Building capacity for heart health promotion: results of a 5-year experience in Nova Scotia,Canada

PURPOSE: To present the outcomes of a capacity-building initiative for heart health promotion. DESIGN: Follow-up study combining quantitative and qualitative methods. SETTING: The Western Health Region of Nova Scotia, Canada. SUBJECTS: Twenty organizations, including provincial and municipal agencies and community groups engaged in health, education, and recreation activities. INTERVENTION: Two strategies were used for this study: partnership development and organizational development. Partnership development included the creation of multilevel partnerships in diverse sectors. Organizational development included the provision of technical support, action research, community activation, and organizational consultation. MEASURES: Quantitative data included number and type of partnerships, learning opportunities, community activation initiatives, and organizational changes. Qualitative data included information on the effectiveness of partnerships, organizational consultation, and organizational changes. RESULTS: Results included the development of 204 intersectoral partnerships, creation of a health promotion clearinghouse, 47 workshops attended by approximately 1400 participants, diverse research products, implementation of 18 community heart health promotion initiatives, and increased organizational capacity for heart health promotion via varied organizational changes, including policy changes, fund reallocations, and enhanced knowledge and practices. CONCLUSIONS: Partnership and organizational development were effective mechanisms for building capacity in heart health promotion. This intervention may have implications for large-scale, community-based, chronic-disease prevention projects.     

Organizational capacity for community development in regional health authorities: a conceptual model

The value of community development (CD) practices is well documented in the health promotion literature; it is a foundational strategy outlined in the Ottawa Charter for Health Promotion. Despite the importance of collaborative action with communities to enhance individual and community health and well-being, there exists a major gap between the evidence for CD and the actual extent to which CD is carried out by health organizations. In this paper it is argued that the gap exists because we have failed to turn the evaluative gaze inward-to examine the capacity of health organizations themselves to facilitate CD processes. This study was designed to explicate key elements that contribute to organizational capacity for community development (OC-CD). Twenty-two front-line CD workers and managers responsible for CD initiatives from five regional health authorities in Alberta, Canada, were interviewed. Based on the study findings, a multidimensional model for conceptualizing OC-CD is presented. Central to the model are four inter-related dimensions: (i) organizational commitment to CD, rooted in particular values and beliefs, leadership and shared understanding of CD; (ii) supportive structures and systems, such as job design, flexible planning processes, evaluation mechanisms and collaborative processes; (iii) allocation of resources for CD; and (iv) working relationships and processes that model CD within the health organization. These four dimensions contribute to successful CD practice in numerous ways, but perhaps most importantly by supporting the empowerment and autonomy of the pivotal organizational player in health promotion practice: the front-line worker.     

Reorienting health services with capacity building: a case study of the Core Skills in Health Promotion Project

This paper presents a case study of the application of a framework for capacity building [Hawe, P., King, L., Noort, M., Jordens, C. and Lloyd, B. (2000) Indicators to Help with Capacity Building in Health Promotion. NSW Health, Sydney] to describe actions aimed at building organizational support for health promotion within an area health service in New South Wales, Australia. The Core Skills in Health Promotion Project (CSHPP) arose from an investigation which reported that participants of a health promotion training course had increased health promotion skills but that they lacked the support to apply their skills in the workplace. The project was action-research based. It investigated and facilitated the implementation of a range of initiatives to support community health staff to apply a more preventive approach in their practice and it contributed to the establishment of new organizational structures for health promotion. An evaluation was undertaken 4 years after the CSHPP was established, and 2 years after it had submitted its final report. Interviews with senior managers, document analysis of written reports, and focus groups with middle managers and service delivery staff were undertaken. Change was achieved in the three dimensions of health infrastructure, program maintenance and problem solving capacity of the organization. It was identified that the critically important elements in achieving the aims of the project-partnership, leadership and commitment-were also key elements of the capacity building framework. This case study provides a practical example of the usefulness of the capacity building framework in orienting health services to be supportive of health promotion.     

A conceptual model for leadership development.

Collaboration among schools of public health and national, state, and local health agencies has resulted in creation of comprehensive public health workforce education and training initiatives that offer integrated, sequential, and accessible professional development programs, including a nation-wide network of public health leadership institutes. A conceptual model for leadership development is presented. It contains seven elements considered critical for design of leadership programs in public health: capacity/competence needs; program target; area served; program content; training level; learning approach; and implementation methods. This model can be used to design leadership as well as public health workforce education and training programs.     

The Jakarta Declaration on health promotion in the 21st century

The Fourth International Conference on Health Promotion, held in Jakarta, Indonesia, in July 1997, focused on the theme: New Players for a New Era--Leading Health Promotion into the 21st Century. Health promotion strategies can change life-styles as well as the social, economic, and environmental conditions that determine health. Most effective are comprehensive approaches that combine public policy efforts, the creation of supportive environments, community action, the development of personal skills, and a reorientation of health services. Also required is the creation of new partnerships for health between different sectors at all levels of society and government. The conference identified five priorities for health promotion in the 21st century: 1) promote social responsibility for health; 2) increase investments for health development, especially for groups such as women, children, older persons, the indigenous, the poor, and marginalized populations; 3) consolidate and expand partnerships for health to enable the sharing of expertise, skills, and resources; 4) increase community capacity and empower the individual; and 5) secure an infrastructure for health promotion through new funding mechanisms, intersectoral collaboration, and training of local leadership.     

Health promotion activities in China from the Ottawa Charter to the Bangkok Charter: revolution to evolution

China has the world's largest population. In the past, the public health system in mainland China has been strongly influenced by the former Soviet Union. Hong Kong and Macao, the Special Administrative Regions (SAR), have been under colonial administration adopting a laisser-faire approach to health policy. Over the most recent decades, mainland China and the two SARs have adopted the Ottawa Charter principles and re-orientated the healthcare systems towards greater community participation, built a healthy environment in different settings and developed capacity in health promotion. Positive results have resulted from efforts to move towards a bottom-up approach to health promotion, using the overarching framework of Healthy Settings. Adequate resources will be needed to build up the infrastructure for sustainable development of health promotion initiatives. This report is selective, rather than comprehensive and will highlight specific health promotion activities in different parts of China, reflecting how the approach to health promotion has evolved since Ottawa. An analysis will be made of the potentials of these initiatives to take forward the spirit of the Ottawa Charter in paving the way for the Bangkok Charter.     

The influence of context on quality improvement success in health care: a systematic review of the literature

Context: The mixed results of success among QI initiatives may be due to differences in the context of these initiatives. Methods: The business and health care literature was systematically reviewed to identify contextual factors that might influence QI success; to categorize, summarize, and synthesize these factors; and to understand the current stage of development of this research field. Findings: Forty‐seven articles were included in the final review. Consistent with current theories of implementation and organization change, leadership from top management, organizational culture, data infrastructure and information systems, and years involved in QI were suggested as important to QI success. Other potentially important factors identified in this review included: physician involvement in QI, microsystem motivation to change, resources for QI, and QI team leadership. Key limitations in the existing literature were the lack of a practical conceptual model, the lack of clear definitions of contextual factors, and the lack of well‐specified measures. Conclusions: Several contextual factors were shown to be important to QI success, although the current body of literature lacks adequate definitions and is characterized by considerable variability in how contextual factors are measured across studies. Future research should focus on identifying and developing measures of context tied to a conceptual model that examines context across all levels of the health care system and explores the relationships among various aspects of context.     

Baseline assessment of organizational capacity for health promotion within regional health authorities in Alberta, Canada

This paper provides a baseline profile of organizational capacity for (heart) health promotion in Alberta's regional health authorities (RHAs); and examines differences in perceived organizational health promotion capacity specific to modifiable risk factors across three levels of staff and across capacity levels. Baseline data were collected from a purposive sample of 144 board members, senior/middle managers and service providers from 17 RHAs participating in a five-year time-series repeated survey design assessing RHA capacity for (heart) health promotion. Results indicate low levels of capacity to take health promotion action on the broader determinants of health and risk conditions like poverty and social support. In contrast, capacity for health promotion action specific to physiological and behavioural risk factors is considerably higher. Organizational "will" to do health promotion is noticeably more present than is both infrastructure and leadership. Both position held within an organization as well as overall level of organizational capacity appear to influence perceptions of organizational capacity. Overall, results suggest that organizational "will", while necessary, is inadequate on its own for health promotion implementation to occur, especially in regard to addressing the broader determinants of health. A combination of low infrastructure and limited leadership may help explain a lack of health promotion action.     

Enacting sustainable school-based health initiatives: a communication-centered approach to policy and practice

Communication plays an important role in all aspects of the development and use of policy. We present a communication-centered perspective on the processes of enacting public health policies. Our proposed conceptual framework comprises 4 communication frames: orientation, amplification, implementation, and integration. Empirical examples from 2 longitudinal studies of school-based health policies show how each frame includes different communication processes that enable sustainable public health policy practices in school-based health initiatives. These 4 frames provide unique insight into the capacity of school-based public health policy to engage youths, parents, and a broader community of stakeholders. Communication is often included as an element of health policy; however, our framework demonstrates the importance of communication as a pivotal resource in sustaining changes in public health practices.     

Towards a sustainable framework for computer based health information systems (CHIS) for least developed countries (LDCs)

PURPOSE: The purpose of this paper is to argue for a theoretical framework by which development of computer based health information systems (CHIS) can be made sustainable. Health Management and promotion thrive on well-articulated CHIS. There are high levels of risk associated with the development of CHIS in the context of least developed countries (LDC), thereby making them unsustainable. DESIGN/METHODOLOGY/APPROACH: This paper is based largely on literature survey on health promotion and information systems. FINDINGS: The main factors accounting for the sustainability problem in less developed countries include poor infrastructure, inappropriate donor policies and strategies, poor infrastructure and inadequate human resource capacity. To counter these challenges and to ensure that CHIS deployment in LDCs is sustainable, it is proposed that the activities involved in the implementation of these systems be incorporated into organizational routines. This will ensure and secure the needed resources as well as the relevant support from all stakeholders of the system; on a continuous basis. ORIGINALITY/VALUE: This paper sets out to look at the issue of CHIS sustainability in LDCs, theoretically explains the factors that account for the sustainability problem and develops a conceptual model based on theoretical literature and existing empirical findings.     

National opportunities for health promotion: the Canadian experience

Health promotion is a fundamental strategy to address the majorissues which confront health systems in developed and developingcountries alike. Chief amongst these issues are unhealthy environments,health inequities and non-communicable diseases. The infrastructuresfor health promotion include mechan isms for development andimplementation of health policy; policies and programs supportiveof community involvement in health promotion programs; reorientationof the health care system towards prevention; and research.Consensus building among key stakeholders from the public andprivate sectors is at the core of the policy development process.A New Perspective for the Health of Canadians (1974) and theWHO Ottawa Charter for Health Promotion (1987) have guided healthpromotion policy and program development at both the nationaland provincial levels, in Canada, a number of initiatives haveplaced into pra ctice the policy frameworks, among them: HealthyCommunities, the Canadian Heart Health initiative, integrationofpreven lion into clinical practice, and structures to supportresearch in health promotion.     

What remains for the future: strengthening community actions to become an integral part of health promotion practice

To mark the 25th anniversary of the Ottawa Charter, this paper will discuss what remains to be achieved in strengthening community actions as an integral part of health promotion practice. To do this, the paper discusses four key elements for the future of health promotion programmes: (1) engage communities to share priorities; (2) build community capacity; (3) mechanisms for flexible and transparent funding; and (4) being creative in order to expand or replicate successful local initiatives. The paper uses a number of international case study examples of how these key elements can be achieved in health promotion programmes. A major challenge for the future is how health promotion agencies can develop and maintain the trust of communities, especially socially marginalized communities in society. The paper concludes by identifying a number of short and longer term challenges to achieve these goals and offers a way forward for a brighter future direction of health promotion practice.     

A socioecological approach to improving mammography rates in a tribal community.

This article highlights the processes and intermediate outcomes of a pilot project to increase mammography rates of women in an American Indian tribe in New Mexico. Using a socioecological framework and principles of community-based participatory research, a community coalition was able to (a) bolster local infrastructure to increase access to mammography services; (b) build public health knowledge and skills among tribal health providers; (c) identify community-specific knowledge, attitudes, and beliefs related to breast cancer; (d) establish interdependent partnerships among community health programs and between the tribe and outside organizations; and (e) adopt local policy initiatives to bolster tribal cancer control. These findings demonstrate the value of targeting a combination of individual, community, and environmental factors, which affect community breast cancer screening rates and incorporating cultural strengths and resources into all facets of a tribal health promotion intervention.     

Improving health with tobacco dollars from the MSA: the Arkansas experience

Analyses of expenditures from the historic tobacco Master Settlement Agreement (MSA) demonstrate the difficulties in achieving support for long-term disease prevention and health promotion initiatives. We report as a policy case study the successful development, political execution, and program deployment of new state health programs funded by Arkansas' MSA funds. Arkansas' success demonstrates the need for political leadership, the development and insertion of empirical health information into the policy deliberations, in-depth knowledge of the political process, and a broad-based coalition committed to improving health.     

Comprehensive approaches to school health promotion: how to achieve broader implementation?

The Health Promoting School (HPS) and Comprehensive School Health Program (CSHP) initiatives have been proposed as a means of going beyond some of the limitations associated with health promotion initiatives aimed at school-aged children. This involves moving beyond practices that rely mainly on classroom-based health education models, to a more comprehensive, integrated approach of health promotion that focuses both on child-youth attitudes and behaviors, and their environment. Despite the tremendous potential of these initiatives in terms of health and educational gains, only rarely are they actually put into practice. This article briefly reviews the features of these initiatives, as well as the extent of their implementation and current benefits. Against that backdrop, the authors identify some issues to consider and propose four conditions with a view to achieving broader practical application of these approaches. These issues, which are discussed from the standpoint of potential avenues of further study and courses of action, relate to the comprehensive, integrated nature of the intervention, the school/family/community partnership, political and financial support from policy makers, and, finally, evaluative research as a support to implementation.     

Evaluation of a national health promotion program in South Australia

Abstract: This paper reports the findings of the evaluation of the South Australian component of the National Better Health Program. The evaluation used analysis of focus-group interviews and key documents to assess the value of the state program. The evaluation demonstrated that for a relatively small investment ($2.4 million was allocated to the project over four years, representing only 0.5 per cent of the annual budget for teaching hospitals in South Australia), much can be achieved by harnessing the energy of local communities. The evaluation concluded that more attention should be directed to structural change, with an emphasis on collaboration across sectors, and community participation. Some key issues for the planning and implementation of health promotion were highlighted: the challenge of marrying local initiatives based on community development with national health promotion objectives; the importance of dedicated cind assured funding; the need for increased training and support for health promotion workers; and the importance of continuing a focus on equity in the implementation of health promotion. The paper concludes by questioning the value of the current Australian goals, targets and strategies for health, given the findings from this evaluation.     

Researching the implementation of community mental health promotion programs

Understanding the process of program implementation plays a critical role in advancing research, practice and policy in mental health promotion. This paper focuses on the implementation of community mental health promotion and considers the challenges presented in implementing and evaluating complex, multifaceted interventions carried out in the context of dynamic community settings. The Rural Mental Health Project1–3 is presented as a case study to illustrate the practical and research challenges encountered in implementing and evaluating a community mental health promotion initiative. This case study highlights the factors that contributed to the successful implementation and evaluation of a community‐based intervention for rural communities on the border region in the Republic and Northern Ireland. Among the factors identified are: a partnership model of working; local co‐ordinating structures and consultation mechanisms; use of a structured planning model to guide program planning and implementation; mobilisation of cross‐community and inter‐agency support; and a comprehensive logic evaluation framework to assess the input, process, impact and outcomes of the project as it unfolded.     

Policy process for health sector reforms: a case study of Punjab Province (Pakistan)

The health sector in the Punjab (Pakistan) faces many problems, and, the government introduced reforms during 1993–2000. This paper explores the policy process for the reforms. A case study method was used and, to assist this, a conceptual framework was developed. Analysis of four initiatives indicated that there were deviations from the government guidelines and that the policy processes used were weak. The progress of different reforms was affected by a variety of factors: the immaturity of the political process and civil society, which together with innate conservatism and resistance to change on the part of the bureaucracy resulted in weak strategic sectoral leadership and a lack of clear purpose underpinning the reforms. It also resulted in weaknesses in preparation of the detail of reforms leading to poor implementation. The study suggests a need for broadening the stakeholders' base, building the capacity of policy‐makers in policy analysis and strengthening the institutional basis of policymaking bodies. Copyright © 2009 John Wiley & Sons, Ltd.     

Research as intervention in heart health promotion

BACKGROUND: Capacity building in health promotion has traditionally involved training interventions to support knowledge, skill and resource building for effective practice. However, there is a need to understand how research can be used to support capacity building and practice. METHODS: Findings are based on a parallel case study comprising qualitative analysis of 66 key informant interviews from five provincial heart health projects (Manitoba, Prince Edward Island, Ontario, Saskatchewan, and Newfoundland and Labrador) as part of the Canadian Heart Health Dissemination Project. FINDINGS: Results indicate research was used primarily to monitor and report results about health promotion capacity and dissemination to stakeholders, and contribute to participatory processes. Respondents noted that research as intervention had an influence on five areas of health promotion capacity and practice: increased heart health promotion knowledge/skills; improved programming, planning and prioritizing; increased motivation for (heart) health promotion initiatives; and cultivation of relationships as well as buy-in. INTERPRETATION: Research was a complementary capacity-building activity, although it did not directly increase program implementation. These findings contribute to linking researchers, practitioners and community decision-makers in the process of enhancing health promotion practice.     

Promoting people's health: challenges and opportunities

Promoting health underlines the right of each individual to the highest attainable standard of health. It stresses the importance of the participation of people and recognizes different sociocultural values and beliefs that are prevalent throughout the world. Working on health development has a sustainable effect only when done comprehensively: personal development, community development, organizational development, and political development. The international conferences that have marked the way of health promotion have been goal posts of an energetic movement to strengthen health worldwide. The Ottawa Charter on Health Promotion has been a worldwide source of guidance for health promotion through its five strategies: building health policy, creating supportive elements, strengthening community action, developing personal skills, and reorienting health services. Moreover, the Jakarta Declaration on "Leading Health Promotion into the 21st Century" identifies five priorities in the next millennium: 1) promote social responsibility for health; 2) increase investments for health development; 3) consolidate and expand partnerships for health; 4) increase community capacity and empower the individual in matters of health; and 5) secure an infrastructure for health promotion. Increasing the investment in health development calls for the need to find new mechanisms for funding as well as reorienting existing resources towards health promotion and health education.