How to institutionalize health promotion programs

Abstract This article presents six implications for practice that suggest how to optimize the institutionalization of health promotion programs. These six implications were derived from a study of ten health promotion programs funded by the Virginia State Health Department and operated by local schools and community health agencies. Institutionalization refers to the long-term survival of health promotion programs, i.e., survival well beyond an initial grant funding period. To generate the implications for practice, a multiple case design for cross-case comparisons was applied to the ten health promotion programs. In brief, the six practice implications are: 1) cultivating a "program champion"; 2) favoring organizations with mature "subsystems"; 3) favoring organizations in which health promotion "fits" with the organization's mission; 4) avoiding brokering relationships; 5) altering lengths of funding periods; and 6) funding existing worthy programs. The significance of these practice implications for both funding and implementing agencies is briefly discussed.     

Impact of a community health promotion program on existing organizations: the Minnesota Heart Health Program.

A community organization strategy was used in the delivery of health education programs by the Minnesota Heart Health Program (MHHP). The effectiveness of the approach was evaluated to determine whether an enhanced health promotion delivery system had developed in MHHP communities by the end of the intervention period or whether the intervention had suppressed community efforts. 'Social connectedness' among providers, as measured by health promotion network size, also was expected to be higher in intervention communities. Six Midwestern communities were studied: the MHHP communities of Mankato, MN and Fargo, ND--Moorhead, MN with two matched comparison communities for each (Winona, MN, St Cloud, MN and Eau Claire, WI, Sioux Falls, SD). Nine areas of health promotion were assessed, including the five heart disease risk factor areas where education campaigns had been implemented (smoking cessation, weight loss, eating patterns, exercise, and heart disease education and screening) and four other areas where community programs are common (chemical dependency; home, personal and drivers' safety; stress management; and cancer education and screening). Indicators of the health promotion delivery system were developed (program options and program participation), and data were collected in separate surveys of 438 community organization providers and 320 larger worksites in the six communities. Results showed no suppression of health promotion delivery systems in MHHP communities. Instead, the survey of larger worksites showed that there was greater participation in heart disease health promotion and greater 'social connectedness' among worksites in both intervention communities. Also, there were more heart disease health promotion programs in the larger intervention community of Fargo-Moorhead. In the community organization survey, results favored the larger intervention community over its comparison communities in heart disease health promotion program options and in 'social connectedness' but not in program participation. However, survey results favored one of the comparison communities (Winona) over the smaller intervention community (Mankato) on all indicators in this survey. The greater impact of the MHHP intervention at worksites suggests that institutionalization may be more likely in stable organizations whose current needs and interests fit the goals of the intervention activity.     

Maintaining prevention in practice: survival of PPIP in primary care settings. Put Prevention Into Practice

INTRODUCTION: Put Prevention Into Practice (PPIP) consists of a kit of office-based tools intended to support the provision of preventive services by primary care providers. The purpose of this study was to examine the institutionalization of PPIP within five primary care clinics funded by the Texas Department of Health to implement PPIP, and to examine the organizational determinants of program institutionalization. METHODS: We utilized an adaptation of the Level of Institutionalizaton (LoIn) scales for qualitative data collection and for development of an institutionalization score for each site. The determinants of institutionalization were derived from the organizational behavior and health promotion literatures and used as categories for analysis. In addition, for purposes of triangulation, chart audit data for three documentation behaviors were also collected. RESULTS: PPIP has been maintained--at varying degrees of integration--in four of the five sites studied, for 6 years after adoption. Organizational factors that facilitated the institutionalization process were the site's institutional strength, the integration of PIPP within extant programs and services, visibility of the program within and outside the site, planning for the termination of grant funding, and presence of a program champion with mid- to upper-level managerial authority. Successful initiation of the program was not a predictor of institutionalization outcomes. CONCLUSIONS: We have highlighted the need to consider organizational determinants of institutionalization in relation to their specific sociopolitical contexts, and in relation to each other, not in isolation.     

Changes in health indicators related to health promotion and microcredit programs in the Dominican Republic.

OBJECTIVE: To assess the impact of health promotion programs and microcredit programs on three communities in the Dominican Republic. One community had only the health promotion program, one community had only the microcredit program, and one community had both a health promotion program and a microcredit program. This pilot project examined the hypothesis that the largest changes in 11 health indicators that were studied would be in the community with both a health promotion program and a microcredit program, that there would be intermediate changes in the community with only a health promotion program, and that the smallest changes would be in the community with only a microcredit program. METHODS: The health promotion programs used community volunteers to address two major concerns: (1) the prevalent causes of mortality among children under 5 years of age and (2) women's health (specifically breast and cervical cancer screening). The microcredit program made small loans to individuals to start or expand small businesses. Outcome measures were based on comparisons for 11 health indicators from baseline community surveys (27 households surveyed in each of the three communities, done in December 2000 and January 2001) and from follow-up surveys (also 27 households surveyed in each of the three communities, in June and July 2002, after the health promotion program had been operating for about 13 months). Households were randomly chosen during both the baseline and follow-up surveys, without regard to their involvement in the microcredit or health promotion programs. RESULTS: The health indicators improved in all three communities. However, the degree of change was different among the communities (P < 0.001). The community with parallel microcredit and health promotion programs had the largest changes for 10 of the 11 health indicators. CONCLUSIONS: Multisector development is known to be important on a macroeconomic scale. The results of this pilot project support the view that multisector development is also important on a microeconomic level, given that the parallel microcredit and health promotion programs resulted in greater change in the measured health indicators than either program alone. As far as we authors know, this is the first published study to quantify changes in health indicators related to parallel health promotion and microcredit programs as compared to control communities with only a health promotion program or a microcredit program.     

Project Salsa: development and institutionalization of a nutritional health promotion project in a Latino community

PURPOSE: Project Salsa was a community-based effort seeking to promote health through nutritional behavior change in a Latino community of San Diego, California. The purpose of this article is to report on program factors related to long-term institutionalization of Project Salsa interventions. DESIGN: Project Salsa was a demonstration rather than an experimental project. To ensure maximum sensitivity to the needs and values of the community, Project Salsa began with an extensive health needs assessment, including development of an advisory council, telephone survey, archival research, and key informant interviews. SETTING: Project Salsa interventions took place in San Ysidro, California, located near the U.S.-Mexico border adjacent to Tijuana from 1987 to 1992. SUBJECTS: The intervention community had 14,500 residents, of which nearly 83% were Latino. INTERVENTIONS: Interventions included coronary heart disease risk factor screenings, meal preparation classes, newspaper columns, point-of-purchase education, school health and cafeteria programs, and breast-feeding promotion. MEASURES: Institutionalization of intervention components. RESULTS: Two of the interventions, the risk factor screenings and school health programs, are still in operation 4 years after the end of project funding. CONCLUSIONS: Four factors common to institutionalized components are presented in the paper.     

Obstacles to and future goals of ten comprehensive community health promotion projects

Over 100 project staff, community coalition members, and other representatives from 10 comprehensive community health promotion projects in the western United States were surveyed two years into a three year funding cycle about: (1) the problems or obstacles they judged as preventing successful completion of their current goals and objectives, and (2) future goals and objectives they envisioned for their projects. The key issues confronting respondents were diverse, although issues around the process of implementing community health promotion programs were cited more frequently than issues related to the content of health promotion. When respondents were asked to prioritize Future Goals in the second survey, consensus across communities was obtained despite broad differences in the type of community surveyed and the health problem targeted. This study identifies the common organizational and community development problems faced by newly emerging community health promotion programs and has implications for other communities involved in designing, implementing, and evaluating community-wide health promotion programs.Drs. Altman (Associate Director), Howard-Pitney (Evaluation Director), Rogers (Director) and Mr. Endres (Community Organizer) are with the Health Promotion Resource Center, Stanford Center for Research in Disease Prevention, Stanford University School of Medicine. At the time this paper was written, Ms. Linzer was a graduate student at the Harvard School of Public Health, Boston, Massachusetts. Kate Lorig, Dr.P.H., is Senior Research Scientist in the Department of Immunology and Rheumatology at the Stanford University School of Medicine.This research was partially supported by grants from the Henry J. Kaiser Family Foundation, Menlo Park, California and the Pew Memorial Trust, Philadelphia, Pennsylvania.     

Implementation of diabetes prevention programs in rural areas: Montana and south-eastern Australia compared

Objective: To identify the key elements that enabled the Greater Green Triangle Diabetes Prevention Project (GGT DPP) and the Montana Cardiovascular Disease and Diabetes Prevention (CDDP) programs successful establishment and implementation in rural areas, as well as identifying specific challenges or barriers for implementation in rural communities. Methods: Focus groups were held with the facilitators who delivered the GGT DPP in Australia and the Montana CDDP programs in the USA. Interview questions covered the facilitators' experiences with recruitment, establishing the program, the components and influence of rurality on the program, barriers and challenges to delivering the program, attributes of successful participants, and the influence of community resources and partnerships on the programs. Results: Four main themes emerged from the focus groups: establishing and implementing the diabetes prevention program in the community; strategies for recruitment and retention of participants; what works in lifestyle intervention programs; and rural‐centred issues. Conclusions: The results from this study have assisted in determining the factors that contribute to developing, establishing and implementing successful diabetes prevention programs in two rural areas. Recommendations to increase the likelihood of success of programs in rural communities include: securing funding early for the program; establishing support from community leaders and developing positive relationships with health care providers; creating a professional team with passion for the program; encouraging participants to celebrate their small and big successes; and developing procedures for providing post‐intervention support to help participants maintain their success.     

Institutionalization of programs in medical education

Through the use of questionnaires and interview schedules during extended site visits, sixteen programs training residents in non-family medicine primary care were studied to determine what factors contributed to program success -- known as "institutionalization" -- or to program failure. The findings revealed that programs were initiated for either philosophic or pragmatic money reasons. For programs to begin, to continue, and to be institutionalized was due to several contributing key factors. These included the resolution of programmatic differences in regard to goals; development of a substantive quality program; presence of forceful and respected leadership; tangible support of the administration and key academic departments; commitment of the teaching staff; anticipation of potential conflicts; participation of the involved lay and professional community; and the availability of some continued funding. The study also revealed that one program was a complete failure and had to be aborted because none of the key factors were present. The study concluded that the best way for institutionalization to occur is to assure that sound and comprehensive planning takes place. With thorough and anticipatory planning, the conditions essential to program institutionalization can be met more easily.     

Is prevention really better than cure? Parameters of the debate and implications for program evaluation design

The relative contributions of health promotion programs andservices to the improvement of community health is the subjectof long-standing debate. Critics of health promotion have arguedthat it does not save costs, has low cost-effectiveness comparedto treatment services, does not attract strong community supportand may be inequitable. The arguments and counter-argumentsthat form the basis of this debate are canvassed in this paper.This is done by applying these various claims not to healthpromotion in isolation, but in comparison with treatment andcare services. The special problems for health promotion—namelythat its benefits are often considerably delayed and only uncertainlyapply to a particular individual and are less in demand thanservices with more immediate benefits-are examined. Demand forhealth promotion and other programs is considered from a politicalperspective. The relative importance of equity and effectivenessas program goals is an important consideration for program andservice managers, not only for health promotion but all healthcare programs. To address further these issues, evaluation of health promotionprograms is urgently needed to establish which programs shouldbe expanded or contracted. These evaluations need to incorporateeconomic appraisal techniques and to assess program demand andequity. The two latter themes can most appropriately occur aspart of process and impact evaluation studies. Implicationsfor the evaluation of different types of health promotion programsare explored. Even if health promotion programs can be demonstratedto justify support on cost, effectiveness and equity grounds,they will face continued political obstacles to their funding.     

Hospital health promotion: swimming or sinking in an upstream business?

Healthy People 2000 (HP 2000) calls on hospitals to offer health promotion programs addressing priority health needs of the community. Historically, this upstream initiative has not been present in health care. With the increasing provision of these programs, this case study examined their content to further understand potential public health impact. The health promotion programs offered to the community--both the general public and corporate employees--by an urban Midwest hospital were assessed over 1 year. This article presents a content analysis of 216 programs that was conducted by measuring seven variables: target group, presentation format, fee, health focus, program providers, contact frequency, and activity. Based on this single case study, hospitals appear to be addressing objectives set forth by HP 2000 for community hospitals. Although moving upstream with health promotion, an analysis of program content suggests modifications may be necessary in order to serve as effective interventions for health priorities.     

Health promotion research and the diffusion and institutionalization of interventions.

To examine the extent to which health promotion research is providing an empirical basis for the diffusion and institutionalization of effective interventions, we conducted a systematic audit of all articles in 12 public health and health promotion journals for the 1994 calendar year. We identified empirical/non-empirical and health promotion/non-health promotion articles. For each study, the health behaviours or outcomes studied, the target group, gender and setting were categorized. Each study was also categorized as belonging to one of four stages: basic research and development, innovation development, diffusion research, and research into institutionalization or policy implementation. Of all articles coded (n = 1210), 33.9% were identified as non-research, 39.5% were health promotion research and 26.6% were non-health promotion research. The vast majority of studies fell within the basic research and development stage (89.6%), with less than 1% categorized as diffusion research and only 5% as institutionalization or policy implementation research. The published studies reviewed provide a limited empirical basis for diffusion and institutionalization of health promotion programs. These findings suggest a need to more systematically monitor research input (funding) and research output (publications), and to develop a more explicit focus on the relevance of the stages of research innovation and development, the issues and/or behaviours addressed, the target population, and the research setting.     

Successfully maintaining program funding during trying times: lessons from tobacco control programs in five states.

Despite negative financial conditions in recent years, several states were able to successfully maintain funding for tobacco prevention and control, which provided an opportunity to understand the factors associated with success. One explanation may be the level of long-term program sustainability in some states. According to a model developed by Saint Louis University researchers, the five elements critical to tobacco control sustainability are state political and financial climate; community awareness and capacity; program structure and administration; funding stability and planning; and surveillance and evaluation. Five states (Nebraska, New York, Indiana, Virginia, and Colorado) maintained funding for their tobacco control programs. Four of these states gained additional legislative appropriations or prevented a massive reduction; Colorado used a statewide ballot initiative to increase funding. On the basis of the sustainability framework, case studies, and prior research, the major lessons learned for maintaining funding were the importance of (1) strong and experienced leadership, (2) broad and deep organizational and community ties, (3) coordinated efforts, (4) strategic use of surveillance and evaluation data, (5) active dissemination of information about program successes, and (6) policy maker champions. The sustainability framework and lessons learned may provide valuable insights for other public health programs facing funding threats.     

Health promotion efforts in pennsylvania schools

Abstract The purpose of this study was to investigate and describe health promotion efforts within Pennsylvania public schools. A questionnaire was designed which addressed the following areas: demographics, health issues and concerns, health promotion programming, and variables pertinent to describe districts without programs. The sample consisted of 275 superintendents of public school districts, 41 of which indicated the existence of a health promotion program in their district. Superintendents of districts with health promotion programs indicated the following: the most frequently offered programs were physical fitness activities, stress management and weight reduction; programs were most frequently offered during the after school hours; many programs were not open to family and community; and the administration of the programs was most frequently the responsibility of a school administrator. The remaining 234 school districts did not have health promotion programs. The reasons cited by the superintendents included limited financial resources, an uninterested faculty and staff, and lack of school board support.     

Health promotion in physician organizations: results from a national study

BACKGROUND: Health promotion programs can be effective in improving the delivery of clinical preventive services and in improving population health; however, the availability of health promotion programs offered through physician organizations, such as medical groups and independent practice associations, are largely unknown. METHODS: This research uses data from the National Study of Physician Organizations and the Management of Chronic Illness, conducted by the University of California, Berkeley, to document the extent to which physician organizations offer health promotion programs. Of 1587 physician organizations nationally with 20 or more physicians, 1104 participated, for a response rate of 70%. RESULTS: Overall, 60% of physician organizations offer at least one health promotion program targeting one or more of eight areas: prenatal education (42%), smoking cessation (39%), nutrition (39%), weight loss (34%), health risk assessments (25%), stress management (25%), substance abuse (20%), and sexually transmitted disease prevention (16%). Factors positively associated with offering health promotion programs include the following: outside reporting of quality measures, public recognition for quality measures, clinical information technology systems, being a medical group, and ownership by a hospital or health plan. CONCLUSIONS: Physician organizations in the United States have a long way to go in offering these important programs to their patients. However, our findings also suggest that health plans, purchasers, and policymakers can play a positive role in increasing the use of these programs. By offering recognition and incentives for quality improvement, and by funding the expansion of information technology, the healthcare community can encourage and enable physician organizations to increase the availability of health promotion programs nationally.     

Essential Resources for Implementation and Sustainability of Evidence-Based Health Promotion Programs: A Mixed Methods Multi-Site Case Study

As of October 2016, use of federal Older Americans Act funds for health promotion and disease prevention will be restricted to the Administration on Aging’s criteria for high-level evidence-based health promotion programs. Dissemination of these programs to rural communities remains limited. Therefore a strong need exists to identify strategies that facilitate program implementation and sustainability. The objective of this study was to compare organizational readiness and implementation strategies used by rural communities that achieved varying levels of success in sustaining evidence-based health promotion programs for older adults. We utilized a qualitative multi-site case study design to analyze the longitudinal experiences of eight rural sites working to implement evidence-based health promotion program over 3 years (8/2012–7/2015). Multiple sources of data (interviews, documents, reports, surveys) from each site informed the analysis. We used conventional content analysis to conduct a cross-case comparison to identify common features of rural counties that successfully implemented and sustained their target evidence-based health promotion program. Readiness to implement evidence-based programs as low at baseline as all site leaders described needing to secure additional resources for program implementation. Sites that successfully utilized six essential resources implemented and sustained greater numbers of workshops: (1) External Partnerships, (2) Agency Leadership Commitment, (3) Ongoing Source of Workshop Leaders, (4) Health Promotion Coordination Tasks Assigned to Specific Staff, (5) Organizational Stability, and (6) Change Team Engagement. The six essential resources described in this study can help rural communities assess their readiness to implement health promotion programs and work secure the resources necessary for successful implementation.     

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.     

Influence of Funding Cuts on Texas School Tobacco Programs*

BACKGROUND: Following the Master Settlement Agreement, state tobacco prevention spending peaked in 2002, but has subsequently been diminishing annually. This study compared the influence of 2004 Texas tobacco program budget cuts on school practices a year after funding loss. METHODS: Three school groups were compared: continuously funded for a 2‐year minimum (n = 109), funded but discontinued (n = 123), and never funded (n = 70). Among the 123 schools with discontinued funding, differences were examined based on funding cut decision level (state or local). Written responses to surveys based on the Centers for Disease Control and Prevention (CDC) School Health Education Profile Tobacco Module were received from 49% of health coordinators and 58% of principals. RESULTS: Principals and health coordinators from continuously funded schools reported more 1) tobacco instrunctional activities; 2) teacher training; 3) student cessation support; 4) program leadership; 5) a district advocate; 6) interest in tobacco use prevention education; 7) use of evidence‐based programs and CDC‐recommended teaching methods; 8) involvement of school staff; 9) student tobacco cessation programs at school and community; 10) family involvement; and 11) staff development funding. Previously funded schools approached profiles of those never funded. Few differences were noted among schools with funding loss due to state or local decisions. CONCLUSION: The continuously funded schools consistently were better positioned to positively reach their students with effective tobacco programs. Funding reductions were associated with rapid reductions in programming. Results emphasize the need for early programmatic initiation of capacity building skill development to ensure implementation and retention of health programs during fiscally challenging circumstances.