Organizational change--key to capacity building and effective health promotion

Contemporary health promotion is now a well-defined discipline with a strong (albeit diverse) theoretical base, proven technologies (based on program planning) for addressing complex social problems, processes to guide practice and a body of evidence of efficacy and increasingly, effectiveness. Health promotion has evolved principally within the health sector where it is frequently considered optional rather than core business. To maximize effectiveness, quality health promotion technologies and practices need to be adopted as core business by the health sector and by organizations in other sectors. It has proven difficult to develop the infrastructure, workforce and resource base needed to ensure the routine introduction of high-quality health promotion into organizations. Recognizing these problems, this paper explores the use of organizational theory and practice in building the capacity of organizations to design, deliver and evaluate health promotion effectively and efficiently. The paper argues that organizational change is an essential but under-recognized function for the sustainability of health promotion practice and a necessary component of capacity-building frameworks. The interdependence of quality health promotion with organizational change is discussed in this paper through three case studies. While each focused on different aspects of health promotion development, the centrality of organizational change in each of them was striking. This paper draws out elements of organizational change to demonstrate that health promotion specialists and practitioners, wherever they are located, should be building organizational change into both their practice and capacity-building frameworks because without it, effectiveness and sustainability are at risk.     

Ecosystemic and communicative approaches in the implementation of territorial agendas for sustainable development and health promotion

This paper analyzes the sustainability of ecosystemic and communicative approaches in terms of strategic planning for the implementation of territorial agendas that seek to integrate the principles of Sustainable Development and Health Promotion. It takes the Sustainable Development and Health Promotion project: Implementation of the Healthy Cities Agenda integrated with Agenda 21 in Traditional Communities of Protected Areas of the Bocaina Region" as a point of reference. It involves action-research that strives to contribute to the promotion of quality of life by means of the implementation of a participative strategic agenda and the promotion of mutual economic sustainability. The work seeks to build theoretical/practical bridges between the approaches and the methodologies and technologies used, assessing their consistency and effectiveness in relation to the principles of sustainable development and health promotion, especially in the empowerment of the local population and the broadening of the autonomy of the community.     

The Promotion of Sustainable Diets in the Healthcare System and Implications for Health Professionals: A Scoping Review

The impacts of the current global food system are already visible in the environment and in the health of the population. The promotion of sustainable diets is key to counter the negative consequences. The healthcare system could be a powerful tool to educate patients by guiding their diets towards sustainability. This study aimed to assess the size and scope of the available literature regarding the promotion of sustainable diets in the healthcare system and to obtain a reliable approximation of the processes and roles related to sustainable diet promotion within healthcare systems. A scoping review where online databases were used to identify English written scientific and grey literature published between 2000–2019 was carried out. The analytical–synthetic approach was used for data charting. Twelve studies were included that were published between 2007–2020. The data highlight education, community and clinical health services, community engagement and policy advocacy, and governance as main action areas along with two transversal aspects, social support, and gender. A systemic approach to the food system is emphasized. Evidence suggests that health professionals have the potential to drive a paradigm shift in food–health environments. Currently, however, their role and potential impact is underestimated within healthcare systems. This review has identified a framework with key areas where processes need to be developed to guarantee sustainable diet promotion in healthcare services.     

Using linking systems to build capacity and enhance dissemination in heart health promotion: a Canadian multiple-case study

The purpose of this paper is to examine the utility of linking systems between public health resource and user organizations for health promotion dissemination and capacity building, and to identify factors related to the success of linking systems. The design is a parallel-case study using key informant interviews and content analysis of project reports (synthesized qualitative and quantitative data) of three provincial dissemination projects of the Canadian Heart Health Initiative-Dissemination Phase. Each provincial project used linking activities with public health user groups including meetings, skill building, resources, collaboration, networking and research feedback to facilitate capacity building for and implementation of heart health promotion activities. This paper presents empirical examples of linking system designs, activities, and qualitative and quantitative changes in the public health user groups' health promotion capacity, program delivery and sustainability. The findings indicate enhanced health promotion skills, partnerships, resources, infrastructure, and increased programming and sustainability in the targeted public health organizations of all three provincial projects. Identified barriers to the success of linking systems included lack of appropriately skilled personnel, funds, buy-in and leadership. We conclude that linking systems can be flexibly used to build capacity and disseminate health promotion innovations, and suggest conditions for success.     

Social capital and health in the least developed countries: A critical review of the literature and implications for a future research agenda

Research on the linkage between social capital and health has grown in recent years; however, there is a dearth of evidence from resource-poor countries. This review examines the association between social capital and physical health (including health behaviours) in the least developed countries (LDCs). Citations were searched using three databases from 1990 to 2011 using the keyword ‘social capital’ combined with the name of each of the 48 LDCs. Of the 14 studies reviewed, 12 took place in Africa and 2 in South Asia. All used cross-sectional study designs, including five qualitative and nine quantitative studies. The literature reviewed suggests that social capital is an important factor for improving health in resource-poor settings; however, more research is needed in order to determine the best measures for social capital and elucidate the mechanisms through which social capital affects health in the developing world. Future research on social capital and health in the developing world should focus on applying appropriate theoretical conceptualisations of social capital to the developing country context, adapting and validating instruments for measuring social capital, and examining multilevel models of social capital and health in developing countries.     

Effectiveness of alliances and partnerships for health promotion

This paper assesses the impact of alliances or partnerships for health promotion in northern and southern nations, as described in published papers and through contemporary accounts of best practice. The balance of evidence from published literature and case study accounts is clear. Alliance or partnership initiatives to promote health across sectors, across professional and lay boundaries and between public, private and non-government agencies, do work. They work in tackling the broader determinants of health and well-being in populations in a sustainable manner, as well as in promoting individual health-related behaviour change. The greater the level of local community involvement in setting agendas for action and in the practice of health promotion, the larger the impact. Volunteer activities, peer programmes and civic activities ensure the maximum benefit from community approaches. In addition, durable structures which facilitate planning and decision-making, such as local committees and councils, are key factors in successful alliances or partnerships for health promotion. Such mechanisms also support the sharing of power, responsibility and authority for change, the maintenance of order and of programmatic relevance, and allow local people one means of reflection and for dissent. At a national, regional, district, village and local community or neighbourhood level, this review found that the existence and implementation of policies for health promotion activities were also crucial to sustainability. The evidence from the review suggests the need for new 'social' indicators to measure the effects of health promotion. Indicators for success which focus only upon benefits for individuals cannot capture adequately the extent of the impact of the many and varied collective, collaborative health promotion initiatives, alliances or partnerships currently underway around the world. These have been shown to affect families, communities, institutions and aspects of the organisation of social and civic life. This paper posits the notion of social capital as one important new framework for organising our thinking about the broader determinants of health and how to influence them through community based approaches to reduce inequalities in health and well-being.Key words: alliances; health promotion; partnerships      

Analysis of preliminary conditions for the implementation of health training programs within the framework of humanitarian aid

NGOs must be able to ensure the appropriate design and quality of their training programmes for health workers implemented in developing countries. It is a question of empowering those countries to become more autonomous, and the purpose of this study is to identify factors that can improve the sustainable management of the population's health through the long-term training of competent health workers. A literature review validated by experts distinguished three main characteristics necessary for the success of such programmes; relevance, feasibility and functionality from an educational perspective. Moreover, in addition to the three aforementioned criteria, a fourth transversal attribute was noted: sustainability. The objective of the programme designer is to assess the presence of these conditions in order to decide whether or not the training programme should be implemented.     

Assessing sustainability of Lifestyle Education for Activity Program (LEAP)

Sustained intervention effects are needed for positive health impacts in populations; however, few published examples illustrate methods for assessing sustainability in health promotion programs. This paper describes the methods for assessing sustainability of the Lifestyle Education for Activity Program (LEAP). LEAP was a comprehensive school-based intervention that targeted change in instructional practices and the school environment to promote physical activity (PA) in high school girls. Previous reports indicated that significantly more girls in the intervention compared with control schools reported engaging in vigorous PA, and positive long-term effects on vigorous PA also were observed for girls in schools that most fully implemented and maintained the intervention 3 years following the active intervention. In this paper, the seven steps used to assess sustainability in LEAP are presented; these steps provide a model for assessing sustainability in health promotion programs in other settings. Unique features of the LEAP sustainability model include assessing sustainability of changes in instructional practices and the environment, basing assessment on an essential element framework that defined complete and acceptable delivery at the beginning of the project, using multiple data sources to assess sustainability, and assessing implementation longitudinally.     

The role of the World Bank in international health: renewed commitment and partnership

During the course of the past ten years, the World Bank has become the single largest external financier of health activities in low and middle income countries and an important voice in national and international debates on health policy. This article highlights the Bank's new strategic direction in the health sector aimed at: improving health, nutrition, and population outcomes of the poor; enhancing the performance of health care systems; and securing sustainable health care financing. Millions of preventable deaths and treatable illnesses, together with health systems that are inefficient, inequitable and ineffective, have motivated expanded Bank support for the health sector in many of its client countries. The new policy directions and system-wide reforms observed in these countries are the result of both demand and supply factors. It is part of a general shift in the Bank's approach to development assistance, which sees systemic reform as a way to improve the impact and sustainability of investments in health. On the demand side, the Bank is trying to adapt to ongoing political, technological, economic, demographic, epidemiological and social pressures. On the supply side, the Bank's growing international experience and substantial financial resources are used to complement the development assistance provided by other organizations and the global effort to improve health and health systems in low and middle income countries.     

A conceptual model of community capacity development for health promotion in the Alberta Heart Health Project

PURPOSE: The objective of this study was to derive a conceptual model of community capacity development for health promotion based on the 5-year demonstration phase of the Alberta Heart Health Project. METHOD: Community actions associated with successful implementation and uptake of initiatives in four diverse target sites were identified by case study evaluation. RESULTS: Thirteen common elements of capacity development were found across the projects and categorized to define three primary dimensions of the process: (a) leadership that provided a driving force for implementation, (b) policy making that ensured diffusion and sustainability, and (c) use of local community resources and infrastructure. A conceptual model was constructed using these 3 dimensions and their interactions. CONCLUSION: Effective implementation of community health initiatives to promote heart health can be conceptualized as the involvement of local leadership, policy advocacy, and enhancement of existing infrastructure. The model highlights building these dimensions of community capacity development for health promotion.     

Ethical dilemmas in current planning for polio eradication.

Intensification of polio eradication efforts worldwide raises concerns about costs and benefits for poor countries. A major argument for global funding is the high benefit-cost ratio of eradication; however, financial benefits are greatest for rich countries. By contrast, the greatest costs are borne by poor countries; the Pan American Health Organization has estimated that host countries bore 80% of costs for polio eradication in the Americas. The 1988 World Health Assembly resolution setting up the Polio Eradication Initiative carried the proviso that programs should strengthen health infrastructures. Drastic cuts in donor funding for health make this commitment even more important. Two international evaluations have reported both positive and negative effects of polio and Expanded Programme on Immunization programs on the functioning and sustainability of primary health care. Negative effects were greatest in poor countries with many other diseases of public health importance. If poor countries are expected to divert funds from their own urgent priorities, donors should make solid commitments to long-term support for sustainable health development.     

The multiple meanings of "empowerment" in the health promotion proposal

Starting with a review of the literature and documents pertaining to health promotion in the developed countries, highlighting the Canadian output, the author reflects on the multiple meanings ascribed to the "empowerment" category/strategy. After a summary of the conceptual development of health promotion ideals, the paper analyzes the theoretical aspects of "empowerment", suggesting its classification into two main approaches: psychological and community-based. The author contends that community "empowerment" helps define health promotion as a proposal aimed at transforming the status quo and the production of healthy subjects. The paper concludes by exploring the potential contributions of social/community "empowerment" to health education practices and reorganization of the Brazilian National Health System (SUS).     

重庆市农村卫生适宜技术推广应用需方回顾性分析

目的:从重庆市农村卫生适宜技术推广的接受人群——需方,了解农村卫生适宜技术推广应用情况。为有针对性地开展农村卫生适宜技术的宣传和应用提供理论依据。方法:对重庆市五个项目示范县接受农村卫生适宜技术的人群的调查问卷进行回顾性分析。结果:在五个项目示范县推广了12项适宜技术,中医7项,西医5项。调查中,接受适宜技术服务人中女性人数多于男性;年龄主要集中在40～59岁组;农民所占的比例最高;接受西医适宜技术人数比中医多。从接受人群角度出发,不同职业分布人群对各项技术的应用情况存在差异。推广的中、西医适宜技术的疗效较好,经济负担不重,达到了推广的预期效果。结论:在农村适宜技术的推广过程中需要根据各适宜技术的接受人群进行有针对的宣传和推广,以保证农村卫生适宜技术持续推广和广泛应用。     

An index of maternal and child health in the least developed countries of Asia

In this article, we propose a new index to measure maternal and child health in the least developed countries (LDCs) of Asia. This new index is applied to a group of countries particularly affected by poverty, which, in the terminology of the United Nations' Conference on Trade and Development, are the poorest of the poor. Our index has been designed by including the variables defined in the Goals of the Millennium Declaration. For this purpose, we used the P(2) distance method for 2008, the last year for which data were available. This index integrates variables of maternal and child health that allow territorial ordering of the LDCs in terms of these partial indicators. This analysis is particularly useful in a scenario such as the LDCs of Asia, which are beset by profound social and economic inequalities.     

Securing funds for health promotion: lessons from health promotion foundations based on experiences from Austria, Australia, Germany, Hungary and Switzerland

Worldwide, countries face the challenge of securing funds for health promotion. To address this issue, some governments have established health promotion foundations, which are statutory bodies with long-term and recurrent public resources. This article draws on experiences from Austria, Australia, Germany, Hungary and Switzerland to illustrate four lessons learned from the foundation model to secure funding for health promotion. These lessons are concerned with: (i) the broad spectrum of potential revenue sources for health promotion foundations within national contexts; (ii) legislative anchoring of foundation revenues as a base for financial sustainability; (iii) co-financing as a means to increase funds and shared commitment for health promotion; (iv) complementarity of foundations to existing funding. Synthesizing the lessons, we discuss health promotion foundations in relation to wider concerns for investment in health based on the values of sustainability, solidarity and stewardship. We recommend policy-makers and researchers take notice of health promotion foundations as an alternative model for securing funds for health promotion, and appreciate their potential for integrating inter-sectoral revenue collection and inter-sectoral funding strategies. However, health promotion foundations are not a magic bullet. They also pose challenges to coordination and public sector stewardship. Therefore, health promotion foundations will need to act in concert with other governance instruments as part of a wider societal agenda for investment in health.     

Healthcare sustainability and the challenges of innovation to biopharmaceuticals in Canada

Governments around the world have focused on issues of sustainability, innovations and priority setting within their health systems. Tension exists between governments' desire to increase biotechnology innovation and the need to address health system sustainability. This commentary will: (1) review government initiatives in biotechnology in health innovation; (2) discuss how innovation, specifically biopharmaceuticals, challenges health system sustainability; and (3) explore how the tension between innovation and sustainability can be addressed using fairness and legitimacy. It is evident that a uni-jurisdictional approach may not be optimal in promoting innovation while ensuring a sustainable health system. Harmonization of biotechnology policies across the federal, provincial, and territorial governments will ensure consistent policies across all branches in order to circumvent the possibility of one governmental branch refusing to reimburse the very innovations other branches are promoting.     

Health promotion in Brazil

The evolution of health promotion within the Brazilian health system is examined, including an assessment of the intersectoral and development policies that have influenced the process. Particular attention is paid to the legal characteristics of the Unified Health System. Human resources formation and research initiatives in health promotion are outlined, with a summary of the obstacles that need to be overcome in order to ensure the effective implementation of health promotion in the future. Up to the end of the 20th Century health promotion was not used as a term in the Brazilian public heath context. Health promoting activities were concentrated in the area of health education, although targeting the social determinants of health and the principle of intersectoral action were part of the rhetoric. The situation has changed during the last decade, with the publication of a national policy of health promotion, issued by the Ministry of Health and jointly implemented with the States and Municipals Health Secretaries. More recently there has been a re-emergence of the discourse on the social determinants of health and the formation of intersectoral public policies as the basis of a comprehensive health promotion. Health promotion infrastructure, particularly around human resources and financing, requires strengthening in order to ensure capacity and sustainability in health promotion practice.     

Human papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): Health system experiences and prospects

Prophylactic vaccines for human papillomavirus (HPV) are being introduced in many countries for the prevention of cervical cancer, the second most important cause of cancer-related death in women globally. This is likely to have a significant impact on the future burden of cervical cancer, particularly where screening is non-existent or limited in scale. Previous research on the challenges of vaccinating girls with the HPV vaccine has focused on evidence from developed countries. We conducted a systematic search of the literature in order to describe the barriers and challenges to implementation of HPV vaccine in low- and middle-income countries. We identified literature published post-2006 to September 2012 from five major databases. We validated the findings of the literature review with evidence from qualitative key informant interviews. Three key barriers to HPV vaccine implementation were identified: sociocultural, health systems and political. A linked theme, the sustainability of HPV vaccines programmes in low- and middle-income countries, cuts across these three barriers. Delivering HPV vaccine successfully will require multiple barriers to be addressed. Earlier research in developed countries emphasised sociocultural issues as the most significant barriers for vaccine roll-out. Our evidence suggests that the range of challenges for poorer countries is significantly greater, not least the challenge of reaching girls for three doses in settings where school attendance is low and/or irregular. Financial and political barriers to HPV vaccine roll-out continue to be significant for many poorer countries. Several demonstration and pilot projects have achieved high rates of acceptability and coverage and lessons learned should be documented and shared.     

Special Delivery: An Analysis of mHealth in Maternal and Newborn Health Programs and Their Outcomes Around the World

Mobile health (mHealth) encompasses the use of mobile telecommunication and multimedia into increasingly mobile and wireless health care delivery systems and has the potential to improve tens of thousands of lives each year. The ubiquity and penetration of mobile phones presents the opportunity to leverage mHealth for maternal and newborn care, particularly in under-resourced health ecosystems. Moreover, the slow progress and funding constraints in attaining the Millennium Development Goals for child and maternal health encourage harnessing innovative measures, such as mHealth, to address these public health priorities. This literature review provides a schematic overview of the outcomes, barriers, and strategies of integrating mHealth to improve prenatal and neonatal health outcomes. Six electronic databases were methodically searched using predetermined search terms. Retrieved articles were then categorized according to themes identified in previous studies. A total of 34 articles and reports contributed to the findings with information about the use and limitations of mHealth for prenatal and neonatal healthcare access and delivery. Health systems have implemented mHealth programs to facilitate emergency medical responses, point-of-care support, health promotion and data collection. However, the policy infrastructure for funding, coordinating and guiding the sustainable adoption of prenatal and neonatal mHealth services remains under-developed. The integration of mobile health for prenatal and newborn health services has demonstrated positive outcomes, but the sustainability and scalability of operations requires further feedback from and evaluation of ongoing programs.     

Getting Australia more active: challenges and opportunities for health promotion

A growing body of evidence demonstrates that regular physical activity promotes health and assists in the prevention of noncommunicable diseases but this is presently curtailed by low and unhealthy participation rates in Australia and comparable industrialised countries. Compounding the problem is knowledge that physical inactivity is independently associated with poor health outcomes. Despite physical activity being described as public health's ‘best bet’ or ‘best buy’, motivating individuals and groups to adopt and maintain physical activity continues to be a major challenge for health professionals. Global advocacy for prevention efforts must be operationalised through national to local strategies to promote and support physical activity in multiple settings including the home, schools and workplace. The Australian health promotion community has and continues to play a leadership role in physical activity promotion. However, there is an urgent need to continue to promote the importance of physical activity, along with its pivotal role in the prevention of non‐communicable diseases, alongside related agendas including healthy diets, tobacco control and environmental sustainability. This commentary overviews the contemporary status of physical activity promotion in Australia and identifies key challenges and opportunities moving forward.