Transcript The Global Polio Eradication Initiative

Challenges and approaches
on evaluation of Health Promotion
Effectiveness
David V. McQueen
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. McQueen
Global Leader
International Union for Health Promotion and Education
(contact) [email protected]
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
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
Threads to carry from Volume I to Volume II
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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
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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
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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:
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Advocate for health based on human rights;
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Invest in sustainable policies, actions and infrastructure to address the
determinants of health;
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Build capacity for policy development, leadership, health promotion
practice, knowledge transfer and research, and literacy;
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Regulate and legislate to ensure high level of protection from harm
and enable equal opportunity for health and well-being for all people; and
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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
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Central to the global development agenda;
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A core responsibility for all of government;
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A key focus of communities and civil society; and
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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:
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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’
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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
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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
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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:
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“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?
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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
Intermediate Outcomes
Neighborhood Living Conditions
Community Development
and Employment Opportunities
SOCIAL
RESOURCES
Standard of living
Culture and history
Social institutions
Built environments
Political structures
Economic systems
Technology
PHYSICAL
ENVIRONMENT
Natural Resources
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
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Concerned
with CAUSE
Health Promotion
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(i.e. etiology)
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Methods
Action
Theory
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Concerned with
CHANGE (i.e.
interventions)
Action
Concepts and
Principles (Values)
Methods
For Health Promotion, Evidence and
Effectiveness are complicated and
related terms
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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
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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
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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
Standards
Guidance
Experiment
High
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
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Shared versus unshared variables in
interventions (epistemology of variables)
Intervention as a problem (power corrupts,
empowerment corrupts)
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Ethics of interventions
(planned interventions
should do no harm)
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“Control” impossible (forces beyond our power)
Naturally occurring interventions
(trump our small, under resourced efforts)
Irritating Ideas (continued)
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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
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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?
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Given current resources
Given current HP capacity
Requiring new HP capacity
So what can we do?
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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
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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
20th 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:
[email protected]
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More
information:[email protected]
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
Some key concepts
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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:
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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:
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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:

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.
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.