Facilitating practice change: lessons from the STEP-UP clinical trial

BACKGROUND: The Study To Enhance Prevention by Understanding Practice (STEP-UP) clinical trial (1997-2000) resulted in sustainable increases in preventive service delivery in primary care practices. However, the process by which practice change can be facilitated has not been well described. METHODS: Comparative case studies were conducted of eight STEP-UP practices with the largest increases in preventive service delivery rates and compared to seven practices with the lowest increases. A multidisciplinary team (research nurse, nurse facilitator, physician principal investigator) used an editing analysis approach to create individual case studies. Then, using an immersion-crystallization approach, the team identified pragmatic lessons for people working to improve primary care practice, and validated these lessons with a participating practice and an additional facilitator. RESULTS: It is not always possible to predict which practices will change based on understanding initial practice conditions. "Malleable moments" can be identified during which practices become open to change. It is important to tie change strategies with existing motivations, or to develop new motivation among potential change agents. Motivation can be developed by discrepant information that challenges self-image, aligning change plans with existing values, or identifying feasible ways of responding to outside pressures or internal demands. Instrumental interventions (such as office systems, tools, new processes) are useful when motivation to change exists, and can build motivation when they meet a perceived need. Disruption in previously workable approaches, either by purposeful information seeking or unanticipated changes, promotes openness to change. CONCLUSIONS: Despite limited ability to predict which practices will change and when, understanding practices' initial conditions and evolution can identify opportunities to craft individualized approaches to positive change.     

Developing the public health practitioner workforce in England: lessons from theory and practice

FOCUS: The paper focuses on public health practitioners who collectively represent one of three key workforce groups identified by England's Chief Medical Officer as critical to the successful delivery of national public health policy priorities. QUESTION: We report on two areas of work which attempt to address the following two-part question: in developing the public health practitioner workforce in England, what is needed, and how do we do it? APPROACH: First, we describe a five-component conceptual framework for developing the public health workforce which is grounded in data derived from a national Open Space event hosted by the University of the West of England in March 2005. The five components are (i) strategic support and oversight; (ii) national technical and professional support; (iii) national career building; (iv) local organisational development, and (v) sub-regional skills development. Key elements of each component are described in the paper. Second, we describe in some detail a new multidisciplinary skills development programme which illustrates one of the framework components (sub-regional skills development). The programme, established in January 2005, is aimed at three key groups of public health practitioners: health visitors (specialist community public health nurse), school nurses and environmental health officers. Its main features and some initial evaluation findings are presented. CONCLUSIONS: To be effective, activities aimed at supporting the development of the public health practitioner workforce should, where possible, aim to be congruent with core public health principles of self-determination and collective responsibility. We also conclude that leadership and vision at a national level, combined with local implementation of evidence-based training programme such as the one described could help to achieve much greater and more rapid progress in skilling up the existing public health practitioner workforce than has been possible up to now. But we note that this requires sustained investment, robust sector-wide delivery frameworks, and a group of committed local public health champions.     

Developing effective policy and practice for health promotion in Scotland

Scotland has recently embarked on a new phase of policy and infrastructure development for improving population health and reducing health inequalities that broadly conforms to the Ottawa Charter and WHO's strategic framework for the prevention and control of non-communicable diseases. The new phase is characterised by an integrated, cross-government approach to improving health with strengthened political and Scottish Executive leadership and investment since devolution. A comprehensive policy framework for improving young people's health and reducing inequalities has been developed across education, health, environment and social justice. It builds on an earlier phase of relative stability and continuity in the health promotion infrastructure with policy focused on CVD and cancer prevention and tackling the behavioural risk factors (smoking, alcohol, diet, physical activity) as well as sexual health and mental health and wellbeing. These national strategies are currently being implemented across Scotland. They combine promotion, prevention, treatment and protection goals and target both population-level and high-risk groups. Crosscutting government objectives and headline targets for addressing poverty, disadvantage and health inequalities now supplement the NHS health improvement targets on smoking, alcohol, physical activity, teenage pregnancy and child immunization. Within the health service, prevention efforts are largely concerned with primary care development (anticipatory care) and health system reform to maximize their impact on reducing health inequalities. Efforts to tackle the social determinants of health and reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government with Community Planning Partnerships as the main vehicle. National level mechanisms for integrated funding, planning and performance reporting to deliver shared priority outcomes have yet to be developed. The development of health improvement strategies has been founded upon a rich source of population health data to monitor changes and improvements, epidemiological studies and evaluation work. The key issues have been to find ways of intervening to accelerate the rate of improvement and to stem the growing health inequalities. A further challenge is to ensure that the lessons from reviews and evaluations of past programmes and strategies are not lost, but help to guide improvements in the complex delivery system and to inform future policy direction. Within the health service, prevention efforts are largely concerned with primary care development and health system reform. Efforts to reduce inequalities in health outcomes are beginning to be connected and mainstreamed across local government.     

Searching for lessons from the New Orleans Health Department: implications for public health practice.

The National Association footline of County and City Health Officials (NACCHO) is the national organization representing local health departments. NACCHO supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.     

Community health promotion: concepts and lessons from contemporary sociology

The idealism on behalf of community interventions from The First International Conference on Health Promotion in 1986 today seems to be reduced. This article argues that there has been too little concern with what kind of social and spatial reality the community actually is among health promotion initiators and researchers. Contemporary sociological approaches to the community, emphasizing how collective and personal identities are developed in a situation with massive external and global influences, are introduced. The article advocates a stronger concern with particular local contexts and the inhabitants' self-interpretations, to learn more about whether and how local identities and cultures can be mobilized in health promotion initiatives. This focus contrasts that on education guiding most community health promotion projects. Inspired by contemporary methodological discussions centering around the concept of mechanism and contextual analysis in community studies, the article also criticizes the quasi-experimental research designs involved in many community health promotion projects.     

Constructing evidence-based health promotion: Perspectives from the field

This paper examines current debates about evidence-based health promotion in the UK within the context of the Jakarta Declaration. It discusses the epistemological issues underlying the debate, and the way in which evidence-based health care is impacting on health promotion in the UK. The empirical content is based on an analysis of 20 interviews with health promotion managers whose views are discussed in terms of three illustrative positions: ‘Cochranes’, ‘Local Voices’, and ‘Pragmatists’. Possible implications for health promotion specialists and theoretical developments are identified. It is concluded that the difficulties experienced by health promotion specialists are strongly related to issues of structure, value and epistemology arising within the context of their work rather than from inappropriate practice or skills.     

Fieldwork challenges: lessons learned from a north-south public health research partnership

The value of collaborative international research in addressing global public health challenges is increasingly recognized. However, little has been written about lessons learned regarding fieldwork to help guide future collaborative efforts. Through a research partnership between two Northern universities, one Southern university, and a Southern faith-based organization, we evaluated a school-based HIV prevention intervention with South African adolescents. In this article, we highlight the seven key fieldwork-related challenges experienced and identify the lessons learned. The underlying theme is that of reconciling a structured and reasoned "desk" planning process with the more fluid and unpredictable reality of conducting fieldwork. This concern is particularly significant in resource-deprived environments and/or contexts that are less familiar to Northern partners. Fieldwork is unpredictable, but obstacles can be minimized through meaningful participation in both planning and field research. Sharing practical lessons from the field can prove a useful resource for both researchers and practitioners.     

Evaluation of a community-based health promotion program for the elderly: lessons from Seniors CAN

PURPOSE: To evaluate the effects of a community-based educational program designed to promote health by enhancing older adults' mastery while decreasing loneliness and stress. METHODS: Between 1999 and 2004, 339 older adults who participated in Seniors CAN completed standardized assessments of mastery, loneliness, and stress, prior to and upon completion of the 4-month intervention. Participants'scores were compared using paired t-tests to measure changes from preintervention to postintervention. Change scores were then subjected to three-way ANOVA to assess the relative effectiveness based upon participants' sociodemographic characteristics. RESULTS: Participants demonstrated significant improvements from preintervention to postintervention for mastery, loneliness, and stress. Additional analysis revealed that improvement in loneliness was significantly greater among low-income ethnic minorities and minorities with a high level of formal education, p < .05. CONCLUSION: The 16-week intervention resulted in significant improvements in constructs associated with better health and a higher quality of life for independent-living older adults. These findings suggest that a community-based educational intervention can be an effective strategy to reduce risk and promote the health and independence of older adults.     

Public health informatics: the nature of the field and its relevance to health promotion practice

The purpose of this article is to introduce the relatively new field of public health informatics and provide examples of how informatics is currently being applied to health promotion activities. Additionally, the article illustrates how informatics is well positioned to play a central role and is likely to be central to disease prevention, health education, and health promotion as it will be practiced in the future.