Improve health promotion participation through community engagement

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 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 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 6
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

Hiba Malek 10
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.

Hiba Malek 11
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.

Hiba Malek 12
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

Hiba Malek 13
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

Hiba Malek 14
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

Hiba Malek 16
(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

Hiba Malek 17
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

Hiba Malek 22
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.

Hiba Malek 23
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
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
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
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?
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?
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.

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