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Susie Sykes, Jane Wills, Keith Popple, The role of community development in building critical health literacy, Community Development Journal, Volume 53, Issue 4, October 2018, Pages 751–767, https://doi-org.gold.idm./10.1093/cdj/bsx019 前言 這篇論文強調了“批判性健康素養”的重要性，并舉出了一個英國社區發展的例子來對照。健康素養一詞和“媒介素養”很像，“**素養”就是你去利用**的能力，而批判健康素養指的是不光被動學習使用現有的資源、做出好的決策，還要為了自己的健康去推動社會、政策的改變。 我認為這篇論文有兩個小點很有意思，一個是強調了參與式研究方法給到社區成員的重要性（這也是作者認為批判性健康素養與其它概念的不同之處），另一個是指出了社區發展與醫療健康議題及部門的疏離狀態。 在這篇文獻里讀到一個概念叫做“健康素養”（health literacy），世衛組織的定義是the personal characteristics and social resources needed for individuals and communities to access, understand, appraise and use information and services to make decisions about health，大致來說是個體、社群/社區想要觸及、理解、評估并使用醫療健康信息與服務時所需要的個人特質與社會資源。 Nutbeam把健康素養分成了三類： 功能性健康素養（functional health literacy），指的是個體理解醫療健康書面信息和數據的能力； 交互性健康素養（communicative or interactive health literacy），指的是在醫療機構等環境理解信息并且做出決策的能力； 批判性健康素養（critical health literacy），指的是使用信息來理解和改變影響其健康的因素的能力。 D’Eath、Barry和Sixsmith的研究指出，現在的干預主要是提升人們的功能性健康素養，也就是促進人們去理解醫療健康的信息，同時干預主要局限在臨床的情境中。 批判性健康素養能夠讓個體、社群/社區更加意識到健康議題對他們可能或者切實的影響，讓他們更有效、更有批判性地與專業人士溝通，并為他們的健康在well informed的前提下做出決定。 更重要的是，批判性健康素養讓個體、社群/社區能夠去挑戰導致健康不平等的服務與政策。 An analysis of the specific characteristics of critical health literacy (Sykes et al., 2013) shows that by developing critical health literacy, individuals and communities can become informed about the health issues that may or do affect them, may be motivated and able to access, manage, understand and critically analyse information on health issues, have the skills to effectively and critically communicate with professionals about health issues and make informed decisions about their own health. Importantly, they will also understand the wider social and political causes of health issues and will be motivated and skilled to act to challenge and campaign for change at a structural level. Individuals and communities with this skill set are therefore important self-managers of their own and society’s health and can become important actors in achieving positive health outcomes and health equity. Of all the domains of health literacy, it is critical, rather than functional, health literacy that will allow individuals and communities to challenge services and policies and tackle the root causes of health inequalities (Cross, Davis, O’Neil, 2017). 我們可以看到這里和弗萊雷意義上“批判意識”的相似性（critical consciousness），所以論文里也借用了弗萊雷的概念，提出了“健康意識覺醒”（health conscientization）。 Exploring health literacy from a critical perspective and borrowing from Freire (1993), critical health literacy is embedded within the idea of 'critical consciousness’ and is about social action for change or as Cross et al. identify it; a form of 'health conscientization’ (p. 136). It is, like community development, an emancipatory process through which individuals and communities become aware of issues and inequities, participate in critical dialogue, and become involved in decision-making and action for health (Zarcadoolas, Pleasant, Greer, 2005). 案例分析 論文舉出了英國一個社區發展機構開展項目的例子。這個機構的宗旨是reduce barriers to health and well-being，而項目的目標是創造一個更好的food system。 項目基于一個叫做’Citizens’ Jury’的模式，來自英國四個disadvantaged地區的居民被邀請加入到被稱作“探尋”（Inquiries）的八次會議當中。 會議從identifying and discussing their concerns around food and barriers to healthy eating 討論他們對食品關心的點、健康飲食又有什么阻礙開始，比如很難搞到（lack of access to）新鮮蔬菜和水果、沒啥烹飪技能等等。 這些關注點（concern）由這個團體成員列好優先級，然后外部的“評論員”（commentators），也就是一些具有相關專門知識的人會被邀請進來談論這些議題、談論這些議題為什么會存在。這個項目會安排兩位觀點不同或者相反的評論員發表觀點，比如連鎖超市的代表可能與反對超市壟斷的代表一起講話。參與者可以對這些評論員提出問題。 在整個進程的尾聲，參與者會運用他們的學習去發起地方性的又或者區域性（region-wide）的活動。 最后，還會有一個campaign weekend，把不同的探尋匯聚在一起，形成一個聯合的行動計劃。 這樣的計劃，依照Sykes等人探索的six identified characteristics of critical health literacy，論文又做了個分析。 進階的個人與社交技能 Advanced personal and social skills 簡單來說，項目過程里，參與者被視作“專家”，并且項目把核心放在了提升參與者的personal & social skills上，結果參與者的自我效能感、社交技能以及更正式的組織計劃能力都得到了提升。這種個人自主性（personal autonomy）是社區發展里集體行動（collective action）的基礎。 進階的信息分析技能 Advanced information and analytical skills 項目過程中有用visual mapping type techniques做了大量關于收集信息并重新組織信息的練習，還有food audit的練習——不同商店對相同食物收取的不同費用blabla。這些都是參與式研究會用到的方法，它們被引入進來促進大家相互學習、對自己的處境有更多認知。 The project generated a great deal of information for participants and employed a number of strategies to develop participants’ skills in these areas. Exercises were frequently used that involved capturing information and reorganizing it into categories or priorities using visual mapping type techniques. Participants had the opportunity to learn specific technical skills related to managing information such as how to do a food audit to capture what different shops were charging for the same food. Such techniques are widely used in participation projects and participatory research and they work to address the address the inequalities in access to resources (Cornwall and Jewkes, 1995). Using such techniques of mutual learning and analysis empowers people as agents who can think critically and investigate their own situations (Holkup et al., 2004), so creating a critical awareness of one’s own situation, an important stage in the Freirean process of conscientization (Freire, 1993). 健康知識 Health knowledge 項目里除了關于健康飲食、肥胖等問題的技術性知識，還有關于食品標簽、食品政策、商超在整個社會政治背景下的“解放性知識”（emancipatory knowledge）。技術性知識固然重要，但只有解放性的知識才能促成社區發展社會動員與變革行動的目標。 與服務供應方及個體高效溝通 Effective interaction between services and individuals 通過跟各類評論員的交流，參與者了解到更多他們可觸及的服務/個人，建立了一些信任。他們還鍛煉了如何以一種建設性的方式挑戰和質疑專業人員。 充分知情的決策 Informed decision making “該項目的主要目標是與參與者合作，使他們能夠基于各種觀點做出明智的決定。有機會和時間思考信息并與同齡人一起探索，無論是正式的還是非正式的。該項目實施的結構化流程意味著，參與者被視為一個整體，通過分階段的決策過程，從接收信息，確定有關應采取的措施的建議，優先考慮這些建議并最終對最佳行動方案進行投票。這意味著決策過程是知情且清晰的，但是非常重要的是在集體而非個人層面上做出決策。”（機翻） 賦權與政治行動 Empowerment and political action 計劃目標很明確的是“通過社區參與計劃賦予個人和社區權力。這試圖通過政治層面的行動，解決健康方面的不平等和不公正，特別是針對弱勢社區存在的健康飲食障礙。”（機翻） its aim was to empower individuals and communities through a programme of community engagement. This sought to address, through action at a political level, inequalities and injustices in health with particular reference to the barriers to healthy eating that exist in disadvantaged communities. “確定可能改變的領域是一個結構化的過程，所有參與者都參與其中。這產生了一份冗長的領域清單，然后各小組通過投票系統對這些領域進行優先排序。這一優先排序過程的結果是，與會者商定了一套他們希望看到的建議。其中一些建議是由更廣泛的主辦組織的宣傳范圍所采納的，另一些則是由社區成員自己采納的。向參與者提供一定程度的持續支持，幫助他們實施變革，被認為是重要的，也是不同于其他審議進程的。 “與會者舉出了許多例子，說明在正式項目結束后，與會者繼續作為集體和個人努力進行變革。例子包括社區層面的倡議，如成立食品合作社和社區烹飪班，組織請愿，游說議員，以及與當地規劃部門和外賣店主合作。項目促進者將其結果描述為從地方個人的集體轉變為地方活動家的運動，在地方、區域和國家各級推動變革。”（機翻） Identifying areas for possible change was a structured process which involved all of the participants. This resulted in a lengthy list of areas which the groups then went on to prioritize through a voting system. The result of this prioritization process was that a set of recommendations were agreed that the participants wanted to see taken forward. Some of these recommendations were taken on by the campaigning remit of the wider hosting organization and some were taken on by the community members themselves. Offering a level of on-going support to the participants in implementing changes was seen as important and unique from other deliberative processes. Numerous examples were given of participants continuing, after the end of the formal project life, to work for change both as a collective and as individuals. Examples ranged from community level initiatives such as the setting up of a food co-op and community cookery classes, to organizing petitions, lobbying MPs and working with local planning departments and takeaway owners. The result was described by project facilitators as a shift from a collective of local individuals to a movement of local activists pushing for change at a local, regional and national level. Discuss “該項目采用參與式和解放式進程，這些進程與社區發展進程相呼應，即努力幫助社區通過提高批判意識來了解他們的共同處境，對他們的日常處境采取質疑的辦法，利用對話來確定這種經歷的原因，并組織變革行動來解決不公正問題(Gilchrist and Taylor, 2011)。” 作者提到這個項目的工作者有留心到“批判性健康素養”這個概念，但并沒有使用它。可能的原因在于，健康素養更多聚焦在了功能性健康素養上，批判性健康素養的理論基礎還很薄弱，無法為社區發展當中復雜的實踐提供支持，或者說，它就是太新了。 更進一步的原因可能在于，盡管強調了跨部門合作，但衛生部門還是有一種孤島思維，而社區發展組織也是更多與地方當局、志愿組織相聯系，對衛生部門的聯系要弱得多。 還有一種可能的解釋是，批判性健康素養與一些已有的概念重合度較高，比如健康行動主義（health activism）。但是批判性健康素養對于information and analytical skills的強調有它獨特的意義。（就跟媒介素養特別像嗷） 結論 “在個人和社區中培養關鍵的衛生知識技能，可以增強社區對一系列健康決定因素的影響。然而，由于缺乏建立這一概念的舉措，因此無法評估這一潛力。這個說明性的案例研究表明，社區發展的目標和進程與關鍵健康素養的特征之間有很強的親和力，但這一概念還沒有進入該領域的對話或實踐中。關鍵健康素養缺乏可操作性，可能是因為它還沒有找到自己的天然歸宿，仍然停留在以功能為重點的衛生領域。然而，如果社區發展領域更明確地采用這一概念，可能會使其有機會實現其潛力。”（機翻） Building critical health literacy skills amongst individuals and communities could increase community influence over a range of determinants of health. However, the lack of initiatives to build the concept means that this potential cannot be assessed. This illustrative case study shows a strong affinity between the goals and processes of community development and the characteristics of critical health literacy and yet the concept has not found its way into the dialogue or practice of the field. It may be that the lack of operationalization of critical health literacy is because it has not yet found its natural home and remains within the functionally focused arena of health. A more explicit adoption of the concept by the field of community development, may however, offer it the opportunity to realize its potential. |
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