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Evaluation in Health Promotion - Principles and Perspectives
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Evaluation in health promotion
Ev
Evalua
aluattion
in healt
healthh
promotion
omotion
pr
inciples and
Principles
es
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WHO Regional Publications
European Series, No. 92
Evaluation in health promotion
Principles and perspectives
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Evaluation in health promotion
Principles and perspectives
Edited by:
Irving Rootman, Michael Goodstadt,
Brian Hyndman, David V. McQueen,
Louise Potvin, Jane Springett
and Erio Ziglio
Health
Canada
Sant
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WHO Regional Publications, European Series, No. 92
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Part 1. Introduction and framework
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Introduction and framework
Introduction to the book
Irving Rootman
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A framework for
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Irving Rootman, Michael Goodstadt,
Louise Potvin and Jane Springett
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Table 1.1. Definitions of health promotion
Source and date
Definition (emphasis added)
Lalonde, 1974 (3)
A strategy aimed at informing, influencing and assisting both individuals
and organizations so that they will accept more responsibility and be
more active in matters affecting mental and physical health
US Department of
Health, Education, and
Welfare, 1979 (19)
A combination of health education and related organizational, political
and economic programs designed to support changes in behavior and in
the environment that will improve health
Green, 1980 (20)
Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and
environmental changes that will improve health
Green & Iverson, 1982
(21)
Any combination of health education and related organizational, economic, and environmental supports for behavior conducive to health
Perry & Jessor, 1985 (22) The implementation of efforts to foster improved health and well-being in
all four domains of health [physical, social, psychological and personal]
Nutbeam, 1985 (23)
The process of enabling people to increase control over the determinants
of health and thereby improve their health
WHO, 1984 (24), 1986
(4) and Epp, 1986 (25)
The process of enabling people to increase control over, and to improve,
their health
Goodstadt et al., 1987
(26)
The maintenance and enhancement of existing levels of health through
the implementation of effective programs, services, and policies
Kar, 1989 (27)
The advancement of wellbeing and the avoidance of health risks by
achieving optimal levels of the behavioral, societal, environmental and
biomedical determinants of health
ODonnell, 1989 (28)
The science and art of helping people choose their lifestyles to move
toward a state of optimal health
Labont & Little, 1992
(29)
Any activity or program designed to improve social and environmental
living conditions such that peoples experience of well-being is increased
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Table 1.2. Definitions of health promotion deconstructed
Source and date
Activities
(programmes, policies, etc.)
Winslow, 1920 (2)
Organized community effort for the education of the individual in personal
health, and the development of the social
machinery
Processes
(underlying mechanisms)
Sigerist, 1946 (1)
Objectives
(instrumental outcomes)
Goals
(ultimate outcomes)
... to ensure everyone a
standard of living
... the maintenance or
improvement of health
Health is promoted
... by providing a decent
standard of living, good labor
conditions, education, physical
culture, means of rest and recreation
Lalonde, 1974 (3)
... informing, influencing and assisting ... so that they [individuals
both individuals and organizations
and organizations] will accept
more responsibility and be
more active in matters affecting mental and physical
health
US Department of Health,
Education, and Welfare,
1979 (19)
A combination of health education and
related organizational, political and economic programs
that will improve health
designed to support
changes in behavior and in the
environment
Green, 1980 (20)
Any combination of health education
and related organizational, political and
economic interventions
... that will improve health
... designed to facilitate
behavioral and environmental
changes
66
Green & Iverson, 1982 (21) Any combination of health education
and related organizational, political and
economic supports
for behavior
conducive to health
6E
Source and date
Activities
(programmes, policies, etc.)
Perry & Jessor, 1985 (22)
The implementation of efforts
Processes
(underlying mechanisms)
Objectives
(instrumental outcomes)
Goals
(ultimate outcomes)
... to foster improved health
and well-being in all four
domains of health [physical,
social, psychological and personal]
Nutbeam, 1985 (23)
The process of enabling peo- over the determinants of ... and thereby improve their
ple to increase control
health
health
WHO, 1984 (24), 1986 (4)
Epp, 1986 (25)
The process of enabling people to increase control over
[their health]
Goodstadt et al., 1987 (26) through the implementation of
effective programs, services, and policies
Kar, 1989 (27)
and thereby to improve
their health
The maintenance and
enhancement of existing levels
of health
The advancement of wellbe and the avoidance of
health risks by achieving opti- ing
mal levels of the behavioral,
societal, environmental, and
biomedical determinants of
health
ODonnell, 1989 (28)
The science and art of helping people
choose their lifestyles
... to move toward a state of
optimal health
Green & Kreuter, 1991 (7)
The combination of educational and
environmental supports for actions and
conditions of living
... conducive to health
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Perspectives
Introduction
Louise Potvin
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Beyond process and outcome
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Environmental conditions
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Table 4.1. Characteristics of positivism and hermeneutics
Positivism
Hermeneutics
Objective observation
Critical subjectivity
Explanation and prediction
Understanding and finding meaning
Search for general knowledge and
standardization
View of every situation as unique
View of social organization as combinations Stress on richness, variety and depth
of similar things
Surface view
Hypothesis testing through formal definition Dialectical cycle to gain knowledge
of ideas and measurement
Mechanistic, with a focus on an object that Dialogue and subjective participation (understanding
has no voice and is submissive
is not real unless it is mutual)
Aim: the power to control the collection of
facts
Aim: enlightenment, edification, enrichment, personal
growth
Emphasis on quantity
Emphasis on quality
Source: adapted from Dahlbom & Mathiassen (4).
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Concrete
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approach to and methods of programme evaluation
Question
Natural sciences
Who performs evaluation? External experts
Social sciences
Community, project staff facilitator
What is examined?
Indicators of success identified by
Predetermined indicators of
success, principally cost and health participants, which may include
health outcomes and gains
outcomes/gains
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Focus on objectivity, distancing
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Usually at programme completion; Merging of monitoring and evalusometimes also mid-term
ation; hence frequent small-scale
evaluation
Why?
To ensure accountability, usually
summative, to determine whether
funding continues
Self-evaluation, simple methods
adapted to local culture; open,
immediate sharing of results
through local involvement in evaluation processes
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take and control corrective action
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Table 4.3. The advantages and disadvantages
of external and internal evaluators
External evaluators
Internal evaluators
Can take a fresh look at the programme
Know the programme well
Are not personally involved
Find it harder to be objective
Are not part of the programmes normal power
structure
Are part of the programmes normal power structure
Gain nothing from programmes, but may gain
prestige from evaluations
May be motivated by hopes of personal gain
Are trained in evaluation methods, may have
experience with other evaluations, are regarded
as experts by programme participants
May not be trained in evaluation methods, have
little or no more training than others in the programme
Are outsiders who may not understand programmes or the people involved
Are familiar with and understand programmes
and can interpret personal behaviour and attitudes
Source: Fuerstein (29).
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Table 6.1. Lindstrms model for the quality of life of children
in Nordic countries
Spheres
Global
External
Dimensions
1. Macro environment
2. Culture
3. Human rights
4. Welfare policies
1. Work
2. Income
Interpersonal
Personal
Examples
Physical environment
Responsiveness to the United Nations
Convention on the Rights of the Child
Welfare distribution
Parental education and satisfaction
with employment
Income distribution
3. Housing
1. Family structure and function
Quality of and satisfaction with housing
Satisfaction with family, lack of
negative events
2. Intimate friends
3. Extended social networks
Support from friends, neighbours and
society
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2. Mental
3. Spiritual
Growth, activity
Self-esteem and mood
Meaning of life
Source: Lindstrm (66).
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Domains
Subdomains
Contents
Being
Physical
Physical health, mobility, nutrition, exercise, fitness and
appearance
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Independence, autonomy, self-acceptance and freedom
from stress
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Physical
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Economic evaluation
of health promotion
Christine Godfrey
Introduction
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Table 7.1. Different types of full economic evaluation
Type of study
Treatment of alternatives
Measurement/
Valuation of costs
in alternatives
Identification of
consequences
Measurement/
Valuation of
consequences
Cost-minimization
analysis
Monetary terms
Identical in all relevant
respects
None
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analysis
Monetary terms
Natural units (life years
Single effect of interest,
gained, numbers stopping
common to both
alternatives, but achieved to smoking, etc.)
different degrees
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Monetary terms
Single or multiple effects, Healthy years or
not necessarily common to (more often) QALYs
both alternatives
Costbenefit analysis Monetary terms
Single or multiple effects, Monetary terms
not necessarily common to
both alternatives
Source: adapted from Drummond et al. (1).
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Table 7.2. An example of costbenefit analysis:
legislation for bicycle helmets in Israel
Benefits and costs
Values (US $)
Benefits
Value of lives saved
8 939 979
Reduced health care costs
17 412 622
Reduced long-term care costs
25 263 243
Reduced need for special education
1 527 131
Productivity gain from reduced disabilities
7 545 779
60 688 754
Costs
Health education programme and helmets
Total social benefits
(20 143 984)
40 544 770
Source: adapted from Ginsberg & Silverberg (17).
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Health promotion: towards
a quality assurance framework
Richard Parish
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Clarify the health promotion
issue or problem
Agree the target groups
Formulate precise programme
objectives: usually educational,
behavioural, environmental or
organizational
Quantify desired outcome
within given period of time
(target setting)
Rewiew possible
methodological approaches
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intervention required and
time limits
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knowledge, attitudes,
behaviour, environmental
factors and organizational
systems
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approximate costs, time limits
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environmental constraints
Consult
stakeholders
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required
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groups, significant mediators
and support systems
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training required
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unproven methods are proposed
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Investigating policy
networks for health:
theory and method in a larger
organizational perspective
Evelyne de Leeuw 22
Introduction
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4
11
Evaluating community initiatives
for health and development
Stephen B. Fawcett, Adrienne Paine-Andrews,
Vincent T. Francisco, Jerry Schultz, Kimber P. Richter,
Jannette Berkley-Patton, Jacqueline L. Fisher,
Rhonda K. Lewis, Christine M. Lopez, Stergios Russos,
Ella L. Williams, Kari J. Harris and Paul Evensen 3 3
Introduction
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Fig. 11.1. The community initiative as a catalyst for change
Dissemination
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Fig. 11.2. Logic model for the documentation and evaluation system of the University of Kansas
Work Group on Health Promotion and Community Development
Phases of
community
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evaluation
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adolescent pregnancy in Geary County, Kansas, 19931996
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13
Evaluating health promotion
programmes in the workplace
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Introduction
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Table 13.1. Participatory evaluation of a health promotion programme: main actions, associated actions and comments
Main actions
Associated actions
Step 1. Clarify the aims Get the participants on board.
Set up an evaluation group.
and objectives of the
proposed programme. Determine what the real health problem is.
Establish baseline information.
Comments
The importance of spending time on this groundwork cannot be overemphasized. Involvement of the right people will ensure commitment
to the use of the information generated and a good response to any
questionnaires. The evaluation group (at least three people) should
reflect the range of interests. Proper clarification makes the evaluation straightforward.
Step 2. Design the
framework for evaluation and what questions to ask.
Decide the purpose of the evaluation and who will use the information.
Decide what questions are useful to ask in relation to achieving aims
and objectives.
Decide from whom to collect information.
Decide whether process as well as outcome information is needed.
Take this action before deciding what measures to use. If the objectives have been stated clearly, this should be relatively easy. Be clear
about the aims of the evaluation; this affects what questions are
asked. The main aim is to see whether the activities in the programme resulted in achieving the stated objectives. Try to look at
process as well as outcome.
Step 3. Design the
framework for evaluation and decide how
to measure change.
Decide what to measure and which methods to use.
Decide on sample size and target population.
Decide when to collect the information.
Good measurement depends on being clear about the issues. Methods should be appropriate to the questions and need not be numerical. Be realistic and honest about limitations of time and money.
Step 4. Collect the data. Make sure data collection is unobtrusive and does not add to partici- There will be problems of confidentiality and bias. Bias is most common in self-reported behaviour. Problems are smaller if all stakeholdpants workload or, if it does, they can see the value of doing it.
ers have been involved. Participation is a key.
Make sure participants are still on board.
Keep participants informed by regular feedback.
Remember that data are not information.
Main actions
Associated actions
Interpret data in association with the evaluation group, comparing
Step 5. Evaluate the
results to determine the what actually happened with what was expected.
effectiveness of the pro- Remember that numbers are only indicators of what the world is like.
gramme.
Step 6. Make recommendations.
Comments
Data are not information until they have been interpreted. This is best
done as a collaborative process, so the participants understand how
the results were obtained. Remember the value of so-called soft
information, and that some health changes take time to be revealed.
If the participants have been involved in the process, they will already
Clarify what is useful.
be committed to acting on the findings and be receptive to results
Cover practical changes for immediate implementation.
Include the costs and benefits of not implementing as well as implementing the recommendations. Challenge existing beliefs.
Look for longer-term changes that may not yet be visible.
Source: Workplace Task Force report. London, Department of Health, 1993.
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Evaluation in urban settings:
the challenge of Healthy Cities
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Part 4
Policies and systems
Introduction
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for healthy public policies at the local level
Levels
Outcomes
Health promotion agendas and issue networks
Healthy public policies
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Cooperative planning
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External evaluation
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structures and actors on
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Fig. 15.4. Desired implementation structure for healthy public policies
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Umbrella Group
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9
16
Evaluation of health promotion
policies: tracking a moving target
Nancy Milio
Introduction
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Evaluation: concept, problem and purpose
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Policy environment
Fig. 16.1. Health organizations and policy-making
Policy impacts
Goods and services: jobs, housing, food, education, environment
Economy
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Technologymedia mix
Ideologies
Political processes
Organizations:
public
private (profit
and non-profit)
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and interpretive
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total population
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Fig. 16.2. Media and policy-making processes
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editorials
opinion poll reports
political advertisements
Publics:
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audiences
taxpayers
voters
political contributors
potential interest-group
members
legislative committees
bureaucratic units
parties
caucuses
lobbies of industry,
labour, professions,
voluntary organizations
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Table 16.1. Strategies for disease prevention and health promotion
Intervention strategy
Focus
Individual-directed, information-mediated change
Homes and communities
Organization settings
Organization-directed change
Policy bodies:
legislatural bodies
independent regulatory agencies
government administration
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government bodies
other organizations
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17
Evaluation of countrywide
health promotion policies:
the Canadian experience
Reg Warren, Irving Rootman and Rick Wilson
Introduction
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challenges and barriers
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18
Health impact assessment
as a tool for health promotion
and population health
C. James Frankish, Lawrence W. Green, Pamela A. Ratner,
Treena Chomik and Craig Larsen
Introduction
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Fig. 18.1. Influences of policies and programmes on health
Policies and programmes
(health or non-health)
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of health
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(outcomes)
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Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). Minister of Public Works and
Government Services Canada, 2001.
&@;
Fig. 18.2. Potential impact of policies and programmes
Environmental
impact
Health
impact
Social
impact
Economic
impact
Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). Minister of Public Works and
Government Services Canada, 2001.
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Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). Minister of Public Works and
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19
Social capital: evaluation
implications for community
health promotion
Marshall W. Kreuter, Nicole A. Lezin,
Laura Young and Adam N. Koplan 55
Introduction
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Town A
(high social capital)
Town B
(low social capital)
Community leaders
Community leaders
Newspaper
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survey
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extension
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Population perceptions of social capital
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References
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Investment for health: developing a
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Part 5
Synthesis and conclusion
23
Evaluation in health promotion:
synthesis and recommendations
Michael S. Goodstadt, Brian Hyndman, David V. McQueen,
Louise Potvin, Irving Rootman and Jane Springett
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VALUES
Positive health, holistic health, social justice, equity, participation
MECHANISM
Empowerment: enhancing capacities of individuals and communities to exercise control over the
determinants of health
PREREQUSITES (DETERMINANTS) OF HEALTH
Income equity/inequity, social status, social support networks, education, employment and working
conditions, physical environments, biology and genetics, personal health practices and coping skills,
healthy/unhealthy child development, health services
Core perspectives
EVALUATION LOOP
Outcomes or
objectives
Action areas
MICRO-LEVEL OBJECTIVES
MESO-LEVEL OBJECTIVES
MACRO-LEVEL OBJECTIVES
Enhanced individual capacities
Enhanced community capacities
Supportive institutional and societal environments
Developing
personal skills
Strengthening
community action
Improved awareness,
knowledge, skills,
decision-making
and behaviour
Enhanced
organizational
capacity
Creating
supportive
environments
Increased
community
capacity and
participation
Building healthy
public policy
Enhanced
health
promoting
policies
Reorienting
health services
More equitable
access to health
care
Increased focus on
prevention and health
promotion in health
care system
Increased
knowledge on
effectiveness
Resource inputs
Generic strategies
Instrumental
activities, products
and outputs
Health
education
Programme,
marketing and
materials
EVALUATION LOOP
Health
communication
Modified
organizational
structures and
climate
Organizational
development
Community
development
Coordination of community
efforts, enhanced community
resources and capacities, and
community coalition building
Policy
development
Laws and
regulations,
policy
statements
Advocacy
Public dialogue
on decisionmaking
INSTRUMENTAL OBJECTIVES, PROCESSES AND OUTCOMES
Intersectoral
collaboration
Coordination of
policies and activities
in sectors that affect
health
Research/
Evaluation
Knowledge
development and
dissemination
PLANNING HEALTH PROMOTION
INITIATIVES
Instrumental
objectives,
processes and
outcomes
Reduced mortality and morbidity
Improved health and wellbeing
Fig. 23.1. Generic logic model for planning and evaluating health promotion
Health promotion goals
Reduced health and social costs
THE FOUNDATIONS OF HEALTH PROMOTION
(Ottawa Charter for Health Promotion)
+
8
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Individuals, communities and societies
achieve/approach their potentials
Overall impacts
!
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77
Evaluation
in health
promotion
Policy-makers, professionals of
all kinds and the general public
increasingly recognize social
and economic factors as important determinants of health. Because health promotion approaches address these factors,
they can play an increasingly
valuable role in protecting and
improving health. At the same
time, funding sources increasingly demand evidence that initiatives give value for money. Health promotion initiatives need effective evaluation to realize their potential: both
to prove their value as investments and to increase their effectiveness in
achieving their aims.
To help meet this need, the WHO European Working Group on Health
Promotion Evaluation examined the current range of qualitative and
quantitative evaluation methods to provide guidance to policy-makers
and practitioners. This book is the result. It comprises an extensive compilation and discussion of the theory, methodologies and practice of evaluating health promotion initiatives in Europe and the Americas. The book
takes three perspectives in examining the issues. It includes a retrospective examination of the evolution of health promotion evaluation. This
provides the context for assessing and understanding the current state of
evaluations of initiatives addressing settings, polices and systems for
promoting health. Finally, the chapter authors and the Working Group as
a whole make many recommendations for improvement that provide a
look into the future.
This book shows how a health promotion approach offers a comprehensive framework for planning and implementing interventions that can effectively address todays major health-related problems. The authors describe how good evaluations assist initiatives in achieving their goals,
provide a wealth of guidance on how to undertake them and call for
greater investment in the evaluation of health promotion. The authors
hope that their work will stimulate policy-makers and practitioners to invest in and undertake good evaluation for good health promotion. This is
their commitment; they hope that readers share it.
ISBN 92 890 1359 1
Sw.fr. 122.
pr
Pr
perspectives
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