Challenges and approaches on evaluation of Health Promotion Effectiveness

1. Challenges and approacheson evaluation of Health Promotion Effectiveness David V. McQueen IUHPE President; Associate Director for Global Health Promotion at CDC, Brazil, May 14, 2008

2. 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. McQueen Global Leader International Union for Health Promotion and Education (contact) cjones@iuhpe.org

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

4. GPHPE : Monographs • *Volume I: McQueen, 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

5. Threads to carry from Volume I to Volume II • 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

6. GPHPE : Next steps • 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

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

8. 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

9. 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.

10. 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: • Advocate for health based on human rights; • Invest in sustainable policies, actions and infrastructure to address the determinants of health; • Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy; • Regulate and legislate to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; and • Partner and build alliances with public private, nongovernmental and international organizations and civil society to create sustainable actions.

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

12. Example: Commitment #1Promotion 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: • Trade; • Products; • Services; and • Marketing Strategies.

13. Commitment #2Make 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.

14. Commitment #3Make 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.

15. Commitment #4Make 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.

16. The challenge of ‘evidence’ • 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

17. How to build “good” evidence • 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

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

19. Distinguish “evidence” of causation and etiology from evidence related to the understanding of interventionsAn example: • “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

20. But what are the components of Social Determinants from a HP Perspective? • 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.

21. It is all about CONTEXT

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

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

24. For Health Promotion, Evidence and Effectiveness are complicated and related terms • 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

25. Complexity and Methodology areIntertwined in Health Promotion • 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

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

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

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

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

30. Irritating Ideas (continued) • 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 reports-systematic review of the lit

31. While the focus today has been on SDOH, because it is the topic of the moment, there are many others • 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

32. What topics in Health Promotion are doable? • Given current resources • Given current HP capacity • Requiring new HP capacity

33. So what can we do? • 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

34. Three things that we need • A better theory of evidence and evaluation for health promotion • Many Comprehensiveevaluations of interventions • Many more health promotion interventions based on the best theory of practice

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

36. Thank You!!

37. 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

38. More information:dvmcqueen@cdc.gov

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

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

42. 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.

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

44. 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.

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

46. 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: • Advocate for health based on human rights; • Invest in sustainable policies, actions and infrastructure to address the determinants of health; • Build capacity for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy; • Regulate and legislate to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; and • Partner and build alliances with public private, nongovernmental and international organizations and civil society to create sustainable actions.

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