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Section 12. Documenting Health Promotion Initiatives Using the PAHO Guide

Example #1: Collaborative Action for Community Change and Risk Reduction for Chronic Disease and Health Disparities in Kansas City, Missouri (USA)

Authors: Jerry Schultz, Steve Fawcett, Vicki Collie-Akers

The Kansas City-Chronic Disease Coalition began in 2000 in Kansas City, Missouri, in response to two events: 1) the Centers for Disease Control and Prevention (CDC) request for proposals for the Racial and Ethnic Approaches to Community Health (REACH) 2010, and 2) minority health status assessments released by two organizations that highlighted significant health disparities among Black and Latino residents of Kansas City.

This urban area was characterized by high rates of poverty and few opportunities to engage in healthy behaviors. The Coalition is comprised of health, community and neighborhood organizations; faith communities, business, as well as residents of Kansas City. Over time, the Coalition included Native Americans as one of its target populations; however efforts to reach that population never came to fruition.

The Coalition’s mission is to improve health outcomes for diabetes and cardiovascular diseases (CVD) by promoting access to quality care, healthy environments, and lifestyles through integrated, affordable, culturally sensitive, and accountable community-based health care and prevention services.

It proposes five interrelated phases:

  • Collaborative planning and capacity building.
  • Targeted action and intervention.
  • Community and system changes.
  • Widespread behavior change.
  • Improving community health outcomes

The Coalition developed a comprehensive action plan that proposed 86 community changes. Through its “Pick Six” program it also provided resources to key partners to support the implementation of six action plan items (e.g., six new or modified programs, policies or practices). Resources included grants, technical support, and program materials.
The Coalition facilitated about 675 community changes between 2001 and 2007. Some examples include: modified clinic operating hours to increase access, adoption of clinical care guidelines, inclusion of health information in neighborhood newsletters, use of church facilities for physical activity, and the development of walking clubs or paths. Findings from the participatory evaluation suggest that the Coalition was an effective catalyst for environmental changes to reduce health disparities related to CVD and diabetes.

Some of the Coalition’s important assets were the wide social network of the first project manager and the development of relationships with a large number of community organizations. However, challenges in implementing mini-grants, including complicated government requirements and internal fiscal management, stressed the relationships that had been established with these organizations. Limited involvement and participation from Latinos (one of the target populations) was also a barrier.

Between 2001 and 2007, the Coalition received large grants as part of the CDC’s REACH 2010 Initiative. A new five-year grant received in 2008 allows for the continuation of this successful initiative and may permit more sustained efforts to address health disparities, with the main adjustment to be made being to develop an effective strategy to engage the Latino community in the initiative.

Example 2: Home Help for the Elderly Program in St. Vincent & the Grenadines

We would like to thank the following individuals who assisted in the preparation of this case study: Carrie Mathews, Juno Lawrence, Patsy Wyllie, Rosita Alexander-Snagg

The Home Help for the Elderly Program, an initiative of the government of St. Vincent & the Grenadines implemented by the Ministry of Social Development, began in August 2002 to improve care and support to elderly population. The initiative intended to benefit persons 60 years and over, those who were isolated and shut in homes, and those with special needs. It included 92 homecare helpers, 2 supervisors, and 1 case worker and it received support from a local church.

The initiative’s mission was to create a supportive environment and a sense of belonging for the elderly while also raising their self-esteem and attending to their basic health and social/emotional needs. It proposed a holistic approach, in which the elderly were assisted with health care and other needs, while the providers were taught about the elderly way of life and how to care for them. The services were provided at no cost to the recipient.

St. Vincent & the Grenadines’ Red Cross provided training in first aid for home helpers. Nurses provided general nursing care and supervised the trainees during their internship. The Ministry of Health provided officers to assist with the training program. Due to the involvement and support of the Ministries, all areas of the country are covered.

Currently, 450 elderly are benefitting from the Initiative, and it is considered to be a cost cutting measure for the government, since it would be more costly if the government were to provide institutional care for this population. Social indicators have changed; community and family response to the elderly has also improved. The elderly reported feeling a sense of comfort and security, and their family members felt comforted knowing that they were being taken care of.
There has been a greater utilization of the health care facilities within districts. The elderly have begun paying more attention to diet and nutrition. Policymakers have gained a better understanding of the profile of the elderly in their society. The training programs have also been a source of employment for the caregivers.

However, there was a lack of male involvement in the project (as home helpers), limited financial and human resources, limited equipment and material, and lack of support from the private sector. Ensuring that the true beneficiaries had access to the program has been a continuous challenge, as well as, ensuring that political interference was kept to a minimum. The Initiative also had no formal documentation and evaluation system.

The initiative contributed to positive changes for the elderly population in St. Vincent & the Grenadines. As the initiative is in the implementation and maintenance stage, evaluation must be considered and this must be an ongoing process. A source to sustain the initiative must also be considered as reliance has been solely on the government.

Example 3: National Wellness Program in St. Vincent & the Grenadines

We would like to thank the following individuals who assisted in the preparation of this case study: Carrie Mathews, Juno Lawrence, Patsy Wyllie, Rosita Alexander-Snagg

Starting in 2006, the Department of Physical Education and Sports in the Ministry of Social Development of St. Vincent & the Grenadines launched the National Wellness Program which was implemented through community groups and institutions. Other participating organizations/institutions included the Ministry of Health & the Environment, Homes for the Aged (Thompson Home, Golden Age Homes), Her Majesty’s Prison, and other community groups in various districts. The initiative was meant to benefit the general population; specifically, individuals who were involved with the participating organizations/institutions.

As chronic non-communicable diseases are a pressing and major problem in St. Vincent & the Grenadines, accounting for 80% of deaths in the country, the initiative’s mission was to sensitize participants about healthy lifestyles and the benefits of participating in regular physical activity. One of the primary aims of this initiative was to change the belief that health is only important when individuals are not well and to make people be more proactive when it comes to their health.

Even though there was no formal monitoring or evaluation system in place, the expansion of the program to other communities has been a positive indication that changes are coming about. Communities reported a heightened awareness about physical activity and expressed an interest in getting involved with the program. There was greater utilization of community resources (e.g. the community centers and recreational sites) and health care facilities within the districts. Positive behavior change was demonstrated by the population’s increased level of physical activity.

The case study reported some challenges such as a lack of male involvement in the project, limited financial and human resources, limited equipment and material, and lack of support from the private sector. In addition, the change in the location for some of the activities has hindered the involvement of some participants. Adequate funding will need to be acquired from other sources.

Example 4: Inuit Tutarvingat (Inuit Centre at NAHO) in Ottawa, Ontario, Canada

We would like to thank the following individuals who assisted in the preparation of this case study: Katherine Minich, Suzanne Jackson

The Inuit Tutarvingat Initiative began in 2000 in response to the Royal Commission on Aboriginal Peoples (RCAP). Participating organizations and institutions included the Metis Centre, First Nations Centre, and the Communications Unit. The Initiative is intended to benefit the Inuit population, which has the poorest health status in the country of Canada. Policy makers, government workers, and the general public are the target audiences for the Initiative.
The main focus of the Initiative is to promote practices that will restore a healthy Inuit lifestyle and improve the health status of the Inuit population through research and dissemination of research results, education and awareness raising, human resource development and sharing information on Inuit-specific health policies and practices. The Initiative seeks these changes at the level of individuals, organizations, community and society.

The Initiative has 5 objectives:

  • Improve and promote Inuit health through knowledge-based activities.
  • Promote understanding of health issues affecting the Inuit population.
  • Facilitate and promote research and develop research partnerships.
  • Foster participation of the Inuit population in the delivery of healthcare.
  • Affirm and protect Inuit traditional healing practices.

Change in the Inuit community has been difficult to capture as the population is greatly dispersed. Also, because no formal monitoring or evaluation system is in place yet, it is difficult to measure change and results. Very little ethnic data is collected so it is hard to tell how Inuits in general are benefitting. Some products and resources target specialized audiences but the uptake and impact of those resources are not known. Organizational level changes have, however, made going for smaller grants easier for staff.

Some challenges faced by the Initiative include difficulty in the retention of Inuit workers, long upstream population health challenges, and changing governments leading to questions regarding the continuity of funding.

Although evidence of effectiveness has yet to be determined due to a lack of formal monitoring and evaluation the Initiative seems to be headed in the right direction. According to the Initiative, communications have been reaching the target audience, the Centre has gained visibility, and resources/partnerships have been established. However, the Initiative needs to focus on fewer issues with longer and more comprehensive projects and to strengthen partnerships with health and education sectors and to develop target materials. Performance monitoring and evaluation must also be developed and improved.

Example 5: Health-Promoting Schools Initiative in Guyana

We would like to thank the following individuals who assisted in the preparation of this case study: Anthony Hunte, Dionne Broone, Juno Lawrence, Lucy Anderson, Lydia Indira Badal, Preeta Sajwack, Guyana Ministry of Health and Ministry of Education

The Health Promoting Schools Initiative began in 2002 in Guyana to address the growing health and social problems that are related to lifestyles and behavior in the country. Lead organizations included the Guyana Ministry of Health, Guyana Ministry of Education, and the Pan American Health Organization (Guyana). Participating organizations included the Caribbean Council for the Blind, the Ministry of Human Services & Social Security, the Cheddie Jagan Dental Clinic, the Ptolemy Reid Rehabilitation Center, Money Gram, the Ministry of Agriculture, the Ministry of Culture and Youth and Sport, Voluntary Service Organizations (VSO), the Linden Economic Advancement Program (LEAP), the Peace Corps, the Guyana Red Cross, Women Across Difference, the World Bank, and the St. Sidwells Anglican Church.

The Initiative was implemented in nurseries, primary and secondary schools along with the respective communities in which the schools were located. Target groups included Parent-Teacher Associations, Community Improvement Advisory Committees, and school-age children of all levels.

The Initiative aims to create supportive environments that encourage positive change through education and skills training among the various target groups. The mission is ‘to create and maintain the capacity of school communities to build health into all aspects of life at the school and improve the health of children, teachers, parents, guardians and other members of the school community. The Initiative is facilitating primary health services and schools to work together, improving their ability to detect and offer assistance to children and young people in a timely fashion, detaining and preventing the adoption of risky behaviors, such as smoking, consumption of alcoholic beverages, substance use, early and risky sexual practices, and early unwanted pregnancy. Technical support was provided by PAHO and the MOH. The PTA provided the human resources and several international agencies provided financial resources.

According to the Initiative, achievements and results of the Health-Promoting Schools Initiative cannot be described due to the lack of formal monitoring or evaluation systems in place to routinely collect the data that would be needed to substantiate any claims. However, the communities involved have reported some behavioral changes among parents and children.

Challenges varied in the different stages of the Initiative. In the planning stage, there were a lack of formal agreements among relevant stakeholders, a lack of adequate funding, and a lack of skilled human resources. During the implementation stage, there was a lack of formal monitoring systems to track progress and a lack of effective communication strategies to communicate to the public about the initiative and to ensure effective communication among stakeholders.

The effort will continue to be sustained through the School Health Units within the Ministries of Health and Education. Both of these units are responsible for coordinating the activities within each ministry and sharing that information with the other ministry through a small committee.

Example 6: Crooked Creek Quality of Life Initiative (CC QOLI): A Community Development Experience in Indianapolis, Indiana, USA

Authors: Alicia Chadwick with Crooked Creek Northwest Community Development Corporation, Helen W. Lands with Fay Biccard Glick Neighborhood Center at Crooked Creek, Mary Beth Riner with Indiana University School of Nursing, and Marty Rugh with St. Vincent Health.

The purpose of this initiative was to improve the quality of life of residents of a geographically defined neighborhood in an urban mid-western city in the United States. An advisory board provided oversight for a comprehensive assessment conducted by nursing students and that was used for developing a proposal that funded an advisory group appointed by the mayor of the city. Using the PAHO Healthy Municipalities, Cities and Communities model, diverse sectors of the community collaborated to address the conditions responsible for health and well-being. Organizations involved included a hospital, social service agency, housing development agency and university.

The goals of the CC QOLI were to improve the quality of life of Crooked Creek residents through: revitalization of built environments (commercial and community buildings, housing, roads, sidewalks, etc.); new collaborations among health, education and social service organizations; and resident engagement in community improvement. Among the initiatives implemented to achieve these goals were: investments in a housing program for low and moderate income residents; construction of a Family Pavilion to address the civic, social, intergenerational, cultural, and recreational needs of Crooked Creek individuals and families; and a School Health Program for area students.

The Fay Biccard Glick Family Pavilion at Crooked Creek was constructed and now provides a wonderful space for community gatherings, youth and family activities, recreation and an affordable venue for wedding receptions, family reunions, graduation ceremonies, open houses and religious services. The School Health Program moved healthcare delivery beyond traditional hospital walls, and is now part of a broader vision to build healthier communities. School corporations have adopted healthier school policies and are able to address chronic issues of asthma, obesity and absenteeism. Investments in Housing have resulted in completion of three congregate living homes for 12 disabled residents—the most recent using “green” building practices, costly repairs to the homes of 33 elderly homeowners, education of 60 potential homebuyers about the home buying process, and down payment assistance for 12 first-time buyers who purchased homes in Crooked Creek.

The Family Pavilion project experienced some difficulties such as having the contractor walked off the job midway through the project resulting in an eight month delay and cost overruns. Another contractor had to be hired and additional funds were raised in order to complete the project. The School Health Program became more complex when partners realized that the unique nature of each school required interventions to be tailored for each particular school’s student population. The Investments in Housing program found the cost of projects were sustainable only to the degree that the organization continued to successfully compete for public and private funds to underwrite projects.

Some of the lessons learned across initiatives included:

  • Collaboration makes individual organizations stronger—a new organization without a track record benefits from partnering with an established organization, which gives others “permission” to be supportive. Established organizations benefit from the energy and entrepreneurial aspects of start-ups.
  • Having a good plan based on good data is crucial to securing funding and support.
  • Program operators need to ensure senior that leaders (senior executives and board members) stay informed and engaged over time in order to sustain initiatives over the long-term, otherwise they risk being replaced by the next new (and not necessarily better) thing.

Example 7: Health through Participation: the experience of Guarulhos in São Paulo, Brazil

Authors: Rosilda Mendes, Paulo Fernando Capucci, Douglas Brandalise, Emilia Broide. We would also like to thank Jonas Diaz for his help in preparing this case study.

The initiative is taking place in Guarulhos, Sao Paulo, as one of the strategies to deal with problems related to health and living conditions with the aims of promoting and enhancing popular participation and establishing a channel of communication for including popular demands into the development of health policies. The priority project Health Through Participation works through promoting local Forums that are open to the public and that are held every two years. Between 2005 and 2007, a total of 37 Forums were held, bringing together 5,700 representatives of local communities, health professionals, health managers, NGO´s, churches, etc.

The initiative’s main objective is to increase the population’s control over health care and management of public policies related to health, as well as to assist in determining the state of health in specific areas at the lowest possible level of division of local urban space. It began in 2005 with the Health Through Participation Forums held in twenty-two areas of the city in conjunction with the Participatory Budget Forums. In 2007, the Health through Participation Plenary Sessions were held in each of the Health Districts which had been organized as the basis for health management. Since the first Plenary Sessions, approximately 1300 representatives have been elected to comprise local Health Councils for the 65 Basic Health Units, hospitals, and specialized health centres in the municipality. By the end of 2009 14 Forums will be held.

The local Health Councils have broadened their scope of action from acting on local health issues to broader social issues. Action, therefore, has become geared to local day-to-day issues affecting the communities. The Project has led to a change in health policy and related areas of municipal administration. The resulting focus of the discussions on public health policy has been publicly credited to the initiative. Improvements were registered at Basic Health Units with regards to the quality of the care given. In addition, there has been a significant advance in identifying more specific health demands on the part of the population. The fact that the public has taken control of health issues has generated a new trend within the population, with popular complaints giving way to specific proposals for change and greater support from the health sector. The public now understands, for example, the logic of investing in primary care through the Basic Health Units rather than in a greater number of large hospitals. There have been positive changes related to the establishment of mechanisms for participation involving many local actors. However, the Councils have tended to have a certain cliquishness which has hindered fuller social participation.

Among the lessons learned from this experience is the need to guarantee support from local government in order to successfully increase social participation and to improve the planning of activities in order to ensure that the project’s sustainability can be maintained. Budgeting is central to supporting the permanent activities required for the Project, as it is fairly complex and involves many players. What is most important for the Project is that it should not stand apart from local activities and politics. It therefore needs to be open-ended.

Example 8: Healthy Schools Initiative in the Departments of Asunción, Central, Misiones, Itapúa y Cordillera in Paraguay

Authors: Health Promotion Directorate–Ministry of Public Health and Social Wellbeing

The Healthy Schools Initiative started in Paraguay in the decade of 1990, spearheaded by the Ministry of Health with the support of the Pan American Health Organization. The objective was to promote health in the school setting and the integral development of boys and girls within the educational community.

In 2000, a pilot project was implemented in 17 schools distributed throughout urban, peri-urban and rural areas of the Departments of Central, Cordillera y Misiones. At each selected school a Management Committee comprised of school authorities, parents, students, local authorities and representatives of organizations and local institutions was formed. The 17 schools focused their action on four areas: primary health care, infrastructure, training, and participatory projects. Although this effort started with great impetus, it was not possible to sustain it overtime. However, it created a fertile ground that allowed some initiatives to be maintained within the framework of Healthy Schools and at times it catalyzed the beginning of new processes.

In October 2008, the authorities of the new government re-launched the Healthy Schools initiative, in a joint project between the Ministries of Health and Education. A data assessment was conducted to jointly analyze and generate a consensus on the criteria for accreditation. Strategic partnerships were established with organizations such as the program VIDA (cardiovascular disease prevention), and with international agencies such as UNICEF, UNDP and UNFPA. Actions undertaken at this stage have emphasized a strong and consistent interest of all stakeholders. It should be pointed out that the Ministry of Education and Culture has modified the “Technical High School Education in Health” curriculum, reorienting it toward health promotion, and thereby contributing to the process of implementing the Healthy Schools Initiatives.

One of the challenges of this initiative has been that numerous experiences in school health describe themselves as a Healthy Schools or `Health-promoting Schools` yet there are no uniform criteria established for its designation. These experiences are promoted by different sectors: the municipality, health districts, local government, and the education community. The current objective is to unify the Strategy by developing criteria for accreditation that guides institutions in the development of lines of action, complemented by a monitoring system. The current goal is to develop a unified strategy at 40 selected schools in 5 Regions. A baseline will be developed, along with a system for continuous and systematic data collection and analysis.

Some difficulties included (1) limited resources and the dispersion of efforts of the Health Promotion Directorate, which made it difficult to carry out a sustained process and (2) the lack of coordination within the Ministry of Health’s programs that hindered integrated action based on common objectives.

Lessons learned included the need for systematic data collection and analysis, dissemination of information among the main stakeholders so that results are assessed, and the need for community empowerment (local governments and other social actors) in order to avoid processes to remain inconclusive.

To facilitate the collective construction of Healthy Schools will help social actors to identify protective factors and stimulate effective responses. Responsibility should be assumed mainly by governmental institutions, linking efforts with other institutions working in this area. The Healthy Schools Strategy creates an opportunity for the school setting to be transformed into a space that fosters the social production of health.

Example 9: Promotion of Healthy Settings and Lifestyles at Primary Schools of Four Mexican States

Authors: Luz Arenas Monreal, Pastor Bonilla Fernández, Cristina Caballero García, Elba Abril, Héctor Hernández P., Sofía Cuevas B.

In 2006 the National Institute of Public Health (INSP) of Mexico initiated the project Promotion of Healthy Settings in Primary Schools in four Mexican States, in collaboration with the Health Services of the States of Guerrero and Jalisco, the Center for Research on Food and Development, and public schools of the states of Morelos, Jalisco, Guerrero, and Sonora. This project was financed by the National Science and Technology Board. It used an integrated approach to improve physical, emotional and social environment for school-aged children and addressed problems affecting this population such as overweight, obesity, addictions, environmental degradation, and family and social violence.

Initially, focus groups were conducted with teachers of the four States to help identify health determinants (living, work, and education conditions; physical environment; psychosocial factors; social and family support networks; etc.) that affected the populations in the areas where the initiative would take place. The main characteristics found among the families of the schoolchildren were: low social class, low educational level among parents, poverty, and migration to the United States. In the first phase, baseline measurement data were collected: weight/age, weight/height, age/height, prevalence of caries and smoking with the following results: coexistence of malnutrition and overweight or obesity among children of all participating schools, high prevalence of cavities, and a significant percentage of children who currently smoke and/or consume alcoholic beverages.

In the second phase, educational interventions were carried out in topics such as: self-esteem and the culture of peace, environmental protection and care, smoking prevention, and nutrition and hygiene. As a result, increases were observed in knowledge related to healthy food and hygiene as well as improvements in skills related to waste separation and care of natural resources. Teachers reported a decrease in violence and an increase in the use of more peaceful ways of resolving conflicts among schoolchildren. Two health committees were formed: one of children and another of parents. Links were established between the schools and local health centers to facilitate the children’s access to services.

The children had difficulty in applying outside of the school setting what they had learned through the initiative, which highlighted the limitations of school-centered initiatives that do not include the community as a whole. There were also difficulties in influencing agencies responsible for the development of public policies (sale of healthy food in schools and its vicinity) in the States of Guerrero and Morelos. In the States of Jalisco and Sonora, where regulations of food sale within the schools were already in place, the initiative managed to raise awareness of families about healthy food consumption.
This project contributed to the inclusion of more integrated health promotion approaches to initiatives taken by the INSP, such as promoting the establishment of a research group on Promotion of Healthy Lifestyles.

Example 10: The Community Mental Health Movement of Bom Jardim, Fortaleza, Brazil

We would like to thank Maria Gabriela Curubeto Godoy for her assistance in preparing this case study.

The Community Mental Health Movement of Bom Jardim, in Fortaleza, Brazil aims to provide services to people with various types of mental illnesses in order to improve their integration into the community and promote individual, group and social empowerment. It is implemented in 22 community centers of 5 neighborhoods located in the “Greater Bom Jardim” area of the municipality of Fortaleza. The initiative focuses on vulnerable, at-risk families, living in extreme poverty. This population is characterized by a low level of education, unemployment, lack of opportunities and low self-esteem.

The initiative started when local church leadership and missionaries working in the region formed a volunteer group to provide shelter and counseling to the population that at that time did not have any access to mental health services. Initially, efforts to include the local government were fruitless. However, with a change of government in 2005, the initiative gained more recognition and momentum, which resulted in the establishments of alliances and an increased flow of resources to expand actions and services. Some of the stakeholders currently involved in the initiative include local and state health departments, indigenous populations, local universities, the private sector, NGOs working with delinquent youth and the PETI Program (Program to Eradicate Child Labor).

The initiative incorporated various strategies to achieve its goals. Community therapy groups were established, as well as other groups aimed at facilitating personal therapeutic processes within collective actions (bio-dance, therapy through art, self-esteem support groups, etc.). Massotherapy, reiki, breathing and relaxation workshops and sessions were offered. Theater and music events were scheduled in public places as a way to the community to take ownership of places that had been dominated by drug trafficking and violence. Various cultural and arts activities were offered, free of charge, to all community members (music, language, painting and theater classes). A community garden and pharmacy were established and professional training was offered to young people. Lastly, efforts were put in place to integrate people with mental illnesses into these activities in order to support a process to decrease stigma attached to mental health problems and to support de-institutionalization of these patients.

Positive outcomes have been reported from this initiative. The general community attitude towards dealing with underserved populations has shifted from a personal to a collective and social perspective. The community’s identity has improved, with those living in Bom Jardim showing pride in their neighborhood, when prior to the initiative they would describe it as ugly and violent. A network has been established to help community members to take better care of themselves. New links have been established with other stakeholders working in the community and with the private sector. Community youth have reported greater motivation to attain a higher education level and stigma related to psychological problems has decreased. The initiative has also received national recognition and various national and regional awards.

Some of the challenges included changes in government that created delays and uncertainty about the initiative’s continuity, difficulty to maintain and increase resources as the initiative expanded, and resistance from other institutions to collaborate with the initiative’s activities.

There is considerable social stigma attached mental illnesses, especially when it is related to underserved and poor populations. This experience demonstrated the viability of empowering, improving social capital and expanding therapeutic and educational activities for these populations. It also promoted a new ways of viewing mental health issues that was inclusive and transformative.

Example 11: Faces, Voices and Places initiative in the municipality of Corredores, Costa Rica

We would like to thank the following individuals and organizations who assisted in the preparation of this case study: Gerardo Galvis, Idalí Ledesman, Sandra Murillo, Xinia Bustamante, the local health team of the city of Neilly, Corredores Food Security Council.

The Faces, Voices and Places (FVP) initiative in Corredores, Costa Rica, started in 2006 as part of a larger initiative that was launched in 1998 to improve food security and nutrition in the region. In Corredores, the initiative also focused on water and sanitation. It involved the Ministry of Health, municipal government, local schools, Paso Canoas market, the Association of Rural Aqueducts, INCAP/PAHO, local health services, community groups, and the local Food Security Committee. A FVP office was established in the municipality to facilitate coordination, implementation and follow-up of activities. The community organization in place allowed for a greater commitment from all those involved to work collaboratively.

The Initiative worked with women, indigenous populations and children in various projects such as food cultivation and bread-making. Schoolchildren were involved in the design and implementation of recycling programs within schools. A community garden was established in two indigenous communities with food production aimed at providing for the population and for sale. Training and resources were offered to those working with solid waste disposal (gloves, appropriate attire) and a local committee of solid waste disposal workers was establish to improve capacity and give more dignity to this important job that contributed to local development and environmental sustainability.

The initiative promoted greater awareness of issues related to food security and nutrition, not only at a household level but also at community level. Infant mortality rates have decreased in Corredores since the beginning of this initiative, which was attributed to increased population awareness and education. All mothers now receive prenatal care regardless of their social situation. A higher level of community empowerment was also observed, with members demonstrating more confidence to identify problems and jointly discuss solutions. Health professionals also reported feeling more motivated to work with the community.

Working within the framework of the FVP initiative helped to attract national attention to this region of the country, resulting in higher commitment and resources available to work with these vulnerable communities and populations. Working with issues related to food security, water and sanitation also helped to identify and have an influence on other issues important to the community, such as environmental degradation and intra-family violence. As a result, the initiative shifted towards a focus on the determinants of health, bringing together various institutions and sectors and highlighting their roles in community wellbeing.

Lack of good management at the national level and among some of the institutions involved was highlighted as a significant challenge. Lack of follow-up from technical personnel at the national level, mostly caused by the remote location of the municipality caused some difficulties. The high level of children dropping out of school to work in the fields also hindered the success of the initiative although there were some efforts by school directors to keep children in schools.
By addressing various determinants of health, this initiative successfully improved the community’s quality of life by empowering women to be more independent and to play a more proactive role at the individual, family and community level; improving access to and the quality of food; and improving family income. It helped to strengthen social cohesion and the community’s capacity to organize itself and be involved in the solutions to their own problems. This experience highlights the importance of going beyond identifying the problems affecting a community, to also understanding their roots and the population’s capacity to make decisions and act individually and collectively.

Example 12: Early Detection of Breast Cancer through Mobile Mammography Services in Uruguay

We would like to thank the following individuals who assisted in the preparation of this case study: Adriana Serra, Elena Garcia Martinez, Maria Isabel Ressio Charvet, Mariana Perera, Mario Gonzalez, Rosana Díaz Rus

The Mobile Mammography Services, which is part of the Early Detection of Breast Cancer Program coordinated by the Honorary Commission to Fight Cancer, was launched in 2003 in four municipalities of the state of Colonia, Uruguay (Juan Lacaze, Colonia Valdense, Nueva Helvencia, and Rosario). It aimed at improving early detection of malignant tumors, as well at improving self-care and self breast exams among women in these municipalities. Mammography services were not available to women living in this remote area of the country prior to this initiative, which required them to travel to the state’s capital for services. This disproportionately affected women from poorer sectors of the community.

Various local stakeholders were involved in the planning stage of the initiative through the establishment of a Local Committee in each of the municipalities selected. This Local Committee raised money to cover the costs of bringing the mobile clinic to the communities and to pay for the health professionals that were staffing it. Community members also offered to transport women who could not get to the mobile clinic on their own, either due to the distance or to having physical disabilities. Due to the limited availability of the mobile services in each community, the emphasis was primarily on women who were 40 years or older, who lived in poorer neighborhoods, and who did not have regular access to health services.

Of the approximately 10,500 women over 40 years old living in these municipalities, the initiative managed to conduct a mammogram on 5,392, which was around 51% of this population group. Demand for services was high. Even though 100% of the appointments available were scheduled, each municipality still had a long waiting list of users who would have liked to have been seen. As a result, two permanent mammogram machines were installed in two of the localities included in this initiative. Even though these services are now only available in private clinics, it came about as a result of the population’s demands for services.

The initiative initially encountered some resistance. Some women were not well acquainted with mammography, which led them to be fearful and anxious of undergoing the examination. It was important to explain to them the science behind the exam and make sure they understood how beneficial it was to undergo. As a result, an informational campaign was created and delivered by local leaders through the media to address the main concerns of the population in regards to mammogram exams.

The initiative also successfully raised awareness of breast cancer through a continuous campaign aimed at improving women’s knowledge about their bodies and their rights. Although this improved women’s self care and awareness about breast cancer, it also created some challenges for the initiative to respond to the demand for services generated by this increased knowledge.

The municipalities included in this initiative had a high level of organization and community participation, which greatly contributed to the successful implementation and planning of the activities. Nevertheless, there were important rivalries among these sites, which created difficulties to establishing networks and collaborative links.

The initiative also resulted in the development of two important policies, one that allows women to take one day off per year to have a mammogram, and another one that offers free mammograms for women aged 40-59 every two years.

Example 13: Azucarlito “Free of Tobacco Smoke Workplace” Initiative in Uruguay

We would like to thank the following individuals who assisted in the preparation of this case study: Adriana Serra, Elena Garcia Martinez, Maria Isabel Ressio Charvet, Mariana Perera, Mario Gonzalez, Rosana Díaz Rus

The Azucarlito “Smoke-free Building” was launched in 2002 as an initiative to maintain a smoke-free work environment in a sugar factory in Paysandú, Uruguay. It started in response to an interest expressed by the factory management and a group of employees to work in a free of tobacco smoke setting. An initial baseline determined that 10% of the factory’s workers were smokers. Smoking cessation programs previously put in place to help staff quit the habit had not been effective.

Initially, activities aimed at improving knowledge about the negative consequences of smoking and the positive benefits of keeping spaces free of tobacco smoke. Also discussed were the distinctions between “active smokers” and “passive smokers.” Groups were set up to discuss individual and collective responsibilities for everyone’s health, which were facilitated by a doctor and a health promotion specialist. Smoking cessation support groups were established. Finally, a policy was implemented from the top management level declaring Azucarlito a “Smoke-free Workplace”, and outlining sanctions that would be applied to those who did not abide by the new rules.

The initiative resulted in many staff members quitting smoking while others significantly reduced the number of cigarettes smoked per day. The initiative gained media attention, which promoted Azucarlito as the “First Free of Tobacco Smoke Workplace” in the country and motivated other organizations to launch their own “Free of Tobacco Smoke Workplace” initiatives.

Leadership and coordination from a community organizer from the Honorary Commission to Fight Cancer was central to the success of the Initiative along with broad participation and support from all levels within the company. The Azucarlito Company had an expressed commitment to protect its workers’ health, which generated support from high levels of management within the company. Leadership from one manager in particular, who was an ex-smoker and who suffered serious health consequences as a result of his habit, was also highlighted as a crucial factor for the success of the experience. Workers also actively participated in all phases of the initiative. Some of the challenges included resistance to participating in the initiative’s activities and programs from smokers within the company, particularly those in higher levels of management.

The Azucarlito “Smoke-Free” initiative established an important and innovative model for health promotion programs and policies in Uruguay. The experience received national recognition and was replicated in various institutions. It also served as a model for the development of the National Decree 268/05, which prohibits smoking in all enclosed spaces in the country as part of the National “100% Spaces Free of Tobacco Smoke” initiative.

Example 14: Making the Rivera Town Council a Free of Tobacco Smoke Workplace in Uruguay

We would like to thank the following individuals who assisted in the preparation of this case study: Adriana Serra, Elena Garcia Martinez, Maria Isabel Ressio Charvet, Mariana Perera, Mario Gonzalez, Rosana Díaz Rus

The “Rivera Town Council Free of Tobacco Smoke” Initiative was launched in 2004 with the aim of transforming the main building of the municipality of Rivera’s Town Council into a workplace free of tobacco smoke. The initiative was designed and implemented by the Town Council’s staff and a coordinator from the Honorary Commission to Fight Cancer. Collaboration also took place with the radio program “Entre Todos” (“Among all of us”), which helped to disseminate information about the initiative and its results to the general population.

Initially, a working group named “Grupo Pro Calidad de Vida” (Group of Quality of Life), comprised of staff and managers from various departments of the Town Council was formed. They were given an office space with access to telephone, computer, printers and the Internet. The working group met regularly to discuss decisions and activities related to the Initiative. In the course of the Project, this group changed in line with the needs of the initiative’s various tasks and phases. The group’s diversity and the high level of commitment and participation from its members were highlighted as one of the main factors affecting the success of the initiative.

One of the main contributions from this group was the drafting of an internal policy regarding smoking in the workplace. This policy, once approved, led to the creation of areas designated for smoking and it transformed the Rivera Town Council into the first Town Council 100% Free of Tobacco Smoke in Uruguay. Smoking cessation programs were also implemented and made available to all staff. The initiative was officially recognized by the Mayor’s office and the city’s legislature approved a change in the municipal statute to support it. Involvement of the mayor in the activities increased during the course of the initiative. Local labor unions also supported the efforts.

An awareness campaign was developed to share information about the magnitude of the problem and the risks of first and second hand smoking to those working in the building. This was done through presentations and workshops with an oncologist and university professors, posters, stickers and other promotional materials such as mouse pads. Ashtrays were also placed in strategic places with reminders for people to deposit their cigarettes before entering the premises.

One of the initial challenges was the fact that tobacco smoke contamination at the workplace was not seen as a problem by staff, management and even health services. As awareness increased due to the Initiative’s efforts, the issue began to be perceived as a problem that needed to be addressed. A positive effect was also noticed on the perception by the local health services staff about how tobacco smoke affected the population’s health as a result of the Initiative. This led to the support of the health services to the initiative’s activities and greater promotion of local public policies to combat tobacco smoke contamination in the workplace.

One important factor hindering the success of this Initiative was the lack of will by some staff members to discontinue smoking at work. The policy aimed at making smokers either quit their tobacco usage or limit their tobacco consumption to non-work related areas. However, it required intense and constant enforcement in order to significantly curtail the tobacco smoke contamination in the workplace.

The Initiative has been sustainable and it managed to maintain a good level of participation in order to secure the results obtained. The level of tobacco smoke contamination in the building has decreased along with the number of smokers among the staff. The non-smoking policy in the workplace is well established and respected. Currently, the working group is focusing on documenting the experience in order to better disseminate its results and lessons learned to the community and health professionals.

Example 15: Community Promotion, Prevention and Education for Cardiovascular Health in Tala, Uruguay

We would like to thank the following individuals who assisted in the preparation of this case study: Adriana Serra, Elena Garcia Martinez, Maria Isabel Ressio Charvet, Mariana Perera, Mario Gonzalez, Rosana Díaz Rus

This community-based initiative, implemented since 2002 in the municipality of Tala, Canelones, aimed at promoting a better understanding of a holistic concept of health and to promoting the adoption of healthy lifestyles. It involved the local government, community organizations, public and private health services, rural and urban schools, local churches, the Honorary Commission for Cardiovascular Health, academia, sports organizations, health professionals, community health workers and community leaders. Initially, a baseline was taken to assess the population’s profile and the major problems affecting it. It demonstrated an aging population that suffered from a high prevalence of preventable conditions. These were mainly caused by changes in eating habits, sedentary lifestyle, alcoholism, smoking, high consumption of psychoactive drugs, and deterioration of social, economic and environmental conditions affecting cardiovascular health. Unemployment was particularly high, especially among the rural population. Health services focused almost exclusively on providing treatment, with very little promotion, prevention and education activities.

Activities included various activities such as a broad media campaign about the importance of healthy lifestyles, the incorporation of health teams in schools, the establishment of community groups and capacity-building activities. A series of projects sprung up from this initial effort (proper waste disposal, vector control, prevention of STDs, substance use and domestic violence, etc.), all under the same strategic line of action and with a focus on the most vulnerable population groups and those with specific cardiovascular risks (obesity, diabetes, addictions, etc.).

Some of the results observed included: increased awareness among health professionals regarding the importance of promoting healthy lifestyles and better understanding of health promotion strategies and mechanisms; greater acceptance of efforts conducted in a participatory manner and with the community; increased knowledge and healthy habits among adolescents and the elderly; greater participation and less isolation of the elderly population; better understanding of issues related to school health with the implementation of a more efficient follow-up and referral system; and the establishment of community health groups such as “Adultos en Movimiento“ (“Adults in Movement”) that works to prevent domestic violence.

One important factor supporting the Initiative was a change in the national government that took place in 2005. This led to an increase in technological developments and a greater emphasis on health issues in the media. It also led to a structural change in the health system, which now geared itself more towards health promotion and education, and strengthened primary health care strategies. This led to the inclusion of various social actors at the local level in the decision-making process, which greatly facilitated the planning and implementation of the initiative. This, in turn, generated greater interest and commitment on the part of the community with the Initiative.