The framework in Box 5. Is the proposed programme feasible and acceptable? What outcomes can be achieved in what time period? How and why will it work? How can it be adapted to maximise effectiveness?
3.8.2 Health Promotion
How is the project working? Is it being implemented as intended? Is the target population being reached? To what extent were intermediate outcome achieved? How were they achieved? Evaluation 6 3 Morgan A Evaluation of health promotion. Understanding Public Health series. Nutbeam D Evaluating health promotion - progress, problems and solutions. Health Promotion International 13 1 Hence theory-based approaches to evaluation move on from the clarification of a programme's aims, objectives and outcomes to articulating the assumptions underlying a programme's design in order to understand more about how and why the programme is supposed to operate to achieve the outcomes.
The Theory of Change approach, developed for the evaluation of comprehensive community initiatives in the US Connell et al, , suggests that all programmes have explicit or implicit 'theories of change' about how and why they will work Weiss, Once these theories have been made explicit they can influence the design of the evaluation to ensure that it assesses whether the theory is correct when it is implemented. This approach reconciles process and outcome measurement, and ensures that practitioners and evaluators draw on established theory and their own observations about how change will happen, and has been used in for example, the Health Action Zone evaluation in England Judge et al, They consider the approach to be 'post-positive' in that it recognizes realities that can be investigated robustly and used to shape policy.
On the other hand it views that the strict positivist approach of experimental design, particularly RCTs, is insufficient to understand the context of programmes and the constant changeability and potential intrusion of 'new contexts and new causal powers'. Realistic evaluation considers that:. The understanding of how mechanisms are fired in certain contexts to produce certain outcomes generates theories about the effectiveness of the programme design 'through a detailed analysis of the programme in order to identify what it is about the measure which might produce change, which individuals and sub-groups and locations might benefit most readily and what social and cultural resources are necessary to sustain the changes.
Both these approaches to evaluating health promotion will utilise both qualitative and quantitative data as appropriate, and critically 'open up the black box' of the intervention in order to understand what is working and why, and to improve the implementation of the intervention in order to increase effect.
Learning to make a difference. Concepts, methods and contexts. Weiss CH Nothing as practical as a good theory: It has increasingly been recognised that these issues also apply to public health evaluation in a wider sense, including that of healthcare interventions.
Previous proponents of the RCT, and of strict systematic review processes based on RCTs and meta-analysis have more recently revised their stance on these issues. As a brief consideration of this three recent papers are discussed as an example of this widening debate. Oakley et al argue the case, somewhat belatedly, for the inclusion of process evaluation in RCTs of complex interventions such as peer led sex education in school based health promotion.
Process evaluations should specify prospectively a set of process research questions and identify the processes to be studied, the methods to be used, and procedures for integrating process and outcome data. Expanding models of evaluation to embed process evaluations more securely in the design of randomised controlled trails is important to improve the science of testing approaches to health improvement.
It is also crucial for persuading those who are sceptical about using randomised controlled trials to evaluate complex interventions not to discard them in favour of non-randomised or non-experimental studies. In their definition complex health interventions include for example surgery and physiotherapy. They summarise their position as:.
Quality can be assessed when other research provides clear indications of how interventions should be administered. Such analyses should be specified in the review protocol and should focus on interactions between the quality and the effects of the intervention'.
Hawe et al propose a radical way of standardising complex community interventions for RCTs in comparison to simple interventions, which pays less attention to the replicability of individual components of an intervention by form eg patient information kit, in-service training sessions and more to their function eg all sites devise information tailored to local circumstances, resources are provided to support all sites to run training appropriate to local circumstances etc. While recognising the complexity of the systems under investigation Hawe et al state that 'complex systems rhetoric should not become an excuse to mean 'anything goes'.
In complex interventions, the function and process of the intervention should be standardised and not the components themselves. Intervention integrity would be defined as evidence of fit with the theory or principles of the hypothesised change process'. British Medical Journal British Medical Journal, However, as we have seen, the direct transference of the methods used for assessing research evidence in clinical medicine can be problematic when applied to health promotion.
Kelly summarises issues to consider when building the evidence base for health promotion:. Evidence of the effectiveness of interventions to reduce health inequalities is poor, and less than 0. Of the evidence that exists, there is more about 'downstream' interventions eg individual behaviour change than 'upstream' interventions eg policy or environmental change.
The RCT dominates the effectiveness literature which has led to the consideration of other forms of evidence as inferior. As Kelly states 'This is not helpful, because while RCTs are good on internal validity, they tend to be much less informative about issues of process and implementation which are vital to know about if the intervention is to be transferred…in health promotion where the issues involved are often highly complex and the settings difficult to control … key information will not be available from trial data.
The problems of synthesising evidence from different research traditions Dixon-Woods et al , and the difficulty of grading the evidence, which applies to both the quality of systematic reviews and of primary research studies. Notwithstanding these difficulties there has been considerable investment in developing robust review methodology for both secondary research, and for tertiary research, ie reviews of reviews for public health.
The following tables provide some brief examples of effective health promotion actions in the areas of:.
- Prevention of disease, injury and illness.
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- Appropriate settings for health promotion (e.g. Schools, the workplace).
Tobacco use - reducing initiation, increasing cessation, and reducing exposure to environmental tobacco smoke Table 5. Food-support programmes for low-income and socially disadvantaged childbearing women in developed countries Table 5. Increasing physical activity - Informational approaches, behavioural and social approaches and environmental and policy approaches Table 5. Motor vehicle occupant injury - Increasing child safety seat use, increasing safety belt use, reducing alcohol impaired driving Table 5.
Housing and Public Health - rehousing and neighbourhood regeneration, refurbishment and renovation , accidental injury prevention, and prevention of allergic respiratory disease Table 5. This is by no means a comprehensive list. Comments in the tables about recommended interventions only list those where there is good evidence, and do not include the extensive caveats in the various reports about the research base.
Similarly they do not include any listings of interventions where there is insufficient evidence to make a judgement about effectiveness. Readers are encouraged to read the full reports to understand more about the underlying issues. The topics selected are to provide a range of recent examples across health issues, and include upstream and downstream interventions. They also vary between systematic reviews and reviews of reviews. The final narrative review on empowerment Wallerstein, provides an interesting example of an inclusive and rigorous approach to reviewing the literature around a key health promotion concept and principle of practice.
Three main sources of reviews have been chosen for their relevance to public health and health promotion evidence:. New York, OUP www. National Institute for Health and Clinical Excellence. To access all NICE public health documents go to www. HEN gives rapid access to reliable health information and advice to policy-makers in evidence-based reports and summaries and access to other sources. Risk behaviour in health and the effect of interventions in influencing health-related behaviour in professionals, patients and the public. Food-support programmes for low-income and socially disadvantaged childbearing women in developed countries.
Food-support programmes aim to improve key maternal and perinatal outcomes.
The lack of any significant impact on low birth weight LBW , pre-term birth and other perinatal outcomes along with the favourable impact on maternal weight gain and nutrient intakes provide a basis both for re-thinking the aims and objectives of current food-support programmes. Setting out-of-reach goals for food-support programmes such as reduction in rates of LBW and pre-term birth is probably not useful until there is strong evidence of what works to improve those outcomes. With respect to the primary outcome of interest, LBW, the results of this review do not provide evidence that food-support programmes have any impact.
However, there are favourable impacts on other outcomes. Health is heavily influenced by factors outside the domain of the health sector, especially social, economic and political forces. These forces largely shape the circumstances in which people grow, live, work and age as well as the systems put in place to deal with health needs ultimately leading to inequities in health between and within countries.
This holistic approach should empower individuals and communities to take actions for their own health, foster leadership for public health, promote intersectoral action to build healthy public policies and create sustainable health systems in the society. It includes interventions at the personal, organizational, social and political levels to facilitate adaptations lifestyle, environmental, etc.
Health promotion is not a new concept. The fact that health is determined by factors not only within the health sector but also by factors outside was recognized long back. William Alison's reports on epidemic typhus and relapsing fever, Louis Rene Villerme's report on Survey of the physical and moral conditions of the workers employed in the cotton, wool and silk factories John Snow's classic studies of cholera , etc.
Sigerist, the great medical historian, who defined the four major tasks of medicine as promotion of health, prevention of illness, restoration of the sick and rehabilitation. His statement that health was promoted by providing a decent standard of living, good labor conditions, education, physical culture, means of rest and recreation and required the co-ordinated efforts of statesmen, labor, industry, educators and physicians.
It found reflections 40 years later in the Ottawa Charter for health promotion. Around the same time, the twin causality of diseases was also acknowledged by J. Ryle, the first Professor of Social Medicine in Great Britain, who also drew attention to its applicability to non communicable diseases. Health education and health promotion are two terms which are sometimes used interchangeably. Health education is about providing health information and knowledge to individuals and communities and providing skills to enable individuals to adopt healthy behaviors voluntarily.
It is a combination of learning experiences designed to help individuals and communities improve their health, by increasing their knowledge or influencing their attitudes, whereas health promotion takes a more comprehensive approach to promoting health by involving various players and focusing on multisectoral approaches.
Health education, anticipatory guidance and parenting skill development
Health promotion has a much broader perspective and it is tuned to respond to developments which have a direct or indirect bearing on health such as inequities, changes in the patterns of consumption, environments, cultural beliefs, etc. The Health Field concept spelt out five strategies for health promotion, regulatory mechanisms, research, efficient health care and goal setting and 23 possible courses of action.
Lalonde report was criticized by skeptics as a ploy to stem in the governments rising health care costs by adopting health promotion policies and shifting responsibility of health to local governments and individuals.
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The landmark concept also set the tone for public health discourse and practice in the decades to come. Growing expectations in public health around the world prompted WHO to partner with Canada to host an international conference on Health Promotion in The Ottawa Charter defined Health Promotion as the process of enabling people to increase control over and to improve their health. To reach a state of complete physical, mental and social well being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment.
Health is, therefore, seen as a resource for everyday life, not the objective of living. The fundamental conditions and resources for health are: Health promotion thus is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well being. The Charter called for advocacy for health actions for bringing about favorable political, economic, social, cultural, environmental, behavioral and biological factors for health, enabling people to take control of the factors influencing their health and mediation for multi sectoral action.
The Charter defined Health Promotion action as one a which builds up healthy public policy that combines diverse but complementary approaches including legislation, fiscal measures, taxation and organizational change to build policies which foster equity, b create supportive environments, c support community action through empowerment of communities - their ownership and control of their own endeavors and destinies, d develop personal skills by providing information, education for health, and enhancing life skills and e reorienting health services towards health promotion from just providing clinical and curative services.
This benchmark conference led to a series of conferences on health promotion - Adelaide , Sundsvall , Jakarta , Mexico-City , Bangkok and Nairobi In Adelaide, the member states acknowledged that government sectors such as agriculture, trade, education, industry and communication had to consider health as an essential factor when formulating healthy public policy. The Sundsvall statement highlighted that poverty and deprivation affecting millions of people who were living in extremely degraded environment affected health.
In Jakarta too poverty, low status of women, civil and domestic violence were listed as the major threats to health. The Mexico statement called upon the international community to address the social determinants of health to facilitate achievement of health-related millennium development goals.
The Bangkok charter identified four commitments to make health promotion a central to the global development agenda; b a core responsibility for all governments c a key focus of communities and civil society; and d a requirement for good corporate practice. The health promotion emblem [ Figure 2 ] adopted at the first international conference on health promotion in Ottawa and evolved at subsequent conferences symbolizes the approach to health promotion.
The logo has a circle with three wings. It incorporates five key action areas in health promotion build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills and reorient health services and three basic HP strategies to enable, mediate and advocate.
True to its recognition of health being more influenced by factors outside the health sector, health promotion calls for concerted action by multiple sectors in advocacy, financial investment, capacity building, legislations, research and building partnerships. The multisectoral stakeholder approach includes participation from different ministries, public and private sector institutions, civil society, and communities all under the aegis of the Ministry of Health.
Health promotion efforts can be directed toward priority health conditions involving a large population and promoting multiple interventions. This issue-based approach will work best if complemented by settings-based designs. The settings-based designs can be implemented in schools, workplaces, markets, residential areas, etc to address priority health problems by taking into account the complex health determinants such as behaviors, cultural beliefs, practices, etc that operate in the places people live and work.
Settings-based design also facilitates integration of health promotion actions into the social activities with consideration for existing local situations. The conceptual framework in Figure 3 below summarizes the approaches to health promotion. It looks at the need of the whole population. The population for any disease can be divided into four groups a healthy population, b population with risk factors, c population with symptoms and d population with disease or disorder.
Each of these four population groups needs to be targeted with specific interventions to comprehensively address the need of the whole population. In brief, it encompassed primordial prevention for healthy population to curative and rehabilitative care of the population with disease. Primordial prevention aspires to establish and maintain conditions to minimize hazards to health.
Appropriate settings for health promotion (e.g. Schools, the workplace) | Health Knowledge
It consists of actions and measures that inhibit the emergence and establishment of environmental, economic, social and behavioral conditions, cultural patterns of living known to increase the risk of disease. Health promotion measures are often targeted at a number of priority disease — both communicable and noncommunicable. The Millennium Development Goals MDGs had identified certain key health issues, the improvement of which was recognized as critical to development.
These issues include maternal and child health, malaria, tuberculosis and HIV and other determinants of health.
Although not acknowledged at the Millennium summit and not reflected in the MDGs, the last two decades saw the emergence of NCD as the major contributor to global disease burden and mortality. NCDs are largely preventable by effective and feasible public health interventions that tackle major modifiable risk factors - tobacco use, improper diet, physical inactivity, and harmful use of alcohol. The following paragraphs showcase the application of an issue based approach of health promotion, using communicable and NCDs as examples capturing the components of individual and community empowerment, health system strengthening and partnership development.
These diseases can be adequately addressed through health promotion approach. Here is one example:. Improving use of ITNs to prevent malaria: Insecticide-treated bed-nets ITNs are recommended in malaria endemic areas as a key intervention at the individual level in preventing malaria by preventing contact between mosquitoes and humans. Available evidence points to the fact that this can be best achieved by social marketing campaigns to promote demand of ITNs. Universal child and family health services have the opportunity to conduct a range of evidence-based health promotion strategies that aim to encourage families to create attitudes, behaviours and environments to promote optimal health for children.
There are many ways in which health promotion is delivered in a universal child and family health service and these may include: There are four core service elements related to health promotion: Prevention of disease, injury and illness Prevention of disease is a core component of child and family health service provision. The combination of monitoring of child and family health whilst conducting preventative health activities provides opportunities for early intervention and detection and the prevention of ill-health. These components may occur during individual contact with parents and carers, or in a group setting [74, 75].
The benefits of a group delivery include peer support and cost-effective use of resources. Health education is not only concerned with the communication of information, but also with fostering the motivation, skills and confidence self-efficacy necessary to take action to improve health. For example, health education by child and family health services includes providing structured breastfeeding support.
Systematic reviews in the Cochrane Library have identified the importance of support to the success of breastfeeding  with both peer and professional support shown to be effective in increasing breastfeeding rates during the first two months following birth. Child and family health nurses are regularly involved in interventions providing structured breastfeeding support to mothers .
It provides parents with the knowledge they need to provide positive experiences and environments for their child and reduces the anxiety for new parents. For example, universal child and family health services are well positioned to actively influence parents and carers to undertake activities that promote literacy development . Furthermore, through play, children practise and master the necessary skills needed for later childhood and adult life . Parents and carers play an important role in the facilitation of play as they respond to and promote the interactions of their child.
Common anticipatory guidance topics based on the review of state and territory frameworks are provided in Table 6. One study found that when more than nine topics were discussed at any one session, parent recall decreased significantly . Services may determine health promotion education strategies beyond the core health promotion topics above to reflect the needs of the community, or their practice wisdom. However, some targeting of messages at each contact is likely to improve the effectiveness of the activities.
Support for mothers, fathers and carers Parents value appropriate support to assist in building confidence across key transition points such as transition to parenthood  and transition to school . Maternal health The health of the mother or primary carer is integral to the health and wellbeing of the child and family.