore, the WHO issued a document

“Health 2020” in 2012 where it is goals are to significantly improve the health and well-

being of populations, reduce health inequalities, strengthen public health and ensure

people-centered health systems that are universal, sustainable, equitable and of high

quality1-2.

Due of everyone has a role in creating a supportive environment for health, there were

a growing expectations for a new public health movement around the world. Therefore, in

1986 and as a response to this movement the first International Conference on health

promotion was held in Ottawa, Canada. The aim of this conference was to continue to

identify actions to achieve the objectives of WHO “Health for all” by the year 2000 and to

set the strategies and programs for health promotion that should be adapted to local needs

and countries, taking into account the different social, cultural and economic systems1.

Health 2020 is based on a strong value base which is reaching the highest attainable

standard of health, for that the present generation should not compromise the environment

of subsequent generations2. So when we say everyone should take responsibility to achieve

this goal it means that people from all walks of life are involved in this process, like families

and communities, professional and social groups. Moreover, all relevant government

sectors like trade, education, industry and finance. All those sections need to give important

consideration to health as an essential factor during their policy formulation for the pursuit

of health1.

As “Health for all” aims to reduce inequalities and improve health and well-being. We

will talk first about the equity in health which means fairness and the needs of people guide

the distribution of opportunities for welfare3. The social and economic inequalities,

transmitted to subsequent generations, result in the indefensible persistence of health

inequalities. Therefore, improving health equity, including both intergenerational inequity

and transmission of inequity, is at the core of Health 2020. The strategies for health equity

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and sustainable development should come together, recognizing the links between social

and economic environments and intergenerational equity2. Second, health and well-being

are public goods and assets for human development and of vital concern to the lives of

every person. Good health for the individual is a dynamic state of physical, mental and social

well-being. It is much more than just the absence of illness or infirmity. Good health for

communities is a resource and capacity that can contribute to achieving strong, dynamic

and creative societies2.

In the figure 1 we can see the classic and well-known model about the determinants of

health. It helps illustrate the interrelationships between the different determinants of

health, recognizing that it is important to consider both the factors that directly influence

individual and community behavior, and the important wider social determinants. The social

determinants are especially important to address because not only can they directly

influence health (such as the effects of poor housing or sanitation) but they also influence

the genuine options and choices people have and their life chances, which in turn affect

their personal decisions, choices and lifestyles2. According to the "Review of social

determinants and the health divide" in the WHO, action is needed on the social

determinants of health, across the life-course to achieve greater health equity and protect

future generations4.

Figure 1. The interaction determinants of health4

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The social determinants of health are very important to address and to talk about

because they reveal the conditions in which people are born, grow, live, work and age,

which they are the key determinants of health equity4.

In order to achieve the Health 2020, the Commission on Social Determinants of Health

set out four priority areas of action that are: investing in health and empowering people,

tackling Europe’s major health challenges of no communicable and communicable diseases,

strengthening people-centered health systems and supportive environments2. Also we

should improve the conditions of daily life in which people are born, live, work and age,

tackle the inequitable distribution of power, money and resources globally, nationally and

locally and develop a workforce that is trained in the social determinants of health to raise

public awareness about this domain which will help to attain a fundamental human right of

the highest standard of health2.

1.2 Health promotion and its implementation

The global definition of health promotion is: the process of enabling people to increase

control over their health and improve it. It is not just the responsibility of health sector, but

goes beyond healthy lifestyles to well-being. Health seen as a recourse for everyday life, not

the objective of living1-3. Furthermore, good health is a major resource for social, economic

and personal development, and important for the quality of life. Therefore, all the factors of

life like environmental, behavioral and biological etc., have a role in improving human

health or worsening it. Health promotion aims to make these factors favorable, through

advocacy for health1.

No doubt that health promotion is widely accepted as a fundamental approach to the

practice of public health and it should lead to improve the health of people and the

environment where they live so our efforts should be directed toward the place where they

are generated5. There should be a joint efforts of all social and productive actors to achieve

health counting on the responsibility of each person in his individual level to take care of his

health and the health of the surroundings and work with communities to set actions and

objectives to maintain a high level of living conditions.

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The Ottawa Charter identifies health promotion action areas as building a healthy public

policy, create supportive environment, strengthen community actions, develop personal

skills, reorient health services and moving into future1. The intervention in those areas will

help to create healthier environments, besides being an area that attracts participation of

individuals and groups because it deals with the needs of communities and will lead to

protect health and to strengthen it by increasing the maximum level of quality of life5.

Without compromising the protection of the nature, build safe environments and the

conservation of natural resources that must be addressed in any health promotion strategy

and activities1.

As we mentioned before that health equality is an important element of public health

and it should be included in any health promotion plan. Besides, the health inequalities are

not exclusively biological in origin but it is also the consequence of human activity so we

should be careful about this point and because they arise as a consequence of human

actions, they can be changed if the causes are changed6. Also we should consider that

women and men should become equal partners in each phase of planning, implementation

and evaluation of health promotion activities1. In addition, according to the NICE public

health guidance, there are two important legal concepts when considering equality:

relevance and proportionality. Relevance assesses how much an issue affects equality.

Proportionality assesses an appropriate outcome. The weight given to equality in a function

should be proportionate to its relevance for that function6. The intervention in health

promotion might have different outcomes: it might improve the health of people in

different groups to the same degree, so that any differences in health between those groups

will remain after the intervention and it may be more effective in one group than in

another. If it is more effective in the more disadvantaged group, the net outcome will be a

reduction in inequity. If it is more effective in the less disadvantaged group, the net

outcome will be an increase in health inequity. At the end, the ideal outcome is to benefit all

groups at the same level and reducing health inequalities6.

As health promotion activities are towards individuals in particular and communities in

general, the community engagement and development is essential to enhance self-help and

social support to develop flexible systems. This requires full and continuous access to

information and learning opportunities, as well as finding a new ways of financial support

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(Funding)1. The health education has serious methodological bases, involving increasing

social awareness about the culture of community participation and empowers groups so

they can make changes in their behavior5 and it will be a great idea to integrate health

education in schools, home, work and community settings. Also the role of the health sector

must move increasingly in a health promotion direction, as well as changes in professional

education and training1.

1.3 Community engagement in health promotion programs and its importance

At the beginning, we have to draw attention to two important definitions: community

engagement and community activity.

Community engagement is “the process of getting communities involved in decisions

that affect them. This includes the planning, development and management of services, as

well as activities which aim to improve health or reduce health inequalities” (Popay 2006)7.

Community activity is "any activity, intervention and performance with participation

groups, have characteristics, needs or common interests and aimed at promoting health,

increasing quality of life and social welfare, enhancing the capacity of the individuals and

groups to approach their own problems, demands or needs"8.

According to the Ottawa Charter1, health promotion works through concrete community

actions in setting priorities and making decisions, planning strategies and implementing

them to achieve better health based on a lot of factors that are used to define communities

(geography, culture and social stratification). Also it mentioned the importance of the

participation of professionals as stakeholders in setting health agenda of activities. Also to

combine individual and collective efforts like the government, society and nongovernmental

organization in pursuing of the target “Health for all” to improve health and well-being4. All

these parts should be joined in an equal partnership1 to get benefit from the variety of

approaches that could be used, including neighborhood committees and forums,

community champions and the collaborative methodology used in initiatives. Although

these approaches have been in existence for several decades, many factors prevent them

from being implemented effectively, including the dominance of professional culture and

lack of professional training for the staff working in public services2. While designing these

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approaches, it is very important to design policies that act across the whole social health

gradient that exist between people and communities, as well as addressing the needs of

people at the bottom and those who are most vulnerable4.

According to the NICE guidance- Community Engagement 2008, a number of national

strategies and targets aiming to improve health and well-being and reduce health

inequalities highlight the importance of involving local communities in health-related

activities, particularly those experiencing disadvantage7. In the figure 2 we can see some

pathways from community participation, empowerment and control to health

improvement.

Figure 2. Pathways from community participation, empowerment and control to health

improvement7

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Community engagement interventions are effective across a wide range of contexts and

using a variety of mechanisms, it has a positive impact on health behaviors, health

consequences and requires resources (financial, time, equipment and people). Those

involved need to understand and agree in advance what will be needed to ensure the long-

term sustainability of the intervention. Also the evaluation of the intervention should place

greater emphasis on long-term outcomes and reporting costs and resources data7-9. In

addition, there is insufficient evidence regarding the long-term outcomes and indirect

beneficiaries to determine whether one particular model of community engagement is likely

to be more effective than any other, and there is weak but inconsistent evidence that

community engagement interventions are cost-effective9. Furthermore, the NICE guidance-

Community Engagement 2008 addressed that the community interventions may result in

additional cost regarding the actions that come with it like, training and development for

the individuals, provision of Braille and loop systems and crèche facilities and carrying out

research and consultation work etc7.

According to the NICE public health guidance, the logic model in the figure 3 focuses on

a range of community engagement roles and activities that aim to improve health and well-

being. It sets out the conceptual link between local community engagement interventions,

the immediate service delivery outcomes and other intermediate outcomes that effect on

health, such as empowerment and social cohesion. Not forget to mention that the primary

purpose of an intervention may be community engagement rather than health

improvement. The model highlights how local funding, resources and other factors influence

intervention delivery and outcomes10.

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Figure 3. Logic model10

In a rapid review of evidence on the impact of community engagement, the evidence

shows that it is difficult to attribute specific benefits to one approach or method in

improving the social determinants of health11. We will demonstrate some of the evidence

on the effectiveness of the community engagement intervention:

Community engagement may have a positive impact on residents’ perceptions of

crime and on community involvement in service delivery.

It may have a positive impact on ‘bonding’ and ‘bridging’ social capital and social

cohesion.

Initiatives that aim to promote community engagement can successfully recruit new

volunteers and establish better links with wider communities. It also has a positive

impact on the way residents of the intervention areas feel about their areas that

leads to improve their quality of life.

Community engagement may have a positive impact on community empowerment

in the areas of capacity building, skills and knowledge development.

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In our study, we are using one of the methodology for active participation from the

individuals, which is the focus groups that used to explore the opinions, knowledge,

perceptions, and concerns of individuals in regard to a particular topic. All our participants

have some knowledge and experience with mihsalud program and health promotion

activities. The focus group is good for in-depth exploration of people’s views on a subject

including their likes and dislikes and it is a very important methodology regarding the

investigation in community engagement studies9.

1.4 NICE guidance

NICE is the abbreviation of the National Institute for Health and Clinical Excellence. It is

responsibility standing for developing national guidance and advice to improve health and

social care. The NICE was established in 1999 in England to ensure that the most clinically

and cost effective drugs and treatments were made widely available to the National Health

Service (NHS). The guidance helps health, public health and social care professionals deliver

the best possible care based on the best available evidence and its recommendations are

systematically-developed based on the best available evidences also12.

All the NICE guidance are easy to access because the NICE committee wants to provide

advice and support to the public and everyone wants to get benefit of it. This service from

NICE aims to improve health care and encourages a quality and safety focused approach, in

which commissioners and providers use NICE guidance and other NICE-accredited sources to

improve outcomes12.

In addition to that, NICE is helping to raise standards of health care around the world by

establishing the NICE International in 2008. Therefore it is very useful and time-saving to

depend on the NICE guidance and its standards to develop guidance in Spain as well as to

improve the programs of health promotion. NICE international is offering advice to

governments and governmental agencies overseas and provides facilitation of knowledge

transfer among decision-makers across countries such as through international meetings.

This service helps building capacity for assessing and interpreting evidence to inform health

policy and on designing and using methods and processes to apply this capacity to their

local country setting13.

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The NICE guidance are being developed methodologically by the independent advisory

committees throughout a wealth of scientific methodology to help underpin and inform the

committees’ decisions and recommendations. Although this science is constantly evolving

but the committees always ensure that NICE stays at the forefront of this challenging field.

This includes internationally recognized scientific methods for evaluating and comparing the

benefits and cost-effectiveness of different form of practice12.

1.5 NICE Public Health guidance 9

NICE guidance takes number of forms which are varied between different health

domains. One of them specialized in public health. The NICE public health guidance is

developed using different methodologies and approaches that can incorporate these

different types of knowledge and evidence at various stages through spectrum of sources to

see if it meets equality and diversity criteria6. The sources include:

organizations

practitioners

the policy community, gained from the wider policy context research, gathered

systematically with a planned design

service users.

In order to develop a public health guidance, NICE depends on a conceptual framework

for public health of values and principles. This comprises 4 vectors – population,

environment, society and organizations – linked to human behavior. These vectors interact

with the human behavior via causal pathways to determine the health of individuals and

populations. For example, patterns of illness can occur in whole populations or

subpopulations. Both illnesses and the resulting patterns have causes6.

Public health guidance is aimed at population, community, organizational, group, family

or individual level, as appropriate. It is also important to develop recommendations and

methods based on the balance between the estimated cost of each intervention and the

expected health benefits, therefore the Public Health Advisory Committee (PHAC) is

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required to make decisions informed by the best available evidence of both effectiveness

and cost effectiveness6.

The process of developing recommendations is not easy and it needs a lot of meeting

sessions including arguments in order to have a good recommendations that meets all the

criteria of the (PHAC). The recommendations should be clear and practical, which means are

easy to understand and can be implemented. They should respect the social value

judgements and reflect the views and experiences of both those being advised to take

action (healthcare professionals) and the people who might be affected by that action (the

target population and their families). Finally, not forget to mention to take account of

relevant theories of public health and informed by the most appropriate and available both

scientific and other evidence. These characteristics of the recommendations are vital in

order to create the “Recommendations List” at the end of this study. In addition we will be

considering that recommendations should not be made on the basis of the total cost or the

resource impact of implementing them. So if the evidence suggests that an intervention

provides health benefits and the cost per person of doing so is acceptable it should be

recommended, even if it would be expensive to implement across the whole population6.

1.6 Community Engagement guidance 2008

In this study we will focus on one of the NICE public health guidance which is

Community Engagement guidance that was issued in February 2008. This guidance aims to

support those working with communities and involved in decisions on health improvement

that affect them. It was elaborated for people working in the NHS and other sectors who

have direct or indirect role in community engagement including those working in local

authorities and the community, voluntary and private sectors7, and following these

recommendations can help these sectors to reduce variations in practice12.

The Community Engagement guidance is currently being updated and its anticipated

publication date is on February 2016, until then the guidance of 2008 is the adopted one.

The updated guidance approaches to improve health and reduce health inequalities10.

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In the figure 4 we can see a diagram about the community engagement overview

elaborated by NICE pathway14. It gives us a view about the steps that should be followed to

reach an effective engagement and participation from the community. The steps are:

1- Community engagement.

2- Evaluation: it should be done in collaboration with the target community and involve

them in setting the objectives and in the planning phase. This should be done before

the activity is introduced.

3- Develop national, regional and local policy: finding new ways and also taking account

of existing community activities and past experiences.

4- Develop long-term initiatives: the community engagement activities have a long-

term nature and are incremental. This will ensure the efficacy of the outcomes and

main goal of sustainability.

5- Build on the local community’s strength and provide training and resources.

6- Work in partnership: all those involve in health promotion activities should be

related to address the wider social determinants of health (Glossary 1). This will help

to increase knowledge of and communication between the sectors (government,

volunteers and community organizations)14.

7- Approaches: this may be done by build mutual trust and respect, identify changes

needed within organizations, agree on level of engagement and power and the

initiatives whether the new or the existing ones15.

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Figure 4. Community engagement overview14

As we mentioned before NICE is trying to involve social value judgments while

developing the recommendations in order to reflect the value of the society12 and based on

the evidence, this guidance looks at how communities can be effectively involved in the

planning, including priority setting and resource allocation, designing, delivery and

governance (Glossary 2) of:

Health promotion (Glossary 3) activities

Activities and initiatives to address the wider social determinants of health7.

The Community Engagement guidance 2008 that we rely on in this study contains

twelve important recommendations divided into four themes and these recommendations

can be used to improve and strengthen the concept of community engagement, develop a

sense of commitment in the individuals towards the society and daily-life health activities

and gives the professionals and health workers a good help when preparing and planning for

Hiba Malek 25

health promotion programs and activities. In addition, the Program Development Group

PDG believes that the recommendations promote a consistent approach to community

engagement and acknowledges that community engagement approaches could be used to

tackle a range of issues with different communities (not just regeneration (Glossary 4)). The

PDG has also based the recommendations on a number of program theory and evaluation

principles7.

Recommendations of the Community Engagement guidance 2008:

The recommendations present the ideal scenario for effective community engagement.

They cover four important themes:

Prerequisites for success: including policy development (5 recommendations).

Infrastructure: to support practice on the ground (3 recommendations).

Approaches: to support and increase levels of community engagement (3

recommendations).

Evaluation (1 recommendation).

1.7 Situation in Spain and the application of health promotion program

Now in Spain there is no guidelines for community engagement in health promotion

programs, but there is other guidelines specialized in the Clinical Practice Guidelines (CPG)

which are a set of recommendations based on a systematic review of the evidence and the

assessment of risks and benefits of different alternatives in order to optimize health care to

patients. The GPC have the potential to reduce variability and improve clinical practice16.

However, in Spain, while it is the opposite somewhere else, the main idea is that the

public health is a branch of medicine, but also they found that the integration of community

activities to promote health, which called in Spain “las actividades comunitarias de

promoción de la salud” (ACPS), will make a difference according to a study that aimed to

discover if the community health programs really work or not17. Also they found that the

evaluation of the ACPS must be consistent and take into account the particularities of

community activities and aspects related to the impact and results. It will be effective to use

the quantitative and qualitative research in the evaluation of the ACPS. Furthermore, it was

Hiba Malek 26

mentioned in the study as a justification of this poor implementation of ACPS in the context

of primary health care is the lack of evidence for such interventions compared to other

biomedical marking content that do have. For example, certain lines of biomedical research

have considerable support from the pharmaceutical industry. Meanwhile, The ACPS hardly

ever will be financed by these companies in the same proportion17. Consequently, the lack

of funding and support for such kind of activities in Spain has a negative impact on any

activities or program directed to promote health and engage the community, because it will

lack the stability of the program and long-term planning benefits.

There is another intervention in Spain to reduce health inequalities implemented by the

Commission to Reduce Social Inequalities in Health that was established in 2008. The

commission should develop proposal for interventions to reduce health inequalities. In May

2010, the Commission presented the document “Moving toward equity: a proposal for

policies and interventions to reduce social inequalities in health in Spain”. The document

listed a total of 166 recommendations, these recommendations highlight that health

inequalities cannot be reduced without a commitment to promote health and equity in all

policies and to move toward a fairer society. In addition the proportion of people who

perceive there health as fair is very poor and it is higher among women than in men and

increases gradually from the middle classes to the most disadvantaged, so that the effects of

inequality are not confined to a small group of vulnerable people, but the entire population,

therefore at the national level, the Ministry of Health and Social Policy has defined the

reduction of inequalities as one of its priorities and this objective requires a real

commitment to promote health in all policies18.

In Spain there are some interventions in the community regarding the primary care.

Working Group on Primary Care Community Oriented. A website Describes basic

information about the group and its activities, and provides access to bibliographic

information and links to pages of evidence in the context of Community

intervention.

Program of Community Activities in Primary Care (PACAP). It is a program of the

initiative developed in the mid-nineties from the Spanish Society of family and

community Medicine, with the aim of promoting community activities in primary

Hiba Malek 27

care. Within the PACAP there is the Network of Community Activities (RAC) that

allows the exchange of community experiences between all the regions of Spain and

other countries.

The Information System Promotion and Health Education (SIPES) is created under

the Inter-territorial Council of the National Health System to provide information on

the actions of health promotion operating in the different regions. It is in early stages

of development.

1.8 Mihsalud program in Valencia city

In this study, we are focusing on one of the health promotion programs in Valencia,

which is the mihsalud program (Women, Children and Men health building). It is a program

of social mobilization and high diffusion in urban environments (outreach) aimed to

promote health in situations of high vulnerability in the city of Valencia. The program

conducted by the Center of Public Health (CSPV) in Valencia city in collaboration with the

ACOEC (Association of Cooperation between Communities)19.

Mihsalud started in 2006 from the Public Health Centre in Valencia. Initially the activities

of the program were prioritized toward Latin American immigrants, but today the program

and the interventions that it does are trying to reach every person in a vulnerable situation

in the city of Valencia. From the perspective of positive health, the program aims to increase

the capacities of people and achieve greater autonomy and responsibility in the control of

health. It is to developed capabilities on the purpose to reduce inequalities and promote

equity through peer education model for health assets, intercultural mediation, gender,

professionals training in cultural competence and diversity care and social action19-20.

Since its launch, the program is carrying out various actions to address the main

problems and to solve them. Some of these actions are: workshops, health promotion,

trainings, and health workers trainings by energizing the territory processing maps and

activation of several information points in the departments of health of the city19-20.

2. Objectives

Hiba Malek 28

The general objective of this study is to elaborate the final report "Recommendations

List" from the recommendations of NICE guideline- Community Engagement 2008 to

implement it to mihsalud program. The list of recommendations will improve the program

by raising the level of readiness to be able to effect the community behavior to be more

engaged in health promotion activities.

Specific objectives are:

1. To extract the "Draft list" after reading the Community Engagement guidance and

mihsalud documents.

2. To take the opinions of professionals and health workers related to mihsalud

program about the applicability of the "Draft List" to mihsalud program and what

they have to add based on their experience in the programs they perform and in the

field.

3. To identify the recommendations of NICE that are incorporated in mihsalud and the

ones that are not incorporated.

4. To identify if there are recommendations not applicable for now.

5. To identify the differences between the opinions of the technical group and the

group of professionals.

6. To elaborate the final report "Recommendations List" that is based on the opinions

in the focus groups, and if it could be applied to other health promotion programs in

the Comunidad Valenciana.

3. Methods

The design of the study arises as a qualitative descriptive study using content analysis.

The method that was applied is a focus group method including professionals and health

workers in the Public Health Centers of Valencia in order to elaborate the final report

“Recommendations List”.

Hiba Malek 29

The team responsible of this study consists of:

- The author of this study is a pharmacist with a bachelor degree in pharmacy and now is

doing the master of Public Health and Health Management in the University of Valencia and

she will be the moderator of the focus groups.

- The professor of this study is a public health physician in the Public Health Centre of

Valencia, also he is an associate professor at the University of Valencia and a researcher

collaborator with FISABIO.

- Pilar López Sánchez is a public health nurse in the Public Health Centre of Valencia, she will

be the facilitator and the note-taker of the focus groups.

3.1 Study preparation and planning

The objective of this phase is to get all the relevant scientific information and to find all

the documents, papers and articles needed in English and Spanish language related to the

NICE guidance-Community engagement, health promotion programs and mihsalud program.

Then to start planning for the structure of the study and how to proceed with the other

phases.

The preparation phase was carried out during the months of February and March, 2015.

3.2 Elaboration of the "Draft List"

The objective of this phase is to read the Community engagement7 2008 and its updates

201410. Then reading the mihsalud program which is a crucial step in the process in order to

come up with list of recommendations called the "Draft List" and to write the questions of

the discussion for the focus groups. The goal of this list is to present it to the participants of

the focus groups who will read it and answer the questions through the discussion.

The preparation of the "Draft List" was in English language (Appendix 1) then it was

translated to the Spanish (Appendix 2) because all the participants are from Spain, therefore

it is better to conduct the meetings in Spanish language along with all the papers needed in

Hiba Malek 30

order to prevent the misunderstanding, to maintain a good context for the meeting and to

save time.

The case was the same with the questions and for the same reasons mentioned above,

the questions was prepared in English language (Appendix 3) then it was translated to

Spanish (Appendix 4).

According to the Qualitative Research Methods: A DATA COLLECTOR’S FIELD GUIDE21,

they indicated that in qualitative method research like the focus groups discussion the

questions should be open-ended questions, that is, questions that require an in-depth

response rather than a single phrase or simple “yes” or “no” answer.

The stage of the elaboration of the "Draft List" and questions was carried out during the

month of April 2015.

Draft List

The Draft list is an extract from reading the Community Engagement guidance 2008, its

updates 2014 and mihsalud program. It is an illustrations for recommendations that can be

used to improve and strengthen the concept of community engagement, develop a sense of

commitment in the individuals towards the society and daily-life health activities that may

lead to healthier life style. It will be used as a material source for discussion in two focus

groups in order to elaborate the final report “Recommendations list”.

Recommendations of the Community Engagement guidance 2008:

The recommendations present the ideal scenario for effective community engagement.

They cover four important themes:

Prerequisites for success: including policy development (5 recommendations).

Infrastructure: to support practice on the ground (3 recommendations).

Approaches: to support and increase levels of community engagement (3

recommendations).

Hiba Malek 31

Evaluation (1 recommendation).

The recommendations considered the evidence of effectiveness and cost effectiveness.

According to the studies reviewed, the scientific evidence considered to be effective to

encourage community participation.

Community engagement is a sustainable goal and it’s a long-term practice that may lead

to a better life for the community in specific and the society in general to achieve the goal

“Health for everyone”

The guidance6 define Sustainability as the long-term health and vitality – cultural,

economic, environmental and social – of a community.

Main beneficiaries:

Communities and groups with distinct health needs.

Communities that experience difficulties accessing health services or have health

problems caused by their social circumstances.

People living in disadvantaged areas, including those living in social housing.

Who should take actions?

1. Those involved in the planning (including coordination), design, funding and

evaluation of national, regional and local policy initiatives.

2. Providers and commissioners (Glossary 5) in public sector organizations, local

authorities (including officers and elected members) and the voluntary sector who

seek to involve communities in planning (including priority setting and funding),

designing, delivering, improving, managing and the governance of:

- Health promotion activities.

- Activities which aim to address the wider social determinants of health.

- Area-based initiatives.

Hiba Malek 32

3. Members of community organizations and groups and community representatives

involved in the above.

Prerequisites for effective community engagement

1. Policy development: plan, design and coordinate activities (including area-based

activities (Glossary 6) that incorporate all the community components and

organizations and take account of existing activities.

2. Long term investment: align long-term approach with local priorities. Identify the

funding resource and the lines for accountability. Set realistic timescale. Build on

past experiences. Clearly state the intended outcomes of the activities.

3. Organizational and cultural change: identify how the culture of public sector

organizations supports or prevents community engagement. Diversity training.

Manage conflicts between communities and the agencies that serve them.

4. Levels of engagement and power: negotiate and agree with all relevant parties how

power will be distributed and state the responsibilities. Recognize local diversity and

let community members decide how willing and able they are to participate. Avoid

technical and professional jargon. Feedback mechanisms.

5. Mutual trust and respect: assess the broad and specific health needs of the

community (under-respected groups). Tailor the approach used.

Infrastructure

6. Training and resources: develop and build on the local community’s strengths and

assets. Provide opportunities and resources for networking. Identify funding sources

for training. Work with NGOs, volunteers. Provide accessible meeting spaces and

equipment. Train individuals from the community to act as mentors.

7. Partnership working: develop statements of partnership working for all those

involved in activities. This will help increase knowledge and improve the

opportunities for joint working and/or consultation on service provision.

Hiba Malek 33

8. Area-based initiatives: encourage local people to be involved in the organization and

by recognizing and developing their skills. Involve communities in decision-making to

have the power to influence decisions.

Approaches

9. Community members as agents of change: recruit local people to plan, design and

deliver activities to improve health. Encourage local communities to form a group of

‘agents of change’. Work with neighborhood managers (Glossary 7) to ensure the

community’s views are heard.

10. Community workshops: run community workshops (art, health, etc.) to identify local

needs and maintain a high level of local participation in health promotion activities

(co-managed by professionals and community members).

11. Resident consultancy: draw on the skills and experience of people with previous

experience of regeneration (Glossary 4) activities to improve social cohesion and

general wellbeing. Empower the concept of work ‘with’ rather than ‘for’ the local

community.

Evaluation

Better evaluation processes are needed to improve the quality of evidence and to

increase understanding of how community engagement and the different approaches used

impact on health and social outcomes.

12. Identify and agree the aims of evaluation with members of the target community.

This should be agreed before the activity is introduced.

Involve them in the planning, design and implementation of an evaluation

framework that:

- encourage joint development.

- considers the theory of change required to achieve success

- embraces a mixed method approach

- indicators that help evaluate work, costs and experiences

- identifies the comparators that will be used.

Hiba Malek 34

The questions for the discussion were:

1- How can we integrate these recommendations into the mihsalud program in order to

improve performance and results of the program?

1.1 What you are currently doing in mihsalud program that matches what say NICE

recommendations?

2- What are the aspects that are not being implemented in the program?

2.1 What you are not currently doing in mihsalud program although this covered by the

recommendations of NICE and therefore should incorporate it?

2.2 What you are currently doing in mihsalud program and contrary to what say NICE

recommendations, therefore it should stop doing it?

3- What are the aspects that cannot be applied in the mihsalud program for now?

4- If the recommendations can be applied to mihsalud program, do you think that can be

applied to other health promotion programs or any other health program?

3.3 Focus groups preparation and implementation

Focus groups are a qualitative data collection method effective in helping researchers to

learn about the social norms of a community as well as the range of perspectives that exist

within that community. Because focus groups seek to illuminate group opinion, the method

is well suited for socio-behavioral research that will be used to develop and measure

services that meet the needs of a given population21.

3.3.1 Participants recruitment

Recruitment and selection of the participants in focus groups was done in cooperation

with Joan Paredes and Pilar Sanchez. The recruitment process was through an e-mail

invitation to the 13 participants (Appendix 5) followed by a phone call reminder before each

meeting to ensure their presence.

Hiba Malek 35

Pilar Snachez was the responsible of sending the e-mail at the beginning of May 2015

because she has all the contacts and she is in touch with the participants, and then she did

the follow up with the participants over the phone.

The Profile of the participants who were invited are:

For the focus group number one, they are 7 health workers related directly to the

implementation and development of the program: 2 family nurses, 1 association and 4

health workers who have a leadership role in the community.

For the focus group number two, they are 1 professional related directly to the program

and 6 professionals not related directly to the implementation of the program. They are in

the administratory level and they are directors of public health centers in Valencia:

A director of a public health center in Valencia.

A health promotion Section Chief of a public health center in Valencia.

A director of nursing department at Dr. Peset Hospital in Valencia.

A director of nursing department at Malvarrosa Clinic Hospital in Valencia.

A Head of Basic Area at Pau Salvador Health Centre in Valencia.

A Nursing Coordinator at Fuente de San Luis Health Centre in Valencia.

A Nurse promotor at the Public Health Centre of Valencia.

3.3.2 The preparation

First, we developed a meeting guide to ensure that it will be organized properly and

trying not to forget any step (Appendix 6). Second, we prepared a presentation in Spanish

language (Appendix 7) to demonstrate it before starting the discussion. The presentation

aimed to give the participants a brief information about NICE guidance and its objectives,

Community Engagement guidance 2008 and its recommendations plus it contained the

“Draft List”.

Hiba Malek 36

In order to make the meeting successful, we have prepared the material needed for

every participant and it was distributed in a folder that contains all the documents needed

in the meeting. The documents were prepared in Spanish language.

At the entrance to the meeting, the participants had to fill in the Sign-in sheet that

contains a general information as shown below in table 1.

Table 1. The Sign-in sheet that should be signed by the participants

Sex Age Profession Continuous relation with

community activities

Continuous relation with health

promotion activities

The folder contained:

- Informed consent sheet (Appendix 8)

- The "Draft List" (Page 30)

- The questions of the discussions (Page 34)

Ethical consideration: On every focus group and at the entrance to the meeting, all

participants must sign the informed consent that is written in Spanish language. In this

informed consent the participants were informed that their statements will be recorded and

accept the rules needed to participate in the focus group. The protection of the

confidentiality of the participants will consider the recommendation of the Article 21 of the

Declaration of Helsinki (World Medical Association, 2013)22 and data protection law (Law

15/1999 of 13 December)23.

The preparation for the two focus groups was carried out during the first two weeks of

May 2015.

3.3.3 The implementation

To start our investigation and after inviting all the participants and preparing all the

documents needed for the discussion, we conducted tow focus groups where we decided to

Hiba Malek 37

invite 13 professionals and health workers to the Public health centers of Valencia. Of those

13 invitees, 12 attended the invitation, therefore the percentage of attendees were 92%.

In coordination with Pilar Sanchez, the meeting was held in “La sala de juntas“ of the

Public Health Centre of Valencia. The duration for each meeting was about an hour and a

half. In order to realize those meetings and reach a good coordination, Pilar and I, took over

the roles of “note-taker” and “moderator” of the meetings, respectively.

Focus group number 1 was held on May the 18th and it was formed of 6 participants,

with 1 male and 5 females. The ages of the participants ranged between 23 and 47 years.

Their professions were: 0 Doctors, 2 Nurses, 3 ASBC (Community Based Health Agent) and 1

Health agent. All of the participants have continuous relation with community activities as

much as their continuous relation with health promotion activities. The Health agent is a

member of ACOEC (Asociación para la Cooperación entre comunidades).

Focus group number 2 was held on May the 19th and it was formed of 6 participants,

with 2 males and 4 females. The ages of the participants ranged between 31 and 60 years.

Their professions were: 3 Doctors, 3 Nurses, 0 ASBC (Community Based Health Agent) and 0

Health agent. All of the participants have continuous relation with community activities as

much as their continuous relation with health promotion activities.

The directors are in the management level and they hold the following jobs positions:

A Section Chief of a public health center in Valencia.

A director of nursing department at Dr. Peset Hospital in Valencia.

A director of nursing department at Malvarrosa Clinic Hospital in Valencia.

A head of Basic Area at Pau Salvador Health Centre in Valencia.

A Nursing Coordinator at Fuente de San Luis Health Centre in Valencia.

A Nurse promotor at the Public Health Centre of Valencia.

The table 2 shows the profiles of the participants and composition of the two focus

groups.

Hiba Malek 38

Table 2. Profiles of participants and composition of focus groups

(total number of participants: 12 participants)

item Focus group 1 Focus group 2

Venue Public Health Centre, Valencia Public Health Centre, Valencia

Sex 1 male & 5 Females 2 males & 4 females

Age Between 23 to 47 years Between 31 to 60 years

Doctors 0 3

Nurses 2 3

ASBC* 3 0

Health Agent 1 0

Continuous relation with

community activities

All yes All yes

Continuous relation with health

promotion activities

All yes All yes

*ASBC (Agente de Salud Base Comunitario): Community Based Health Agent

* Health Agent (Agente de Salud): A member of ACOEC (Asociación para la Cooperación

entre comunidades).

At the beginning of the meeting, in the informed consent, the participants were

informed that the meeting will be audio taped because this will help us in realizing proper

analysis of all the data and later on in the transcription stage.

3.3.4 Debriefing session

After each meetings a debriefing session (Appendix 9-10) was carried out between me,

the moderator, and Pilar Sanchez, the note-taker. It is important to have the debriefing

session right after the meeting to expand the notes taken and to log any additional

information about the focus group while it is still fresh in the memory21.

Hiba Malek 39

3.4 Transcription of the recordings

To transcribe the audio recordings, me, the moderator, I had to listen to the tapes and

simultaneously write down everything that was said on the tape. The transcription was done

in Spanish language and it took about three weeks to be done. It was carried out during

June 2015.

The transcription for the first focus group could be found in appendix 11, and for the

second one in appendix 12.

3.5 Analysis

After having all the transcriptions, it was analyzed by a content analysis for the data,

taking into consideration common and different points between the recommendations of

NICE guidance and the mihsalud program. It was done following the below steps:

Coding: in order not to reveal the names of the participants and for confidentiality

purposes, we gave a number as a code for each participants. Doing so will keep the

order of the answers and prevent fell in the bias of information.

Preparing 4 tables (As shown below) to summarize every question and to have a

short clear statement from every participant that would be useful in writing the

results. The numbers in the tables are used to indicate the code that was given to

each participant.

Table 3. What are the aspects of these recommendations that are being applied to mihsalud program

Recommendations/NICE

guidance

What you are currently doing in mihsalud program that matches what say

NICE recommendations?

1- “El planificar designar y coordinar actividades que son los talleres, nos

organizamos antes de ir, tenemos una guía que ofrecemos y también nos

adaptamos a las necesidades que nos puedan surgiendo”.

2- “Evitar la jerga técnica y profesional, incorporar mecanismo de

Hiba Malek 40

Focus Group #1

retroalimentación creo que también se hace. La confianza mutua, adecuar el

enfoque utilizado, evaluar las necesidades de salud generales”.

3- “Respeto a la evaluación se realizan evaluaciones internas con los equipos y

centros de salud pública a parto al año pasado se hice una evaluación externa”.

4- “son la formación de agente de salud en base comunitaria que viene

enfocado estas entre infraestructura e enfoques. La realización de nuestras

fortalezas y activos de la comunidad local mediante del "Rapid upraisel" y el

mapa comunitario”.

5- “Reconocemos la diversidad de las personas y trabajamos con asociaciones y

hacemos talleres en una manera que las personas lo entiendan y se integran”.

6- “En cuanto a la infraestructura por lo mismo sí que se intentar fomentar el

trabajo entre de asociaciones servicios sanitarios y todo eso y se intenta

fomentar que la persona se participe de la propia comunidad que participen de

forma activa. Eso también del enfoque”.

Focus group #2

1- “se está haciendo todo lo relacionado con la infraestructura. Si sé que están

planificando talleres comunitarios y además se tienen en cuenta las personas

que residen en la comunidad”.

2- “uno la planificación la coordinación y el diseño del programa. Dos la

confianza y el respeto mutuo”.

3- “En la parte infraestructura sí que se está actuando los tres requisitos que

indicando y en los enfoques también”.

4- “Yo consideró que el programa que sigue la mayoría de recomendaciones.

Dentro de los prerrequisitos la inversión a corto plazo y dentro de lo que es la

infraestructuras y enfoques sí que la sigue. En evaluación intenta a hacer una

parte”.

5- “Pienso que sí que tienen objetivos a corto plazo sin embargo no tengo muy

claro si las prioridades locales a largo plazo se están cumpliendo”.

6- “El punto tres de la infraestructura como el punto uno de los enfoques creo

que se cumplen con los forros que se realizan mensualmente”.

Hiba Malek 41

Table 4. What are the aspects of these recommendations that are not being applied to mihsalud program

Recommendations/NICE

guidance

What you are not currently doing in

mihsalud program although this

covered by the recommendations of

NICE and therefore should incorporate

it?

What you are currently doing in

mihsalud program and contrary to

what say NICE recommendations,

therefore it should stop doing it?

Focus group #1

1- “la continua del proyecto y una

evaluación externa a lo mejor más

constante”.

1- “no veo nada que vaya en

contra”.

2- “los tiempos del sector público se

adecuan a los necesidades de este

proyecto participativo que le falta

problema burocráticos”.

2- “depender de una entidad

bancaria para que esto continúe”.

3- “La sostenibilidad del programa del

proyecto y que es incluya dentro del

sistema sanitario público”.

3- “sí que debería forma parte del

sistema sanitario público para tener

una continuidad a largo plazo”.

4- “La participación del sector público

para la continuidad del proyecto en

sostenibilidad”.

4- “Lo que se está haciendo es una

financiación a corto plazo que va en

contra”.

5- “la continuidad del programa y que

se incluyen en el sistema sanitario

público”.

5- “Pienso que está todo ordenado”.

6- “La integración del proyecto en la

administración pública también”.

6- “debería incluirse la

administración de una continuidad”.

1- “de la evaluación en la que

identificar y acordar las objetivos de

evaluación con los miembros de la

comunidad del destino creo que eso no

se hace previamente e involucrarlos en

la planificación el diseño y la aplicación

de un marco de evaluación creo que

tampoco se hace”.

1- “no hay nada”.

Hiba Malek 42

Focus group #2

2- “considero que no está completo a

todos los niveles creo que es el punto 4

corresponde a la decisión comunitaria.

Los niveles de participación y poder de

la comunidad actualmente creo que no

está y el desarrollo”.

2- “no encuentro en este momento

ningún punto”.

3- “los enfoques en tercer punto cuando

hay que tener en cuenta la opinión de

personas residentes”.

3- “las indicadores que no se están

trabajando para la evaluación

suficiente y los que están trabajando

para ello no se ha tenido en cuenta

la opinión de la sociedad y la gente

sociales y asociaciones”.

4- “para asegurar esa financiación a

largo plazo”.

4- “es no asegurar la sostenibilidad,

entonces estamos generando unas

falsas expectativas respecto a la

participación”.

5- “En cuanto a los niveles de

participación y el poder creo que falta

algo en cuanto a lo que es la

distribución del poder y la

responsabilidades. Y por último que

sería también con lo mismo seria la

parte de participación local de la

población en el punto 2 y 3 de los

enfoques”.

5- “Yo estoy de acuerdo en que el

único que se tendría que dejar de

hacer es no dejar plan por el futuro

del programa”.

6- “en la parte de prerrequisitos el

punto 2 no se cumple no hay una

inversión a largo plazo en el programa

porque la entidades que financian no

dan esa financiación a largo plazo”.

6- “Yo considero que en contra no

hay nada de ninguno de los puntos

que hay en la guía NICE”.

Hiba Malek 43

Table 5. Aspects that cannot be applied in the mihsalud program right now

Recommendations/NICE

guidance

What are the aspects that cannot be applied in the mihsalud program for

now?

Focus group #1

1- “Pienso que el tema del trabajo con la comunidad que la comunidad se

integre de la plena participación del Proyecto”.

2- “lo que no se hace también es potenciase trabajo “con” en lugar de “por” en

la comunidad local”.

3- “No se puede aplicar actividades a largo plazo por el hecho de la continuidad

que tiene duración de once meses entonces por tanto no podemos ver

resultados ni planificar actividades a largo plazo”.

4- “la participación del sector público por cuestiones políticas para la

continuidad del programa”.

Focus group #2

1- “Creo que en las recomendaciones que tenemos por escrito seria todo

aplicable”.

2- “lo que corresponderían con infraestructura en el punto formación y recursos

por el problema que hay de financiación a largo plazo”.

3- “todo aquello que implica un largo plazo”.

4- “Yo creo que todo es aplicable. No encuentro ningún cosa que no”.

5- “Yo también pienso que todo es aplicable”.

Table 6. Study applicability to other health programs

Recommendations/NICE

guidance

If the recommendations can be applied to mihsalud program, do you think

that can be applied to other health promotion programs or any other health

program?

1- “Pienso que sí”

2- “Sí”

3- “Pienso que estas recomendaciones se pueden aplicar a cualquier otros de

Hiba Malek 44

Focus group #1

los programas dirigidos a promover la salud en la comunidad”

4- “Yo creo que las recomendaciones de este NICE se pueden aplicar a cualquier

programa de promoción de la salud y al centro de salud”

5- “Yo creo que si se puede aplicar a cualquier programa”

6- “Creo que se puede aplicar a otro programa y a cualquier de ella y además

servir para la inauguración de los mismo”

Focus group #2

1- “Sí”

2- “Exactamente igual que si están aplicando al programa mihsalud todas las

recomendaciones son aplicables a cualquier programa de promoción de la

salud en el entorno comunitario”

3-“ Sí, evidentemente es una forma, metodología de estudiar cómo funciona

una programa”

4- “Yo también opino que sí. Creo que se le hiciéremos conseguiríamos trabajar

con más eficiencia y mayor satisfacción personal“

5- “Debería ser sí”

6- “Yo creo que sí también”

The process will conclude with the preparation of a final report the "Recommendations

list" explaining procedures to improve the community engagement in mihsalud program.

4. Results

4.1 Reviews of the team of mihsalud program

To start with the results, we have created the table shown below, which is table 7.

Reviews of mihsalud team program on the implementation of the recommendations of NICE

guidance - Community Engagement 2008. The table summarize the answers to the first

three questions that shown in the discussion in page 34 and it sums up the opinions of

participants in the first focus group. They were 6 participants and they are all young health

workers related directly to the execution of mihsalud. They are the people who work in the

Hiba Malek 45

program, they go to the field and interact with target communities. The table represents

what are the aspects of the 12 recommendations that are being applied and are not being

applied to the program and in addition it shows the aspects that cannot be applied to the

program for now. In the table we have highlighted in bold the opinions that have prevailed

in the answers of the participants and we have also wrote the other opinions of the

participants.

As for the recommendations that match the mihsalud program, regarding the

prerequisites for success there were a consent in the opinion of participants about the

planning, designing and coordinating activities and workshops in advance following a guide

for it. Levels of engagement and power, negotiate and agree with all relevant parties on

how power will be distributed and state the responsibilities. Health needs evaluation and

mutual trust. Work with associations which is a strength point for the program. There is a

high Levels of engagement of all relevant parties how power will be distributed and state

the responsibilities. Recognize local diversity and let community members decide how

willing and able they are to participate. Avoid technical and professional jargon. Feedback

mechanisms are well admitted and organized. There is a good assessment of the health

needs of the community and adaptation of the approaches used with the members of the

community is also being done. Regarding the infrastructure, they work with NGOs and

volunteers, provide accessible meeting spaces and equipment and train individuals from the

community to act as mentors. Another strength point is developing statements of

partnership working for all those involved in activities. Regarding the approaches, almost all

the recommendations are followed in mihsalud program such as recruiting local people to

plan, design and deliver activities to improve health and encouraging local communities to

form a group of ‘agents of change’ which is in Spain called “agente de salud”. Run

community workshops to identify local needs and maintain a high level of local participation

in health promotion activities. Draw on the skills and experience of people with previous

experience of regeneration activities to improve social cohesion and general well-being.

Regarding the evaluation, they are doing internal evaluation organized with the teams and

public health centers, and the last year they did an external evaluation.

As for the recommendations that could join the program, there were shared ideas

between the participants about the importance of finding a multiple resource for funding

Hiba Malek 46

and register the program in the public health sector to give continuity to the program. Not

only the registration but the participation of the public health sector in the program is also

required. Regarding the organizational and cultural change, there should be diversity

training and let the community participate totally in the planning. Another important idea

that let the individuals interact between both themselves and community is to empower the

concept of work ‘with’ rather than ‘for’ the local community.

There is one recommendations that would not be applicable to the program for now,

which is the long-term investment because parts of the program last for eleven months and

the lack of financial support will prevent long-term planning and designing activities.

Hiba Malek 47

Table 7. Reviews of mihsalud team program on the implementation of the recommendations of NICE guidance - Community Engagement 2008.

Recommendations/NICE guidance

What you are currently doing

in mihsalud program that

matches what say NICE

recommendations?

What you are not currently doing

in mihsalud program although

this covered by the

recommendations of NICE and

therefore should incorporate it?

What you are currently doing

in mihsalud program and

contrary to what say NICE

recommendations, therefore

it should stop doing it?

What are the aspects that

cannot be applied to

mihsalud program for now?

Prerequisites for success: including

policy development, 5

recommendations.

1) Policy development: plan, design

and coordinate activities (including

area-based activities that

incorporate all the community

components and organizations and

take account of existing activities.

*1- “El planificar designar y

coordinar actividades que son

los talleres, nos organizamos

antes de ir, tenemos una guía

que ofrecemos y también nos

adaptamos a las necesidades

que nos puedan surgiendo”.

6- “La integración del proyecto

en la administración pública

también”.

2) Long term investment: align long-

term approach with local priorities.

Identify the funding resource and

the lines for accountability. Set

realistic timescale. Build on past

4- “La participación del sector

público para la continuidad del

proyecto en sostenibilidad”.

2- “depender de una entidad

bancaria para que esto

continue”.

3-“Nuestro proyecto tiene

duración de once meses

por tanto no se puede

aplicar actividad a lo

largo plazo”

Hiba Malek 48

experiences. Clearly state the

intended outcomes of the activities.

3) Organizational and cultural

change: identify how the culture of

public sector organizations supports

or prevents community

engagement. Diversity training.

Manage conflicts between

communities and the agencies that

serve them.

5- “trabajamos con

asociaciones y hacemos

talleres en una manera que las

personas lo entiendan y se

integran”.

1-“ Pienso que el tema del trabajo

con la comunidad que la

comunidad se integre de la plena

participacion del proyecto”.

2- “el tema de gestión de la

diversidad los curriculum de los

profesionales de los recursos

sanitario creo que faltaría”

3-“ evidentemente la formación,

la diversidad no existe”

3- “si que debería forma

parte del sistema sanitario

público para tener una

continuidad a largo plazo”.

4) Levels of engagement and power:

negotiate and agree with all

relevant parties how power will be

distributed and state the

responsibilities. Recognize local

diversity and let community

members decide how willing and

able they are to participate. Avoid

technical and professional jargon.

Feedback mechanisms.

2- “Evitar la jerga técnica y

profesional, incorporar

mecanismo de

retroalimentación creo que

también se hace”

1- “algo de si que está

haciendo también es los

deberes de participación y

el poder”

5- “Reconocemos la diversidad

de las personas”

Hiba Malek 49

5) Mutual trust and respect: assess

the broad and specific health needs

of the community (under-respected

groups). Tailor the approach used.

1-“si que hay una

evaluación de las

necesidades”

2- “La confianza mutua,

adecuar el enfoque utilizado,

evaluar las necesidades de

salud generals”

Infrastructure: to support practice

on the ground, 3 recommendations.

6) Training and resources: develop

and build on the local community’s

strengths and assets. Provide

opportunities and resources for

networking. Identify funding sources

for training. Work with NGOs,

volunteers. Provide accessible

meeting spaces and equipment.

Train individuals from the

community to act as mentors.

6- “En cuanto a la

infraestructura por lo mismo si

que se intenta

fomentar el trabajo entre de

asociaciones servicios

sanitarios y todo eso y se

intenta fomentar que la

persona se participe de la

propia comunidad que

participen de forma activa.

Eso también del enfoque”.

7) Partnership working: develop

statements of partnership working

for all those involved in activities.

This will help increase knowledge

1- “Pues trabajar de

manera conjunta buena

asociación promovemos

todo el trabajo en red si

Hiba Malek 50

and improve the opportunities for

joint working and/or consultation

on service provision.

que es uno de los puntos

fuertes de este proyecto

esta promoción del trabajo

en red”

8) Area-based initiatives: encourage

local people to be involved in the

organization and by recognizing and

developing their skills. Involve

communities in decision-making to

have the power to influence

decisions.

Approaches: to support and

increase levels of community

engagement, 3 recommendations.

9) Community members as agents

of change: recruit local people to

plan, design and deliver activities to

improve health. Encourage local

communities to form a group of

‘agents of change’. Work with

neighborhood managers to ensure

the community’s views are heard.

4- “son la formación de agente

de salud en base comunitaria

que viene enfocado estas

entre infraestructura e

enfoques. La realización de

nuestras fortalezas y activos

de la comunidad local

mediante del "Rapid upraisel"

y el mapa comunitario”

1- “remiembro de la

comunidad como agentes

de cambio hecho antes

Hiba Malek 51

como el curso de agente

salud”

10) Community workshops: run

community workshops (art, health,

etc.) to identify local needs and

maintain a high level of local

participation in health promotion

activities (co-managed by

professionals and community

members)

1- “Los talleres

comunitarios también creo

que se llevan acabo bien en

salud y sobre todo”

11) Resident consultancy: draw on

the skills and experience of people

with previous experience of

regeneration activities to improve

social cohesion and general

wellbeing. Empower the concept of

work ‘with’ rather than ‘for’ the

local community

6-“ se intenta fomentar que

la persona se participe de la

propia comunidad que

participen de forma activa”

2- “lo que no se hace también es

potenciase trabajo “con” en lugar

de “por” en la comunidad local”.

Evaluation: 1 recommendation.

12) Identify and agree the aims of

evaluation with members of the

target community. This should be

agreed before the activity is

3- “Respeto a la evaluación se

realizan evaluaciones

internas con los equipos y

centros de salud pública a

parto al año pasado se hice

1-“ una evaluación externa a

lo mejor más constante”

Hiba Malek 52

introduced.

Involve them in the planning, design

and implementation of an

evaluation framework that: -

encourages joint development

- considers the theory of change

required to achieve success

- embraces a mixed method

approach

- indicators that help evaluate work,

costs and experiences

- identifies the comparators that will

be used.

una evaluación externa”.

* The numbers are used to indicate the code that was given to each participant in the focus group

Hiba Malek 53

The forth question that talks about the applicability of the recommendations to other

health promotion programs, all the participants agreed on the same answer which is "Yes".

In general, they all said that if the recommendations are applicable to mihsalud program

then they are for sure applicable to other programs in Valencia City. One of the participants

said that as the recommendations are beneficial to this program then it can be beneficial to

any program that includes community participation in health promotion programs. All the

answers were direct without providing any other argument about this question. In the table

below we are providing summarize for the answers to the forth question.

Table 8. Reviews of the mihsalud team program on the applicability of the recommendations to

other health promotion programs.

If the recommendations can be applied to mihsalud program, do you think that can be applied to

other health promotion programs or any other health program?

*1- “Pienso que sí”

2- “Sí”

3- “Pienso que estas recomendaciones se pueden aplicar a cualquier otros de los programas

dirigidos a promover la salud en la comunidad”

4- “Yo creo que las recomendaciones de este NICE se pueden aplicar a cualquier programa de

promoción de la salud y al centro de salud”

5- “Yo creo que si se puede aplicar a cualquier programa”

6- “Creo que se puede aplicar a otro programa y a cualquier de ella y además servir para la

inauguración de los mismo”

* The numbers are used to indicate the code that was given to each participant in the focus

group.

4.2 Reviews of the directors related to mihsalud program

For the second focus group, we have done the same table that shown below, which is

table 9. Reviews of directors involved in mihsalud program on the implementation of the

recommendations of NICE guidance - Community Engagement 2008. The table summarize

the answers to the first three questions that shown in the discussion in page 34 and it sums

up the opinions of the participants in the second focus group. They were 6 participants and

they are directors related to mihsalud. The table represents what are the aspects of the 12

Hiba Malek 54

recommendations that are being applied and are not being applied to the program and in

addition it shows the aspects that cannot be applied in the program for now. In the table we

have highlighted in bold the opinions that have prevailed in the answers of the participants

and we have also wrote the other opinions of the participants.

As for the recommendations that match the program, regarding the prerequisites for

success, all the points are met more or less especially the planning, designing and

coordinating of activities. The short-term investment, diversity training, mutual trust and

respect also performed. Regarding the infrastructure, almost all the points are met based on

the opinions of the participants especially designing community workshops, depending on

the local community’s strengths and assets, working with NGOs and associations. For

examples, there are forums that are held on a weekly basis to encourage local people to be

involved in the organization and developing of their skills. Regarding the approaches,

forming “agente de salud” which is “agents of change” and depending on the preexistent

skills and individuals who live in the community. Regarding the evaluation, there is an

opinion saying that we are doing an evaluation or we are trying to do an evaluation.

As for the recommendations that could join the program, it would be more useful to

identify funding resources to be able to align long-term approach with local priorities,

establish a diversity training and manage conflicts between communities and agencies that

serve them. The sustainability of the program is a must. The fourth point from prerequisite

for success should incorporate it more in the program in terms of distribution of the power

and state the responsibilities. Also the fifth point of mutual trust and respect is missing.

About the area-based initiatives in the infrastructure, encourage local people to be involved

in the organization and developing of their skills, a participant expressed that this is being

done with the population at risk in the community but not with the locals. Referring to

approaches, there are some points that should be added to the program like the

neighborhood manager, the part of local participation of population in the point 2 and 3

from approaches and the third point when we must take into consideration the opinions of

community residents. In the evaluation, to identify and agree on the evaluation objectives

with community members, this is not done previously and involve them in the planning,

designing and implementation of an evaluation framework too. The evaluation indicators

are not taking into account the views of society, the people and social associations.

Hiba Malek 55

As for the recommendations that would not be applicable to the program for now,

everything related to the long-term planning due to the short duration of the program, the

problem that emerged with the lack of financial support on the long-term. This will prevent

the team from building a good structure, conducting a professional training for the people

related with the program and develop the strengths of the local community.

Hiba Malek 56

Table 9. Reviews of directors involved in mihsalud program on the implementation of the recommendations of the NICE guidance - Community Engagement 2008

Recommendations/NICE guidance

What you are currently doing in

mihsalud program that matches

what say NICE recommendations?

What you are not currently

doing in mihsalud program

although this covered by the

recommendations of NICE and

therefore should incorporate it?

What you are currently doing

in mihsalud program and

contrary to what say NICE

recommendations, therefore

it should stop doing it?

What are the aspects that

cannot be applied to mihsalud

program for now?

Prerequisites for success:

including policy development, 5

recommendations.

1) Policy development: plan,

design and coordinate activities

(including area-based activities)

that incorporate all the community

components and organizations

and take account of existing

activities.

*2- “Considero que se está

haciendo uno la planificación la

coordinación y el diseño del

programa”

6- “los prerrequisitos se cumplen

más o menos todos, sobre todo el

punto uno con la planificar diseñar

y coordinar las actividades”

2) Long term investment: align

long-term approach with local

priorities. Identify the funding

resource and the lines for

accountability. Set realistic

4- “Dentro de los prerrequisitos la

inversión a corto plazo”

4- “para asegurar esa

financiación a largo plazo”

4- “es no asegurar la

sostenibilidad, entonces

estamos generando unas

falsas expectativas respecto a

la participación”.

3- “todo aquello que implica

un largo plazo”.

Hiba Malek 57

timescale. Build on past

experiences. Clearly state the

intended outcomes of the

activities.

3) Organizational and cultural

change: identify how the culture of

public sector organizations

supports or prevents community

engagement. Diversity training.

Manage conflicts between

communities and the agencies that

serve them.

5- “La gestión y de conflictos de

comunidades y los organismos

tengo dudas no lo sé con

seguridad”

4) Levels of engagement and

power: negotiate and agree with

all relevant parties how power will

be distributed and state the

responsibilities. Recognize local

diversity and let community

members decide how willing and

able they are to participate. Avoid

technical and professional jargon.

Feedback mechanisms.

5- “En cuanto a la formación a la

diversidad pienso que sí que se

cumple”

2- “considero que no está

completo a todos los niveles

creo que es el punto 4

corresponde a la decisión

comunitaria. Los niveles de

participación y poder de la

comunidad actualmente creo

que no está y el desarrollo”

5- “En cuanto a los niveles de

participación y el poder creo

que falta algo en cuanto a lo

que es la distribución del poder

Hiba Malek 58

y las responsabilidades”

5) Mutual trust and respect: assess

the broad and specific health

needs of the community (under-

respected groups). Tailor the

approach used.

2- “Consideró que se está haciendo,

Dos la confianza y el respeto

mutuo”

6- “el punto cinco de confianza y

respeto porque también se

evalúan las necesidades

comunitarias”

Infrastructure: to support practice

on the ground, 3

recommendations.

6) Training and resources: develop

and build on the local community’s

strengths and assets. Provide

opportunities and resources for

networking. Identify funding

sources for training. Work with

NGOs, volunteers. Provide

accessible meeting spaces and

equipment. Train individuals from

the community to act as mentors.

1- “se está haciendo todo lo

relacionado con la infraestructura.

Si sé que están planificando

talleres comunitarios y además se

tienen en cuenta las personas que

residen en la comunidad”

5- “creo también que se cumple en

el trabajo conjunto en asociación

también”

6- “Respecto a la infraestructura

también creo que se cumplen los

tres. El punto uno se capacita a los

individuos de la comunidad con el

curso de formación acción de los

agentes de salud”

2- “lo que corresponderían con

infraestructura en el punto

formación y recursos por el

problema que hay de

financiación a largo plazo, en

cuanto a la estructura montar

de estructura, de espacios y

sobre todo para formar a todo

lo que corresponde a

desarrollar la fortalezas de la

comunidad local”.

7) Partnership working: develop

statements of partnership working

for all those involved in activities.

6- “El punto dos se trabajan en

manera conjunta con las

asociaciones que es como la forma

Hiba Malek 59

This will help increase knowledge

and improve the opportunities for

joint working and/or consultation

on service provision.

del trabaja del programa”

8) Area-based initiatives:

encourage local people to be

involved in the organization and by

recognizing and developing their

skills. Involve communities in

decision-making to have the

power to influence decisions.

6- “El punto tres de la

infraestructura como el punto uno

de los enfoques creo que se

cumplen con los foros que se

realizan mensualmente y después

los talleres comunitarios también

se cumplen”

5- “creo que las iniciativas

basadas en el territorio dice que

debería animar a la gente de

zona a que participen en la

organización creo que se está

realizando con la población en la

comunidad de riesgo pero no con

la gente de la zona”

Approaches: to support and

increase levels of community

engagement, 3 recommendations.

9) Community members as agents

of change: recruit local people to

plan, design and deliver activities

to improve health. Encourage local

communities to form a group of

‘agents of change’. Work with

neighborhood managers to ensure

the community’s views are heard.

6- “El punto tres de la

infraestructura como el punto uno

de los enfoques creo que se

cumplen con los foros que se

realizan mensualmente”.

1- “Este todo figura la gerente de

barrio que no sé si se recoge en

nuestro territorio”

10) Community workshops: run 1- “Si sé que están planificando 5- “por último que sería también

Hiba Malek 60

community workshops (art, health,

etc.) to identify local needs and

maintain a high level of local

participation in health promotion

activities (co-managed by

professionals and community

members).

talleres comunitarios y además se

tienen en cuenta las personas que

residen en la comunidad”

con lo mismo seria la parte de

participación local de la

población en el punto 2 y 3 de los

enfoques”

11) Resident consultancy: draw on

the skills and experience of people

with previous experience of

regeneration activities to improve

social cohesion and general

wellbeing. Empower the concept

of work ‘with’ rather than ‘for’ the

local community.

3- “los enfoques en tercer punto

cuando hay que tener en cuenta

la opinión de personas

residentes”

Evaluation: 1 recommendation.

12) Identify and agree the aims of

evaluation with members of the

target community. This should be

agreed before the activity is

introduced.

Involve them in the planning,

design and implementation of an

evaluation framework that: -

4- “En evaluación intenta a hacer

una parte”

1- “de la evaluación en la que

identificar y acordar las

objetivos de evaluación con los

miembros de la comunidad del

destino creo que eso no se hace

previamente e involucrarlos en

la planificación el diseño y la

aplicación de un marco de

evaluación creo que tampoco se

3- “las indicadores que no se

están trabajando para la

evaluación suficiente y los que

están trabajando para ello no

se ha tenido en cuenta la

opinión de la sociedad y la

gente sociales y asociaciones”

Hiba Malek 61

encourages joint development

- considers the theory of change

required to achieve success

- embraces a mixed method

approach

- indicators that help evaluate

work, costs and experiences

- identifies the comparators that

will be used.

hace”.

* The numbers are used to indicate the code that was given to each participant in the focus group.

Hiba Malek 62

Regarding the forth question, like in the first group, all the participants agreed on the

same answer which is “Yes”. They all answered based on their experience in other programs

that promote health as well as other activities. They all have a good perspective and life

experience in community-based programs. Therefore due to their wide experience, the

answers were concise and precise with positive consent like one of the answers that was

“Exactamente igual” which means that exactly the same recommendations that are

applicable to mihsalud could be applicable to any health promotion program regarding the

community section. Another participant was very selective with the words while answering

and said that the recommendations are a methodology to study how a program works. In

addition following these recommendations will give a high level of efficiency and personal

satisfaction, based on another participant’s answer.

In the table below we are providing summarize for the answers to the forth question

and to attract the attention we have highlighted the strength words that reflect the strength

of the consensus of opinions with positive approval in answers.

Table 10. Reviews of the directors on the applicability of the recommendations to other health

promotion programs

If the recommendations can be applied to mihsalud program, do you think that can be applied to

other health promotion programs or any other health program?

*1- “Si”

2- “Exactamente igual que si están aplicando al programa mihsalud todas las recomendaciones

son aplicables a cualquier programa de promoción de la salud en el entorno comunitario”

3-“Si, evidentemente es una forma, metodología de estudiar cómo funciona un programa”

4- “Yo también opino que sí. Creo que se le hiciéremos conseguiríamos trabajar con más eficiencia

y mayor satisfacción personal“

5- “Debería ser sí”

6- “Yo creo que si también”

*The numbers are used to indicate the code that was given to each participant in the focus

group.

Hiba Malek 63

4.3 Reviews of the program team and directors related to the program

In this part of the results we are going to combine the answers of the program team and

directors to demonstrate the degree of compliance with the recommendations of NICE

guidance - Community Engagement 2008. We will interpret this degree of compliance

through three levels:

1- Recommendations that are incorporated to mihsalud: from the table it seems that

the recommendations that mostly incorporated to mihsalud program are from the

infrastructure and approaches. The three points of infrastructure are incorporated

such as work with NGOs and volunteers and build on past experiences in the

community. Run community workshops, weekly forum for public and form “agents

of change”. The same case in approaches like identify local needs and active

participation from the people based on their skills. Planning and taking into account

the local residents. In prerequisites for success, also there is a good part of the

recommendations that have been implemented such as working with a guideline and

everything is organized in advanced, work with associations and evaluate the needs

of population, recognize diversity, mutual trust, respect and feedback mechanism.

Regarding evaluation, the program has internal evaluation and only one external

evaluation was done last year.

2- Recommendations that are not incorporated to mihsalud: or we can call it areas of

improvement in the program that should be mostly in prerequisites and in

evaluation. In prerequisites they should register the program in the public sector to

be more involved in the program to ensure its continuity. Although there is a

diversity recognition, but there is no diversity training. Increase the level of

participation from all the community members and distribution of power and

responsibilities. In evaluation, identify and agree the aims of evaluation with

members of the target community in advance and involve them in the planning,

designing and implementation of an evaluation framework. Run a constant external

evaluation and the indicator should take account the opinion of the residents. In

infrastructure, the community workshops should include all the residents of the

Hiba Malek 64

community and not only the population at risk. Finally, in approaches, increase the

work and cooperation with neighborhood managers and take into consideration the

opinion of the community residents, empower the concept of work ‘with’ rather

than ‘for’ the local community.

3- Recommendations that cannot be applied now to mihsalud: luckily, a large number

of the recommendations are already incorporated to mihsalud and the rest of them

can be incorporated too. Only the part related to long-term planning and designing

activities cannot be applied now because of the lack of long-term funding. Actually,

part of the program depends on the support from "Obra Social La Caixa", but it is

only for a short period of time and the team managers should look for other funding

resources to be able to execute the program efficiently. One opinion said that

because of the lack of investment we will not be able to develop and build on the

local community’s strengths and assets, provide sources for training, meeting spaces,

equipment and train individuals from the community to act as mentors.

Hiba Malek 65

Table 11. Degree of compliance with the recommendations of the NICE guidance - Community Engagement 2008, in the reviews of the program team and directors involved.

Recommendations/NICE guidance

What you are currently doing

in mihsalud program that

matches what say NICE

recommendations?

What you are not currently doing

in mihsalud program although this

covered by the recommendations

of NICE and therefore should

incorporate it.

What are the aspects that

cannot be applied in mihsalud

program for now?

Prerequisites for success: including policy development, 5

recommendations.

1) Policy development: plan, design and coordinate activities (including

area-based activities that incorporate all the community components

and organizations and take account of existing activities.

- Everything is organized in

advanced. There is a guideline.

- Plan, design and coordinate

activities is done.

- Register the program in the

Public sector.

2) Long term investment: align long-term approach with local priorities.

Identify the funding resource and the lines for accountability. Set

realistic timescale. Build on past experiences. Clearly state the intended

outcomes of the activities.

- Short-term investment.

- Participation of the public sector

for the continuity of the program.

- look for funding resources to be

able to function on the long-term

- Everything related with long-

term investment can’t be

applied.

3) Organizational and cultural change: identify how the culture of public

sector organizations supports or prevents community engagement.

Diversity training. Manage conflicts between communities and the

agencies that serve them.

- Work with associations.

- Workshops for the people to

participate.

- There is no diversity training and

not all community participate in

the activities.

- manage conflicts between

communities and the people.

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4) Levels of engagement and power: negotiate and agree with all

relevant parties how power will be distributed and state the

responsibilities. Recognize local diversity and let community members

decide how willing and able they are to participate. Avoid technical and

professional jargon. Feedback mechanisms.

- Diversity recognition.

- Avoid technical jargon.

- Feedback mechanism.

- Distribution of power.

- Engagement levels and the

distribution of power and

responsibilities should be better.

5) Mutual trust and respect: assess the broad and specific health needs

of the community (under-respected groups). Tailor the approach used.

- Needs evaluation.

- Mutual trust and respect.

Infrastructure: to support practice on the ground, 3 recommendations.

6) Training and resources: develop and build on the local community’s

strengths and assets. Provide opportunities and resources for

networking. Identify funding sources for training. Work with NGOs,

volunteers. Provide accessible meeting spaces and equipment. Train

individuals from the community to act as mentors.

- Work with NGOs.

- build on past experiences.

- Community workshop.

- Courses “Agente de salud”.

- The lack of long-term

investment can effect

negatively this point.

7) Partnership working: develop statements of partnership working for

all those involved in activities. This will help increase knowledge and

improve the opportunities for joint working and/or consultation on

service provision.

- Working with partnership is an

essential part of the program.

8) Area-based initiatives: encourage local people to be involved in the

organization and by recognizing and developing their skills. Involve

communities in decision-making to have the power to influence

decisions.

- Monthly forums for public and

workshops.

- The workshops are done with

population at risk only and not

with all the population of the

communities.

Approaches: to support and increase levels of community engagement,

3 recommendations.

9) Community members as agents of change: recruit local people to

- This point is done with

forming “agents of change”.

- should work more with the

neighborhood managers.

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plan, design and deliver activities to improve health. Encourage local

communities to form a group of ‘agents of change’. Work with

neighborhood managers to ensure the community’s views are heard.

10) Community workshops: run community workshops (art, health, etc.)

to identify local needs and maintain a high level of local participation in

health promotion activities (co-managed by professionals and

community members).

- Community workshops to

identify local needs.

- Planning and taking into

account the local residents.

- increase the level of local

participation.

11) Resident consultancy: draw on the skills and experience of people

with previous experience of regeneration activities to improve social

cohesion and general wellbeing. Empower the concept of work ‘with’

rather than ‘for’ the local community.

- Active participation from the

people based on their skills.

- Empower the concept of work

‘with’ rather than ‘for’ the local

community.

- Take into consideration the

opinion of the community

residents.

Evaluation: 1 recommendation.

12) Identify and agree the aims of evaluation with members of the

target community. This should be agreed before the activity is

introduced.

Involve them in the planning, design and implementation of an

evaluation framework that: - encourages joint development

- considers the theory of change required to achieve success

- embraces a mixed method approach

- indicators that help evaluate work, costs and experiences

- identifies the comparators that will be used.

- Always conducting internal

evaluation and one external

evaluation last year.

- Constant external evaluation.

- Identify and agree the aims of

evaluation with members of the

target community in advance and

involve them in the planning,

design and implementation of an

evaluation framework.

- The indicator should take account

the opinion of resident.

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Regarding the forth question, both groups coincide on the same positive and optimistic

answer. All the participants answered that yes these recommendations could be applied to

other promotion programs or any other health program in Valencia and in Spain. In

addition, it was obvious in their answers that as long as the recommendations are applicable

to this program then they are applicable to other health promotion programs.

4.4 The final report, the “Recommendations List”

The “Recommendations list” is aiming to improve the participation of the community in

mihsalud and to make the work reflects the needs and priorities of those who will be

affected by the program. After conducting two focus groups and doing the transcription and

results, we can elaborate the list of recommendations. Like we have seen in the results,

there were points where the participants agreed that parts of NICE recommendations have

been already applied to the program, therefore we don’t have to include it in this list. Other

recommendations cannot be applied to the program for now so we can’t include them in

the list either. The rest of the recommendations and what the participants suggest that it

should be included in the program or should be taken into consideration for the next steps

while setting up the strategy of the program, are the foundations that we relied on to build

up this list of recommendations.

Based on the questions from the discussion that were very specific and aimed to collect

the opinion of the participants in details especially the question about the aspects that are

not currently been doing in mihsalud program although they have been covered by the

recommendations of NICE and therefore should incorporate it. We had a series of ideas and

suggestions from the participants, some of them were dominants and some of them were

unique with examples. After reading all the transcriptions we extracted all the ideas that

most suit mihsalud and we turned it into recommendations form. In order to be able to

demonstrate the recommendations, we have divided it into internal and external

recommendations. The two sections are relevant to the structure of the mihsalud program

and easy to understand. The internal recommendations are seven and they refer to what

the directors and health workers can do to improve the program and its structure, planning

phase, quality of people who execute the program, to get more people involved in the

Hiba Malek 69

program and to reach more vulnerable population. Meanwhile the external

recommendations are also seven recommendations that refer to what directors and health

workers can do to give the program more sustainability, to spread it on the public health

sector level and to be able to work on a long-term so the program will be more efficient.

“Recommendations List”:

Internal recommendations:

1- During the preparation of the program, the NICE recommendations should be taken

into account in order to set the general and specific objectives of the program. It

should be reviewed and discussed with the team to see what could fit in the

program guide.

2- One of the principle points in the program consist of doing training for the people to

have more Health Agents (Agentes de Salud) who help in the field. This could be

more efficient if there were a proper training for the professionals at some points.

3- There should be more specific plan to be able to identify the needs of the target

population in general and their health needs in particular. This could be through

community workshops that are designed and tailored to promote health.

Recognition of the territories’ needs and shortages. This must be done in

cooperation with associations, NGOs and other resources that may have more

information about these territories.

4- Make the residents of the community more involved in setting out their objectives

and making decisions. This will make the program reach more number of people in

need.

5- In order to integrate these recommendations to improve the performance of the

program, they should be working on two levels: one at the management level to

ensure long-term maintenance and another at a partnerships level, involving the

participants more in evaluating of results.

6- Specific objective for the program could be: to spread the program by seeking the

involvement of all professionals in the community and the community itself. For

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example, it could help presenting the program in schools that have children from the

vulnerable communities. It is a good way to get to know this program at schools. This

could reach the target community because most vulnerable communities have

children, and the children go to school, then by going to the schools to spread the

program it will reach a large part of the community. In addition at the level of the

high health responsible who are the primary care professionals, they should get

involved in the program to reach more population.

7- Regarding the evaluation in which to identify and agree on the objective of the

evaluation, it should be done previously with the community members and involve

them in planning the design and implementation of an evaluation framework plus

they are not taking into account the views of the society and associations to set the

indicators of the evaluation.

External recommendations:

1- The program is a part of the public health system, therefore it should be registered

and recognized by the public sector. This step will give the program more credibility

and will set lines for accountability.

2- Area-based Initiatives: involve communities in decision-making because they feel

more liberty to express their opinion and to give recommendations that make them

more involved in the program.

3- The sustainability of the program is its weakness point: some activities of the

program like the community territory revitalization last only for eleven months

which is a small period of time, but other activities last more and they are

continuous like forums and Health Agents courses. This will prevent the program

team and directors to set long-term objectives and the plan will be only for a short-

term. Therefore, the participation of the public sector has its impact on the

continuity of the program because not ensuring sustainability will lead to create false

expectations regarding participation.

4- Looking for more funding resources: without the financial aid the program cannot

continue and cannot be efficient. It will help a lot to have more than one sponsor for

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the program because now part of it depends on one bank entity and no one knows if

it will continue for the next year or not. In addition this limitations is not good for the

performance of the team in one part, and at the other part it will effect on the

people who get the services of the program. This should be in coordination with the

public sector.

5- Increase the population awareness about what the program is. The culture of the

community engagement in the health activities does not exist in our society and if

there isn’t a good base and the population failed to understand that part of their

day-to-day life, it will be very difficult for them to understand this intervention.

6- Introduce the mihsalud program to other health departments so they start

implementing it which will help to spread the program and give it more coverage in a

form more complementary.

7- Favoring a culture change in the public organizations, aimed at reaching every

professional at its level of performance. Enhance networking between all

organizations will lead to better coordination and performance.

5. Discussion

At the beginning of the discussion, it is very important to start talking about the two

focus groups that we have conducted. The importance of each group is that they are two

different groups, yet they are complementary. The program team give their opinion based

on their experience of implementing the program on the ground and dealing with people.

They share with them their interests and needs, then they convey the image of the situation

and their information to their supervisors during a weekly meeting. So their opinions are

very important because they emerge from the community itself where the real life is. The

directors of the program are well experienced in the community health field and their

opinions are based on their experience and also on the feedback they get from their teams.

They manage the program in their centers and they can identify its weaknesses and

strengths in a direct and effective wording. So their opinion is so valuables for this study and

it can upgrade the program to a high degree of efficiency.

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It is very important to strengthen the community actions and participation1. We have

seen that the program depends on the community residents in planning, designing and

coordinating the activities in advance which is the essence of the community engagement.

However, this stage should take into consideration all the residents of the community and

not to limit it to a particular category like population at risk. The community development

draws on existing human and material resources, existing personal skills and community

initiatives to enhance self-help and social support, and to develop flexible systems for

strengthening public participation in health matters. This requires full and continuous access

to information and learning opportunities for health, as well as funding support1. Based on a

study about the Community-based participatory research31 (CBPR) on the tribal

communities, the CBPR improves health and reduce health disparities with principles of co-

learning and long-term commitment.

Health promotion is not possible without the community participation24 in all it is

components, not only the residents but also the government, NGOs, associations and

looking for partnerships. Therefore, it is very important to register the program in the public

sector and look for more participation from the governments. Based on a case study of the

University of Brighton’s experience of evaluating such partnerships25, the support from

senior management is vital and the deputy vice-chancellor is part of the audit working group

and there is recognition at institutional level for the full range of the university’s community

partnership work. Achieving the sustainability of mihsalud and its continuity for a long-term

is essential to reach its goals with high level of community participation. So integrating the

public sector and have partnership is one part of the process, the other part is to look for

more funding resources for the program. The success of a health promotion program

depends on a good relationship of the three agents who are the protagonists of the

program. The three agents are:

1- Health administration on which the program depends.

2- Services, where technicians and professionals are there in the community to address

its problems.

3- The associations and the general public. Will be the protagonists of the process. The

process should incorporate both associations and groups formally constituted as

other actors and social leaders24.

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Although the community engagement and interventions might be costly because

participation is specified in a territory and requires instruments and channels that make it

possible24 plus the money spent on trainings and equipment7, but the NICE guidance makes

the best use of money while delivering high-quality care for patients and service users with

the most clinically- and cost-effective treatments available12. There is a study about

community-based health promotion program: Enhance Wellness26 (EW) that helps prevent

disabilities and improves health and functioning in older adults. It assessed the effect of EW

participation on health care costs. The outcomes were decreasing the total costs among EW

participants than nonparticipants, but this difference was not significant.

Health promotion is a continuous process with a beginning but not an end. Participation

is a process, both individually and collectively, in where citizens learn to participate. The

concepts of community activity, health promotion and health education, are used

sometimes as equivalent. The interplay between them is clear and strong which can lead to

confusion24. Mihsalud program provides community workshops, training and monthly

forums to people. Also it recognizes the diversity of each community and each person, but it

doesn’t provide diversity training. It is very important to conduct trainings that are

professional and useful even though it is too easy nowadays to get information through the

internet and social networks that are a place to exchange information and practical advice27.

The training cannot be effective if the participants are forced to participate and to avoid a

wrong participation it could be useful to define the eligibility criteria for a program

participation in a fairly explicit way28. The training for the communities has to be facilitated

in school, home, work and community settings1 which will help spreading the program,

increase the level of participation and the quality of the individuals. Doing so will change the

way the individuals behave toward both each other and communities which will help to

improve health and well-being and decrease health inequalities.

The degree of empowerment of individuals and groups in a community is the key to

move to the level of participation24 and let the individuals be part of the decision making

process is a smart act from the directors to get benefits from their existence skills and

experiences and it is crucial to increase the sense of leadership and responsibilities among

communities, furthermore it would be more beneficial to activate the role of neighborhood

Hiba Malek 74

managers in this process. It is proven in the study of Citizens’ participation in health:

education and shared decision-making27 that the formation of expert patients and training

peer strategies are increasingly being incorporated into the political agendas of public

health because patients may be experts in their own illnesses and managers of their own

health and may thus take more active role in decisions about their health, such as in shared

decision making, as part of initiatives, and as part of evaluation of public health activities

and health services27.

The large part that needs improvement in mihsalud is the evaluation part where they

have an internal evaluation and one external last year. The evaluation of community

engagement activities can focus on short, medium and longer-term outcomes29. Health

education and health promotion programs are complex phenomena which require the

application of multiple methodologies in order to properly understand or evaluate them and

recently qualitative approaches to evaluate community interventions were adopted by an

increasing number of evaluators to help understand and address these complexities. As a

consequence the issue no longer is whether to use quantitative or qualitative methods, but

rather how they can be combined to produce more effective results30. It will be beneficial to

mihsalud conducting such an effective evaluation because it will help to:

improve practice by identifying and articulating lessons, achievements and

benchmarks

contribute to engagement capability development by providing feedback on

performance

present opportunities for further citizen involvement in the evaluation process

contribute to performance monitoring and reporting for public sector

accountability29.

The most important values in community engagement process are integrity coupled

with humility. These values underlie how we present ourselves, and support our goals in

doing this work31 and providing the final report, the “Recommendations list” to improve the

community participation in mihsalud. The recommendations were elaborated based on the

opinion of the participants in the focus groups and taking into consideration what NICE

guidance6 says about writing recommendations.

Hiba Malek 75

5.1 Limitations

The main limitation of this study may be due to the differences in the concept between

NICE guidance that was elaborated to be applied and practiced in England and a health

promotion program (mihsalud) in Valencia. However, the NICE guidance aims to be

international and to be a standard for the healthcare practice worldwide16.

In addition to this point, we have another limitation that is obvious to mention. For now

the Public Health guidance that we have which is Community Engagement guidance is not

new, it was issued in 2008. In this study we applied this guidance to a present program that

is still developing since 2007 which may include some incapability of timing. The new

guidance will be issued in 2016. Until then the 2008 guidance is the adopted one that we

can rely on to conduct a study and to get benefits of its recommendations.

It may be also important to mention that we are not involving all the individuals related

to mihsalud program because of the shortage of time. We have recruited health workers

and managers that are related to the program and we didn’t included a group of its

beneficiaries which may lead to an information and selection bias. We have a small sample

size, but we have overcame this limitation by the quality of people that we have recruited

for the focus groups.

5.2 Applicability & future lines

In this study we covered the recommendations from the point of view of the health

workers and directors who are related directly and indirectly to mihsalud. Their opinion is

very valuable and to measure the recommendations for this program it is good enough to

conduct these two focus groups, although it will be more useful to take the opinion of the

target population. Doing so will cover all the parts that may be related to the program.

In addition all the participants in the discussions expressed their desire to know the

results of the study. So it will be very useful to conduct a meeting in October 2015 for the

participants to present the “Recommendations list” that they should start to apply on

mihsalud and then to conduct a follow up meeting in October 2016 to see if the

recommendations have been applied or not, and if not then why? This step is very

Hiba Malek 76

important to give continuity to the study and to the program as well. Also this study can be

replicated to asses participation in health promotion and preventive programs carried out in

public health centers or primary care centers in Valencia.

As we mentioned before, the Community Engagement guidance was issued in 2008.

Therefore it would be much recommended to do another study when the new version of

the guidance is issued in 2016. To be up-to-date and in line with the new recommendations

from NICE guidance.

6. Conclusion

As a conclusion of this study, it is important to address the most relevant subjects that have

been raised:

1- It is important to start incorporating the community participation in the daily-life health

activities and to improve the community health perspective which may lead to achieving the

goal health for everyone.

2- There is a need to involve local communities in planning, designing and implementing

health related activities, particularly those experiencing disadvantages.

3- We can reach a large number of individuals and expand the target population to let more

people participate in and benefit from health promotion programs like mihsalud and raise

the culture of participation among all the levels of communities.

4- The Community Engagement guidance is very important as a guidance on how to increase

community participation in health promotion programs and depending on this guidance will

raise the standard of healthcare with the most cost effective way13, which is very important

to mihsalud because of the lack of funding.

5- Depend on preexistent skills and initiatives and develop new health professionals in the

community through adequate trainings and workshops. Cooperate with neighborhood

managers to organize activities.

Hiba Malek 77

6- Conduct a constant evaluation and identify the aim of evaluation with the members of

target community in advance, and develop indicators that help evaluate work, cost and

experiences.

7- In this study we have provided a “Recommendation list” on how to improve the

community engagement and participation in mihsalud in order to improve health and well-

being and reduce health inequalities.

8- The fourteen recommendations that we elaborated emerged from the opinions of people

who are well experienced in mihsalud, in particular, and in health promotion activities, in

general. So these opinions are credible and we turned them into recommendations to be

more clear and easy to understand in an organized way.

9- Incorporating these recommendations in mihsalud will increase the participation and

without a doubt, based on the opinion of the professionals, it will be beneficial to apply it to

other programs.

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8. Glossario7

8.1 Wider social determinants of health: The wider social determinants of health

encompass a range of social, economic, cultural and environmental factors known to be

among the worst causes of poor health and inequalities between and within countries.

They may include: unemployment, housing, unsafe workplaces, urban slums,

globalization and lack of access to healthcare.

8.2 Governance: The term governance refers to the overall exercise of power in a

corporate, voluntary or state context. It covers action by executive bodies, assemblies

(for example, national parliaments) and judicial bodies.

8.3 Health promotion: Health promotion comprises non-pharmacological activities that

seek to prevent disease or ill health or improve physical and mental wellbeing. An

example is the provision of advice to help communities reduce accidental injuries.

8.4 Regeneration: Regeneration is the process of improving an area by making changes

to – and investing in – the social, economic and environmental infrastructure. It can also

define action to tackle urban and rural problems in areas which have gone into decline.

8.5 Commissioners and providers: Commissioners may work in PCTs (Primary Care

Trust), local authorities and a range of other organizations. They decide who should

provide services and what form these should take. As part of this role they carry out

needs assessment and service reviews (including seeking feedback from service users),

contracting and procurement. Organizations or departments that provide services are

known as 'providers'. Again, they could be part of a PCT, local authority or another

organization in the community, voluntary and private sectors.

8.6 Area-based initiatives: Area-based Initiatives focus on geographic areas of social or

economic disadvantage. These publicly-funded initiatives aim to improve the quality of

life of residents and their future opportunities. They are managed through regional, sub

regional or local partnerships. Examples include Sure Start and New Deal for

Communities.

8.7 Neighborhood managers: Neighborhood managers offer a single point of contact for

local residents, agencies and businesses. They have the authority to negotiate with

service providers and to negotiate for change both locally and at senior level.

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9. Appendix

Appendix 1. Draft List in English

Recommendations to improve participation in health promotion program in Spain through

the NICE guidance -Community Engagement.

A qualitative descriptive study using content analysis in which focus group technique1

will be used to discuss the Draft List with the participants in order to elaborate the final

report which is the Recommendation List.

The Community Engagement Guidance2 aims to support those working with

communities and involving in decisions on health improvement that affect them in order to

reduce health inequalities and improve health and wellbeing of the individuals in the

society.

Objectives

The general objective of this study is to improve community & social participation in the

mihsalud program by elaborating the report "Recommendations List" taken from the

Community Engagement Guidance and apply it to the mihsalud program in Valencia.

Draft List

The Draft list is an extract from reading the Community Engagement Guidance 2008, its

updates 20143 and mihsalud program. It is an illustrations for recommendations that can be

used to improve and strengthen the concept of community engagement, develop a sense of

commitment in the individuals towards the society and daily-life health activities that may

lead to healthier life style. It will be used as a material source for discussion in 2 focus

groups in order to elaborate the final report: the Recommendation list.

Recommendations:

The recommendations present the ideal scenario for effective community engagement.

They cover four important themes:

Hiba Malek 82

Prerequisites for success: including policy development (5 recommendations)

Infrastructure: to support practice on the ground (3 recommendations)

Approaches: to support and increase levels of community engagement (3

recommendations)

Evaluation (1 recommendation).

The recommendations considered the evidence of effectiveness and cost effectiveness.

According to the studies reviewed, the scientific evidence considered to be effective to

encourage community participation.

Community engagement is a sustainable goal and it’s a long-term practice that may lead

to a better life for the community in specific and the society in general to achieve the goal

“Health for everyone”

The guidance define Sustainability as the long-term health and vitality – cultural,

economic, environmental and social – of a community.

Main beneficiaries:

Communities and groups with distinct health needs

Communities that experience difficulties accessing health services or have health

problems caused by their social circumstances

People living in disadvantaged areas, including those living in social housing.

Who should take actions?

1. Those involved in the planning (including coordination), design, funding and

evaluation of national, regional and local policy initiatives.

2. Providers and commissioners in public sector organizations, local authorities

(including officers and elected members) and the voluntary sector who seek to

involve communities in planning (including priority setting and funding), designing,

delivering, improving, managing and the governance of:

a. Health promotion activities

Hiba Malek 83

b. Activities which aim to address the wider social determinants of health

c. Area-based initiatives.

3. Members of community organizations and groups and community representatives

involved in the above.

Prerequisites for effective community engagement

1. Policy development: plan, design and coordinate activities (including area-based

activities) that incorporate all the community components and organizations and

take account of existing activities.

2. Long term investment: align long-term approach with local priorities. Identify the

funding resource and the lines for accountability. Set realistic timescale. Build on

past experiences. Clearly state the intended outcomes of the activities.

3. Organizational and cultural change: identify how the culture of public sector

organizations supports or prevents community engagement. Diversity training.

Manage conflicts between communities and the agencies that serve them.

4. Levels of engagement and power: negotiate and agree with all relevant parties how

power will be distributed and state the responsibilities. Recognize local diversity and

let community members decide how willing and able they are to participate. Avoid

technical and professional jargon. Feedback mechanisms.

5. Mutual trust and respect: assess the broad and specific health needs of the

community (under-respected groups). Tailor the approach used.

Infrastructure

6. Training and resources: develop and build on the local community’s strengths and

assets. Provide opportunities and resources for networking. Identify funding sources

for training. Work with NGOs, volunteers. Provide accessible meeting spaces and

equipment. Train individuals from the community to act as mentors.

Hiba Malek 84

7. Partnership working: develop statements of partnership working for all those

involved in activities. This will help increase knowledge and improve the

opportunities for joint working and/or consultation on service provision

8. Area-based initiatives: encourage local people to be involved in the organization and

by recognizing and developing their skills. Involve communities in decision-making to

have the power to influence decisions.

Approaches

9. Community members as agents of change: recruit local people to plan, design and

deliver activities to improve health. Encourage local communities to form a group of

‘agents of change’. Work with neighborhood managers to ensure the community’s

views are heard.

10. Community workshops: run community workshops (art, health, etc.) to identify local

needs and maintain a high level of local participation in health promotion activities

(co-managed by professionals and community members).

11. Resident consultancy: draw on the skills and experience of people with previous

experience of regeneration activities to improve social cohesion and general

wellbeing. Empower the concept of work ‘with’ rather than ‘for’ the local

community.

Evaluation

Better evaluation processes are needed to improve the quality of evidence and to

increase understanding of how community engagement and the different approaches used

impact on health and social outcomes.

12. Identify and agree the aims of evaluation with members of the target community.

This should be agreed before the activity is introduced

Involve them in the planning, design and implementation of an evaluation

framework that:

Hiba Malek 85

- encourages joint development

- considers the theory of change required to achieve success

- embraces a mixed method approach

- indicators that help evaluate work, costs and experiences

- identifies the comparators that will be used.

Cost & Savings:

The guidance is unlikely to result in a significant shift in the use of NHS resources.

However, recommendations on the following may result in additional costs:

1- Training and development

2- Employing agents of change, either paid or voluntary

3- Evaluation of community engagement activities

4- Provision of Braille and loop systems and crèche facilities.

5- Carrying out research and consultation work

Glossary

Commissioners and providers: Commissioners may work in PCTs (Primary Care Trust), local

authorities and a range of other organizations. They decide who should provide services and

what form these should take. As part of this role they carry out needs assessment and

service reviews (including seeking feedback from service users), contracting and

procurement. Organizations or departments that provide services are known as 'providers'.

Again, they could be part of a PCT, local authority or another organization in the community,

voluntary and private sectors.

Area-based initiatives: Area-based Initiatives focus on geographic areas of social or

economic disadvantage. These publicly-funded initiatives aim to improve the quality of life

of residents and their future opportunities. They are managed through regional, sub

regional or local partnerships. Examples include Sure Start and New Deal for Communities.

Hiba Malek 86

Neighborhood managers: neighborhood managers offer a single point of contact for local

residents, agencies and businesses. They have the authority to negotiate with service

providers and to negotiate for change both locally and at senior level.

Regeneration: regeneration is the process of improving an area by making changes to – and

investing in – the social, economic and environmental infrastructure. It can also define

action to tackle urban and rural problems in areas which have gone into decline.

References

1- Mack N, Woodsong C, MacQueen KM, Guest G, Namey E. Methods : Methods [Internet]. Occasional

Paper Royal College Of General Practitioners. 2002. 4 p. Available from:

http://eprints.soton.ac.uk/170017/

2- Sustainable Cities Institute. Community Engagement. Natl Leag Cities [Internet]. 2012;(April 2009).

Available from:

http://www.sustainablecitiesinstitute.org/view/page.basic/class/tag.topic/community_engagement

3- Programme IP. National Institute for Health and Care Excellence. 2012;1–38.

Hiba Malek 87

Appendix 2. Draft List in Spanish

Recomendaciones para mejorar la participación en un programa de promoción de la salud

en España a través de la guía NICE de Participación Comunitaria

La Guía NICE de Participación Comunitaria1 tiene como objetivo apoyar a las personas

que trabajan con las comunidades tratando de involucrarlas en las decisiones sobre la

mejora de la salud que les afectan con el fin de reducir las desigualdades en salud y mejorar

la salud y el bienestar de los individuos en la sociedad.

Se plantea un estudio descriptivo cualitativo que utilizara el análisis de contenido a

través de la técnica de grupo focal2 para discutir el "Draft list" o “Propuesta de

recomendaciones” de la guía con el fin de elaborar un informe final, que será la

"Recommendations list" o “Recomendaciones para mejorar la participación comunitaria en

un programa de salud”.

Objetivo

El objetivo general de este estudio es mejorar la participación comunitaria y social en el

programa mihsalud a partir de la elaboración del informe "Recommendations list" resultado

de aplicar la Guía NICE de participación Comunitaria1 a este programa.

Draft List o “Propuesta de Recomendaciones”

La Draft List o “Propuesta de Recomendaciones” es un extracto de la lectura de la Guía

NICE de participación Comunitaria de 2008, sus actualizaciones de 20143 y el programa

mihsalud. Es un ejemplo de que tipo de recomendaciones pueden ser utilizadas para

mejorar y fortalecer el concepto de participación comunitaria, desarrollar un sentido de

compromiso en los individuos hacia la sociedad y con las actividades de salud de la vida

diaria que pueden conducir a un estilo de vida más saludable. Será utilizado como fuente de

material para la discusión en 2 grupos focales y elaborar el informe final:

"Recommendations list" o “Recomendaciones para mejorar la participación comunitaria en

un programa de salud”.

Hiba Malek 88

Las Recomendaciones:

Las recomendaciones presentan el escenario ideal para la participación efectiva de la

comunidad. Abarcan cuatro temas importantes:

Prerrequisitos para el éxito: incluyendo el desarrollo de políticas (5

recomendaciones)

Infraestructura: apoyar la práctica sobre el terreno (3 recomendaciones)

Enfoques: apoyar y aumentar los niveles de participación de la comunidad (3

recomendaciones)

Evaluación (1 recomendación).

Las recomendaciones consideran la evidencia de la eficacia y su coste-efectividad. Según

los estudios revisados, la evidencia científica considera que cada una de estas

recomendaciones es eficaz para fomentar la participación de la comunidad.

La participación comunitaria es un objetivo sostenible y es una práctica a largo plazo

que puede conducir, específicamente, a una vida mejor para la comunidad y, en general,

para la sociedad, avanzando hacia la meta de "Salud para todos".

La guía define sostenibilidad como la salud a largo plazo y la vitalidad - cultural,

económica, ambiental y social - de una comunidad.

Principales Beneficiarios:

Las comunidades y grupos con distintas necesidades de salud

Las comunidades que experimentan dificultades de acceso a servicios de salud o que

tienen problemas de salud causados por sus circunstancias sociales

Las personas que viven en zonas desfavorecidas, incluidas las que viven en viviendas

sociales.

¿Quién debe actuar?

Hiba Malek 89

1. Las personas involucradas en la planificación (incluida la coordinación), el diseño, la

financiación y la evaluación de las iniciativas de políticas nacionales, regionales y

locales.

2. Los proveedores y los comisionados en las organizaciones del sector público,

autoridades locales (incluyendo funcionarios y miembros electos) y el sector del

voluntariado que buscan involucrar a las comunidades en la planificación (incluido el

establecimiento de prioridades y la financiación), el diseño, la entrega, la mejora, la

gestión y la gobernanza de:

- Actividades de promoción de la Salud

- Actividades que tienen como objetivo abordar más los determinantes sociales

de la salud

- Iniciativas basadas en el territorio

3. Los miembros de las organizaciones comunitarias y los grupos y representantes de la

comunidad que participan en los anteriores.

"Draft list" o “Propuesta de recomendaciones” extraídas de la guía NICE:

Prerrequisitos para el éxito de la participación:

1. Desarrollo de políticas: planificar, diseñar y coordinar las actividades (incluidas las

actividades basadas en el territorio) que incorporan todos los componentes y

organizaciones de la comunidad y tengan en cuenta las actividades existentes.

2. La inversión a largo plazo: alinear un enfoque a largo plazo con las prioridades

locales. Identificar los recursos de financiación y las líneas de rendición de cuentas.

Establecer plazos realistas. Basarse en experiencias pasadas. Indicar claramente los

resultados esperados de las actividades.

3. El cambio organizacional y cultural: identificar cómo la cultura de las organizaciones

del sector público apoya o impide la participación comunitaria. Formación sobre la

Hiba Malek 90

diversidad. Gestionar conflictos entre las comunidades y los organismos que les

sirven.

4. Los niveles de participación y el poder: negociar y ponerse de acuerdo con todas las

partes pertinentes de cómo se distribuye el poder y las responsabilidades. Reconocer

la diversidad local y dejar que las y los miembros de la comunidad decidan cómo

quieren y pueden participar. Evitar la jerga técnica y profesional. Incorporar

mecanismos de retroalimentación

5. La confianza mutua y el respeto: evaluar las necesidades de salud generales y

específicas de la comunidad (a partir del respeto a los diversos grupos existentes).

Adecuar el enfoque utilizado.

Infraestructura

6. Formación y recursos: desarrollar y construir sobre las fortalezas y activos de la

comunidad local. Proporcionar oportunidades y recursos para la creación de redes.

Identificar las fuentes de financiación para la formación. Trabajar con las ONG, el

voluntariado. Proporcionar espacios de encuentro accesibles y equipos. Capacitar a

individuos de la comunidad para actuar como mentores.

7. Trabajar de manera conjunta o en asociación: desarrollar formas de trabajo conjunto

para todos los que participan en las actividades. Esto ayudará a aumentar el

conocimiento y mejorar las oportunidades de trabajo conjunto y/o consulta sobre la

prestación de servicios.

8. Iniciativas basadas en el territorio: animar a la gente de la zona para que participen

en la organización a través de reconocer y desarrollar sus habilidades. Involucrar a

las comunidades en la toma de decisiones para poder de influir en las decisiones.

Enfoques

9. Miembros de la comunidad como agentes de cambio: reclutar a gente del ámbito

local para planificar, diseñar y ofrecer actividades para mejorar la salud. Animar a las

Hiba Malek 91

comunidades locales para formar grupos de 'agentes de cambio'. Trabajar con los

gerentes de barrio, área, etc. para asegurar que las opiniones de la comunidad son

escuchadas.

10. Talleres comunitarios: ejecutar talleres comunitarios (arte, salud, etc.) para

identificar las necesidades locales y mantener un alto nivel de participación local en

las actividades de promoción de la salud (cogestionadas por profesionales y

miembros de la comunidad).

11. Tener en cuenta la opinión de las personas residentes: aprovechar los conocimientos

y la experiencia de las personas con experiencia previa en actividades de

regeneración para mejorar la cohesión social y el bienestar general. Potenciar el

concepto de trabajo "con" en lugar de "por" la comunidad local.

Evaluación

Se necesitan mejores procesos de evaluación para mejorar la calidad de las experiencias

y para aumentar la comprensión de cómo la participación de la comunidad y los diferentes

enfoques utilizados impactan en los resultados sanitarios y sociales.

12. Identificar y acordar los objetivos de la evaluación con los miembros de la

comunidad de destino. Esto debe ser acordado antes de introducir la actividad.

Involucrarlos en la planificación, el diseño y la aplicación de un marco de evaluación

que:

- anime el desarrollo conjunto

- considere la teoría del cambio necesario para lograr el éxito

- contemple un enfoque mixto de la metodología

- incorpore indicadores que ayuden a evaluar el trabajo, costes y experiencias

- identifique los criterios de comparación que se utilizarán.

Hiba Malek 92

Costes y ahorros

La guía es poco probable que provoque un cambio significativo en el uso de los recursos

del NHS (Sistema Nacional de Salud). Sin embargo, las recomendaciones pueden

representar costes adicionales en:

1- Formación y desarrollo

2- Utilización de agentes de cambio, ya sean remunerados o voluntarios

3- Evaluación de las actividades de participación comunitaria

4- Provisión de sistemas de Braille, lenguaje de signos y servicios de guardería

5- Realización de investigaciones y trabajo de consultoría

Glosario

Comisionados y proveedores: Los comisionados pueden trabajar en los PCTs (Primary Care

Trust), autoridades locales y otras organizaciones. Ellos deciden quién debe proporcionar

servicios y qué forma deben tomar éstos. Como parte de este papel, llevan a cabo la

evaluación de las necesidades y opiniones sobre un servicio (incluyendo la búsqueda de

retroalimentación de los usuarios de los servicios), la contratación y las adquisiciones. Las

organizaciones o departamentos que prestan servicios son conocidos como 'proveedores'.

Una vez más, podrían ser parte de un PCT, la autoridad local u otra organización en la

comunidad, voluntarios y sectores privados.

Iniciativas basadas en el territorio: Se centran en áreas geográficas de desventaja social o

económica. Estas iniciativas financiadas con fondos públicos tienen como objetivo mejorar

la calidad de vida de los residentes y sus oportunidades futuras. Ellos son gestionados a

través de asociaciones regionales o locales. Los ejemplos incluyen Sure Start y New Deal for

Communities.

Gerentes de barrio: Las o los gerentes de barrio ofrecen un único punto de contacto para

los residentes locales, los organismos y las empresas. Tienen la autoridad para negociar con

Hiba Malek 93

los proveedores de servicios y negociar para el cambio tanto a nivel local como a nivel

superior.

Regeneración: La regeneración es el proceso de mejorar una área haciendo cambios en - o

invirtiendo en- la infraestructura social, económica y ambiental. También puede definir

actuaciones para hacer frente a los problemas urbanos y rurales en áreas que han entrado

en declive.

Referencias

1- Sustainable Cities Institute. Community Engagement. Natl Leag Cities [Internet]. 2012;(April 2009).

Available from:

http://www.sustainablecitiesinstitute.org/view/page.basic/class/tag.topic/community_engagement

2- Mack N, Woodsong C, MacQueen KM, Guest G, Namey E. Methods : Methods [Internet]. Occasional

Paper Royal College Of General Practitioners. 2002. 4 p. Available from:

http://eprints.soton.ac.uk/170017/

3- Programme IP. National Institute for Health and Care Excellence. 2012; 1–38.

Hiba Malek 94

Appendix 3. Focus group discussion in English

Discussion

1- How can we integrate these recommendations into mihsalud program in order to

improve performance and results of the program?

1.1 What you are currently doing in mihsalud program that matches what say NICE

recommendations?

2- What are the aspects that are not being implemented in the program?

2.1 What you are not currently doing in mihsalud program although this covered by the

recommendations of NICE and therefore should incorporate it?

2.2 What you are currently doing in mihsalud program and contrary to what say NICE

recommendations, therefore it should stop doing it?

3- What are the aspects that cannot be applied in mihsalud program for now?

4- If the recommendations can be applied to mihsalud program, do you think that can be

applied to other health promotion programs or any other health program?

Hiba Malek 95

Appendix 4. Focus group discussion in Spanish

Discusión

1. ¿Cómo podemos integrar estas recomendaciones al programa mihsalud con el fin de

mejorar el rendimiento y los resultados del programa?

1.1 Lo que SI se está haciendo actualmente en el programa mihsalud que coincide

con lo que dicen las recomendaciones de NICE

2. ¿Cuáles son los aspectos que NO se están aplicando en el programa?

2.1 Lo que NO se está haciendo actualmente en el programa mihsalud aunque SI

este contemplado en las recomendaciones de NICE y por lo tanto, se debería de

incorporar.

2.2Lo que SI se está haciendo actualmente en el programa mihsalud y va EN CONTRA

a lo que dicen las recomendaciones de NICE y por la tanto, se debería dejar de hacer.

3. ¿Cuáles son los aspectos que NO se pueden aplicar en el programa mihsalud en estos

momentos?

4. Si las recomendaciones se pueden aplicar al programa mihsalud, ¿Crees que se

pueden aplicar a otros programas de promoción de la salud o cualquier programa de

salud?

Hiba Malek 96

Appendix 5. Invitation e-mail

evaluacion de la participación comunitaria en el programa mihsalud

Pilar López Sanchez

May 5

CC

Desde el Centro de Salud Pública de Valencia, nos gustaría invitaros a una reunión que tendremos el

próximo martes 19 de mayo, de 12 a 14 horas, aquí en nuestro centro, para evaluar la participación

comunitaria en el programa mihsalud y en general en otros programas de salud desde la evidencia.

La reunión será moderada por Hiba Malek y forma parte de la tesina del master de salud púbilca de la

Universitat de Valencia que está realizando.

Pensamos que es una oportunidad para encontrarnos, compartir nuestra experiencia en relación al

programa mihsalud y aprender nuevas cosas sobre evidencia y participación.

Un saludo y os esperamos,

Mª Pilar López Sánchez

Enfermera de Salud Pública

Centro de Salud Pública de Valencia

Consellería de Sanidad

Ciudad Administrativa 9 de Octubre

C/ Castan Tobeñas, 77- Torre B, planta -1

Hiba Malek 97

46018 Valencia

Teléfono 96 1. 24 .80. 83

CONFIDENCIALIDAD: El contenido de este mensaje y el de cualquier documentación anexa es confidencial y

va dirigido únicamente al destinatario del mismo. Si usted no es el destinatario, le solicitamos que nos lo

indique, no comunique su contenido a terceros y proceda a su destrucción.

CONFIDENCIALITAT: El contingut d’este missatge i el de qualsevol documentación annexa és confidencial i

va dirigir únicamente al destinatari. Si vosté no és el desintari, li demanem que ens ho indique, no

comunique el seu contingut a tercers i destruïsca’l.

Hiba Malek 98

Appendix 6. Meeting guide for the focus group

Focus Group Guide

Moderator (M): Note-taker:

Date:

Participant #:

Venue: Public Health Centre of Valencia

Consent form

Consent form for focus group participants are completed in advance on the entrance to

the meeting room (Appendix 8) by all those seeking to participate. Organizers and

facilitators should use it to make sure participants understand the information in the

Consent forms.

1- Introduction:

Moderator: Bienvenido, Gracias por venir a nuestro grupo de discusión. Mi nombre es Hiba y

este es mi colega -------.

Pass on the Sign-In Sheet with a few quick demographic questions (age, gender, cadre, and

years at this facility) around to the group while I’m introducing the focus group.

M: Gracias por aceptar participar usted. Nos interesa mucho conocer su opinión valiosa

sobre cómo guía participación comunitaria puede ser útil para mejorar la participación de la

comunidad en el programa mihsalud. La información que nos proporciona es

completamente confidencial, y no vamos a asociar su nombre con todo lo que diga en el

grupo focal. Nos gustaría grabar los grupos focales para que podamos asegurarnos de

capturar los pensamientos, opiniones e ideas que escuchar del grupo. No hay nombres se

Hiba Malek 99

unen a los grupos focales y las grabaciones serán destruidos tan pronto como se transcriben.

Entendemos lo importante que es que esta información se mantiene como privado y

confidencial. Vamos a pedir a los participantes a respetar la confidencialidad de los demás.

Ahora me gustaría preguntar a cada uno de ustedes a presentarse y lo que hace?

¿Por cuánto tiempo ha estado en este trabajo?

2- Explanation of the process:

El moderador podrá pedir al grupo si alguien ha participado en un grupo focal antes y se

explicará que los grupos focales se están utilizando cada vez más a menudo en la salud y

servicios humanos de investigación.

About focus groups

We learn from you (positive and negative)

Not trying to achieve consensus, we’re gathering information

3- Logistics:

M: la discusión tendrá una duración de aproximadamente una hora y media, por favor

siéntase libre para moverse, para ir al baño y salida.

Materials and supplies for focus groups:

1. 3 Sign-in sheets

2. Consent forms (one copy for participants, one copy for the team)

3. Pens & notebook for the moderator and the note-taker

4. 1 tape recorder with multiple cassettes tapes and spare batteries

5. Focus Group Guide for Facilitator

6. Recommendation sheet which is summary for the community engagement guidance

in English. One copy for each participant.

Hiba Malek 100

7. "Draft list" sheet in Spanish language. One copy for each participant.

Reglas básica:

El moderador pedirá al grupo que sugiera algunas reglas básicas. Después lo hacen, el

moderador debe asegurarse de lo siguiente están en la lista:

• Todos deben participar.

• La información proporcionada en el grupo focal debe ser confidencial

• Permanecer con el grupo y por favor no tener conversaciones laterales

• Apagar los teléfonos celulares si es posible

• Diviértete

4- Turn on the Tape Recorder

5- Discussion:

At the beginning of the discussion, the moderator should make sure that the participants

understand every recommendation and the following question, then gives them time to

think before answering the questions and doesn’t move too quickly.

M: Vamos a empezar la discusión por una pequeña presentación sobre el estudio, entonces

vamos a empezar con el proyecto de lista que queremos que la discusión sea sobre.

Queremos que escucha con atención a cada recomendación y de acuerdo a su experiencia

como profesional que le gustaría llevar a su opinión con respecto a las siguientes preguntas:

Discusión

1. ¿Cómo podemos integrar estas recomendaciones al programa mihsalud con el fin de

mejorar el rendimiento y los resultados del programa?

1.1Lo que SI se está haciendo actualmente en el programa mihsalud que coincide

con lo que dicen las recomendaciones de NICE

Hiba Malek 101

2. ¿Cuáles son los aspectos que NO se están aplicando en el programa?

2.1 Lo que NO se está haciendo actualmente en el programa mihsalud aunque SI

este contemplado en las recomendaciones de NICE y por lo tanto, se debería de

incorporar.

2.2Lo que SI se está haciendo actualmente en el programa mihsalud y va EN CONTRA

a lo que dicen las recomendaciones de NICE y por la tanto, se debería dejar de hacer.

3. ¿Cuáles son los aspectos que NO se pueden aplicar en el programa mihsalud en estos

momentos?

4. Si las recomendaciones se pueden aplicar al programa mihsalud, ¿Crees que se

pueden aplicar a otros programas de promoción de la salud o cualquier programa de

salud?

Categories: Community engagement, Community participation, health promotion, wellbeing

and participation.

6- Closure

M: ¿Hay alguna otra información acerca de su experiencia con este campo que crea que

puede ser útil para mí saber?

Muchas gracias por venir y compartir sus pensamientos y opiniones con nosotros. Su tiempo

es apreciado y sus comentarios han sido de gran ayuda.

Hiba Malek 102

Appendix 7. The presentation for the focus group

Hiba Malek 103

Hiba Malek 104

Hiba Malek 105

Hiba Malek 106

Hiba Malek 107

Hiba Malek 108

Appendix 8. Consent form

HOJA INFORMATIVA Y CONSENTIMIENTO INFORMADO

Nombre del participante: __________________________________________

Nos gustaría invitarle a participar en el estudio de investigación que se ha estado

haciendo para el master de Salud Pública y Gestión Sanitaria de la Universidad de Valencia.

El equipo del estudio está formado por Hiba Malek farmacéutica y alumna del master, Joan

J. Paredes Carbonell, tutor del presente proyecto y que trabaja como médico de salud

pública del Centro de Salud Pública de Valencia e investigador colaborador de FISABIO y

Pilar López Sánchez que trabaja como enfermera de salud pública del Centro de Salud

Pública de Valencia

Objetivo del estudio:

El objetivo general de este estudio es mejorar la participación comunitaria y social en el

programa mihsalud elaborando el informe "Recommendation List", a partir de la

Community Engagement guidance y aplicándolo al programa mihsalud en Valencia.

La "Recommendation List" podría utilizarse para mejorar y potenciar el concepto de

participación de la comunidad, desarrollar un sentido de compromiso de los individuos hacia

la sociedad y de las actividades de salud de la vida diaria que pueden dar lugar a un estilo de

vida más saludable.

Consentimiento informado

Entiendo, ante todo, que la participación en este estudio es completamente voluntaria.

Si decido participar en el estudio deberé contestar algunas cuestiones por el equipo de

investigación. Dicha actividad se realizará el día ___ del mes de _____ en la sala __ del

Hiba Malek 109

Centro de Salud Pública de Valencia a las ___ horas. Se realizarán un grupo focal durante

una hora y media aproximadamente. El equipo de investigación estará presente durante

toda la actividad. La información obtenida quedará registrada en una grabadora de sonido y

en el cuaderno de campo que estará tomando algún miembro del equipo investigador.

Confidencialidad:

Todos los datos y la información que proporcione durante el estudio, serán tratados con

total confidencialidad. Las grabaciones de audio, así como los datos recabados en el

cuaderno de campo, serán de uso exclusivo para los investigadores. Cualquier información

que pueda identificarle por su nombre no será compartida con nadie fuera del equipo

investigador. No se le podrá identificar en ninguna de las publicaciones que se pudieran

llegar a realizar como fruto de la presente investigación.

Todos los datos personales y los archivos sonoros y escritos obtenidos serán

incorporados a un sistema de archivos encriptado que quedará bajo la custodia del equipo

investigador, que garantizará la confidencialidad de los mismos, pudiendo los afectados

ejercer su derecho al acceso, cancelación u oposición en el momento en que consideren

oportuno, dirigiéndose a la siguiente dirección:

Centro de Salud Pública de Valencia

Ciudad Administrativa 9 de Octubre

Edificio B, planta B, -1

C/ Castan Tobeñas, 77. 46018 València

Tel. 961-248069

Abandono del estudio:

Entiendo que soy libre de abandonar el estudio en cualquier momento, puesto que mi

participación en este estudio es voluntaria.

El equipo de investigación del estudio le agradece de antemano su tiempo y dedicación.

Hiba Malek 110

¿Ha leído la hoja informativa? SI / NO

¿Ha tenido la oportunidad de hacer preguntas y aclarar todas aquellas dudas que tenga

sobre el estudio? SI / NO

¿Ha recibido respuestas satisfactorias a todas sus preguntas? SI / NO

¿Entiende que es libre de dejar el estudio en cualquier momento? SI / NO

¿Está de acuerdo en participar en el estudio? SI / NO

Valencia, a ______________ de ____________ de ____________

Nombre y apellidos del participante. Firma

Nombre y apellidos del equipo investigador. Firma

Hiba Malek 111

Appendix 9. Debriefing session 1

Focus Group Debriefing Form

Archival #: 1

Sita: Centro de Salud Pública, Valencia

Number of participants: 6 participants Moderator: Hiba Malek

Date: 18- May- 2015 Note-Taker: Pilar López Sanchez

- Hiba presente Sonia.

- Pide el consentimiento para realizar el grupo focal.

- hay 6 participantes.

- Hiba explique que es el guía NICE y el guía de Community Engagement que tiene 12 recomendaciones.

- Explique los grupos focales.

- Se hace una lectura de las recomendaciones para que se entiende antes de comenzar la discusión.

- Se eliminan las dudas.

- Comienza el grupo focal.

Cada participante ha dado su opinión.

Hiba Malek 112

Appendix 10. Debriefing session 2

Focus Group Debriefing Form

Archival #: 2

Sita: Centro de Salud Pública, Valencia

Number of participants: 6 Moderator: Hiba Malek

Date: 19- May- 2015 Note-Taker: Pilar López Sanchez

- Grupo focal con directores de Centros sanitarios y coordinadores de centros que conocen el programa mihsalud.

- Cada participante presenta.

- Hiba presente su trabajo y le explique después se leen las preguntas y la lista de recomendaciones. Se deja un tiempo para

preparar.

- A continuación comienza el grupo focal a 13h.

-Concluye 13:30h.

Hiba Malek 113

Appendix 11. Focus group transcription 1

Focus Group Transcript

Archival #: 1

Sita: Centro de Salud Pública, Valencia

Number of participants: 6 participants

Date: 18- May- 2015 Moderator: Hiba Malek

Start: 12 p.m. End: 1:30 p.m. Note-Taker: Pilar López Sanchez

Pregunta 1:

¿Cómo podemos integrar estas recomendaciones al programa mihsalud con el fin de

mejorar el rendimiento y los resultados del programa?

1- Podemos integrarlas en el primer mes de formación. Podemos establecer unos días para

ver cuales, para coger los estos prerrequisitos que hemos visto hoy y ver cuáles lo más

importante y a cuáles deberíamos llegar como objetivo principal, no como, a partir de esto

tener una meta. La meta para mi seria el trabajo con la comunidad, el integrarlos y hacerlos

las actividades muchas veces vamos, proponemos un tema y nos faltaría escuchar o que

proponer que vengan ellos también con nosotros hacer los talleres que sí que hay ciertas

personas de la comunidad que están formando para poder desde centro hacer la educación

igual-igual que es lo que también tratas de este proyecto. Pero a veces sí que desde mi punto

de vista pienso que nos falta ese compañerismo con las, con sector, un punto más más

personal para saber cómo hacer los talleres.

2- En la primera de prerrequisitos para el éxito de la participación creo que el punto uno sí, sí

que se da. El punto número dos que habla sobre el tema de largo plazo no se da justamente

en este programa mihsalud porque se va dando anualmente en este caso fue 2014 y ahora

2015 y no sabemos y 2016 y sucesivos años se van a dar desafortunadamente porque no

está implementado dentro de la salud, centro de la salud pública de Valencia , no tiene como

algo fijo ni siquiera lo ven los centros de salud o le están empezando a ver, hay una ONG que

Hiba Malek 114

lo está financiando pero no lo he financiado porque ella puede si, sino porque hay otra ONG

u otra entidad bancaria que la que da el dinero. Entonces cuando esta entidad bancaria veía

que esto no va ya esta se termine el proyecto entonces todo el trabajo que estamos

haciendo, bueno, muy bien hecho está, pero quedar allí. Entonces no habrá continuidad. La

sostenibilidad es el punto flaco y fuerte que este programa tiene. Es eso. En cuanto al

cambio organizacional creo que falta por parte de sector público impide la participación

comunitaria. Supongo que no es de manera que lo hace porque si, sino porque su, sus

estamentos cómo está su manera organizacional en este caso la Generalitat valenciana o

sanidad no fomenta, no fomenta ese vínculo a participación en centro de salud barrio

asociaciones. Y creo que lo se está generando a través de mihsalud es eso. Intentar hacer

red, entra-asociaciones, centro de salud, la gente, la barro. Pero vuelvo a decir como no hay

sostenibilidad de este programa eso quedara en el aire o puede ser en el caso del

apartamento diez que hay un centro de salud fuente de san Luis que se está empezando a

querer enganchar pero claro eso se da tiempo como tiempo desafortunadamente nosotros

tenemos limitado hasta 2015 no lo sabemos. Luego niveles de participación si hay, hay

participación sin intenta evitar la jerga técnica y profesional porque se intenta hacer que

esto sea más horizontal a través de la educación entre iguales y el tema de formación sobre

la diversidad, gestionar conflictos entre comunidades y organismos, yo creo que está medias

porque sí que si hace el tema de inter-cualidad o relaciones con otra culturas a través del

tema de la salud y el uso correcto de los servicios, pero gestionar conflictos y todo eso quizás

yo lo he visto en otra comunidades sí que si lo hacen.

3- En cuanto a los prerrequisitos para el éxito de la participación creo que todos los puntos

están llevando acabo excepto el punto 2 que habla del enfoque a largo plazo. Nuestro

proyecto tiene duración de once meses por tanto no se puede aplicar actividad a lo largo

plazo, son a corto plazo y si son realistas como viene aquí. El tema de las organizaciones de

sector público se apoya o impiden a participación comunitaria se trata un proyecto de salud

pública llevado acabo por una ONG, colaboración con entidad bancaria por tanta el respaldo

público, digamos ese reconocimiento público que forme parte del sistema sanitario público

no existe, por tanto ese enfoque créenos que falta, realmente no que sea un proyecto

integrado dentro del marco de la sanidad pública. Tema formación sobre diversidad creo que

falta información sobre la diversidad cuanto, a nivel de los profesionales y todo,

Hiba Malek 115

evidentemente la formación, la diversidad no existe. A veces un poco a lo mejor lo que uno

que puede leer o informarse pero dentro de la formación propio de los profesionales no

existe, es algo o punto que debería existir. En cuanto a la infraestructura todos los puntos se

llevan a cabo. En cuanto al enfoque el tema de los talleres comunitarios, los talleres son

dirigidos a promover la salud, la identificación de las necesidades locales se hace con el

reconocimiento de los territorios y con los informadores clave tanto a nivel asociaciones y los

otros recursos que tiene información. Tú puedes identificar necesidades a población pero no

como tal si no la salud y aparte de allí salen necesidades evidentemente. En cuanto a la

evaluación los objetivos de la evaluación con los miembros de la comunidad están enfocado

dese la comunidad. Los objetivos de la población no están, yo creo que no es parte de la

comunidad, esa, no hay gente de la comunidad que esté participando en esos objetivos

decidiendo cuales son los objetivos de la población. En cuanto a los indicadores si se están

aplicando, todavía están en marcha para poder evaluarlos.

4- Viendo estas recomendaciones creo que son muy importantes pero en algunas de ellas no

podemos influir por en el nivel en el que participamos. Pero algunas están integradas y

pondría un énfasis en la participación de la comunidad en este proyecto. En la permanencia

del programa que solo tiene una duración de once meses, que sería importante la

continuidad para generar una mejora de los resultados. Y también poner énfasis en los

criterios de evaluación que todavía no los tenemos bien, en buen término para poder tener

una retroalimentación favorable y poder seguir hacia adelante.

5- Todas las semanas planificamos y coordinamos actividades en cada territorio que

trabajamos y "silencio".

6- Bueno yo creo que para integrar estas recomendaciones en el programa mihsalud. Creo

que la mayoría o sean que todo el programa contempla las recomendaciones no sé si se

habrá basado en ella o no pero las contempla y sí que ,bueno, que creo que se deberían

como han dicho antes las compañeras se deberían tener en cuenta durante el periodo de

formación a lo mejor igual que se revisan los objetivos generales y específicos del programa

se podría revisar el programa para ver si se ajusta y como se podría ajustar más o menos

este esta guía, no? ya están haciendo, están aplicando a los servicios tanto salud pública que

la lleva el proyecto junto con la asociación y se están intentando implicar cada vez más a los

servicios sanitarios a los directores de los hospitales de la atención primaria y a los centros

Hiba Malek 116

de salud en lo que se está realizando el proyecto. En cuanto a la evaluación, la otra yo creo

que casi todas sí que hay que muchos de los puntos forman parte del objetivo del programa

y en cuanto a la evaluación el único punto que yo creo que se han tenido en cuenta o se han

realizado la evaluación del programa y se está haciendo pero sí que ahora se están

introduciendo los indicadores nuevos que se han hecho, están evaluando ahora una vez que

se ha empezado el proyecto porque ya estamos esperando todavía pero por dificultades

técnicas, no?

Pregunta 1.1:

Lo que si se está haciendo actualmente en el programa mihsalud que coincide con lo que

dicen las recomendaciones de la guía NICE?

1- El planificar designar y coordinar actividades que son los talleres, nos organizamos antes

de ir, tenemos una guía que ofrecemos y también nos adaptamos a las necesidades que nos

puedan surgiendo. Eso sí que esta no es así al tun tun, ordenado y bien hecho estructurado,

después algo de sí que está haciendo también es vale los deberes de participación y el poder:

negociar y ponerse de acuerdo con las partes principales de cómo distribuirse el poder y

responsabilidades, en el grupo mismo en el periodo de formación hicimos como reparto de

tareas a quien responde cada causa, por ejemplo el registro de las conversaciones

informales, visita a puntos informativos, hay aquellas causas que no responden a los agentes

de salud y hay otras causas compartidas con la enfermera y otras que son totalmente de la

enfermera, entonces esa repartición de tareas sí que se da, y también la confianza mutua y

respeto el evaluar a los necesidades de salud, generar específicas de la comunidad. Bueno

vimos el territorio y evaluamos internamente la población, vemos que necesidades pueden

tener más, si es una población muy joven con muchos hijos o a lo mejor pueden tener más

falta de información sobre métodos anticonceptivos adaptando también que sí que hay una

evaluación de las necesidades. En cuanto a temas de infraestructura el capacitar a los

individuos de la comunidad para actuar como mentores para solicitar a curso de agente de

salud que coge forma a los propios líderes de la comunidad podríamos decir paraqué haga

como educadores entre iguales entre sus amigos familia y compañeros. Pues trabajar de

manera conjunta buena asociación promovemos todo el trabajo en red sí que es uno de los

puntos fuertes de este proyecto esta promoción del trabajo en red. Iniciativas basadas en el

territorio, involucrar las comunidades en tomar las decisiones para poder influir en las

Hiba Malek 117

decisiones estas poco a poco cuando ya vas introduciendo de la población en el sector vas

viendo que te puede dar recomendaciones. Pues sí que nos había falta a lo mejor un taller o

información sobre el cuidado del niño para involucrarse en el tema de los talleres. La

participación a lo mejor que más que puede tener. Enfoques, remembro de la comunidad

como agentes de cambio hecho antes como el curso de agente salud eso muy importante

para formar a las gentes como líderes bien formados y capacitarlos para ejercer como tal.

Los talleres comunitarios también creo que se llevan a cabo bien en salud y sobre todo. En el

trabajo "con” la comunidad en vez de "por" la comunidad el hacerlo con ellos, entonces

nosotros no somos un servicios que venimos a darlos tal, si no, os gusta también sí que

participen ellos y que los talleres no los damos nosotros, una charla, si algo técnico y teórico.

Sí que no es algo totalmente dinámico y que ellos van a participar y hacerse protagonistas

ellos de su salud y el tome de confidencia. Después y el tema de evaluación que es algo que

ya hemos comentado antes que no depende de nosotros.

2- Sobre prerrequisitos en la participación, el desarrollo y planificar, diseñar actividades eso

se da. Basadas en el territorio si porque antes de empezar a trabajar en la zona básica de

salud, si el equipo de agente de salud con enfermera hemos recorrido palmo a palmo y se da

ese reconocimiento en el lugar donde vamos a trabajar. El tema de los niveles de

participación sí que también se está dando por esto momento que estaba diciendo,

reconocer la diversidad local, bueno decidan como quieren y pueden participar eso es un

poco a media porque una vez conocido lugar e empezar a hacer contacto con la personas

que tienen capacidad liderazgo le va comentando como es el proyecto pero a su vez es eso

también te dicen sus necesidades, entonces son especia de si algo mas in conjunto, pero ellos

como tal no deciden de directo. Evitar la jerga técnica y profesional, incorporar mecanismo

de retroalimentación creo que también se hace. La confianza mutua, adecuar el enfoque

utilizado, evaluar las necesidades de salud generales, si eso todo tiene que ver porque se

empezó a hacer un trabajo en una zona básica de salud pero reconociéndola. En cuanto a la

infraestructura sí que se trabaja con ONGs se proporcionen pasos de encuentro accesibles y

capacitan a los individuo de la comunidad para actuar a través el curso de agente de salud.

Se trabaja también en forma conjunta con asociaciones se trata de crear esa red de apoyo

entre asociaciones, centro de salud, agente de salud y la comunidad. Iniciativas basadas en

el territorio a la gente en la zona que participen para desarrollar sus habilidades sí que se da.

Hiba Malek 118

El tema de enfoques diseñar planificar actividades también, trabajar con los gerentes del

barrio los líderes comunitarios que nosotros hemos detectado. Talleres comunitarios o

talleres de salud que hacemos si también se dan, se identifica las necesidades porque

cuando vas a las asociaciones o a los sitios y ves y pregunta cuáles son tus usuarios/usuarias,

que tipo de necesidades tienen, eso de dicen. Me gustaría que hable sobre fertilidad

anticonceptivo que hable sobre el sueño.

3- Que está haciendo en coordinación con la guía NICE. El prerrequisitos para participación

están llevando acabo toda las herramientas aquí indicadas excepto el punto 2 que es la

cuestión de largo plazo, en el parte del sector público sí que se apoyan porque ese parte

dentro de los centros de salud el proyecto. El infraestructura todos los puntos indicados

también están llevando a cabo desde el proyecto al igual que el enfoque. Y respeto a la

evaluación se realizan evaluaciones internas con los equipos y centros de salud pública a

parto al año pasado se hice una evaluación externa.

4- En mi opinión lo que dice la guía NICE con respecto a lo que es el proyecto mihsalud creo

que están llevando a cabo la siguiente actividades que son la formación de agente de salud

en base comunitaria que viene enfocado estas entre infraestructura e enfoques. La captación

de recursos con ACUET, el centro de salud y la CAIXA. El trabajo en conjunto con ONGs y

asociaciones para mejorar la participación entre ambos. La participación o el espacio de

encuentro que es el foro de segundo martes. Los gerentes de bario como líderes

comunitarios y lo que es el trabajo del barrio y también captar los miembros de la

comunidad como agentes de cambio y realización de talleres comunitarios en promoción de

la salud. La realización de nuestras fortalezas y activos de la comunidad local mediante del

"Rapid upraisel" y el mapa comunitario.

5- Todas las semanas planificamos y coordinamos actividades e identificamos claramente los

resultados. Reconocemos la diversidad de las personas y trabajamos con asociaciones y

hacemos talleres en una manera que las personas lo entiendan y se integran.

6- En cuanto a los prerrequisitos sí que se dan en cuenta mediante la formación inicial la

reunión de equipo y la reunión de cada departamento. Reconocimiento de territorio

previamente de la gerente del barrio. En cuanto a la infraestructura por lo mismo sí que se

intentar fomentar el trabajo entre de asociaciones servicios sanitarios y todo eso y se intenta

fomentar que la persona se participe de la propia comunidad que participen de forma activa.

Hiba Malek 119

Eso también del enfoque. De la evaluación por lo que hemos dicho antes que se hacen

evaluación interna y una externa y que también proceso introducir de nuevos incitadores.

Pregunta 2:

¿Cuáles son los aspectos que NO se están aplicando en el programa mihsalud?

1- De infraestructura está todo. Enfoques pienso que también. El tema de la continuidad eso

es el básico, eso pienso que es el único que no está ampliando, a parte de la evaluación el

inversión a largo plazo.

2- Lo que no se da creo que sobre todo el punto como dije el proyecto a largo plazo la

sostenibilidad del programa es el punto débil, la participación del sector público al programa

mihsalud no es totalmente fija. En mihsalud que supongo que tendrá que ir construyendo. Y

sobre el tema de gestión de la diversidad los currículos de los profesionales de los recursos

sanitarios creo que faltaría y no sé.

3- Los aspectos que no están aplicando es el largo plazo luego la participación de sectores

públicos el reconocimiento del proyecto dentro que forma parte dentro del sistema sanitario

y la continuidad duración de once meses.

4- Lo que no se está llevando acabo es la inversión a largo plazo para la sostenibilidad del

programa y la participación del sector público al reconocimiento de este proyecto para esta

sostenibilidad.

5- Lo que so se está es la continuidad del programa.

6- Lo que no se está aplicando lo que han dicho mis compañeros la inversión a largo plazo, la

sostenibilidad por el parte pública y lo que comentaban antes de que problema técnicos

están haciendo evaluación interna y externa pero los indicadores sí que están muy

intentando marcarlos para que se evidencia no resultado que está teniendo el programa.

Pregunta 2.1:

¿lo que no se está haciendo actualmente en el programa mihsalud aunque si se esté

contemplando el las recomendaciones de NICE y por lo tanto se debería de incorporar?

1- Como antes lo que no se está haciendo y debería incorporarse es la continua del proyecto

y una evaluación externa a lo mejor más constante.

2- También el punto uno es el mismo lo que debería hacerse que tuve una sostenibilidad. 2

Hiba Malek 120

que lo tiempos del sector público se adecuan a los necesidades de este proyecto participativo

que le falta problema burocráticos.

3- La sostenibilidad del programa del proyecto y que es incluya dentro del sistema sanitario

público.

4- La participación del sector público para la continuidad del proyecto en sostenibilidad.

5- Lo mismo la continuidad del programa y que se incluyen en el sistema sanitario público.

6- La integración del proyecto en la administración pública también.

Pregunta 2.2:

¿Lo que si se está haciendo actualmente en el programa mihsalud y va en contra a lo que

dicen las recomendaciones de NICE y por lo tanto se debería dejar de hacer?

1- Yo pienso que no veo nada que vaya en contra de los establecidos los requisitos para la

participación.

2- También o dar la vuelta lo que dice la compañera 1 lo que no debería ser tal vez es

depender de una entidad bancaria para que esto continúe por lo tanto volvemos a lo mismo

que es el sector pública debería asumir este financiación de este programa. Ponerlo dentro

su bolsa de cartera de servicio.

3- Las recomendaciones de la guía NICE creo que no vaya ninguna en contra si que debería

forma parte del sistema sanitario público para tener una continuidad a largo plazo.

4- Lo que se está haciendo es una financiación a corto plazo que va en contra de las

recomendaciones NICE que debería ser a una planificación a largo plazo para que el proyecto

tenga frutos en el futuro.

5- Pienso que está todo ordenado.

6- Creo que está todo de las recomendaciones solo que debería incluirse la administración de

una continuidad.

Pregunta 3:

¿Cuáles son los aspectos que no se pueden aplicar en el programa mihsalud en estos

momentos?

1- Pienso que el tema del trabajo con la comunidad que la comunidad se integre de la plena

participación del proyecto es un tema que tenemos que trabajar bastante porque es aparte

es una población muy cambiante de las condiciones bastante personales y sociales y

Hiba Malek 121

económicos bastante difíciles que impide también esa plena integración del programa que

dificulta a lo mejor esa participación. Hacer partícipes todavía más en el proyecto.

2- También como ha dicho la compañera falta también esa porque hay un paso primero

conocemos los equipos de salud y luego vamos a ver que necesitas las personas. Tal vez lo

que no se hace también es potenciase trabajo “con” en lugar de “por” en la comunidad local.

3- No se puede aplicar actividades a largo plazo por el hecho de la continuidad que tiene

duración de once meses entonces por tanto no podemos ver resultados ni planificar

actividades a largo plazo.

4- Yo creo que lo que no se puede aplicar al 100% es la participación del sector público por

cuestiones políticas para la continuidad del programa.

5- (no tiene nada a decir)

6- lo que no se puede aplicar a largo plazo la participación de parte de los sectores de tanto

de la población como de centro sanitario eso no ha transmitido cierta dificultado.

Pregunta 4:

Si las recomendaciones se pueden aplicar al programa mihsalud. ¿Crees que se pueden

aplicar a otros programas de promoción de salud o cualquier programa de la salud?

1- Pienso que sí en este programa se puede hacer claro que se puede hacer en otros.

2- Sí como son beneficios para este también pueden ser beneficios para cualquier programa

de participación.

3- Pienso que estas recomendaciones se pueden aplicar a cualquier otro de los programas

dirigidos a promover la salud en la comunidad.

4- Yo creo que las recomendaciones de este NICE se pueden aplicar a cualquier programa de

promoción de la salud y al centro de salud.

5- Yo creo que sí se puede aplicar a cualquier programa.

6- Creo que se puede aplicar a otro programa y a cualquier de ella y además servir para la

inauguración de los mismo.

Hiba Malek 122

Appendix 12. Focus group transcription 2

Focus Group Transcript

Archival #: 2

Sita: Centro de Salud Pública, Valencia

Number of participants: 6

Date: 19- May- 2015 Moderator: Hiba Malek

Start: 12 p.m. End: 1:30 p.m. Note-Taker: Pilar López Sanchez

Pregunta 1:

¿Cómo podemos integrar estas recomendaciones al programa mihsalud con el fin de

mejorar el rendimiento y los resultados del programa?

1- Creo que para mejorar el rendimiento y los resultados del programa deberíamos de hacer

es dar difusión a nivel de la población de lo que es el programa. Creo que en nuestra

sociedad hay poca cultura de intervención comunitaria y si no hay una buena basa, si la

población no consigue entender que forma parte de su día-día es muy difícil que entiendan

esa intervención de repente.

2- Considero que para poder integrar las recomendaciones para mejorar el rendimiento y los

resultados del mismo debería efectivamente que darle más difusión entre los restos de

departamentos e implantar esta misma programa al resto de los departamentos para que se

conociera de forma más complementaria.

3- Para mejorar el rendimiento y el resultados creo que se debería trabajar a dos niveles; uno

a nivel gerencias de administración para garantizar el mantenimiento a largo plazo, y otro a

un nivel más de asociaciones y participantes en los que entren más a la hora de preparar la

programación y evaluación de los resultados.

4- Favoreciendo un cambio de cultura de la organización de lo público, dirigido a trabajo en

red, desde cada profesional, desde su nivel de actuación.

5- Yo creo que con la difusión y buscando la implicación de todos los profesionales de la

Hiba Malek 123

comunidad y de toda la comunidad en sí. Por ejemplo, pienso que se podría trabajar

presentando difundiendo el programa en los colegios que tenemos allí a los niños de la

población vulnerable, y que es una forma dando conocer este programa en un centro

educativo creo que se podrían llegar a un parte de la comunidad afectada, por lo menos la

percepción que yo tengo, es que la mayoría de las comunidades vulnerables tienen niños,

hay siempre niños, y los niños están todos escolarizados, entonces enterándonos a los

colegios para difundir el programa pienso que se puede llegar a un gran parte de la

comunidad. Y luego a nivel de los grandes responsables de salud que al fin acabo son los

profesionales de atención primaria creo que se difunde pero no termina de llegar

información, no sé exactamente porqué, puede ser que no hemos terminado de implicar el

asunto, habría que analizar el porqué.

6- Yo creo que las recomendaciones más o menos ya forman parte del programa, ya están

en el programa, ya se cumplen, pero para ver la mejor rendimiento de los resultados yo creo

que se debería trabajar un poco en los indicadores que se propusieron, evaluarlos y ver los

resultados, que es pendiente.

Pregunta 1.1:

Lo que si se está haciendo actualmente en el programa mihsalud que coincide con lo que

dicen las recomendaciones de la guía NICE?

1- Consideró que se está haciendo todo lo relacionado con la infraestructura. En cuanto a la

formación y recursos a trabajar de manera conjunta con las asociaciones y las iniciativas

basadas en el territorio. También lo que tiene que ver con enfoques. Este todo figura la

gerente de barro que no sé si se recoge en nuestro territorio. Si sé que están planificando

talleres comunitarios y además se tienen en cuenta las personas que residen en la

comunidad.

2- Consideró que se está haciendo actualmente en el programa mihsalud y que coincide con

lo que dice las recomendaciones de NICE, uno la planificación la coordinación y el diseño del

programa. Dos la confianza y el respeto mutuo, consideró que hay aspectos que no se están

aplicando en el programa o es difícil a aplicación. Uno de esos es establecer plazas realistas

para la implementación y desarrollo del programa porque en estos momentos no tenemos

plazos específicos y dependemos de lo que es la cobertera presupuestaria que establece

plazos están en el aire.

Hiba Malek 124

3- Consideró que sí que están realizando en el programa mihsalud es dentro de los

prerrequisitos el desarrollo de las políticas planificación desarrollo coordinación y actuar

como sobre las organizaciones y niveles de participación y confianza mutua. En la parte

infraestructura sí que se está actuando los tres requisitos que indicando y en los enfoques

también.

4- Yo consideró que el programa que sigue la mayoría de recomendaciones. Dentro de los

prerrequisitos la inversión a corto plazo y dentro de lo que es la infraestructuras y enfoques

sí que la sigue. En evaluación intenta a hacer una parte.

5- Yo pienso que lo cumple en la planificación diseño y coordinación de las actividades

aunque creo que se podría mejorar coordinando con colectivos de atención primaria. Pienso

que sí que tienen objetivos a corto plazo sin embargo no tengo muy claro si las prioridades

locales a largo plazo se están cumpliendo. En cuanto a la formación a la diversidad pienso

que sí que se cumple. La gestión y de conflictos de comunidades y los organismos tengo

dudas no lo sé con seguridad. La confianza mutua y el respeto se cumplen. En la

infraestructura en el punto uno creo también que se cumple. En el trabajo conjunto en

asociación también. Desconozco el trabajo con los gerentes del barrio. Sí que se cumplen los

talleres comunitarios. Y desconozco las actividades de regeneración.

6- Yo creo que respecto a los prerrequisitos se cumplen más o menos todos, sobre todo el

punto uno con la planificar diseñar y coordinar las actividades y el punto cinco de confianza y

respeto porque también se evalúan las necesidades comunitarias. Respecto a la

infraestructura también creo que se cumplen los tres. El punto uno se capacita a los

individuos de la comunidad con el curso de formación acción de los agentes de salud. El

punto dos se trabajan en manera conjunta con las asociaciones que es como la forma del

trabaja del programa. El punto tres de la infraestructura como el punto uno de los enfoques

creo que se cumplen con los forros que se realizan mensualmente y después los talleres

comunitarios también se cumplen.

Pregunta 2:

¿Cuáles son los aspectos que NO se están aplicando en el programa mihsalud?

No hay respuestas.

Hiba Malek 125

Pregunta 2.1:

¿Lo que no se está haciendo actualmente en el programa mihsalud aunque si se esté

contemplando el las recomendaciones de NICE y por lo tanto se debería de incorporar?

1- Considero que la inversión a largo plazo no se está realizando y se debería de realizar. Y de

aquí paso a la parte de la evaluación en la que identificar y acordar las objetivos de

evaluación con los miembros de la comunidad del destino creo que eso no se hace

previamente e involucrarlos en la planificación el diseño y la aplicación de un marco de

evaluación creo que tampoco se hace.

2- En cuanto a los aspectos que no se están aplicando al programa coincido también en

establecer los plazos realistas en cuanto a la financiación a largo plazo del programa

actualmente no se está completo. Y Luego considero que no está completo a todos los

niveles creo que es el punto 4 corresponde a la decisión comunitaria. Los niveles de

participación y poder de la comunidad actualmente creo que no está y el desarrollo.

3- Los aspectos que no están aplicando en el programa en cuanto a los prerrequisitos el

segundo punto la inversión a largo plazo no se tiene, cada año se va, la inversión parece algo

concreto y se funciona año año sin saber la que viene y que va a pasar. Tampoco está

cumpliendo toda la parte de evaluación, se están empezando a trabajar en algunos

indicadores pero aún está la cosa bastante, en sus inicios y además luego no está

participando de forma activa a nivel comunitario. Y por el medio que da un punto en el que

genera bastantes dudas que son los enfoques en tercer punto cuando hay que tener en

cuenta la opinión de personas residentes. El inicio del programa fue con gente vulnerable

exactamente residente, en los últimos años cuando se está incorporándose asociaciones de

vecinos y ya como ligadas más territorio concreto no nacer constancia de vulnerabilidad.

4- Respecto a lo que no se está aplicando yo resaltaría la planificación conjunta tanto desde

salud pública con primaria con ayuntamiento con entidades locales para asegurar esa

financiación a largo plazo porque la evolución va dirigida a ese largo plaza. Las actividades

en promoción de salud si cada año vamos esperando pues no aseguramos esa evolución.

5- Yo coincido con mi compañera en que aunque se planifican y se coordinan las actividades

yo creo que no se están haciendo con todos los componentes por lo menos desconozco a mi

nivel si se está haciendo esa coordinación contando con todos los agentes de primaria con

las asociaciones locales y la ayuntamiento, y por lo menos desde mi punto de vista esto sería

Hiba Malek 126

algo que no está cumpliendo puede que esté equivocada. Creo que efectivamente falta una

inversión a largo plazo y creo que es importante. En cuanto a los niveles de participación y el

poder creo que falta algo en cuanto a lo que es la distribución del poder y las

responsabilidades. En la infraestructuras creo que las iniciativas basadas en el territorio dice

que debería animar a la gente de zona a que participen en la organización creo que se está

realizando con la población en la comunidad de riesgo pero no con la gente de la zona no sé

si sería un objetivo a cumplir, entonces como tengo duda no sé si se cumpliría o no. Y por

último que sería también con lo mismo seria la parte de participación local de la población

en el punto 2 y 3 de los enfoques.

6- Al igual que mis compañeros también creo que en la parte de prerrequisitos el punto 2 no

se cumple no hay una inversión a largo plazo en el programa porque la entidades que

financian no dan esa financiación a largo plazo. Después en el punto 3 de enfoques también

creo que no se tienen en cuenta la opinión de las personas residentes o la estructura que

tiene el programa que va a dirigida a gente vulnerable y es más como una gestión del

programa desde arriba que es para impartir conocimiento de salud a la comunidad.

Pregunta 2.2:

¿lo que si se está haciendo actualmente en el programa mihsalud y va en contra a lo que

dicen las recomendaciones de NICE y por lo tanto se debería dejar de hacer?

1- Yo considero que no hay nada que se está haciendo en contra de las recomendaciones de

NICE salgo garantizar el programa a largo plazo.

2- Coincido con mi compañera y no encuentro en este momento ningún punto que se esté

haciendo que vaya en contra las recomendaciones de NICE.

3- Yo no encuentro nada que vaya en contra quizás que no está haciendo exactamente como

dice el NICE y entre ellos los indicadores que no se están trabajando para la evaluación

suficiente y los que están trabajando para ello no se ha tenido en cuenta la opinión de la

sociedad y las gentes sociales y asociaciones.

4- En contra me pienso que es no asegurar la sostenibilidad porque las personas que están

llevando a cabo el programa que implican a las demás personas que hacen que participen no

saben si el año que viene van a continuar, entonces estamos generando unas falsas

expectativas respecto a la participación.

Hiba Malek 127

5- Yo estoy de acuerdo en que el único que se tendría que dejar de hacer es no dejar plan por

el futuro del programa.

6- Yo considero que en contra no hay nada de ninguno de los puntos que hay en la guía NICE.

Pregunta 3:

¿Cuáles son los aspectos que no se pueden aplicar en el programa mihsalud en estos

momentos?

1- Creo que en las recomendaciones que tenemos por escrito seria todo aplicable, no hay

nada que pone en el documento en las recomendaciones de la NICE que a mi entender no se

pueda cumplir, lo que pasa que es un proceso largo y costoso y de cambio cultural y de

políticas sociales y además.

2- Quizás un punto de los cuales no se podrían aplicar en esto momento en el programa

mihsalud con respecto a las recomendaciones de NICE posiblemente fueran lo que

corresponderían con infraestructura en el punto formación y recursos por el problema que

hay de financiación a largo plazo, en cuanto a la estructura montar de estructura, de

espacios y sobre todo para formar a todo lo que corresponde a desarrollar la fortalezas de la

comunidad local.

3- Creo que lo que no se puede aplicar en este momento es todo aquello que implica un largo

plazo, todo lo que es una programación una evaluación que implica largo plazo hay no

podemos entrar.

4- Yo creo que todo es aplicable. No encuentro ningún cosa que no.

5- Yo también pienso que todo es aplicable.

6- Yo pienso que todo es aplicable aunque en estos momentos exactamente por la de la

financiación pues no se podría. Lo que he comentado antes del punto tres de los enfoques

tampoco pero por el diseño del programa, y en cuanto a la evaluación el mismo que aún no

están como aprobaos los indicadores que puedan evaluar el impacto del programa con la

comunidad.

Pregunta 4:

Si las recomendaciones se pueden aplicar al programa mihsalud. ¿Crees que se pueden

aplicar a otros programas de promoción de salud o cualquier programa de la salud?

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1- Sí.

2- Exactamente igual que si están aplicando al programa mihsalud todas las

recomendaciones son aplicables a cualquier programa de promoción de la salud en el

entorno comunitario.

3- Sí, evidentemente es una forma, metodología de estudiar cómo funciona un programa.

Poder aplicar a cualquiera de ellos.

4- Yo también opino que sí. Creo que se le hiciéremos conseguiríamos trabajar con más

eficiencia y mayor satisfacción personal.

5- Debería ser sí.

6- Yo creo que sí también.