This paper was presented as a technical background paper at the WHO sixth Global Conference on Health Promotion in Bangkok Thailand, August 2005. It describes what we know about the effectiveness of four of the Ottawa Charter health promotion strategies from eight reviews that have been conducted since 1999. The six lessons are that (i) the investment in building healthy public policy is a key strategy; (ii) supportive environments need to be created at the individual, social and structural levels; (iii) the effectiveness of strengthening community action is unclear and more research and evidence is required; (iv) personal skills development must be combined with other strategies to be effective; (v) interventions employing multiple strategies and actions at multiple levels are most effective; (vi) certain actions are central to effectiveness, such as intersectoral action and interorganizational partnerships at all levels, community engagement and participation in planning and decision-making, creating healthy settings (particularly focusing on schools, communities, workplaces and municipalities), political commitment, funding and infrastructure and awareness of the socio-environmental context. In addition, four case studies at the international, national, regional and local levels are described as illustrations of combinations of the key points described earlier. The paper concludes that the four Ottawa Charter strategies have been effective in addressing many of the issues faced in the late 20th century and that these strategies have relevance for the 21st century if they are integrated with one another and with the other actions described in this paper.

In attempting to use a realistic evaluation approach to explore the role of Community Parents in early parenting programs in Toronto, a novel technique was developed to analyze the links between contexts (C), mechanisms (M) and outcomes (O) directly from experienced practitioner interviews. Rather than coding the interviews into themes in terms of context, intervention elements (mechanisms) and outcomes separately and which could be assembled into CMO configurations by the analyst, they were coded as linked dyads and triads directly from the practitioner narratives. Out of all of the linked codes entered, there were a maximum of three with the same combination, presenting challenges for typical qualitative data analysis. This article examines a novel technique that was developed in an attempt to expand this method beyond the circumstances described in the realistic evaluation literature to date. The bulk of the article focuses on the linked coding and analysis procedures, the challenges faced, and the original solutions that were developed to analyze the CMO relations and generate the mid-range theories necessary to move to the next stage of a realist evaluation approach. The features that distinguish this linked coding method from other methods (e.g. Qualitative Comparative Analysis), the major benefits and drawbacks, the utility of the approach within evaluation practice, and its application to realist synthesis and research are discussed.

Urban resilience research is recognizing the need to complement a mainstream preoccupation with “hard” infrastructure (electrical grid, storm sewers, etc.) with attention to the “soft” (social) infrastructure issues that include the increased visibility of and role for civil society, moving from (top-down, paternalistic) government to (participatory) governance. Analyses of past shock events invariably point to the need for more concerted efforts in building effective governance and networked relations between civil society groupings and formal institutions before, during, and after crisis. However, the literature contains little advice on how to go about this. In this paper, we advance a Connected Community Approach (CCA) to building community resilience with a specific focus on the relationship between community and formal institutions. In the literature review that informs this work, we assess the current, limited models for connecting communities to formal institutions, as well as the emerging role of community-based organizations in this work, and we offer our own assessment of some of the key tensions, lacunae, and trends in the community resilience field. Principally, we explore the potential of the CCA model, as spearheaded by the East Scarborough Storefront and the Centre for Connected Communities in Toronto, Canada, as a promising approach for building the relational space between civil society and the state that is so often called for in the literature. The paper concludes with future directions for research and practice.

In Haiti, the number of women dying in pregnancy, during childbirth and the weeks after giving birth remains unacceptably high. The objective of this research was to explore determinants of maternal mortality in rural Haiti through Community-Based Action Research (CBAR), guided by the delays that lead to maternal death. This paper focuses on socioecological determinants of maternal mortality from the perspectives of women of near-miss maternal experiences and community members, and their solutions to reduce maternal mortality in their community. The study draws on five semi-structured Individual Interviews with women survivors of near-misses, and on four Focus Group Discussions with Community Leaders and with Traditional Birth Attendants. Data collection took place in July 2013. A Community Research Team within a resource-limited rural community in Haiti undertook the research. The methods and analysis process were guided by participatory research and CBAR. Participants identified three delays that lead to maternal death but also described a fourth delay with respect to community responsibility for maternal mortality. They included women being carried from the community to a healthcare facility as a special example of the fourth delay. Women survivors of near-miss maternal experiences and community leaders suggested solutions to reduce maternal death that centered on prevention and community infrastructure. Most of the strategies for action were related to the fourth delay and include: community mobilization by way of the formation of Neighbourhood Maternal Health/Well-being Committees, and community support through the provision/sharing of food for undernourished women, offering monetary support and establishment of a communication relay/transport system in times of crisis. Finding sustainable ways to reduce maternal mortality requires a community-based/centred and community-driven comprehensive approach to maternal health/well-being. This includes engagement of community members that is dependent upon community knowledge, political will, mobilization, accountability and empowerment. An engaged/empowered community is one that is well placed to find ways that work in their community to reduce the fourth delay and in turn, maternal death. Potentially, community ownership of challenges and solutions can lead to more sustainable improvements in maternal health/well-being in Haiti.

The Dalla Lana School of Public Health uses an “add-on” or concentration model of global health education. Records of masters’ graduate cohorts across five disciplinary fields from 2006 to 2009 were classified as to prior experience at application and completion of global health concentration requirements. Alumni from the first two cohorts (2006-08 and 2007-09) were interviewed using a semi-structured interview guide. Prior experience was not linked consistently with the number of elective courses, location of practica or completion of requirements. Successful completion of the global health requirements depended more on the student’s base disciplinary program. Interviewed alumni with medium prior experience reported greater satisfaction with the concentration. Alumni with lower prior experience wanted more courses and support with practica. The pros and cons of a concentration model of global public health graduate education are discussed.

The present study’s aim has been to investigate, identify and interpret the views of pediatric primary healthcare providers on the recognition and management of maternal depression in the context of a weak primary healthcare system. Twenty six pediatricians and health visitors were selected by using purposive sampling. Face to face in-depth interviews of approximately 45 minutes duration were conducted. The data were analyzed by using the framework analysis approach which includes five main steps: familiarization, identifying a thematic framework, indexing, charting, mapping and interpretation. Fear of stigmatization came across as a key barrier for detection and management of maternal depression. Pediatric primary health care providers linked their hesitation to start a conversation about depression with stigma. They highlighted that mothers were not receptive to discussing depression and accepting a referral. It was also revealed that the fragmented primary health care system and the lack of collaboration between health and mental health services have resulted in an unfavorable situation towards maternal mental health. Even though pediatricians and health visitors are aware about maternal depression and the importance of maternal mental health, however they fail to implement detection and management practices successfully. The inefficiently decentralized psychiatric services but also stigmatization and misconceptions about maternal depression have impeded the integration of maternal mental health into primary care and prevent pediatric primary health care providers from implementing detection and management practices.