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Ev
Evalua
aluattion
Evaluation in health promotion
in healt
healthh
promotion
promotion
inciples and
Principles
es
perspectives
WHO Regional Publications
European Series, No. 92
Evaluation in health promotion
Principles and perspectives
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Evaluation in health promotion
Principles and perspectives
Edited by:
Irving Rootman, Michael Goodstadt,
Brian Hyndman, David V. McQueen,
Louise Potvin, Jane Springett
and Erio Ziglio
Health Santé
Canada Canada
WHO Regional Publications, European Series, No. 92
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Contents
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Part 1. Introduction and framework
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Part 1
Introduction and framework
Introduction to the book
Irving Rootman
WHO European Working Group on Health Promotion
Evaluation
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health promotion evaluation
Irving Rootman, Michael Goodstadt,
Louise Potvin and Jane Springett
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Table 1.1. Definitions of health promotion
Source and date Definition (emphasis added)
Lalonde, 1974 (3) A strategy “aimed at informing, influencing and assisting both individuals
and organizations so that they will accept more responsibility and be
more active in matters affecting mental and physical health”
US Department of “A combination of health education and related organizational, political
Health, Education, and and economic programs designed to support changes in behavior and in
Welfare, 1979 (19) the environment that will improve health”
Green, 1980 (20) “Any combination of health education and related organizational, politi-
cal and economic interventions designed to facilitate behavioral and
environmental changes that will improve health”
Green & Iverson, 1982 “Any combination of health education and related organizational, eco-
(21) nomic, and environmental supports for behavior conducive to health”
Perry & Jessor, 1985 (22) “The implementation of efforts to foster improved health and well-being in
all four domains of health [physical, social, psychological and personal]”
Nutbeam, 1985 (23) “The process of enabling people to increase control over the determinants
of health and thereby improve their health”
WHO, 1984 (24), 1986 “The process of enabling people to increase control over, and to improve,
(4) and Epp, 1986 (25) their health”
Goodstadt et al., 1987 “The maintenance and enhancement of existing levels of health through
(26) the implementation of effective programs, services, and policies”
Kar, 1989 (27) “The advancement of wellbeing and the avoidance of health risks by
achieving optimal levels of the behavioral, societal, environmental and
biomedical determinants of health”
O’Donnell, 1989 (28) “The science and art of helping people choose their lifestyles to move
toward a state of optimal health”
Labonté & Little, 1992 “Any activity or program designed to improve social and environmental
(29) living conditions such that people’s experience of well-being is increased”
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Table 1.2. Definitions of health promotion deconstructed
Source and date Activities Processes Objectives Goals
(programmes, policies, etc.) (underlying mechanisms) (instrumental outcomes) (ultimate outcomes)
Winslow, 1920 (2) “Organized community effort for the edu- “... to ensure everyone a “... the maintenance or
cation of the individual in personal standard of living” improvement of health”
health, and the development of the social
machinery”
Sigerist, 1946 (1) “... by providing a decent “Health is promoted”
standard of living, good labor
conditions, education, physical
culture, means of rest and rec-
reation”
Lalonde, 1974 (3) “... informing, influencing and assisting “... so that they [individuals
both individuals and organizations” and organizations] will accept
more responsibility and be
more active in matters affect-
ing mental and physical
health”
US Department of Health, “A combination of health education and “… designed to support “… that will improve health”
Education, and Welfare, related organizational, political and eco- changes in behavior and in the
1979 (19) nomic programs” environment”
Green, 1980 (20) “Any combination of health education “... designed to facilitate “... that will improve health”
and related organizational, political and behavioral and environmental
economic interventions” changes”
Green & Iverson, 1982 (21) “Any combination of health education “… for behavior” “… conducive to health”
and related organizational, political and
economic supports”
66
6E
Source and date Activities Processes Objectives Goals
(programmes, policies, etc.) (underlying mechanisms) (instrumental outcomes) (ultimate outcomes)
Perry & Jessor, 1985 (22) “The implementation of efforts” “... to foster improved health
and well-being in all four
domains of health [physical,
social, psychological and per-
sonal]”
Nutbeam, 1985 (23) “The process of enabling peo- “… over the determinants of “... and thereby improve their
ple to increase control” health” health”
WHO, 1984 (24), 1986 (4) “The process of enabling peo- “… and thereby to improve
Epp, 1986 (25) ple to increase control over their health”
[their health]”
Goodstadt et al., 1987 (26) “… through the implementation of “The maintenance and
effective programs, services, and poli- enhancement of existing levels
cies” of health”
Kar, 1989 (27) “… and the avoidance of “The advancement of wellbe-
health risks by achieving opti- ing”
mal levels of the behavioral,
societal, environmental, and
biomedical determinants of
health”
O’Donnell, 1989 (28) “The science and art of helping people “... to move toward a state of
choose their lifestyles” optimal health”
Green & Kreuter, 1991 (7) “The combination of educational and ... conducive to health”
environmental supports for actions and
conditions of living”
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Step 1. Describing the programme
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Part 2
Perspectives
Introduction
Louise Potvin
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Beyond process and outcome
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Environmental conditions
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Effort
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Table 4.1. Characteristics of positivism and hermeneutics
Positivism Hermeneutics
Objective observation Critical subjectivity
Explanation and prediction Understanding and finding meaning
Search for general knowledge and View of every situation as unique
standardization
View of social organization as combinations Stress on richness, variety and depth
of similar things
Surface view
Hypothesis testing through formal definition Dialectical cycle to gain knowledge
of ideas and measurement
Mechanistic, with a focus on an object that Dialogue and subjective participation (understanding
has no voice and is submissive is not real unless it is mutual)
Aim: the power to control the collection of Aim: enlightenment, edification, enrichment, personal
facts growth
Emphasis on quantity Emphasis on quality
Source: adapted from Dahlbom & Mathiassen (4).
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approach to and methods of programme evaluation
Question Natural sciences Social sciences
Who performs evaluation? External experts Community, project staff facilitator
What is examined? Predetermined indicators of Indicators of success identified by
success, principally cost and health participants, which may include
outcomes/gains health outcomes and gains
How? Focus on objectivity, distancing Self-evaluation, simple methods
evaluators from other participants; adapted to local culture; open,
uniform, complex procedures; immediate sharing of results
delayed, limited distribution of through local involvement in evalu-
results ation processes
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sometimes also mid-term ation; hence frequent small-scale
evaluation
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summative, to determine whether take and control corrective action
funding continues
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Table 4.3. The advantages and disadvantages
of external and internal evaluators
External evaluators Internal evaluators
Can take a fresh look at the programme Know the programme well
Are not personally involved Find it harder to be objective
Are not part of the programme’s normal power Are part of the programme’s normal power struc-
structure ture
Gain nothing from programmes, but may gain May be motivated by hopes of personal gain
prestige from evaluations
Are trained in evaluation methods, may have May not be trained in evaluation methods, have
experience with other evaluations, are regarded little or no more training than others in the pro-
as experts by programme participants gramme
Are outsiders who may not understand pro- Are familiar with and understand programmes
grammes or the people involved and can interpret personal behaviour and atti-
tudes
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in Nordic countries
Spheres Dimensions Examples
Global 1. Macro environment Physical environment
2. Culture Responsiveness to the United Nations
3. Human rights Convention on the Rights of the Child
4. Welfare policies Welfare distribution
External 1. Work Parental education and satisfaction
with employment
2. Income Income distribution
3. Housing Quality of and satisfaction with housing
Interpersonal 1. Family structure and function Satisfaction with family, lack of
negative events
2. Intimate friends Support from friends, neighbours and
3. Extended social networks society
Personal 1. Physical Growth, activity
2. Mental Self-esteem and mood
3. Spiritual Meaning of life
Source: Lindström (66).
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Domains Subdomains Contents
Being Physical Physical health, mobility, nutrition, exercise, fitness and
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from stress
Spiritual Personal values and standards and spiritual beliefs
Belonging Physical Physical aspects of the immediate environment
Social Relationships with family, friends and acquaintances
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of health promotion
Christine Godfrey
Introduction
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Table 7.1. Different types of full economic evaluation
Type of study Treatment of alternatives
Measurement/ Identification of Measurement/
Valuation of costs consequences Valuation of
in alternatives consequences
Cost-minimization Monetary terms Identical in all relevant None
analysis respects
Cost–effectiveness Monetary terms Single effect of interest, Natural units (life years
analysis common to both gained, numbers stopping
alternatives, but achieved to smoking, etc.)
different degrees
Cost–utility analysis Monetary terms Single or multiple effects, Healthy years or
not necessarily common to (more often) QALYs
both alternatives
Cost–benefit analysis Monetary terms Single or multiple effects, Monetary terms
not necessarily common to
both alternatives
Source: adapted from Drummond et al. (1).
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Table 7.2. An example of cost–benefit analysis:
legislation for bicycle helmets in Israel
Benefits and costs Values (US $)
Benefits
Value of lives saved 8 939 979
Reduced health care costs 17 412 622
Reduced long-term care costs 25 263 243
Reduced need for special education 1 527 131
Productivity gain from reduced disabilities 7 545 779
60 688 754
Costs
Health education programme and helmets (20 143 984)
Total social benefits 40 544 770
Source: adapted from Ginsberg & Silverberg (17).
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Health promotion: towards
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Clarify the health promotion
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objectives: usually educational, time limits
behavioural, environmental or
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required
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unproven methods are proposed necessary
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Investigating policy
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theory and method in a larger
organizational perspective
Evelyne de Leeuw 22
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11
Evaluating community initiatives
for health and development
Stephen B. Fawcett, Adrienne Paine-Andrews,
Vincent T. Francisco, Jerry Schultz, Kimber P. Richter,
Jannette Berkley-Patton, Jacqueline L. Fisher,
Rhonda K. Lewis, Christine M. Lopez, Stergios Russos,
Ella L. Williams, Kari J. Harris and Paul Evensen 3 3
Introduction
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Evaluating health promotion
programmes in the workplace
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Introduction
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Table 13.1. Participatory evaluation of a health promotion programme: main actions, associated actions and comments
?
Main actions Associated actions Comments
Step 1. Clarify the aims Get the participants on board. The importance of spending time on this groundwork cannot be over-
and objectives of the Set up an evaluation group. emphasized. Involvement of the right people will ensure commitment
proposed programme. Determine what the real health problem is. to the use of the information generated and a good response to any
Establish baseline information. questionnaires. The evaluation group (at least three people) should
reflect the range of interests. Proper clarification makes the evalu-
ation straightforward.
Step 2. Design the Decide the purpose of the evaluation and who will use the informa- Take this action before deciding what measures to use. If the objec-
framework for evalu- tion. tives have been stated clearly, this should be relatively easy. Be clear
ation and what ques- Decide what questions are useful to ask in relation to achieving aims about the aims of the evaluation; this affects what questions are
tions to ask. and objectives. asked. The main aim is to see whether the activities in the pro-
Decide from whom to collect information. gramme resulted in achieving the stated objectives. Try to look at
Decide whether process as well as outcome information is needed. process as well as outcome.
Step 3. Design the Decide what to measure and which methods to use. Good measurement depends on being clear about the issues. Meth-
framework for evalu- Decide on sample size and target population. ods should be appropriate to the questions and need not be numeri-
ation and decide how Decide when to collect the information. cal. Be realistic and honest about limitations of time and money.
to measure change.
Step 4. Collect the data. Make sure data collection is unobtrusive and does not add to partici- There will be problems of confidentiality and bias. Bias is most com-
pants’ workload or, if it does, they can see the value of doing it. mon in self-reported behaviour. Problems are smaller if all stakehold-
Make sure participants are still on board. ers have been involved. Participation is a key.
Keep participants informed by regular feedback.
Remember that data are not information.
Main actions Associated actions Comments
Step 5. Evaluate the Interpret data in association with the evaluation group, comparing Data are not information until they have been interpreted. This is best
results to determine the what actually happened with what was expected. done as a collaborative process, so the participants understand how
effectiveness of the pro- Remember that numbers are only indicators of what the world is like. the results were obtained. Remember the value of so-called soft
gramme. information, and that some health changes take time to be revealed.
Step 6. Make recom- Clarify what is useful. If the participants have been involved in the process, they will already
mendations. Cover practical changes for immediate implementation. be committed to acting on the findings and be receptive to results
Include the costs and benefits of not implementing as well as imple-
menting the recommendations. Challenge existing beliefs.
Look for longer-term changes that may not yet be visible.
Source: Workplace Task Force report. London, Department of Health, 1993.
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Evaluation in urban settings:
the challenge of Healthy Cities
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Introduction
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Levels Outcomes
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Evaluation of health promotion
policies: tracking a moving target
Nancy Milio
Introduction
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96 Policy environment Policy impacts
Economy Goods and services: jobs, housing, food, education, environment
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Table 16.1. Strategies for disease prevention and health promotion
Intervention strategy Focus
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health promotion policies:
the Canadian experience
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18
Health impact assessment
as a tool for health promotion
and population health
C. James Frankish, Lawrence W. Green, Pamela A. Ratner,
Treena Chomik and Craig Larsen
Introduction
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Fig. 18.1. Influences of policies and programmes on health
Policies and programmes
(health or non-health)
Derterminants Health impact
of health (outcomes)
Quality of life
Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). © Minister of Public Works and
Government Services Canada, 2001.
&@;
Fig. 18.2. Potential impact of policies and programmes
Environmental Health
impact impact
Social Economic
impact impact
Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). © Minister of Public Works and
Government Services Canada, 2001.
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Source: Frankish, J. et al. Health impact assessment as a tool for population health promotion and
public policy. A report submitted to the Health Promotion Development Division of Health Canada
(http://www.hc-sc.gc.ca/hppb/healthpromotiondevelopment/pube/impact/impact.htm).
Ottawa, Health Canada, 1996 (accessed 21 February 2001). © Minister of Public Works and
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19
Social capital: evaluation
implications for community
health promotion
Marshall W. Kreuter, Nicole A. Lezin,
Laura Young and Adam N. Koplan 55
Introduction
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Town A Town B
(high social capital) (low social capital)
Community leaders Community leaders
A B
Newspaper Cooperative Newspaper Cooperative
C extension D extension
Telephone agents Telephone agents
survey survey
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Fig. 19.2. A social capital model of community change
Population perceptions of social capital
Institutional More positive Less positive Institutional
infrastructure infrastructure
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Positive Population Population Population
community frustration frustration frustration
perception supports
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References
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general
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Investment for health: developing a
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Types of investment Life conditions Settings Lifestyles Behaviour
Public/Private development
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Table 22.2. Sample map of health gain
Population Gains in sectors
groups
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Part 5
Synthesis and conclusion
23
Evaluation in health promotion:
synthesis and recommendations
Michael S. Goodstadt, Brian Hyndman, David V. McQueen,
Louise Potvin, Irving Rootman and Jane Springett
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Fig. 23.1. Generic logic model for planning and evaluating health promotion
Individuals, communities and societies
Overall impacts Reduced health and social costs
achieve/approach their potentials
Health promotion goals Improved health and wellbeing Reduced mortality and morbidity
THE FOUNDATIONS OF HEALTH PROMOTION
VALUES
(Ottawa Charter for Health Promotion)
Positive health, holistic health, social justice, equity, participation
MECHANISM
Empowerment: enhancing capacities of individuals and communities to exercise control over the
determinants of health
Core perspectives PREREQUSITES (DETERMINANTS) OF HEALTH
Income equity/inequity, social status, social support networks, education, employment and working
conditions, physical environments, biology and genetics, personal health practices and coping skills,
healthy/unhealthy child development, health services
MICRO-LEVEL OBJECTIVES MESO-LEVEL OBJECTIVES MACRO-LEVEL OBJECTIVES
Outcomes or
Enhanced individual capacities Enhanced community capacities Supportive institutional and societal environments
objectives
EVALUATION LOOP
Developing Strengthening Creating Building healthy Reorienting
Action areas supportive
personal skills community action public policy health services
environments
Improved awareness, Increased Enhanced Increased focus on Increased
Instrumental Enhanced More equitable
knowledge, skills, community health prevention and health knowledge on
objectives, organizational access to health
decision-making capacity and promoting promotion in health effectiveness
PLANNING HEALTH PROMOTION
processes and capacity care
and behaviour participation policies care system
outcomes
Resource inputs
INITIATIVES
Generic strategies Health Health Organizational Community Policy Intersectoral Research/
Advocacy Evaluation
education communication development development development collaboration
Modified Coordination of community Laws and Coordination of
Programme, efforts, enhanced community Public dialogue Knowledge
organizational regulations, policies and activities development and
Instrumental marketing and
structures and resources and capacities, and policy
on decision-
in sectors that affect
materials making dissemination
activities, products climate community coalition building statements health
and outputs
EVALUATION LOOP INSTRUMENTAL OBJECTIVES, PROCESSES AND OUTCOMES
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77
Evaluation Policy-makers, professionals of
all kinds and the general public
increasingly recognize social
in health and economic factors as impor-
tant determinants of health. Be-
cause health promotion ap-
promotion proaches address these factors,
they can play an increasingly
valuable role in protecting and
improving health. At the same
time, funding sources increas-
ingly demand evidence that initiatives give value for money. Health pro-
motion initiatives need effective evaluation to realize their potential: both
to prove their value as investments and to increase their effectiveness in
pr
achieving their aims.
To help meet this need, the WHO European Working Group on Health
Promotion Evaluation examined the current range of qualitative and
quantitative evaluation methods to provide guidance to policy-makers
and practitioners. This book is the result. It comprises an extensive com-
pilation and discussion of the theory, methodologies and practice of eval-
uating health promotion initiatives in Europe and the Americas. The book
takes three perspectives in examining the issues. It includes a retrospec-
tive examination of the evolution of health promotion evaluation. This
provides the context for assessing and understanding the current state of
evaluations of initiatives addressing settings, polices and systems for
promoting health. Finally, the chapter authors and the Working Group as
Pr
a whole make many recommendations for improvement that provide a
look into the future. perspectives
This book shows how a health promotion approach offers a comprehen-
sive framework for planning and implementing interventions that can ef-
fectively address today’s major health-related problems. The authors de-
scribe how good evaluations assist initiatives in achieving their goals,
provide a wealth of guidance on how to undertake them and call for
greater investment in the evaluation of health promotion. The authors
hope that their work will stimulate policy-makers and practitioners to in-
vest in and undertake good evaluation for good health promotion. This is
their commitment; they hope that readers share it.
ISBN 92 890 1359 1
Sw.fr. 122.–
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