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      

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.     

Policies alone are not enough: Workplace health development in the public,private and voluntary sectors

A 2001 survey of public (n?=?28), private (n?=?113) and voluntary sector (n?=?64) workplaces in Sefton, Merseyside indicated that there were significantly different levels of health-related policy provision across the three sectors, with the public sector having the highest level of provision (7.18 policies on average), followed by the voluntary (5.09 policies on average) and the private sector (3.94 policies on average). Policies already in place were mostly based around health and safety (89%), smoking (80%), sickness absenteeism (68%) and manual handling (49%). Workplaces reported that in order to benefit their employees’ health they wanted to improve: the physical work environment (38%); communications (31%); job content/organization (30%) and wage levels (29%). In addition, they wanted to develop stress management (51%) and family-friendly (25%) policies. The major perceived barriers to implementing these policies were: lack of time/monetary resources (70%); not having the skills/expertise (37%); knowing which issues are priorities (25%); and knowing where to go to for help (17%). In order to achieve this, workplaces would like support in the form of: advice/information (63%); free health and safety checks (52%); training courses (49%) and monetary subsidies (49%). This study uniquely compares the public, private and voluntary sectors, highlighting that the sectors with the most health policies in place (public and voluntary) are also the sectors with the greatest number of reported difficulties, e.g. absenteeism, recruitment and retention. Recommendations from this study are that a ‘one-size-fits-all’ approach to health promotion would be inadequate to bring about changes in practice; that health promotion campaigns should focus on addressing the contextual difficulties, e.g. lack of resources, facing the voluntary and public sector, rather than on solely developing policy provision; and that information and advice for workplaces should be tailored to this end.     

Barriers to addressing the societal determinants of health: public health units and poverty in Ontario, Canada

Despite Canada's reputation as a leader in health promotion and population health concepts, actual public health practice for the most part remains wedded to downstream strategies focussed on behaviour change. In Canada's largest province this has led to the implementation of a heart health promotion approach focussed on diet, activity and tobacco use. This is so despite increasing evidence that these approaches are generally ineffective, particularly for those at greatest risk. In addition, these strategies appear to divert public and governmental attention away from addressing the broader societal determinants of health. Examples of Ontario public health units that have begun to address societal determinants of health provide a counterbalance to the dominant paradigm that frames health as an individual responsibility. These new approaches focus attention upon the health-threatening effects of governments' regressive social and economic policies in a manner consistent with the best principles of health promotion.     

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.     

Healthy nature healthy people: 'contact with nature' as an upstream health promotion intervention for populations

Whilst urban-dwelling individuals who seek out parks and gardens appear to intuitively understand the personal health and well-being benefits arising from 'contact with nature', public health strategies are yet to maximize the untapped resource nature provides, including the benefits of nature contact as an upstream health promotion intervention for populations. This paper presents a summary of empirical, theoretical and anecdotal evidence drawn from a literature review of the human health benefits of contact with nature. Initial findings indicate that nature plays a vital role in human health and well-being, and that parks and nature reserves play a significant role by providing access to nature for individuals. Implications suggest contact with nature may provide an effective population-wide strategy in prevention of mental ill health, with potential application for sub-populations, communities and individuals at higher risk of ill health. Recommendations include further investigation of 'contact with nature' in population health, and examination of the benefits of nature-based interventions. To maximize use of 'contact with nature' in the health promotion of populations, collaborative strategies between researchers and primary health, social services, urban planning and environmental management sectors are required. This approach offers not only an augmentation of existing health promotion and prevention activities, but provides the basis for a socio-ecological approach to public health that incorporates environmental sustainability.     

Beyond evidence--to ethics: a decision-making framework for health promotion, public health and health improvement

Echoing the rise of 'evidence-based medicine', the concept of evidence-based policy and practice in the inter-related fields of health promotion, public health and health improvement has attracted increasing attention over the past two decades. More recently, again with roots traceable to biomedical thinking, there has been growing interest in ethics in relation to these fields. This paper links these two topical themes in a practical way. It explores the extent to which policies and activities 'on the ground' can and should be based on evidence, and considers the relative places of evidence and ethics in decision-making. It goes on to present the 'decision-making triangle', a framework that gives primacy to a set of ethical principles--with available evidence and plausible theory being used to inform the application of these. After introducing the concept of 'ethical logic modelling', the paper concludes by suggesting an 'ethical imperative' for health promotion, public health and health improvement: to make decisions based on the explicit application of ethical principles, using available evidence and theory appropriately.     

General practice and public health: Assessing the impact of the new GMS contract

Over the past 30 years, the important role of primary care in public health has been widely recognised, and in the UK a range of measures to support public health in general practice have been introduced since the late 1980s. In 2004 a new general medical services contract was introduced changing the way general practitioners are reimbursed in the NHS. The new contract shifted the emphasis from the individual practitioner to the practice and introduced a new performance incentive framework, the Quality Outcomes Framework, which rewards performance through targeted financial payments. The performance framework identifies specific areas of clinical and organisational performance and patient experience activities–including a number of health promotion activities–and practices attract points for attaining performance targets. This paper examines the experience and impact of the new GMS contract on public health activities in general practice. While the contract has only been operating for three full years, there is emerging evidence to suggest that it may have a negative impact on public health activities in general practice. The use of financial incentives appears to be skewing practice towards areas that are rewarded, which may not be those that maximise health outcomes, and there is some emerging evidence suggesting that there is a negative effect on health inequalities. This paper reviews current evidence on public health incentives in general practice within a wider context of the impact of incentives for public health.     

The role and theoretical evolution of knowledge translation and exchange in public health

BACKGROUND: There is an increased emphasis in public health research on effective models and strategies to support knowledge translation (KT), the exchange, synthesis and ethically sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, KT can be seen as an acceleration of the knowledge cycle-an acceleration of the natural transformation of knowledge into use (Canadian Institutes of Health Services Research. Knowledge Translation Strategy, 2004). The most recent conceptualizations consider the complexities of public health decision-making. The role of practitioners and communities is increasingly considered. METHODS: We identify, describe and discuss the theoretical underpinnings of KT and recommend a way forward to build the evidence for more effective practice. RESULTS: Theoretical perspectives increasingly influence research on KT in public health. A range of innovative work is being conducted to explore methods for KT using practical tools, often with the support of government. CONCLUSIONS: KT describes a crucial and to date under-developed element of the research process. There is an important gap in theoretically informed empirical studies of effectiveness of proposed approaches in public health, health promotion and preventive medicine, and thus much of the debate remains abstract. There is clearly an urgent policy need to establish the effectiveness of KT models in a range of contexts. This must include both the consideration of development and the utilization of knowledge.     

Evidence-based public health: what does it offer developing countries?

The global burden of disease and illness is primarily situated in developing countries. As developing countries have limited resources, it is particularly important to invest in public health and health promotion strategies that are effective. Systematic reviews are central to evidence-based public health and health promotion practice and policy. This paper discusses issues surrounding the relevance of evidence-based public health and systematic reviews to the health of developing countries. It argues that there is a lack of systematic reviews relevant to the health priorities of developing countries; many interventions reviewed can not be implemented in resource-poor situations; and, a limited amount of primary research is conducted in developing countries. The paper further argues that improvements in public health are determined not only by effective health services and interventions, but through an approach that includes other sectors and influences broader structural and systematic barriers to health. Given the social complexity of human development, and the inter-sections amongst different development goals, there is no question that gains in developing country public health are unlikely to emerge from systematic reviews alone, but will require decisions about inter-sectoral collaboration and social policy initiatives. Nonetheless, evidence around intervention effectiveness has an important role to play in addressing health priorities in developing countries and resource-poor areas. The public health evidence base urgently needs strengthening, with dedicated effort towards increasing the relevance of primary evidence and systematic reviews.     

Designs and methods used in published Australian health promotion evaluations 1992–2011

Objective: To describe the designs and methods used in published Australian health promotion evaluation articles between 1992 and 2011. Methods: Using a content analysis approach, we reviewed 157 articles to analyse patterns and trends in designs and methods in Australian health promotion evaluation articles. The purpose was to provide empirical evidence about the types of designs and methods used. Results: The most common type of evaluation conducted was impact evaluation. Quantitative designs were used exclusively in more than half of the articles analysed. Almost half the evaluations utilised only one data collection method. Surveys were the most common data collection method used. Few articles referred explicitly to an intended evaluation outcome or benefit and references to published evaluation models or frameworks were rare. Conclusion: This is the first time Australian‐published health promotion evaluation articles have been empirically investigated in relation to designs and methods. There appears to be little change in the purposes, overall designs and methods of published evaluations since 1992. Implications: More methodologically transparent and sophisticated published evaluation articles might be instructional, and even motivational, for improving evaluation practice and result in better public health interventions and outcomes.     

Facilitating effective health promotion practice in a public health unit: lessons from the field

OBJECTIVES: Health promotion is a core function of public health services and improving the effectiveness of health promotion services is an essential part of public health service development. This report describes the rationale, the process and the outcomes of a realignment designed to improve the effectiveness of health promotion activities in a public health unit (PHU) in New Zealand. METHODS: A practice environment analysis revealed several factors that were hindering the effectiveness of the health promotion unit's (HPU) activities. Two primary change mechanisms were implemented. The first was an outcomes-focused model of planning and service delivery (to support evidenced-based practice), the second was the reorganisation of the HPU from a topics-based structure to an integrated one based on a multi-risk factor paradigm of population health. RESULTS: During the realignment barriers were encountered on multiple levels. At the individual level, unfavourable attitudes to changes occurred because of a lack of information and knowledge about the benefits of evidence and research. At higher levels, barriers included resourcing concerns, a lack of organisational commitment and understanding, and tensions between the political need for expedient change and research and development need for timely consideration of the impact of different models of practice. CONCLUSIONS AND IMPLICATIONS: This realignment took place within the context of a changing public health environment, which is significantly altering the delivery of public health and health promotion. Realignments designed to facilitate more effective health promotion and public health practice will continue, but need to do so in the light of others' experience and debate.     

It's in your hands: the value of handsearching in conducting systematic reviews of public health interventions

BACKGROUND: While there is an emerging evidence base in public health, the evidence can often be difficult to find. Indexing of journals in MEDLINE has assisted those conducting systematic reviews to more easily identify published studies. However, information technology and the processes associated with indexing are not infallible. Studies may not be correctly marked by study design which may mean they are missed in the electronic searching process. Handsearching for evidence of intervention effectiveness has therefore become a recognized tool in the systematic review process. METHODS: Resources to guide handsearching activity currently are clinically focused, and may not be sensitive to the characteristics of public health studies where study terminology may differ. In response to this issue, the Cochrane Health Promotion and Public Health Field (the Field) developed and implemented a small study to recruit and support handsearchers from around the world to identify health promotion and public health trials and systematic reviews. A strategic framework was developed to recruit and support handsearchers to search six public health-related journals. RESULTS: In total, 131 trials and 21 systematic reviews were identified. The greatest value of handsearching was found to be in supplement editions and abstract sections of journals CONCLUSIONS: The study focused exclusively on indexed journals with the intention that tools and methods developed could be used to explore the potential for handsearching in non-indexed journals and for unpublished studies. The findings from this study will continue to support handsearching efforts and in doing so contribute to high quality systematic reviews of public health interventions.     

The role of a Prospective Public Health Intervention Study Register in building public health evidence: proposal for content and use

Evidence-informed practice is a key component of public health and the focus of much discussion, of which the nature of evidence and how it is best gathered and appraised has formed a large part. Prospective registration of trials is now a key component of rigour and quality in clinical research and has been supported at an international level through the WHO International Clinical Trials Registry Program. This paper discusses the scope and benefits of trial registration in clinical research, including greater transparency and reduced publication bias. It then considers the potential for a Prospective Public Health Intervention Studies Register specific to the needs of public health and aspects to be included in such a register. It is argued that this initiative has the potential to facilitate increased global cooperation and efficiency in the production of high quality evidence and ultimately in improved health outcomes for populations.     

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

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

The nature of evidence resources and knowledge translation for health promotion practitioners

Governments and other public health agencies have become increasingly interested in evidence-informed policy and practice. Translating research evidence into programmatic change has proved challenging and the evidence around how to effectively promote and facilitate this process is still relatively limited. This paper presents the findings from an evaluation of a series of evidence-based health promotion resources commissioned by the Victorian Department of Human Services. The evaluation used qualitative methods to explore how practitioners for whom the resources were intended, viewed and used them. Document and literature review and analysis, and a series of key informant interviews and focus groups were conducted. The findings clearly demonstrate that the resources are unlikely to act as agents for change unless they are linked to a knowledge management process that includes practitioner engagement. This paper also considers the potential role of knowledge brokers in helping to identify and translate evidence into practice.