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Self-Help + Health Promotion: One Relationship at a Time

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I Introduction

Many people are uncertain about the nature of self-help - what it is,
what evidence exists in support of its application, and how it relates
to health promotion. The following article is an attempt to provide a
working definition of self-help, a brief look at some of the existing
evidence, and a few examples of how the self-help approach has been
successfully applied in support of health promotion.

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II What Exactly is Self-Help?

An unscientific poll of some self-help resource centres across Canada
included the following elements in determining what a self-help group
would look like:

  • run by and for the members;
  • came together with a common issue, concern, problem, or condition;
  • were generally open to new members;
  • did not charge but might ask for a nominal donation;
  • shared power and decision-making equally; and
  • could involve face-to-face meetings, telephone conversations, or Internet chats.

In some instances, the term mutual aid was also used to reinforce the
idea that attending such a group meant giving as well as getting
assistance and that the ideal is a balance between the two.

In the context of health promotion, the Self-Help Resource Centre
identifies self-help as a process of learning with and from each other,
in which participants offer mutual aid/peer support in dealing with a
problem, issue, condition, or need which is shared in common. While
acknowledging the diversity in their personal situation, participants
nonetheless work together to investigate alternative solutions to their
shared issue and are thus empowered by this process.
   
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III Some Evidence in Support of Self-Help

How do we know self-help works? That is a little more difficult to
ascertain due to the issues of members' comfort, concern about breach
of confidentiality, and resources for the necessary research to
substantiate the benefits of self-help. Nonetheless, there is a growing
body of evidence that indicates self-help can prove useful as a
complementary adjunct to traditional approaches.

A number of studies have shown how self-help can create a supportive
environment in which individuals can confront and deal with issues of
concern to them. Krause (2003) studied groups associated with bowel
disorders and found self-help groups pivotal for successful adjustment
to the condition. Masudomi, Isse, Uchiyama and Watanabe (2004)
identified self-help groups as a significant factor in lowering
mortality rates among alcoholics, particularly for those alcoholics who
were socially isolated. Clark et al (2000) described the seeking and
sharing of information in testicular-cancer groups as their primary aim
(rather than emotional support).

Self-help has also been used as a tool to address stigma, to develop
personal skills, to empower individuals, and to take action in local
communities.  Mothers of sexually abused children felt that a
group where they could talk about their feelings would help alleviate
the stigmatization they experienced from family, friends, and
professionals, as well as from themselves (Hill, 2001). Supportive
environments were also helpful to those living an alternative lifestyle
such as single parents, divorced individuals, and gays and lesbians
(Ben-Ari, 2002).

Charlton and Barrow's 2002 study of Parkinson's disease groups revealed
a key difference between self-help group members versus non-members:
members not only acknowledged their illness but felt encouraged to make
adjustments in response to the illness in their everyday living, while
non-members had lower levels of acceptance and made changes only when
absolutely necessary. In taking charge of their situation, people are
empowered to make changes that enhance their lives, whether on a
personal, interpersonal, or collective basis. This issue of personal
empowerment is further supported by studies of self-help groups for
obesity (Latner, 2000) and addictions (Humphreys et al, 2004) in that
members discover ways to take control over their situations.  Once
personal empowerment has been realized, some members choose to leave as
they feel the group has served its purpose.  Conversely, some stay
with the group and gain interpersonal empowerment through supporting
others, as was seen with family members of the mentally ill (Citron,
Solomon & Draine, 1999).

Once people begin to gain back some sense of control and to work with
others who have similar concerns, education and advocacy can follow.
Families of loved ones with a mental illness can become advocates in
the area of insurance quality and community health services (Citron et
al, 1999). They can also become lay educators as the Schizophrenia
Society of Ontario has done through its 10-week psycho educational
sessions for families with a recently diagnosed loved one. Or, as
Hatzidimitriadou (2002) suggests, they can become part of a whole
category of mental health self-help groups he calls "social movement
groups" who wish to play a role improving the delivery of mental health
in their community. One such group, Parents for Children's Mental
Health, has grown so rapidly it now has a provincial reach in support
of its agenda.

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IV Points of Intersection: Self-Help & Health Promotion 

In all of this, where is the health promoter? Do they have a role, and
if so, what kind?  While the identified focus of self-help is the
authentic voice of lived experience (Special Proceedings, 2004), it has
been found that many self-help groups do desire professional
involvement (Stewart, 1990), so long as power struggles do not become
an issue (Ben-Ari, 2002). Health promoters can provide support to
self-help groups in a number of ways, from initiating a group to acting
as a resource person or guest speaker.

However, understanding how self-help is complementary to health
promotion can involve operationalizing the theoretical framework.
Sometimes "the changes we are asking the public to make are hard to do"
(Special Proceedings, 2004), so we need to investigate how we can
"change the context to eliminate the problem or minimize its
consequences" (Link & Phelan). Can anyone do what we are asking or
only those with the resources to do so (Link & Phelan)? Do we know
why people don't always act on the information we have communicated to
them? Are we relying on the transmission of information to ignite a
lifestyle change?

Dr. Lugi Resegotti (2005) offers an interesting thought, which ties
into the nature of self-help. He suggests that the mere transmission of
information sets up an asymmetrical system of unfairness in which the
person with knowledge passes it on to a recipient. However,
communication is about relationship, and relationship is what builds
capacity. "Communicating is sharing not only knowledge, experience, and
feelings, but also fears and weaknesses. Only when one realizes that
others share our weaknesses, our fears, and our difficulties, do we
feel that they are equal to us" (Resegotti, 2005). As you can see, this
places the health promoter in a difficult position, particularly if
they do not share the issue, condition, or situation of the communities
health promoters wish to assist. Still, there are areas where health
promotion can incorporate the tenants of self-help in ways that produce
results and are cost effective. A quick overview of some elements of
health promotion reveals how many points of intersection there are with
self-help. 

At a workshop on best practices, participants identified 10 points they
thought were necessary for health promotion programs/initiatives:

  1. Include participant/community involvement in all stages of planning, implementation, and evaluation/
  2. Be effective (demonstrate positive outcomes).
  3. Be sustainable.
  4. Be based on needs of community.
  5. Be evidence based.
  6. Be based on capacities of community.
  7. Have, on a regular basis, valid/reliable/generalizable evaluations.
  8. Increase client empowerment.
  9. Be adaptable and open to new approaches (continuous search for improvements).
  10. Be consistent with health promotion principles
    such as equity & social justice (Goodstadt  & Kahan, 1999).

Some of these principles have been applied to self-help initiatives,
which were themselves attempts to expand the traditional definition of
self-help.

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V The Lived Experience

A. The Empowering Stroke Prevention Project

In 2003 the Self-Help Resource Centre obtained funding from the Ontario
Ministry of Health and The Change Foundation to determine how self-help
strategies might work in the education and prevention of stroke. An
article about the experience was subsequently published in The
Community Psychologist (see Poole, Gilgan & Kranias (2005)). While
limited to one year, The Empowering Stroke Prevention Project managed
to cover a lot of ground. A gap analysis was done, partnerships with
three communities (two urban and one rural) were initiated, and focus
groups and community meetings were organized. Childcare and honorariums
were provided and the resultant materials were co-developed with the
participants. Volunteers from the participant groups were then
recruited to test the materials and were given additional education in
stroke and its prevention, as well as facilitation and community
building skills. These volunteer "lay health promoters" then began
organizing their own community and discussion meetings, outreach to
seniors, and various popular theatre presentations. The program was
evaluated, including feedback from the lay health promoters and
workshop participants.

From this experience, a number of lessons were learned about
integrating health promotion and self-help. One barrier to
implementing the program came from health agencies that did not see how
this type of self-help initiative could be connected to stroke
prevention. Another was that working with diverse communities whose
needs were in dynamic flux, required a flexible and adaptable response
on the part of the lay promoters. Avenues for effective delivery of the
program included providing safe transportation, sharing information
while preparing a meal, giving information and examples via
storytelling and dancing. The lessons learned have subsequently been
incorporated into the second phase of the Stroke Prevention Project,
and is focused on building relationships between agencies and
communities. In Phase II three Ontario communities have been targeted.

B. Mutually Ours

Another example of a self-help initiative is Mutually Ours, an ongoing
project sponsored by the Self-Help Resource Centre and funded by the
United Way. The project is designed to train, mentor, and mobilize new
community leaders from at-risk communities within the greater Toronto
area. Through a series of workshops volunteers are trained in
communication skills, dealing with diversity, outreach and networking,
effective community meetings and basic fundraising. Then, these
community leaders recruit and train groups of community members to work
on a specific project that benefits the community. Mutual Ours applies
the principles of self-help (joining together and working towards a
common goal, building and implementing strategies and evaluating
success), which in turn foster stronger relationships and a sense of
pride in making their community a healthier place to live.

As with any project, there were barriers to overcome, which included
finding appropriate space, adjusting to parents' schedules, providing
childcare and transportation, and spreading the word about the
opportunities inherent in the program. However, to date Mutually Ours
has resulted in the formation of a community run theatre group, boys
and girls club, and sports activities for children and youth where
previously there had been few programs. Despite being part-time
project, the project continues to encourage and support the graduation
of new leaders and the establishment of new community-run programs
which graduates feel makes for healthier and growth-producing
environments.

C. Diversify the Source, Enhance the Force

Even while Mutually Ours seeks new volunteer community leaders to step
forward, more and more people are seeking all kinds of volunteer
opportunities, including new Canadians.  In an attempt to address
this desire, the Self-Help Resource Centre developed an approach based
on mutual aid, incorporating the need of newcomers to integrate and
understand Canadian culture and the need of organizations to reflect
and respond to the needs of an increasingly diverse population. The
project was called Diversity the Source, Enhance the Force: Using Peer
Support to Create Volunteer Opportunities for New Canadians or DSEF for
short. Focus groups provided information that was used to establish the
project model, which emphasized group peer support, orientation,
transportation assistance, flexible placements, ESL practice, and
recognition certificates. With the assistance of 17 partner agencies,
11 mutual aid groups, 22 peer facilitators and more than 100 newcomers
in 4 cities, the project had a dramatic impact on all concerned.

Throughout the project, DSEF provided agencies with assistance in the
preparation of its staff, recruitment, and training of peer
facilitators and a suggested time-limited process for the engagement of
newcomers as potential volunteers. Agencies and newcomer volunteers
were asked for feedback and their input was also incorporated in the
final draft of the project. A number of benefits were identified:

  • on an individual level, the New Canadian volunteers
    improved their English, increased their self-confidence, and enhanced
    their volunteer/employment opportunities;
  • on an organizational level, agencies enhanced their
    volunteer base and in so doing were given an opportunity to reflect and
    build on their organizational policies; and
  • on a local level, the project was instrumental in
    the development of community networks and in the integration of the
    model into other local initiatives (DSEF, 2002).

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VI Conclusion

As can be seen from the examples above, self-help can be used in a
variety of ways to promote and enhance the health of individuals and
their communities. To do so requires a clear understanding of the
definition of self-help and the ability to respond creatively to the
needs of community partners. Applying self-help approaches to chronic
disease prevention, addictions, mental health, smoking, nutrition, or
physical activity can be both efficient and effective, particularly
when it calls on the existing skills and abilities of community
volunteers, but also when it assists in expanding the potential
outreach and impact into the community beyond. If, as has been
suggested, we need to "pay more attention to front line local
implementation" (Law, 2004), then "the answers lie in communities"
(Frank, 2004).

Self-help is a method to build communities, one relationship at a time.

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VII References

Ben-Ari, A.T. (2002). Dimensions and predictions of professional
involvement in self- help groups: A view from within. Health &
Social Work, 27(2), 95-103.

Charlton, G.S. & Barrow, C.J. (2002). Coping and self-help group
membership in Parkinson's disease. An exploratory qualitative study.
Health and Social Care in
the Community, 10(6), 472-478.

Citron, M., Solomon, P. & Draine, J. (1999). Self-help groups for families of persons
with mental illness: Perceived benefits of helpfulness. Community Mental Health
Journal, 35(1), 15-30.

Clark, A. et al. (2002). Practice development in cancer care: Self-help
for men with testicular cancer. Nursing Standard, 14(50), 41-46.

Frank, J. Special edition proceedings of the first CDPA Conference, Nov. 2004, p.9.

Hatzidimitriadou, E. (2002). Political ideology, helping mechanisms and
empowerment  of mental self-help/mutual aid groups. Journal of
Community & Applied Social
Psychology, 12, 271-285.

Hill, A. (2001). "No-one else would understand": Women's experiences of
a support group run by and for mothers of sexually abused children.
British Journal of Social Work, 31, 385-397.

Humphreys, K. et al. (2003). Self-help organizations for alcohol and drug problems:
Toward evidence-based practice and policy. Journal of Substance Abuse Treatment, 26, 151-158.

Krause, M. (2003). The transformation of social representations of
chronic disease in a self-help group. Journal of Health Psychology,
8(5), 599-615.

Latner, J.D. (2000). Self-help in the long-term treatment of obesity. Obesity Reviews, 2, 87-97.

Law, M. Special edition proceedings of the first CDPA Conference, Nov. 2004, p. 9.

Link, B.G. & Phelan, J.C. (date unknown). Fundamental sources of
health inequalities, Part II, Chapter 5: Promoting population health
and reducing disparities.
Available at http://www.rwjf.org/files/research/071-Part%202-Chapter%205.pdf

Masudomi, I., Isse, K., Uchiyama, M. & Watanabe, H. (2004). Self-help groups reduce
mortality risk: A 5-year follow-up study of alcoholics in the Tokyo metropolitan
area. Psychiatry and Clinical Neurosciences, 58, 551-557.

Poole, J., Gilgan, E. & Kranias, G. (2005). Stopping Strokes with Self-Help? Findings
from the Empowering Stroke Prevention Project in Toronto, Canada in Expanding
the Potential for Self-Help and mutual support to improve well-being:Continuities
and Vitality in New Contexts. The Community Psychologist, Spring 2005, p. 33.

Resegotti, L. (2005). Communicating health or communicating for health. The Health
Promotion Exchange, Twentieth Edition, Fall 2005, p.6.

Self-Help Resource Centre (2002). Diversity the source, Enhance the force: Using peer
support to create volunteer opportunities for New Canadians. Developed by The
DSEF Project Team and Partners.

Stewart, J.J. (1990). Professional interface with mutual-aid self-help groups: A review
Social Science Medicine, 31(10), 1143-1158.