Parallel-tracking bottom-up approaches within chronic disease prevention programmes

Abstract

IntroductionThe purpose of this commentary is to discuss how toaccommodate top-down and bottom-up approaches at eachphase of chronic disease prevention programmes. Thecommentary uses a theoretical example of targeting a highrisk group in New Zealand.Chronic disease prevention programmes are typicallydesigned to address changes in lifestyle and behaviourcentred on, for example, diabetes prevention. There isevidence to suggest that lifestyle and behaviour pro-grammes that include multi-risk factor interventions suchas increasing physical activity, dietary modifications andweight loss can significantly reduce the incidence of dia-betes in persons at high risk (Knowler et al. 2002;Tuomilehto et al. 2001). In practice, chronic disease pre-vention programmes are most commonly implemented asactivities set within the context of a programme. Profes-sionally led, it is the practitioner or their agency thatchooses the design, the means of implementation andevaluation of the programme. This includes the selection of‘targeted groups’ and the methods to be used to reach them.The issues to be addressed are traditionally based on epi-demiological evidence, rather than on the concerns of theindividuals and communities to whom it should concern.This style of programming is called ‘top-down’. Bottom-upprogrammes are fewer in design and address the concernsof the beneficiaries based on discussions with them prior toimplementation. The concerns are prioritised and thendeveloped into a form that makes sense to all the pro-gramme stakeholders (Laverack and Labonte 2000).It is important to remember that the terms ‘top-down’and ‘bottom-up’ are ideal types of practice. ‘Top-down’describes programmes where problem identification comesfrom those in top structures ‘down’ to the community.‘Bottom-up’ is the reverse, where the community identifiesits own problems and communicates these to those whohave the decision making authority. The practitioner willtry to use their influence to ‘push-down’ a predefinedagenda onto the community through top-down program-ming. The community attempts to ‘push-up’ an agendabased on their immediate concerns that are often not thesame as those identified by the practitioner. The failure oftop-down programming to accommodate bottom-up con-cerns may have a detrimental effect on outcomes. Forexample, the modest success of top-down programminghas only been with higher socio-economic groups: between1998 and 2004 there was a 9% decrease in smoking in thelowest quintile in Australia compared to a 35% decrease inthe highest quintile (Baum 2007). This is because top-downprogramming uses strategies that are effective at reachingthe educated and self-motivated sectors of society and arenot specifically tailored for low socio-economic or mar-ginalised groups.The challenge is how to accommodate bottom-upapproaches within the dominant top-down styles of pro-gramming. This requires a fundamental change in the waywe think about chronic disease prevention programmes.Rather than viewing the issue as a bottom-up versus top-down tension, accommodating both can be better viewed asa ‘parallel track’. The tensions between the two then occurat each stage of the programme cycle making their reso-lution much easier to achieve (Laverack 2004). The mainpurpose of the programme remains unchanged with a focuson the more conventional top-down issues and so fitswithin the expectations of, and is therefore acceptable to,