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WHO Regional PublicationsEuropean Series, No. 92
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Evaluation in health promotionPrinciples and perspectives
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Evaluation in health promotionPrinciples and perspectives
Edited by:Irving Rootman, Michael Goodstadt,Brian Hyndman, David
V. McQueen,
Louise Potvin, Jane Springettand Erio Ziglio
WHO Regional Publications, European Series, No. 92
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Part 1. Introduction and framework3,"0
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Part 1Introduction and framework
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Introduction to the bookIrving Rootman
WHO European Working Group on Health Promotion Evaluation !""
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1A framework for
health promotion evaluationIrving Rootman, Michael
Goodstadt,
Louise Potvin and Jane Springett
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What is health promotion? " !B!"! 9"3!3
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Table 1.1. Definitions of health promotion
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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, politi-cal 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,
eco-nomic, 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
-
66
Table 1.2. Definitions of health promotion deconstructed
Source and date Activities(programmes, policies, etc.)
Processes (underlying mechanisms)
Objectives (instrumental outcomes)
Goals(ultimate outcomes)
Winslow, 1920 (2) Organized community effort for the edu-cation
of the individual in personal health, and the development of the
social machinery
... to ensure everyone a standard of living
... the maintenance or improvement of health
Sigerist, 1946 (1) ... by providing a decent standard of living,
good labor conditions, education, physical culture, means of rest
and rec-reation
Health is promoted
Lalonde, 1974 (3) ... informing, influencing and assisting both
individuals and organizations
... so that they [individuals and organizations] will accept
more responsibility and be more active in matters affect-ing mental
and physical health
US Department of Health, Education, and Welfare, 1979 (19)
A combination of health education and related organizational,
political and eco-nomic 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, political and economic
supports
for behavior conducive to health
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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 per-sonal]
Nutbeam, 1985 (23) The process of enabling peo-ple to increase
control
over the determinants of health
... and thereby improve their health
WHO, 1984 (24), 1986 (4)Epp, 1986 (25)
The process of enabling peo-ple to increase control over [their
health]
and thereby to improve their health
Goodstadt et al., 1987 (26) through the implementation of
effective programs, services, and poli-cies
The maintenance and enhancement of existing levels of health
Kar, 1989 (27) and the avoidance of health risks by achieving
opti-mal levels of the behavioral, societal, environmental, and
biomedical determinants of health
The advancement of wellbe-ing
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
Source and date Activities(programmes, policies, etc.)
Processes (underlying mechanisms)
Objectives (instrumental outcomes)
Goals(ultimate outcomes)
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evaluation in health promotionJane Springett
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Source: adapted from Dahlbom & Mathiassen (4).
Positivism Hermeneutics
Objective observation Critical subjectivity
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Search for general knowledge and standardization
View of every situation as unique
View of social organization as combinations of similar
thingsSurface view
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measurement
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Who performs evaluation? External experts Community, project
staff facilitator
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Indicators of success identified by participants, which may
include health outcomes and gains
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participants; uniform, complex procedures; delayed, limited
distribution of results
Self-evaluation, simple methods adapted to local culture; open,
immediate sharing of results through local involvement in
evalu-ation processes
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mid-term
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small-scale evaluation
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whether funding continues
To empower local people to initiate, take and control corrective
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initiatives in health promotionDennis Raphael
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Source: Lindstrm (66).
Spheres Dimensions ExamplesGlobal 1. Macro environment Physical
environment
2. Culture3. Human rights
Responsiveness to the United Nations Convention on the Rights of
the Child
4. Welfare policies Welfare distributionExternal 1. Work
Parental education and satisfaction
with employment 2. Income Income distribution3. Housing Quality
of and satisfaction with housing
Interpersonal 1. Family structure and function Satisfaction with
family, lack of negative events
2. Intimate friends3. Extended social networks
Support from friends, neighbours and society
Personal 1. Physical Growth, activity2. Mental Self-esteem and
mood3. Spiritual Meaning of life
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Being Physical Physical health, mobility, nutrition, exercise,
fitness and appearance
Psychological Independence, autonomy, self-acceptance and
freedom from stress
Spiritual Personal values and standards and spiritual
beliefs
Belonging Physical Physical aspects of the immediate
environment
Social Relationships with family, friends and acquaintances
Community Availability of societal resources and services
Becoming Practical Home, school and work activities
Leisure Indoor and outdoor activities, recreational
resources
Growth Learning things, improving skills and relationships,
adapting to life
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7Economic evaluationof health promotion
Christine Godfrey
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Monetary terms Single effect of interest, common to both
alternatives, but achieved to different degrees
Natural units (life years gained, numbers stopping smoking,
etc.)
Costutility analysis Monetary terms Single or multiple effects,
not necessarily common to both alternatives
Healthy years or (more often) QALYs
Costbenefit analysis Monetary terms Single or multiple effects,
not necessarily common to both alternatives
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bicycle helmets in Israel
Source: adapted from Ginsberg & Silverberg (17).
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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 (20 143 984)
Total social benefits 40 544 770
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planning
Take account of the natureof the issues, level ofintervention
required andtime limits
Take account of existingknowledge, attitudes,behaviour,
environmentalfactors and organizationalsystems
Have due regard ofapproximate costs, time limitsand social,
economic andenvironmental constraints
Determine immediate targetgroups, significant mediatorsand
support systems
Determine skills deficit andtraining required
Modify programme ifnecessary
Clarify the health promotionissue or problem
Agree the target groups
Formulate precise programmeobjectives: usually
educational,behavioural, environmental ororganizational
Quantify desired outcomewithin given period of time(target
setting)
Rewiew possiblemethodological approaches
Agree intervention approach
Determine precise resourcesrequired
Acquire funding and otherresources
Allocate tasks
Pilot-test progamme whereunproven methods are proposed
Execute programme
Evaluate programme
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9Investigating policy
networks for health:theory and method in a larger
organizational perspectiveEvelyne de Leeuw 2
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11Evaluating community initiatives
for health and developmentStephen 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
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? Table 13.1. Participatory evaluation of a health promotion
programme: main actions, associated actions and comments
Main actions Associated actions Comments
Step 1. Clarify the aims and objectives of the proposed
programme.
Get the participants on board.Set up an evaluation
group.Determine what the real health problem is.Establish baseline
information.
The importance of spending time on this groundwork cannot be
over-emphasized. 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 evalu-ation straightforward.
Step 2. Design the framework for evalu-ation and what ques-tions
to ask.
Decide the purpose of the evaluation and who will use the
informa-tion.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
objec-tives 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 pro-gramme resulted in achieving the stated objectives. Try
to look at process as well as outcome.
Step 3. Design the framework for evalu-ation 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.
Meth-ods should be appropriate to the questions and need not be
numeri-cal. 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-pants workload or, if it
does, they can see the value of doing it.Make sure participants are
still on board.Keep participants informed by regular
feedback.Remember that data are not information.
There will be problems of confidentiality and bias. Bias is most
com-mon in self-reported behaviour. Problems are smaller if all
stakehold-ers have been involved. Participation is a key.
-
Source: Workplace Task Force report. London, Department of
Health, 1993.
Step 5. Evaluate the results to determine the effectiveness of
the pro-gramme.
Interpret data in association with the evaluation group,
comparing what actually happened with what was expected. Remember
that numbers are only indicators of what the world is like.
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.
Step 6. Make recom-mendations.
Clarify what is useful.Cover practical changes for immediate
implementation.Include the costs and benefits of not implementing
as well as imple-menting the recommendations. Challenge existing
beliefs. Look for longer-term changes that may not yet be
visible.
If the participants have been involved in the process, they will
already be committed to acting on the findings and be receptive to
results
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Part 4Policies and systems
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healthy public policies at the local level
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Levels Outcomes
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group dynamics
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workEncouragement ofintegrated strategy
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16Evaluation of health promotion
policies: tracking a moving targetNancy Milio
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17Evaluation of countrywidehealth promotion policies:
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