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A community Development project should be able to demonstrate the public health practice in entirety, apply the public health theories and put into practice the community development principles. One of the principles is being able to address the priority need of the community with their full participation thereby empowering them and most importantly working within the social model of health.
The social model of health is a theoretical frame work which considers the health of individuals and the community as a result of complex and interacting social, economic, environmental and personal factors. (Ottewill and wall, 2003). This framework operates on the belief that improved health and wellbeing is achieved by focusing on the social and environmental determinants of health in tandem with biological and medical factors. The social model of health says that 50% of our health is determined by wider determinants such as Housing, Income and educational level which affects not only the individuals but the community as a whole (CDHN, 2009), therefore a community development approach to health attempts to work upstream, concentrating on the root cause of ill health such as poverty and educational disadvantage.
Kelleher and Marshall (2002) suggested that working within the social model of health permits individuals and communities to construct their own definition of health and therefore identify important factors that influence health depending on the specific context.
The conception of a community is based on the thought that how people behave and their wellbeing is influenced by their interaction with others (SCCD, 2001). An evidence based definition of a community is a group of people with diverse characteristics who are linked by social ties, share common perspectives and engage in joint action in geographical setting or location. This definition therefore qualifies the Muslim women in Glasgow North as a community.
This reflective essay aims to give an explanation and in depth analysis of a non governmental Scottish charity project run by Muslim women for Muslim women in Glasgow, with a view of identifying good practice, relevance to public health practice development and the application of the theory to practice. The subject of the community placement will be referred to as ‘the resource center’ through out this essay in order to protect the real names and identities of the center and its staff. The resource center handles social matters like racial harassment, bereavement, divorce cases, access to education, forced marriages, immigration matters, mental health issues, relationship matters, housing issues and domestic Violence.
For the purpose of this essay I would be focusing on Domestic Violence. This write-up will go a long way to explain and critically analyse the extent to which the protection, provision and prevention of domestic violence against women project identifies with public health practice. A brief review of the literature of domestic abuse will be discussed thereafter. I will afterwards analyse the project while discussing issues like health need assessment, health inequality, partnership planning , monitoring and evaluation as good public health practices identified in the project. I intend to finally discuss the reflection and relevance of the study while making the necessary recommendations.
Domestic Violence and Public Health
Domestic violence could be defined as any incident of threatening behavior, violence, or abuse (psychological, physical, sexual, financial, and emotional) between adults who are or have been in intimate partners or family members regardless of gender or sexuality. Gender-based violence includes a host of harmful behaviours that are directed at women and girls because of their sex, including wife abuse, sexual assault, and dowry-related murder, and marital rape, selective malnourishment of female children, forced prostitution, female genital mutilation and sexual abuse of female children. Vulnerable persons or a child in the environment where they are witnessing domestic abuse are also inclusive. (Scottish Executive central research unit, 2000) The British Medical Association (2006) explained in its publication that a child who has witnessed domestic abuse has an increased risk of experiencing mental health problems in adult live.
Domestic Violence is associated with Health Inequality in the society especially towards the women and children. It constitutes the male abuse of power which occurs in all social groups not caused by stress, alcohol, unemployment, mental illness or by the women (Scottish Executive central research unit, 2000)
Domestic Violence is a major public health issue affecting all age, socio- economic group and all sectors of life.. it is currently being recognized by the government not just as a criminal issue but also as a public health matter(Government proposal on domestic violence, 2003).Domestic Abuse is a housing issue, human right issue, child protection issue, mental health issue and all these according to the social model of health are determinants of health. A Recent report by the triennial maternal mortality (CEMACH, 2004) showed that domestic abuse is a risk factor for maternal death and for the year 2000- 2002 eleven new mothers were murdered within six weeks of giving birth by their partners. It also increases the chances of pregnant women drinking, smoking which then affects the life of the unborn child thereby increasing the infants’ mortality rate.
The high prevalence of Domestic Violence impacts economically on the society. Support systems are overstretched; there is increased cost of providing medical care for about 100,000 women seeking medical help due to domestic abuse. A lot of women are homeless with about 7000 women and children looking for safety shelter everyday (Seymour, 2001)
Violence against women has recently been recognized by the United Nations as a fundamental abuse of women’s human rights. The sensitivities and stigma associated with domestic abuse, the conceptualization of it primarily as a judicial and legal issue, and the lack of data on the dimension of the abuse have hampered understanding and the development of appropriate intervention (Lori et al, 1994)
Incidence and prevalence of domestic Abuse
Domestic violence accounts for between 16% and one quarter of all recorded violent crime. (Home Office,2004; Dodd et al., 2004; BCS, 1998; Dobash and Dobash, 1980). According to Stanko, (2000) an incident is reported to the police every minute. Women are much more likely than men to be the victim of multiple incidents of abuse, and of sexual violence. 45% women and 26% men had experienced at least one incident of inter-personal violence in their lifetimes(Walby and Allen, 2004), however when there were more than 4 incidents (i.e. ongoing domestic or sexual abuse) 89% of victims were women. In 2004 according to Walby and Allen(2004) there are 13 million separate incidents of physical violence or threats of violence against women from partners or former partners making an average of 2 women a week killed by a male partner or former partner and this constitutes around one-third of all female homicide victims. (Department of Health,2005.) The British Crime Survey conducted in 2000 found that women are most likely to be sexually attacked by men who are known to them. 45% of rapes reported to the survey were perpetrated by current partners. (Home Office Research Study 237, 2002). One Scottish survey found that a majority of men who said that they were victims of domestic violence, were also perpetrators of violence (13 of 22), and on being re-interviewed, a further 13 later said they had actually never experienced any form of domestic abuse. (Scottish Executive Central Research Unit, 2002).
On the international level consistent findings has been recorded. An analysis of 10 separate domestic violence prevalence studies by the Council of Europe showed that 1 in 4 women experience domestic violence over their lifetimes, and between 6-10% of women
Suffer domestic violence in a given year. (Council of Europe, 2002).Another study done by the World Health Organisation, domestic violence was found to be widespread in all 10 countries studied, though there was considerable variation between countries, and between cities and rural areas. (Garcia-Moreno, C., et al., 2005) .Krug et al (2002) found that internationally 40% -70% of female murder victim were killed by their partner and about 4% – 8% of men. Domestic violence is internationally acknowledged to be one of the major health Inequalities affecting women particularly, and forms a significant obstacle to their receiving effective health care. (World Health Organisation,1997; United Nations, 1993). Different form of abuse is been experienced by women with partner abuse (non-sexual) being the most commonly experienced type of intimate violence among both men and women. 28% of women and 17% of men reported having experienced such abuse. (Coleman et al. 2007) stalking is also was commonly experienced with 9% of women and 7% of men reported having Experienced it in the last year with obscene or threatening phone calls being the common forms. (Coleman et al 2007). Nearly half of women (48%) who had experienced intimate partner violence since the age of 16 had experienced more than one type of intimate violence. Men were less likely to have experienced multiple forms of intimate violence (33%). (Coleman et al. 2007) Serious sexual assault was most likely to be committed by someone known to the victim (89% of female and 83% of male victims). Just over half (54%) of female victims reported that a partner or ex-partner had been the offender. (Coleman et al. 2007). Women also suffer from non sexual family abuse (coleman at al.2007)
Domestic violence has huge impact both physically ,psychologically, and health wise on both the women and their children A study of 200 women’s experiences of domestic violence commissioned by Women’s Aid, found that 60% of the women had left because they feared that they or their children would be killed by the perpetrator.(Humphreys & Thiara, 2002). In the same study, 76% of separated women suffered post-separation violence, and more than half of those with post-separation child contact arrangements with an abusive ex-partner continued to have serious, ongoing problems with this contact (Humphreys and Thiara, 2002).There are a greater risk of homicide by these women at the point of separation or after leaving a violent partner. (Lees, 2000).A study showed that 42% of all female homicide victims, compared with 4% of male homicide victims, were killed by current or former partners in England and Wales in
the year 2000/01. This equates to 102 women, an average of 2 women each week (Home Office, 2001). Domestic violence was found to be “the single most quoted reason for becoming homeless”(Cramer and Carter 2002) .
Violence against women has serious consequences for their physical and mental health, and women who have experienced abuse from her partner may suffer from chronic health problems of various kinds. (Stark and Flitcraft, 1996; Williamson, 2000; British Medical Association, 1998; Crispand Stanko, 2001) Abused women are more likely to suffer from depression, anxiety, psychosomatic systems, eating problems and sexual dysfunction. Violence may also affect their reproductive health. (WHO,2000). 70% of incidents of domestic violence result in injury, (compared with 50% of incidents of acquaintance violence, 48% of stranger violence and 29% of mugging.) (Dodd et al., 2004) 75% of cases of domestic violence result in physical injury or mental health consequences to women. (Home Office, 2001) The cost of treating physical health of victims of domestic violence, (including hospital, GP, ambulance, prescriptions) is £1,220,247,000, i.e. 3% of total NHS budget. (Walby, 2004) The cost of treating mental disorder due to domestic violence is £176,000,000. (Walby,2004). Between 50% and 60% of women mental health service users have experienced domestic violence, and up to 20% will be experiencing current abuse. (Department of Health , 2003). Domestic violence has been identified as a prime cause of miscarriage or still-birth (Mezey, 1997), and of maternal deaths during childbirth (Lewis and Drife, 2001, 2005).Children are also hugely affected by domestic violence. At least 750,000 children a year witness domestic violence. (Department of Health, 2002). And Children who live with domestic violence are at increased risk of behavioural problems and emotional trauma, and mental health difficulties in adult life. ( Kolbo, et al., 1996; Morley and Mullender, 1994; Hester et al.,2000) Nearly three quarters of children on the ‘at risk’ register live in households where domestic violence occurs and 52% of child protection cases involving domestic violence. (Department of Health , 2002; Farmer and Owen, 1995).
COMMUNITY DEVELOPMENT PROJECT/SUSTAINABILITY
Community development means a community involvement that helps people to help themselves by encouraging them to be involved in collective activities to ultimately solve a mutual problem and aim towards achieving common goal (Gilchrist, 2007). Barr and Hashagen (2000) described community development as a agenda that comprise of processes like empowerment, learning, democracy and outcomes, backed up by good funding, staff, information, proper evaluation and dissemination. Some of the key Qualities of a good community development project as suggested by the Scottish Government (SE, 2004) are, community involvement, community learning and development; the use of knowledge, skills, strengthening and improving communities, people led development and the role of the individual partner in decision making. Improving public services and providing assess to main stream services for both the high and low socio economic class is also very important (SE, 2004). The resource center follows a community development approach having the muslim women as the target community and their projects of have the above defined roles as they are all community led projects which eventually empowers the people of the community. it is service user positive and involves full participation from people of the community. they center has drop in sessions for clients during week days ,free access to computers and a resource library containing an expanding range of books, leaflets, magazines, on different topics especially on Islamic topics particularly Focused towards women. Information on services and resources in Glasgow and rest of Scotland is also available in the library.
They center is managed by both staff and volunteers who give high quality service to the community and in return receive training, work experience, make New friends and often increase their confidence , skills and knowledge.
The sustainability plan for mwrc appeared to rely on the sponsorship of the partner organizations for both the training and running of the organization. Gray, (2007) suggested that the potential to contribute to sustainability is by direct action and by setting good examples of practice especially in the area of accountability. The Resource center being totally a voluntary organization, receives funding from the council, Voluntary action fund, Scottish community foundation , Gannochy trust, Culture and sport Glasgow, and women’s Fund for Scotland for sustainability. This sustainability arrangement is not strong as it relies on uncertain financial targets and a limited timeframe to achieve those (Gray, 2007) and could lead to the abrupt termination of projects once the funding is no more.
HEALTH NEED ASSESSMENT
Health need assessment offers a good take off point for a community development project in order to have targeted projects which are very beneficial to the people of the community and it also helps in preventing health inequality (Arblaster et al 1996).
Billings (2002) described health need assessment as identification of factors that must be addressed in order to improve the health of the population and as suggested by Twinn et al(1990) involves the collection data to identify health need of the community and its analysis to prioritise strategies in health improvement. They Local population could be involved to discern for themselves what they consider their priority needs (Billing 2002). They involvement of the local community is commonly employed in community development projects to ensure that priority projects are carried out and also to tackle health inequality. Bidmead and Cowley(2005) also highlighted the importance of client/professional partnership towards promoting a fruitful health need assessment.
In practice the theory of health need assessment was applied in the resource center which started its journey in 1997 and opened its doors to the public in April 2002. It is a Scottish charity run by women with the purpose of breaking down barriers and enabling Muslim women to participate in all aspect of society without having to compromise their belief and values. Following the health need assessment which was done through the involvement of the Muslim community, the vital needs and concern identified are Lack of knowledge of help available leading to poor take up of mainstream services by Muslim women in need, Lack of confidence that they mainstream services will be able to understand the issues affecting them and institutional discrimination preventing uptake of services, Increase in Islamophobia and fear of discrimination and harassment leading to decreasing interaction with mainstream society at all levels and most importantly Family and marriage problems.
In order to address these concerns, they operate at three different levels,Working with policy makers and mainstream provider to overcome the barriers to civic participation and access to services; undertaking development work to build the confidence of Muslim women, address their issues and promote social cohesion and providing a range of direct helping services to women in a way that meets their specific needs .As highlighted by Bidmead and Cowley(2005) the services of trained volunteers were employed to further enhance the client/professional relationship thereby promoting better assessment.
Partnership is a very important concept in community development and public health as a whole as it underpins both public health policy and practice. It is an essential tool being employed to tackle the social model of health. it encourages community involvement and individual roles and helps to co-coordinate the group activity in order to avoid overlap (Warren et al 1974).
El Ansari et al(2001) saw partnership as an official relationships among people who usually have same purposive goal while Hudson and Hardy(2001) identified that partnership may not only be official as it also occurs between professionals and non professionals existing either horizontally or vertically between levels(Powel and Exworthy 2002). Bidmead and Cowley(2005a) defined partnership as “A Respectful ,negotiated way of working together that enables choices; participation, and equity within an honest, trusting relationship that is based in empathy, support and reciprocity. Though argued by Challis at el(1988) that partnership is word difficult to give helpful meaning in practice ,partnership could be seen as an effective relationship between clients and practitioner geared towards achieving an aim through collaboration and active involvement(Warren et al 1974).
Partnership is currently been acknowledged in both government policy and practice(Scottish Executive1998;secretary of state for northern Ireland 1998;secretary of state wales 1998) as there is a limit to what an agency working alone on its own can achieve(Huxham and Macdonald 1999). Major advance in health involves improvement in all aspect of living both socially and economically(Mckeown,1976) and this is only achievable through collaborative efforts of individual, community, organizations and Government (WHO 1991).
Barnes and Sullivan also argues that partnership is a major tool in tackling health inequality as it enables government resources to be appropriately and evenly distributed to both the the rich and the ethnic minority to improve health services. Davis and Fallowfield (1991) suggested that partnership improves professional contentment and reduces stress though for effectiveness aimed goals should be made clear and professional skill and knowledge upheld despite complimentary expertise of the community(Bidmead and Cowley 2005a) . Partnership though very beneficial is not without some pitfalls some of which are issues with co-ordination, joining up goals and policy, accountability and participation (Sullivan and skelcher 2002) .Douglas, (2009) feels that partnership working can leave participants confused and unclear about their role once there is lack of clear leadership, guidance and support..He also stated that infrastructure built around some individual in partnership goes down once the individuals are no more. The risks and negative aspect of partnership working include partnership overload and partnership fatigue, the potential for overdoing it; hence there should be a limit to the number that constitutes a workable partnership (Bamford et al, 2003).Baginsky (2007) feels that most partnerships lack clarity and consistency in use of eligible criteria and there is need for clarity of roles and assigning of responsibilities. Inter-organizational partnerships is been seen as the key to better partnerships(Hudson and Hardy 2002). Despite these pitfalls, development of partnership approaches is encouraged by policy makers and the Government in community development projects
In Practice, there are evidences of application of theory of partnership for example in order to further achieve its aim, MWRC is actively involved in partnerships and Advisory groups to enable community cohesion, and overcome stereotypes and misunderstanding between communities. They partner with both the community, local agencies, the government and international bodies to encourage community participation and ensure that more need based projects are carried out. They issue brought up by Hudson and Hardy (2002) is also being applied by the resource center as they are involved in inter-organizational partnership. As stated by Huxham and Macdonald(1999) a lot of achievement was made by the resource center through their partnership with the Government and some local agencies. Self employment opportunity workshop was organized in partnership with and delivered by Business Gateway Glasgow aimed at sensitizing the women on the need to be self-employed to enable them to be financially dependent. Money Advice workshops organized in partnership with Glasgow city Councils financial inclusion team provided information about financial issues with the aim of empowering women to allow them to deal with financial issues and difficulties. The participants found the workshop very informative and educating. Support was provided for the singe mothers through the Single mothers workshop organised in partnership with REED with the aim of encouraging single mothers into the work force. They Muslim and ethnic minority women were through the Steps to excellence for personal success a programme built around the core concept of the pacific institute affirmed of the right of all individuals to achieve their God given potentials and empower people through education and training to allow them to recognize their ability to choose growth ,personal freedom, and personal excellence. The effectiveness of partnership involvement and individual roles(warren at el 1974) were very evident in the practice of the resource center.
Having discussed the theories of Community development projects, health need assessment and partnership with their application in practice, I would then discuss Health inequality, Monitoring and Evaluation.
Health inequality has been a universal problem though Darey Smith et al (2001a) described it as inequality in health experienced by black and minority ethnic groups. Health inequality has long been associated with ethnicity and socio -economic statue(Acheson 1998:11). . The international community emphasizes the importance of tackling inequalities as a matter of urgency (WHO, 2005)
Baggort(2000) described health inequality as the inequity or the inequality that are seen as being unfair. Health inequality is a major issue for public health practitioner working at the community level and efforts are made to indentify what can be done at the local level. Arblaster et al(1996) and Gillies (1998a,b) commented on the effectiveness of inter-sectorial partnership as a way of tackling health inequality. public health practitioners can facilitate partnership with relevant agencies for specific health need of the people as well as advocate for those needs (Roberts 2000).Lobbying of policy makers at all levels to influence health policies has also been seen as way of tacking health inequalities (muir Gray 2001) and the use of media has been found very effective(Chapman 2001).Advocacy and Lobbying is one of the tools employed in the resource center for example through Advocacy the provides a voice for Muslim women that contribute to the government consultations, policy, and Strategy in adult learning issues. The advocacy programmes include professional advocacy, face to face with the service user and ongoing advocacy in family issues. Also through representations in the learning link Scotland policy and Executive committee, awareness is being drawn to the needs and issues affecting Muslim women access to learning and education
Roberts(2000) stated that involvement of the people of the community to identify their health need and taking action towards solution through development of healthy living projects help to tackle inequality as well as make people of the lower socio economic status and minority group have access to the health care. Patterson and Judge(2002) also suggested that referral systems in health care and home visiting are also very effective ways of reducing health inequality. In Practice, there are evidence of the huge effort made to prevent health inequality and increase the accessibility to health care by the ethnic minority especially the muslim women. Information, Advice-Free, confidential faith and culturally non judgmental information and advice on Domestic Abuse and family issues is provided primarily through drop in sessions and also by appointment. Service users initially receive assessment and help on their first visit and as encouraged by Patterson and Judge (2002) referrals are made with their agreement for other services in the main stream or elsewhere. The service is provided in the service user preferred language as most of the staff and volunteers are bilingual and interpreters are also available.
The social model of health considers how wider determinants than the presence or absence of disease have an impact on people’s health (Dahlgren & Whitehead, 1991, CDHN, 2005, Graham, 2007) hence the provision of other services to help increase the quality of life of the women. Such services are Counseling provided by trained volunteer counselors and counseling approach is used with the service users to enable them make informed decision and choices. For many women this helps them to talk through personal issues while also receiving practical help, and for majority of the clients the find this approach very appropriate. Formal counseling using person centered approach is also provided where necessary, Provision of Helpline and Help mail service to offer information, advice and a listening ear in a faith and culturally sensitive way. The Helpline operators speak English and also have available interpreters and they use various mediums to reach out to the most vulnerable and isolated Muslim women in Scotland to ensure equality in distribution of health care. They helpline staff continue to strive to work in partnership with both mainstream and private sector organization to ensure that the Muslim women are able to engage and voice out their needs in the society. They Help mail is a dedicated confidential email address available for women who would prefer the mail .its receives over 200 mails and its increasing becoming popular with agencies seeking advice and information on issues concerning Muslim women. And the Provision of friends and support to isolated, lonely and abused Muslim women who lack confidence to do things alone. A huge effort is being made to ensure that health inequality is prevented.
MONITORING AND EVALUATION
The input in the PPP Project, the process, impact and outcome of the programmes of they project is monitored and evaluated most especially through the response of the people regarding all the activities, workshops and seminars. Monitoring and Evaluation was a continuous process relying heavily on feedback from questionnaires. The MWRC used these questionnaires to form a framework for monitoring and evaluation. This method of evaluation is qualitative and when compared to the LEAP (Learning, Evaluation and Planning, 2008) model led by need, focused on outcomes, participation, partnership building and knowledge enhancing, it has some similarities though does not follow it completely. This form of evaluation also help to carefully monitor the projects progress while focusing on the relation between inputs, outputs and process (Hashagen and Susan,2007). This method of evaluation also enables the identification of additional outcomes as LEAP is a framework that is designed to enable positive planned change to be made to the needs that have been identified. It is outcome focused because the primary purpose of community lead development is to make a real, and measurable difference to the quality of personal and community lives.
In practice, planning for change in response to the identified need was done and an outcome focused evaluation carried out to assess the success of the action plan. A focus on outcomes is essentially a focus on results. As Stated by the Scottish Government (2010) for the purposes of reliable evaluation, the connection between the need identified, the action taken and the outcome achieved should always be clear.
Project report is also written and sent to the funders, and policy makers to show which aims and objectives that are achieved and the extent to which the achieved objectives lead to the desired outcome..A financial report is also written at the end of every year and sent to funders to show accountability and how cost effective the programmes were. Using the LEAP model of evaluation, indicators are used to measure whether outcomes were achieved and evidence collected as the project goes along and in comparison the MWRC evaluation ultimately followed similar guidelines . Also in comparison with the LEAP model Health risk assessment was done prior to the onset of the project to identify potential risks and hazards.
Some of the disadvantages of this method of evaluation is in the area of cost effectiveness which only incorporates QALYs as the health related outcome measure (Powell, 2007) and this as suggested by Powell(2007) could affect the sustainability of the project. With this method of evaluation the outcomes measured are individualistic and could be influenced by bias and memory and the individuals cannot show the impact of the project on the community especially in a short timescale(Hashagen and Paxton,2007)
They major limitations or challenges encountered in the project are; lack of Funding or funding ending and leading to end of a project, having to deal with immigration issues of most of the clients, languages barrier , and training of all the staff and volunteer but despite these challenges ,achievements were made over t
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