Manager beliefs regarding worksite health promotion: findings from the Working Healthy Project 2

PURPOSE: To explore differences in manager beliefs about worksite health promotion programs (HPPs). DESIGN: Cross-sectional written survey. SETTING: Twenty-four manufacturing worksites, with 11,811 employees and 1719 eligible managers. SUBJECTS: Sixty-six percent (1133/1719) of managers completed the survey; 1047 managers were categorized by level (169 senior, 567 middle, and 311 line supervisors). ANALYSIS: Results are reported on overall manager beliefs (and by manager level) about importance, efficacy, barriers, and benefits of HPPs. Multilevel analysis modeled the influence of manager level, age, and experience with HPPs on beliefs about HPPs, while accounting for worksite-level effects. RESULTS: Seventy-five percent of managers believed that offering HPPs is highly important. Eighty percent believed that HPPs improved employee health, 68% believed that they reduced health care costs, and 67% believed that they improved employee morale. Few significant differences by manager level were observed on the perceived importance of health promotion, employer responsibilities for health promotion and protection, and efficacy of health promotion strategies or perceived benefits. Senior managers (vs. line supervisors) were significantly less likely to believe that space or cost was a barrier to offering HPPs and were less likely than middle managers or line supervisors to believe that production conflicts were barriers to offering HPPs. CONCLUSION: Targeted interventions to address manager beliefs, including differences by age, experience, and manager level, are worth consideration when planning worksite HPPs.     

Realist review--a new method of systematic review designed for complex policy interventions

Evidence-based policy is a dominant theme in contemporary public services but the practical realities and challenges involved in using evidence in policy-making are formidable. Part of the problem is one of complexity. In health services and other public services, we are dealing with complex social interventions which act on complex social systems--things like league tables, performance measures, regulation and inspection, or funding reforms. These are not 'magic bullets' which will always hit their target, but programmes whose effects are crucially dependent on context and implementation. Traditional methods of review focus on measuring and reporting on programme effectiveness, often find that the evidence is mixed or conflicting, and provide little or no clue as to why the intervention worked or did not work when applied in different contexts or circumstances, deployed by different stakeholders, or used for different purposes. This paper offers a model of research synthesis which is designed to work with complex social interventions or programmes, and which is based on the emerging 'realist' approach to evaluation. It provides an explanatory analysis aimed at discerning what works for whom, in what circumstances, in what respects and how. The first step is to make explicit the programme theory (or theories)--the underlying assumptions about how an intervention is meant to work and what impacts it is expected to have. We then look for empirical evidence to populate this theoretical framework, supporting, contradicting or modifying the programme theories as it goes. The results of the review combine theoretical understanding and empirical evidence, and focus on explaining the relationship between the context in which the intervention is applied, the mechanisms by which it works and the outcomes which are produced. The aim is to enable decision-makers to reach a deeper understanding of the intervention and how it can be made to work most effectively. Realist review does not provide simple answers to complex questions. It will not tell policy-makers or managers whether something works or not, but will provide the policy and practice community with the kind of rich, detailed and highly practical understanding of complex social interventions which is likely to be of much more use to them when planning and implementing programmes at a national, regional or local level.     

La teoría del cambio: una herramienta para la planificación y la evaluación participativa en salud comunitaria

There is a growing interest in finding innovative approaches to the evaluation of complex interventions in public health. This methodological note presents the theory of change as a useful tool to facilitate both the planning and the evaluation of community health promotion interventions. A theory of change is a visual representation of how a programme or intervention works, in which its different components can be identified, together with how they relate to each other: what its objectives are, its expected results and through which actions they are expected to be achieved. It can be an applied research tool, developed using participatory approaches together with all relevant stakeholders, who can identify and jointly decide what to evaluate and how to.     

Making sense of 'gender': from global HIV/AIDS strategy to the local Cambodian ground

Interventions aiming to promote gender equality are a common feature of global HIV/AIDS policies. To develop effective interventions, it is important to understand how globally established concepts (e.g. 'gender') are (re)interpreted and legitimated locally. This paper examines what happens when the concept of 'gender' hits the local ground in the context of an internationally funded HIV/AIDS intervention in Cambodia. Interviews with participants reveal that 'gender' is itself understood to mean equal rights. Some elements of this concept are rejected as inapplicable in Khmer society, while others are hybridised with existing knowledges. The analysis demonstrates how relational, symbolic and material dimensions of the place into which HIV/AIDS programmes intervene shape not only what 'sense' participants make of new knowledge, but also their capacity to use it. Further, the paper argues that to achieve the desired health-enhancing outcomes, international health organisations must avoid essentialising local spaces as static and 'traditional'; rather, they must attend to and build on the ambiguities of existing knowledges and the changing dynamics of the places they enter.     

Applying logics of change to the evaluation of community development in health promotion

Evaluation of community-oriented health promotion programs requirethat professional evaluators clearly distinguish between exogenouslyand endogenously defined goals and definitions of ‘success’.Acknowledging the different dynamics which underpin community-ledchange and externally initiated health programs and interventionsis essential to this task. It will be argued that the intersectionof, and boundaries around, exogenous and endogenous change canbest be understood and clarified through the application of‘logics of rationality’, adapted from social theory.Community activity is characterised by what we have called ‘lifeworldrationality’ community-based health promotion interventionsare characterised by ‘formal ratonality’. In addition,we suggest that the value dimensions (‘substantive rationality’)underpinning programs and interventions may be overlooked bypolicy makers, program planners and professional evaluatorsunder pressure to demonstrate cost-effectiveness and efficiency.Key requirements for successful and appropriate evaluation ofcommunity-based programs which are sensitive to the needs andsuccess criteria of communities include a shared understandingby the researchers, program sponsors and community actors ofthe nature of the changes sought. The co-production of healthpromotion standards and of indicators to judge the performanceof the program or intervention by all stakeholders should bepreferred over the trend for establishing community-controlledprocess evaluations to coexist alongside expert-controlled impactevaluations. It is argued that current approaches to standardsetting and indicator development to judge the processes andimpacts of interventions are inadequate and several principlesfor improving their content are given. A locally controlledethnographic approach to evaluate endogenous community-led changeis described in the hope that program planners and evaluatorsmay become more sensitive and receptive to local knowledge.We suggest that engagement with what we have termed the ‘communitystory’ should be a fundamental requirement for the planningand evaluation of community health programs.     

Investigating community-based health and health promotion for homeless people: a mixed methods review

Homeless people are susceptible to a range of health problems, yet in terms of health promotion, tend to be a hard-to-reach, marginalized group. Robust evidence regarding the ability to engage with this population via effective health promotion programmes is essential if policy and practice are to be informed to improve the health of homeless people. A structured review was conducted with the aim of examining what is known about community-based health promotion for homeless people. Six databases were searched and 8435 records screened. Thirteen studies met the inclusion criteria. A mixed-methods 'combined separate synthesis' approach was used to accommodate both quantitative and qualitative evidence within one review. Three themes emerged: (i) incorporating homelessness, (ii) health improving and (iii) health engaging. The review has implications for health promotion design, with evidence suggesting that as part of a tailored approach, homeless people must be actively involved in intervention development, ensuring that appropriate, acceptable and potentially effective individual elements are incorporated into community-based interventions.     

A simple framework to describe what works best: improving awareness, enhancing motivation, building skills, and providing opportunity

Behavior change is often complex, conceptually challenging, and open to dispute as to the effectiveness of specific interventions. Defining "what works best" in health behavior change discussions is often problematic and can be contentious. In this issue of The Art of Health Promotion the author offers a simple framework to determine what is likely to work best in producing long-term behavior change. The article identifies four components that are highly associated with successful behavior change. These include improving awareness, enhancing motivation, building skills, and providing opportunity for practicing the new skills. This simple framework is likely to be a very useful tool in communicating the essentials of successful behavioral intervention to all major stakeholders in health promotion.     

Improving health promotion through central rating of interventions: the need for Responsive Guidance

Background

In several countries, attempts are made to improve health promotion by centrally rating the effectiveness of health promotion interventions. The Dutch Effectiveness Rating System (ERS) for health promotion interventions is an improvement-oriented approach in which multi-disciplinary expert committees rate available health promotion interventions as ‘theoretically sound’, ‘probably effective’ or ‘proven effective’. The aim of this study is to explore the functioning of the ERS and the perspective of researchers, policy-makers and practitioners regarding its contribution to improvement.

Methods

We interviewed 53 selected key informants from research, policy and practice in the Netherlands and observed the assessment of 12 interventions.

Results

Between 2008 and 2012, a total of 94 interventions were submitted to the ERS, of which 23 were rejected, 58 were rated as ‘theoretically sound’, 10 were rated as ‘probably effective’ and 3 were rated as ‘proven effective’. According to participants, the ERS was intended to facilitate both the improvement of available interventions and the improvement of health promotion in practice. While participants expected that describing and rating interventions promoted learning and enhanced the transferability of interventions, they were concerned that the ERS approach was not suitable for guiding intervention development and improving health promotion in practice. The expert committees that assessed the interventions struggled with a lack of norms for the relevance of effects and questions about how effects should be studied and rated. Health promotion practitioners were concerned that the ERS neglected the local adaptation of interventions and did not encourage the improvement of aspects like applicability and costs. Policy-makers and practitioners were worried that the lack of proven effectiveness legitimised cutbacks rather than learning and advancing health promotion.

Conclusion

While measuring and centrally rating the effectiveness of interventions can be beneficial, the evidence based-inspired ERS approach is too limited to guide both intervention development and the improvement of health promotion in practice. To better contribute to improving health promotion, a more reflexive and responsive guidance approach is required, namely one which stimulates the improvement of different intervention aspects, provides targeted recommendations to practitioners and provides feedback to those who develop and rate interventions.

     

Applicability and transferability of interventions in evidence-based public health

The context in which public health programmes operate can play an important role in influencing their implementation and effectiveness. An intervention that has been shown to be effective in one setting may turn out to be ineffective somewhere else, even supposing it can be implemented there. Therefore, systematic reviews of public health interventions should appraise the applicability of the intervention process and the transferability of the intervention effectiveness to other localities. However, applicability and transferability appraisal is seldom reported in systematic reviews of public health and health promotion interventions. This paper aims to introduce an innovative approach to bridging this gap. A list of attributes that may impact on applicability and transferability can be developed, based on knowledge of the proposed intervention. Then the applicability and transferability of the intervention to the local setting can be rated, and given a score, based on knowledge of the local setting. This approach provides a useful tool for evaluating public health interventions and provides a reliable basis for informed decision making in resource-poor settings, where rigorous primary studies are lacking and where very limited resources put a high demand on evidence-based approaches to health promotion.     

A framework for evaluating health promotion programs

Evaluation of health promotion interventions is essential in order to collect evidence about the efficacy of a program, identify ways to improve practice, justify the use of resources, and identify unexpected outcomes. This paper clarifies the role of evaluation as a crucial component of health promotion interventions. Moreover, it summarises the key elements of the most widely used planning/evaluation frameworks necessary for constructive evaluations of health promotion interventions and incorporates them into a single approach. It provides a methodical framework for the provision of evaluation guidance to health promotion practitioners and discusses the importance of including evaluation when planning any health promotion intervention. The focus of this paper is on the essential elements of the evaluation of health promotion programs.     

A census of economic evaluations in health promotion

While policy makers argue for a greater share of health resources to go to health promotion, action is stalled by, among other things, the perception that little is known about which interventions offer the best health returns. Additionally, what is missing is any sense of what the economic literature in health promotion looks like overall. Where is the economic evidence plentiful and where is it scant? The project described here compiled a census of economic evaluations in health promotion. Studies were classified according to a four-part typology that documented the strategic intent of the intervention, the risk factor being addressed, the population most affected and the setting in which the intervention took place. Since 1990, there have been over 400 economic evaluations of health-promoting interventions in the peer review and grey literatures. Of these, 90% address biological or behavioral determinants of health. Relatively little is known about the economics of population health advocacy or interventions to tackle the social and economic determinants of health. Initiatives are in place to increase the availability of economic evidence. Research is also needed into how to support decision makers' use of imperfect, incomplete and uncertain information.     

Employees attitudes to workplace health promotion programs for cancer prevention

OBJETIVE: We describe a method for feasibility assessment of workplace health promotion (WHP) programs as a necessary prerequisite of any WHP program. METHODS: A total of 167 employees from five workplace communities participated in the study. A questionnaire on the basic components of feasibility (risk factors, attitudes to workplace health promotion interventions, and social-occupational context) was administered. RESULTS: Risk behaviours were common among the employees interviewed. Health promotion in the workplace was favorably viewed by 79% of subjects but reported participation would be lower. Interventions on diet and physical activity received the highest acceptance. Participation would be greatest among local administration employees. CONCLUSIONS: The method demonstrated its utility in obtaining useful data for designing workplace health promotion interventions.     

Local health policy development processes in the Netherlands: an expanded toolbox for health promotion

Although much research has been done on the existence and formation of risk and issue based health policies, there is only little insight in health policy development processes in a broader context. This hampers intervention in these policy processes to adequately develop integrated and effective health policies. Legislation in the Netherlands requires municipalities to develop and implement local health policies. These policies are supposed to aim at the promotion of health across sectors and with a strong community involvement. Health policy development processes have been studied in four Dutch municipalities. For each case, we identified a range of stakeholders and monitored the change or stability of their characteristics over 3 years. In addition, for each case, three overlaying maps of networks were made addressing communication and collaboration actions within the defined set of stakeholders. We point out a number of barriers which impede integrated policy development at the local level: the importance given to local health policy, the medical approach to health development, the organizational self-interest rather than public health concern, the absence of policy entrepreneurial activity. Furthermore, this article advocates the use of complementary theoretical frameworks and the expansion of the methodological toolbox for health promotion. The value of stakeholder and network analysis in the health promotion domain, at this stage, is two-fold. First, mapping relevant actors, their positions and connections in networks provides us with insight into their capacity to participate and contribute to health policy development. Second, these new tools contribute to a further understanding of policy entrepreneurial roles to be taken up by health promotion professionals and health authorities in favour of the socio-environmental approach to health. Notwithstanding the value of this first step, more research is required into both the practical application as well as in the theoretical connections with, for example, Multiple Streams theory.     

The waiting time for heart interventions: trends for percutaneous coronary interventions and cardiothoracic interventions

OBJECTIVE: (a) To describe trends in the number of heart interventions performed over time, (b) to determine the length of waiting lists for elective heart interventions in the Netherlands according to the monthly survey of the Supervisory Committee for Heart Interventions in the Netherlands [Begeleidingscommissie Hartinterventies Nederland (BHN)], (c) to compare the length of the waiting lists with existing standards, and (d) to determine the reliability of the waiting list survey. DESIGN: Prospective. METHOD: Data were obtained from the monthly waiting list survey of the 13 heart centres in the Netherlands (1 January 1999-30 November 2002) and from the intervention registry (1 January 1999-30 June 2001), which was complete for 10 centres. Both the survey and the maintenance of the registry are carried out by the Supervisory Committee for Heart Interventions in the Netherlands. RESULTS: (a) The number of percutaneous coronary interventions performed in the Netherlands has increased. The number of cardiothoracic interventions remained stable. (b) The number of patients waiting for a percutaneous coronary intervention is increasing by 16% per annum. In November 2002 there were 751 patients on the waiting list. The number of patients waiting for a cardiothoracic intervention increased by 20% per annum until August 2001 and since then there has been a decrease of 21% per annum. In November 2002, 1557 patients were on the waiting list. (c) The percentage of patients treated within existing standards has fallen to 78% for percutaneous coronary interventions and to 53% for cardiothoracic interventions. (d) The length of the waiting list and the waiting times obtained in the survey concurred with the data taken from the intervention registry. CONCLUSIONS: The length of the waiting list for heart interventions has increased and complies increasingly less with existing standards. The monthly waiting-list survey was a reliable method of determining the length of waiting lists for elective heart interventions.     

Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions

Social ecological models that describe the interactive characteristics of individuals and environments that underlie health outcomes have long been recommended to guide public health practice. The extent to which such recommendations have been applied in health promotion interventions, however, is unclear. The authors developed a coding system to identify the ecological levels that health promotion programs target and then applied this system to 157 intervention articles from the past 20 years of Health Education & Behavior. Overall, articles were more likely to describe interventions focused on individual and interpersonal characteristics, rather than institutional, community, or policy factors. Interventions that focused on certain topics (nutrition and physical activity) or occurred in particular settings (schools) more successfully adopted a social ecological approach. Health education theory, research, and training may need to be enhanced to better foster successful efforts to modify social and political environments to improve health.     

Efficacy of text messaging-based interventions for health promotion: A meta-analysis

This meta-analysis investigated the efficacy of text messaging-based health promotion interventions. Nineteen randomized controlled trials conducted in 13 countries met inclusion criteria and were coded on a variety of participant, intervention, and methodological moderators. Meta-analytic procedures were used to compute and aggregate effect sizes. The overall weighted mean effect size representing the impact of these interventions on health outcomes was d = .329 (95% CI = .274, .385; p < .001). This effect size was statistically heterogeneous (Q₁₈ = 55.60, p < .001, I² = 67.62), and several variables significantly moderated the effects of interventions. Smoking cessation and physical activity interventions were more successful than interventions targeting other health outcomes. Message tailoring and personalization were significantly associated with greater intervention efficacy. No significant differences were found between text-only interventions and interventions that included texting plus other components. Interventions that used an individualized or decreasing frequency of messages over the course of the intervention were more successful than interventions that used a fixed message frequency. We discuss implications of these results for health promotion interventions that use text messaging.     

Realist randomised controlled trials: A new approach to evaluating complex public health interventions

Randomized trials of complex public health interventions generally aim to identify what works, accrediting specific intervention ‘products’ as effective. This approach often fails to give sufficient consideration to how intervention components interact with each other and with local context. ‘Realists’ argue that trials misunderstand the scientific method, offer only a ‘successionist’ approach to causation, which brackets out the complexity of social causation, and fail to ask which interventions work, for whom and under what circumstances. We counter-argue that trials are useful in evaluating social interventions because randomized control groups actually take proper account of rather than bracket out the complexity of social causation. Nonetheless, realists are right to stress understanding of ‘what works, for whom and under what circumstances’ and to argue for the importance of theorizing and empirically examining underlying mechanisms. We propose that these aims can be (and sometimes already are) examined within randomized trials. Such ‘realist’ trials should aim to: examine the effects of intervention components separately and in combination, for example using multi-arm studies and factorial trials; explore mechanisms of change, for example analysing how pathway variables mediate intervention effects; use multiple trials across contexts to test how intervention effects vary with context; draw on complementary qualitative and quantitative data; and be oriented towards building and validating ‘mid-level’ program theories which would set out how interventions interact with context to produce outcomes. This last suggestion resonates with recent suggestions that, in delivering truly ‘complex’ interventions, fidelity is important not so much in terms of precise activities but, rather, key intervention ‘processes’ and ‘functions’. Realist trials would additionally determine the validity of program theory rather than only examining ‘what works’ to better inform policy and practice in the long-term.     

What can global health institutions do to help strengthen health systems in low income countries?

Weaknesses in health systems contribute to a failure to improve health outcomes in developing countries, despite increased official development assistance. Changes in the demands on health systems, as well as their scope to respond, mean that the situation is likely to become more problematic in the future. Diverse global initiatives seek to strengthen health systems, but progress will require better coordination between them, use of strategies based on the best available evidence obtained especially from evaluation of large scale programs, and improved global aid architecture that supports these processes. This paper sets out the case for global leadership to support health systems investments and help ensure the synergies between vertical and horizontal programs that are essential for effective functioning of health systems. At national level, it is essential to increase capacity to manage and deliver services, situate interventions firmly within national strategies, ensure effective implementation, and co-ordinate external support with local resources. Health systems performance should be monitored, with clear lines of accountability, and reforms should build on evidence of what works in what circumstances.     

Why don't stage-based activity promotion interventions work?

Despite the well-described benefits of regular physical activity, around 70% of adults in the UK fail to meet current activity recommendations. Interventions based on the Transtheoretical, or Stages of Change, Model of behaviour change have been proposed as one potentially effective method of promoting physical activity levels. However, two recent reviews have found little evidence that individualized stage-based activity promotion interventions are any more effective than control conditions in promoting long-term adherence to increased levels of physical activity. Possible reasons for this are: that exercise behaviour is a more complex group of behaviours than currently recognized; that many algorithms for determining current stage of activity change have not been validated; that exercise behaviour is determined by a number of factors not addressed by stage-based interventions; that the stages of change model encourages focus on stage progression which is not always associated with behaviour change; and that truly stage-based interventions are highly complex requiring more than one level of development and evaluation--a challenge that has not yet been met. Thus, stage-based activity promotion interventions may simplify exercise behaviour beyond what is useful for practitioners and health promoters. Paradoxically, stage-based activity promotion interventions that have been developed to date may have failed to appreciate the true complexity of the task.     

Réflexions et perspectives concernant l’evidence-based health promotion dans le contexte français

In France, current structuring of preventive and health promotion policies has created a context favoring evidence-based actions. Yet, in health promotion and health education, interventions are very much setting dependent, potentially compromising this type of approach to health promotion. Thus, in an attempt to inform participants in health promotion in the French setting of ongoing international debates on the topic, we present the main limitations developed in literature, highlighting recent work responding to the challenge. Our analysis is focused on three points: the issue of the level of intervention and indicators to assess efficacy and effectiveness of health promotion interventions; the issue of research methodologies, their capacity to demonstrate efficacy and effectiveness of health promotion interventions and the transferability of their outcomes; the issue of the external validity of studies, and in particular the information necessary for understanding complex mechanisms of intervention. On the basis of this analysis, and with the aim of improving evidence-based health promotion practices, we propose practical perspectives in the French environment for policymakers, local practitioners and researchers. To conclude, we link this issue with the concept of knowledge transfer, which is developed in other countries.