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True patient participation is difficult and takes dialogue

BMJ 2016; 352 doi: (Published 17 March 2016) Cite this as: BMJ 2016;352:i1506

Re: True patient participation is difficult and takes dialogue

A plea for participation.

Although Ditters states that participation is difficult,(1) it is an essential part of the different stages of health promotion practice, including needs assessment, implementation and evaluation.(2,3)

Health needs assessment is often the first stage in health promotion planning frameworks and for some time many authors have commented on participation, for example -
“For those health promoters who work with individual clients, there is increasing recognition of the importance of client participation in the assessment of needs.”(4)

But why is participation so crucial in health needs assessment? Firstly, its importance can be argued in terms of the patients “rights”.(5) If a doctor is studying part of a patient’s life and is about to pass some judgement - it must be a basic right that the patient should be fully involved. Secondly, a patient’s motivation to change is likely to be greater if his or her perspective is taken into consideration and becomes an integral part of the process.(6)

The third point is in terms of effectiveness -
“The guru instructs by metaphor and parable, but the pilgrim learns through the telling of his own tale.”(7)

Effective health promotion starts from where people are developmentally, socially and emotionally(8), and this type of information can only be ascertained with the full participation of the patient.

For needs assessment at higher levels (e.g. local authority level), participation is just as important: and, again the case can be argued in terms of rights, motivation and effectiveness. In addition, having the community involved from an early stage can also provide “political push” both within certain organisations and within the community.

Finally, the Jakarta Declaration, drawn up to help to address the challenges of promoting health in the 21st Century and produced by experts considering the evidence on effectiveness endorses the importance of participation. (9)
“There is now clear evidence that: ……………participation is essential to sustain efforts. People have to be at the centre of health promotion action and decision-making processes for them to be effective………..”(9)


1) Ditters J. True patient participation is difficult and takes dialogue. BMJ 2016;352:i1506

2) Watson M. Normative needs assessment: is this an appropriate way in which to meet the new public health agenda? International Journal of Health Promotion and Education 2002; 40(1),4-8.

3) Green J, Tones K, Cross R and Woodall J. Health promotion. Planning & Strategies. London: Sage 2015.

4) Naidoo J and Wills J. Health Promotion Foundations for Practice. London: Bailliere Tindall 2000.

5) Seedhouse D, and Lovett L. Practical Medical Ethics. Chichester: John Wiley 1992.

6) Prochaska J and Di Clemente C. In search of how people change, American Psychologist 1992;47:1102-1114.

7) Kopp S. If You Meet the Buddha on the Road, Kill Him! London: Sheldon Press 1974.

8) Weare K. The contribution of education to health promotion, in Bunton R and Macdonald G (eds) Health Promotion. Disciplines, diversity and developments. London: Routledge 2002.

9) WHO. The Jakarta Declaration on Leading Health Promotion into the 21st Century, Health Promotion International 1997;12:261-264.

Competing interests: No competing interests

22 March 2016
Michael Craig Watson
Associate Professor of Public Health.
University of Nottingham, Faculty of Medicine and Health Sciences, Queen's Medical Centre, Nottingham. NG7 2HA