Challenges and approaches on evaluation of Health Promotion

Challenges and approaches on evaluation of Health Promotion Effectiveness David V. Mc. Queen IUHPE President; Associate Director for Global Health Promotion at CDC, Brazil, May 14, 2008

The Global Programme on Health Promotion Effectiveness A programme coordinated by the International Union for Health Promotion and Education in collaboration with numerous international partners. Catherine Jones GPHPE Coordinator David V. Mc. Queen Global Leader International Union for Health Promotion and Education (contact) cjones@iuhpe. org

GPHPE: Distinguishing aspects The GPHPE: n Is a worldwide programme. n Advocates the importance of effectiveness to researchers, practicitioners and decision-makers. n Supports local approaches, given the different stages of the development of the field, and the strong influence of social and cultural context

GPHPE : Monographs • *Volume I: Mc. Queen, David V. , & Jones, Catherine M. , eds. (2007) Global Perspectives on Health Promotion Effectiveness. New York: Springer • A critical reflection on the state of health promotion effectiveness, issues and questions • Health promotion effectiveness analysed from theoretical and practical points of view. • A multi-volume series; now developing Volume II addressing emerging areas of interest

Threads to carry from Volume I to Volume II n n n n Reaffirming and reflecting on the topic in Volume I Taking a focused, strategic approach Capturing the gripping issues of the day to which HP can or could contribute more Looking at where theory & practice might better come together by understanding the context of interventions Developing a communications strategy to target a wider audience Providing a base source document for further work in evaluation Incorporating capacity building for health promotion evaluation Providing innovative formats – debate and dialogue- case histories

GPHPE : Next steps n n n n Increasing focus on developing capacity Enlargement and strengthening of initiatives Increased networking and exchange across globe, Developing partnerships (e. g. Cochrane PH) Focus on methodological issues Focus on KSTE issues and evidence Focus on broad salient topics, e. g urbanization, settings, SDOH

Consider: Social Determinants of Health The global context for health promotion vis a vis the SDOH has changed markedly n n New patterns of communication Commercialization Global environmental change Inequities increasing globally

Social Determinants of Health presents questions of evidence, Some argue*: To manage the challenges of globalization, policy must be coherent across all levels of government, United Nations bodies, and other organizations, including the private sector. Hypothesis to be proven

Of course these arguments and assertions derive in part from the text of the Bangkok Charter The Bangkok Charter identifies actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion. The Charter affirms that policies and partnerships to empower communities, and to improve health and health equality, should be at the centre of global and national development.

Strategies for Health Promotion in a Globalized World Health promotion has an established repertoire of proven effective strategies (AN ASSUMPTION) which need to be fully utilized. To further advance these strategies, all sectors and settings must act to: n Advocate for health based on human rights; n Invest in sustainable policies, actions and infrastructure to address the determinants of health; n Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy; n Regulate and legislate to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; and n Partner and build alliances with public private, nongovernmental and international organizations and civil society to create sustainable actions.

HP Commitments to Health for All The four key commitments of health promotion are ultimately questions of evidence and effectiveness n Central to the global development agenda; n A core responsibility for all of government; n A key focus of communities and civil society; and n A requirement for good corporate practice.

Example: Commitment #1 Promotion of Health Central to Global Development Strong intergovernmental agreements that increase health and collective health security are needed. Effective mechanisms for global governance for health are required to address all the harmful effects of: n n Trade; Products; Services; and Marketing Strategies.

Commitment #2 Make the Promotion of Health a Core Responsibility for All of Government All governments at all levels must tackle poor health and inequalities as a matter of urgency because health is a major determinant of socioeconomic and political development. To ensure this, all levels of government should make the health consequences of policies and legislation explicit, using tools such as equity-focused health impact assessments.

Commitment #3 Make the Promotion of Health a Key Focus of Communities and Civil Society Well organized and empowered communities are highly effective in determining their own health, and are capable of making governments and the private sector accountable for the health consequences of their policies and practices. (Assertions) Civil society needs to exercise its power in the marketplace by giving preference to the goods, services and shares of companies that exemplify corporate social responsibility.

Commitment #4 Make the Promotion of Health a Requirement for Good Corporate Practice The private sector, like other employers and the informal sector, has a responsibility to ensure health and safety in the workplace, and to promote the health and wellbeing of their employees, their families and communities. The private sector can also contribute to lessening wider global health impacts, such as those associated with global environmental change by complying with local national and international regulations and agreements that promote and protect health.

The challenge of ‘evidence’ n n Recognize what we “know” versus what we “wish for”. What work needs to be done What is “inside” the evidence debate What is “outside” the debate

How to build “good” evidence n n Distinguish evidence of success from evidence of harm Methodology of deleting vs building evidence – reduction vs complexity Operationalize judgment Distinguish evidence from effectiveness from evaluation

How to build “better” evidence n n n Be reflexive Methods Follow complexity with the methods Move away from reduction Collect more information Assess more interventions Be innovative

Distinguish “evidence” of causation and etiology from evidence related to the understanding of interventions An example: n “The health of populations is affected by and is a product of the social determinants in the population”* *This is an etiological statement asserting causation

But what are the components of Social Determinants from a HP Perspective? n n n LIFESTYLE: Collective pattern of life conduct LIFE CONDUCT: Pattern of behavior of an individual in their day-to-day lives LIFE CONDITIONS: Patterns of resources of an individual or group (including health status) LIFE SITUATION: Collective pattern of life conditions LIFE CHANCES: Structural-based probability of correspondence of lifestyle and life situation Adapted from Rutten, A. (1995). The implementation of health promotion: a new structural perspective. Social Science & Medicine, 41(2), 1627 -1637.

It is all about CONTEXT

SOCIOCULTURAL ENVIRONMENT FRAMEWORK Determinants EQUITY AND SOCIAL JUSTICE SOCIAL RESOURCES Standard of living Culture and history Social institutions Built environments Political structures Economic systems Technology PHYSICAL ENVIRONMENT Natural Resources Intermediate Outcomes Neighborhood Living Conditions Community Development and Employment Opportunities Health Outcome Civic Engagement & Participation in Decision-Making Community Customs, Norms and Processes Opportunities for Learning and Developing Capacity Health Promotion, Prevention and Care Opportunities HEALTHIER COMMUNITIES

The “problem” in understanding the notion of “context” is our work focus: PH/epi focus n Concerned with CAUSE Health Promotion n (i. e. etiology) n n n Methods Action Theory n n n Concerned with CHANGE (i. e. interventions) Action Concepts and Principles (Values) Methods

For Health Promotion, Evidence and Effectiveness are complicated and related terms n n n Effectiveness is a broad, loosely defined term, generally linked to the notion of “outcomes” (tied to causality) Notion that effective health promotion leads to changes in the determinants of health is distal Underlying epistemology of “outcomes” is complicated

Complexity and Methodology are Intertwined in Health Promotion n Most community-based health promotion interventions include a complex mixture of many disciplines, many variables of varying degrees of measurement difficulty, and dynamic changing settings This complexity is increased when the social context is introduced and tied to the notion of causality as in the SDOH Understanding this complexity requires a mixture of complex methodologies and considerable time to unravel causal relationships

A different approach n n Evidence is: Strength of knowledge base for what is causally related Effectiveness is: Agreement about translating the evidence to application

Understanding change processes*: where effectiveness meets evidence Low Innovation Creativity Effectiveness Political compromise “Zone of Chaos & Complexity” Trial & Error High Standards Guidance Experiment High *HAD: modified Low Evidence

Zone of Chaos and Complexity: Characteristics Multiple causality Multiple settings Multiple outcomes Multiple actors Multiple paradigms Cultural diversity Variation/probabalistic Politics

Irritating Ideas n n Shared versus unshared variables in interventions (epistemology of variables) Intervention as a problem (power corrupts, empowerment corrupts) n Ethics of interventions (planned interventions should do no harm) n n “Control” impossible (forces beyond our power) Naturally occurring interventions (trump our small, under resourced efforts)

Irritating Ideas (continued) n n n Intervention deceit (curb appeal, eyewash) Evaluation –advisory boards Evaluation reports and analyses not unbiased External policy makers base their assessment on evidence in these biased reports External evaluators base their assessment of evidence on the biased published reportssystematic review of the lit

While the focus today has been on SDOH, because it is the topic of the moment, there are many others n n Each needs to be treated with reflexivity Each needs to be seen as complex Each needs to be evaluated in the Health Promotion context Each needs to be seen in terms of the notions of evidence and effectiveness

What topics in Health Promotion are doable? n n n Given current resources Given current HP capacity Requiring new HP capacity

So what can we do? n n We have some initial findings that health promotion interventions on the social determinants of health work However, comprehensive and/or systematic reviews have only been conducted on a few interventions and almost entirely on western literature

Three things that we need n n n A better theory of evidence and evaluation for health promotion Many Comprehensive evaluations of interventions Many more health promotion interventions based on the best theory of practice

AND, More of your work represented at the - The 20 th IUHPE World Conference on Health Promotion and Education to be held in Geneva Switzerland, Summer 2010

The International Union for Health Promotion and Education The IUHPE aims to connect and support everyone committed to health promotion and health education wherever they are in the world. IUHPE Headquarters 2, rue Auguste Comte - 92170 Vanves - France TEL: 33 1 46 45 0059 - FAX: 33 1 46 45 00 45 - EMAIL: mclamarre@iuhpe. org

n More information: dvmcqueen@cdc. gov

The Bangkok Charter for Health Promotion in a Globalized World As developed prior to and during the 6 th Global Conference on Health Promotion*, Bangkok, Thailand August 2005 *Ottawa, Adelaide, Sundsvall, Jakarta, Mexico

Some key concepts n n n Links to Ottawa in RED Links to key areas of HP work YELLOW Links to emerging and new areas

Bangkok Charter: Scope and Purpose The Bangkok Charter identifies actions, commitments and pledges required to address the determinants of health in a globalized world through health promotion. The Charter affirms that policies and partnerships to empower communities, and to improve health and health equality, should be at the centre of global and national development.

Bangkok Charter: Audience The Bangkok Charter reaches out to people, groups and organizations that are critical to the achievement of health, including: n n n Governments and politicians at all levels; Civil society; Private sector; International organizations; and The public health community.

Bangkok Charter: Definition of Health Promotion Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. It is a core function of public health and contributes to the work of tackling communicable and noncommunicable diseases and other threats to health.

Addressing Determinants of Health The global context for health promotion has changed markedly since the development of the Ottawa Charter: n n n Increasing inequalities within and between countries New patterns of consumption and communication Commercialization Global environmental change, and Urbanization

Strategies for Health Promotion in a Globalized World Health promotion has an established repertoire of proven effective strategies (AN ASSUMPTION) which need to be ( fully utilized. To further advance these strategies, all sectors and settings must act to: n Advocate for health based on human rights; n Invest in sustainable policies, actions and infrastructure to address the determinants of health; n Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy; n Regulate and legislate to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; and n Partner and build alliances with public private, nongovernmental and international organizations and civil society to create sustainable actions.

Commitments to Health for All The four key commitments are to make the promotion of health: n Central to the global development agenda; n A core responsibility for all of government; n A key focus of communities and civil society; and n A requirement for good corporate practice.