Correspondence
Susan Rifkin
[email protected] Colorado School of Public Health, Denver, CO 80209, USA 1
I want to commend Audrey Prost and colleagues on their study of the contribution of participatory women’s groups to improve birth outcomes in poor communities in low-income and middle-income countries (May 18, p 1736).1 Their work is an important contribution to highlight the crucial importance of participation in health care improvement. I would be remiss, however, if I did not challenge the analytical framework in which these data are presented. To frame participation in women’s groups underpinned by Participation Learning and Action (PLA) as the intervention limits the understanding of participation. PLA, the most recent manifestation of Participatory Action Research, 2 is an approach that involves the intended beneficiaries in all aspects of the intervention design. It values the learning outcomes equal to the material outcomes. The value of PLA lies in the examination of outcomes that also lead to the empowerment, eventual ownership, and sustainability of that intervention. Participation, it has been argued, is better understood in both theory and practice as a process.3 To present participatory women groups as an intervention with a direct causal relationship to improved health outcomes is simplistic. The interpretation of data would be more robust if the process of participation was disaggregated, and issues around the transformation of attitudes and behaviours, power and control, and sustainability of health outcomes were addressed. Although such an investigation is complicated, the validity of these findings and the generalisability of what appears to be a panacea for a crucial global health problem are questionable. I declare that I have no conflicts of interest.
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Prost A, BolbournT, Seward N, et al. Women’s groups practicing participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Tandon R. The historical roots and contemporary tendencies in participatory research: implications for health care. in: de Koning K, Martin M, eds. Participatory Research in Health: Issues and Experiences. London: Zed Books, 1996. Rifkin SB. Paradigms lost: toward a new understanding of community participation in health programs. Acta Tropica 1996; 61: 79–92.
Authors’ reply Susan Rifkin raises three important issues in relation to participatory women’s groups to improve maternal and newborn health.1 The first is that supporting participation in women’s groups does not in itself make an intervention participatory. Instead, being true to Participatory Learning and Action would require involvement of the intended beneficiaries in all aspects of the intervention, and valuing of the process of participation as much as its practical outcomes. On this matter we agree. The women’s group studies tread a fine line between valuing participation as a bottom-up, long-term, locally owned transformational process to redress inequities, and strategically engineering top-down health promotion approaches to improve health outcomes within the time constraints of trials.2 The tension of integrating bottom-up and top-down approaches is at the heart of many health interventions. The women’s group interventions examined in our meta-analysis, by necessity, sit within a range of participation, and do not claim to encompass all, or the purest forms, of participation.3 Rifkin’s second criticism is that presenting participatory women’s groups as an intervention with a direct causal relationship to improved health is simplistic. The meta-analysis does support a causal relationship between
participatory groups and reduced maternal and neonatal deaths. Several mechanisms, acting through both proximal (eg, improved behaviours) and distal (eg, women’s empowerment) outcomes, are likely to be implicated. Our meta-analysis has gone some way towards identifying changes in behaviours linked to reduced mortality. Opening the black box further involves generation and testing of hypotheses about more distal mechanisms, which was beyond the scope of the metaanalysis. Finally, Rifkin argues that the generalisability of our findings is questionable. Participatory women’s groups did reduce mortality in many settings. Further exploration of mechanisms can only help to increase the validity of the findings and transferability of the intervention to new settings. Cesar Victora commented that people who study empowerment are rarely those who do trials.4 Indeed, reviews have denounced the absence of studies measuring the effect of participatory approaches on health outcomes.5 We chose to measure this effect. Trials are vehicles to deploy a range of approaches to understanding change. In this sense, they are only reductionist if we allow them to be so. We invite Rifkin and others who promote participation not to shy away from trials, and to propose new methods for integrating process and impact assessments.
Corbis
Trials of participation to improve maternal and newborn health
We declare that we have no conflicts of interest.
*Audrey Prost, Mikey Rosato, Prasanta Tripathy, Anthony Costello
[email protected] Institute for Global Health, University College London, London WC1N 1EH, UK (AP, MR, AC); and Ekjut, Chakradharpur, Jharkhand, India (PT) 1
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Prost A, Colbourn T, Seward N, et al. Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis. Lancet 2013; 381: 1736–46. Labonte R, Laverack G. Capacity building in health promotion, Part 1: for whom? And for what purpose? Crit Public Health 2001; 11: 111–28.
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Howard-Grabman L, Snetro G. How to mobilise communities for health and social change. Baltimore, MD: Health Communication Partnership/USAID, 2003. Victora CG. Participatory interventions reduce maternal and child mortality among the poorest, but how do they work? Int J Epidemiol 2013; 42: 503–05. Marston C, Renedo A, McGowan CR, Portela A. Effects of community participation on improving uptake of skilled care for maternal and newborn health: a systematic review. PLoS One 2013; 8: e55012.
Tobacco control has always challenged tobacco interests Ronald Labonte’s perspectives (June 22, p 2158)1 on advocacy are interesting, but his assertion that “tobacco control initially was never about challenging corporate interests” is wrong. As Proctor2 and many others have shown comprehensively, tobacco companies have consistently responded to research demonstrating the dangers of smoking by seeking to deny and undermine the evidence, and they have consistently opposed any action that might be effective in reducing smoking. In 1952, only 2 years after the seminal papers by Doll and Hill3 and Wynder and Graham,4 the Reader’s Digest article, “Cancer by the Carton” was “a brave, bold decision to publish and take on the formidable tobacco giants” 5 that, along with related media coverage, resulted in the first declines in smoking since World War 2,5 and the tobacco industry’s “Frank Statement” and “Not Yet Proven” campaign of “distraction, false reassurance, and manufactured ignorance”.2 In 1953, reports in Time magazine and the New York Times “caused an outgassing of panic on Wall Street, with tobacco stocks falling more sharply than at any time since the Great Depression”.2 Challenges to the industry continued, with the first report from the Royal College of Physicians in 1962 and the US Surgeon General in 682
1964, and Senator Robert Kennedy’s summary as long ago as 1967 stating that “the cigarette industry is peddling a deadly weapon. It is dealing in people’s lives for financial gain. Cigarettes would have been banned years ago were it not for the tremendous economic power of their producers.” From the outset, tobacco control has been about challenging the global tobacco industry. Millions of preventable deaths later, it remains so. I declare that I have no conflicts of interest.
Mike Daube
[email protected] Faculty of Health Sciences, Curtin University, Perth, WA 6008, Australia 1
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Labonté R. Health activism in a globalising era: lessons past for efforts future. Lancet 2013; 381: 2158–59. Proctor RN. Golden Holocaust: Origins of the Cigarette Catastrophe and the Case for Abolition. California: University of California Press, 2012. Doll R, Hill A. Smoking and carcinoma of the lung. BMJ 1950; 2: 739–48. Wynder E, Graham E. Tobacco smoking as a possible etiologic factor in bronchogenic carcinoma. JAMA 1950; 143: 329–36. Pemberton M. How we started a revolution. Reader’s Digest, 2013. http://www. readersdigest.co.uk/magazine/readers-digestmain/how-we-started-a-revolution (accessed June 26, 2013).
Author’s reply Mike Daube’s comment that there was opposition to the tobacco industry from the earliest days of tobacco control efforts is a correct and useful elaboration of my claim that initially it “was never about challenging corporate interests”.1 Never was too strong a term. But my contention that taking on tobacco corporate interests was not high on the agenda of initial control policies still stands, and derives from two lines of argument. The first is my own experience as a health promotion practitioner from the early 1970s to the mid-1990s, working primarily in Canada but also in shorter bursts in many other high-income countries (Australia, New Zealand, UK, and several European countries). Until at least the mid-1980s, health
promotion emphasis was on the smoker (or potential smoker) and not on the product. This lifestyle approach to health behaviour remains a central programme strategy of many, if not most, public health authorities today. The second argument is that expression of outrage at the tobacco industry, as some did as early as the 1950s, is not the same as regulation of the industry in ways that challenged its profitability or limited its scope of practice. It was not until the 1970s that some municipal smoking restrictions and radio and TV advertising bans were enacted in countries such as the USA, Canada, and other early adopters. It was the 1980s before restaurant bans took hold and larger warning labels were required; and the 1990s before taxation policies, sponsorship bans, workplace smoking bans, and lawsuits against tobacco transnational companies became more commonplace. My point is simply that it took some time for the critiques of tobacco corporate practices to become accepted public health advocacy, leading to regulatory interventions that did challenge their economic interests. Through the Framework Convention on Tobacco Control, this approach is now globalising. Not that all governments today, however, act with policy coherence. Some are using trade treaties to challenge other countries’ tobacco control measures; others have become reliant on tobacco crop production or consumption tax on the one hand, while engaging in programmes and policies to reduce consumption on the other. The concept that Mike Daube and I are in complete agreement on is that the need to regulate tobacco transnationals is as much a part of a progressive public health agenda today as when it was first mooted 50 years ago. I declare that I have no conflicts of interest.
Ronald Labonté
[email protected] University of Ottawa,Institute of Population Health,Ottawa, Ontario K1N 6N5, Canada
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