Enhancing the science base for implementation in health promotion as an action strategy for...

Enhancing the science base for implementation in health

promotion as an action strategy for sustainable development

Discussant: Mark DoorisUniversity of Central Lancashire

Preston, UK

World Health Organisation Collaborating CentreWorld Health Organisation Collaborating CentreHealth Promotion Research CentreHealth Promotion Research Centre

National University of Ireland Galway National University of Ireland Galway Ollscoil na hÉireann, GaillimhOllscoil na hÉireann, Gaillimh

Symposium on Enhancing the Science Base of Implementation in Health Promotion as an Action Strategy for Sustainable Development

Researching the Implementation of Health Promotion

Professor Margaret Barry

M. Barry Geneva 2010

Focus on Implementation

• Importance advances in developing the research base for health promotion policy and practice interventions over the last 20 years

• The generation and use of evidence in implementing and sustaining effective health interventions is under-researched

• Bridge the gap between research and practicetranslating from research to effective practice and

from effective practice into research


Expanding the Evidence Base

• Developing effective policy and programme interventions is only the first step in improving health and wellbeing– transferring to real world settings and sustaining them is a

long term process necessary for maximising population impact

• Phases of the diffusion process– Initial design - pilot testing, efficacy and effectiveness trials

– Dissemination – how well information about the intervention and its value is known

– Adoption – whether the intervention is taken up

– Implementation – how well the intervention is conducted

– Sustainability – whether the intervention is maintained over time


Expanding the Evidence Base

• Evaluation research to date has largely focused on initial design and intervention outcomes– paucity of data on the quality of implementation necessary

for positive outcomes to be produced and sustained

• Emerging implementation science– science of adoption and implementation of

evidence-based interventions that are scaled up– Type II translational research

• Expand the health promotion evidence base – guide the effective dissemination, adoption and

sustainability of effective interventions across diverse cultural and economic settings


Why Implementation Matters

• Determining how or why an intervention works – documenting actual implementation– assessing variability across change agents and settings

• Interpreting outcomes - distinguish between ineffective interventions and effective interventions that are poorly implemented

• Providing feedback for quality improvement• Advance knowledge on best practice for effective

intervention adoption, replication and sustainability(Durlak, 1998; Dane & Schneider, 1998; Mihalic et al., 2002;

Domitrovich & Greenberg 2000; Durlak & DuPre, 2008)


Factors Influencing Programme Implementation

• Characteristics of the intervention• Characteristics of the implementer• Delivery system – organisational capacity• Support system – training and technical assistance• The setting or organisational context in which the

intervention is being implemented• Characteristics of the intervention

recipients/participants• Complex interaction of these factors (Chen 1998; Fixsen et al., 2005; Greenberg et al., 2006;

Greenhalgh et al, 2004)


Implementation Principles

• The content and structure of the intervention– theory and evidence base– identify core components– quality of materials– quality and structure of technical support

• The process of planning, implementation and training systems

• Implementation support system - facilitatory and inhibitory factors in the local setting or context

– readiness, ecological fit, organisational support etc.

(Barry & Jenkins, 2007; Barry, Domitrovich and Lara, 2005)


Sustainability

• Few interventions are sustained over time regardless of their impact (Rogers, 2003)

• Sustainability requires system transformation- organisation and structural change

• Limited research on the factors that predict sustainability

• Sustainability is a change process that is multifaceted, ongoing and cyclical

• Critical to fostering effective sustainable practice change


The challenges

• Health promotion interventions - dynamic change in complex systems – change process at a whole system level – context, culture and organisational factors

• Process of change is not a linear process– multiple interdependent systems

• Limitations of the traditional research paradigm– complexity, rigour vs relevance, systems change

• Support for systems research– systems thinking paradigm


The challenges

• Work bi-directionally to bridge science and practice– collaboration with practitioners in documenting

implementation across the stages of planning, initial implementation, full scale delivery and sustainability

– evidence may lag behind innovative practice

• Use of pluralistic methods– knowledge base of intervention participants and

implementers– rules of evidence at each stage of evidence building

• Collaborative, systematic and systems-based approach to documenting the implementation of effective practice in different contexts

• Generate contextually sensitive practice-based evidence

20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland

The role of an implementation theory between impact research and process evaluation with regard to health promoting schools

IUHPE Geneva 2010

Dr. Wolfgang DürDirector Ludwig Boltzmann Institute Health Promotion ResearchAUSTRIA, Vienna

20th IUHPE World Conference on Health Promotion, 11-15 July 2010, Geneva Switzerland 13

The whole-school approach for health promoting schools

6 core- components healthy school policies material environment of schools social environment of schools individual health and skills connections to the community health services(c.f. St Leger et al., 2010)

deficits of the WSA many separate and unlinked parts introduces complexity and causes

confusion no organizational model of the school no clear intervention concept

Many separate and unconnected parts: health promotion basic and quality management didactics theory of education


What is implementation?

No definition in Health Promotion Glossary (Nutbeam et al. 2006)

Seen as „put a plan into action“, realization, execution Naive, mechanistic plan-do-relation

whole school approach,health promoting school

approach

Program Implemen-

tation Evaluation

Planning model

What to do? How to do it? Do it! Check, what you‘ve done!


Definition

fulfil, perform, conduct, realize, concretize, specify, execute, “put into action”, do

“Implementation is the realization of an application, or execution of a plan, idea, model, design, specification, standard, algorithm, or policy.” (Wikipedia)

“Implementation research investigates the gap between programs and their realization” (ref. Hillmann 2007)


Change Theory (ref. Weiner et al. 2008: 293ff)

theoryof health

theoryof health

promotion

theoryof healthimpact

Programtheory

Theory of the organization

empirical research

Program adoption

theory

Implemen-tation theory

ResultsPlanning

model

Interventions can fail Reasons are:

bad program bad program adoption bad planning difficulties in the implementation process!

Needed is an implementation theory that explains the relation between the intervention and the intervened system

Aspects of such a theory have implications for the conduction and evaluation of interventions

Evaluation


The Vienna Health Impact Model

organisationgovernance

decision makingprocesses

organisationformal expectations

structural premisses

organisationcore/support processes

operative performance

organisationoutput

results

individualself-awareness

conscious & living processes

individualdispositions

mental & somatic premisses

individualachievements

quality of life

individualre-/acting

behaviour

A B

D C

FE

H G

2

3

1

5

6

7

8

9

10

11

12

13

14

4

social environmentmacro

(e.g. politics, laws, acts, media, economy …)

meso(e.g. communities, settings,

networks …)

micro(e.g. social support, personal

Capitals: social, symbolic, cultural, economic …)

material environment(e.g. building, facilities, hygiene, food, water,

ergonomic workplace, sanitation, noise, air …)


The Vienna Organizational Health Impact Model




structural premisses



organisationoutput

results






quality of life


behaviour

A B

D C

FE

H G

2

3

1

5

6

7

8

9

10

11

12

13

14

4

social environmentmacro



networks …)


Capitals: social, symbolic, cultural, economic …)




Vienna Organizational Health Impact Model: unfolding the autopoiesis of organizations

processes

Astructures

B1

1. As a social system, organizations consist of processes and structures

2. decision making processes build the basic autopoietic operation that leads to structural premisses

communication structures programs (purposeful/conditional) person-specific, personnel

decision making premisses

3.operative performance actions, interactions, occupa-

pations, behaviors role-specific, etiquette-specific,

individualized

performance

2

4.results Performance is observed by

the organization according to its goals (transfer action into information)

organizational culture!!

results

4

3D C






quality of life


behaviour

FE

H G

6

7

8

9

10

13

14

11

12

5

ORGANIZATIONsocial environmentmacro



networks …)


capitals: social, symbolic, cultural, economic …)




Systemic organization theory and the PDCA-Cycle


=HP program

adoption

decisionpremises

=HP program

planning


=HP

implementation

results=

HP results

Plan

DoCheck

Actmenue

eating cooking

recipe

The systemic organization theory is compatible with the well known PDCA-cycle (Deming 1982) and can be seen as the unfolding of the organization’s autopoiesis (Maturana & Varela 1990; restaurant analogy taken from Simon 2007)



decision makingProcesses


structural Premisses

organisationcore/support processesoperative

performance

organisationoutput

Results

A B

D C

2

3

1

4

Theory of the organizationC-box represents all actions, behaviours, interactions performed on the grounds of the organization

“The chaos (Peters), the ocean (Luhmann) on which organizations thrive”

These are either role-specific (planned), supportive to role fulfilment (e.g. reproduction of workforce), or individual (smoking, chatting, mobbing…)

Behaviours and interactions are self-referential and develop their own dynamic aside from organizational standards and defaults.

By role-expectations, standards and eigen-dynamics the C-box can be described as the organization’s “real” daily routines.

Explanations to the C-Box




HP agenda setting



HP program adoption



HP implementation

organisationoutput

Results

HP results

A B

D C

2

3

1

4

Programtheory


Program adoption

theory

Implemen-tation theory

Planning model

Like routine actions and interactions, interventions (innovations) follow social expectations and plans; as related to routines, they are

either add-ons – competing for resources or add-ins – competing for attention, power, influence, survival in the system

Success or failure of interventions (gap between planned and realized outcomes) is explained by a change or implementation theory

Evaluation

HP intervention in an organization


Common change theories in HP (1)

Chen (1990, 2005; and following Weiss 1997) action model

encompasses program adoption, planning model and structures (actors)

change model (still) based on linear-causal relations: intervention-determinant-

outcome evaluation as the feedback and regulation mechanism for the action

model Implementation (change) theory

implementation as a link between action and change model; seen as set of managerial methods „to put into action“ no specific implementation theory explaining gaps between planned

and realized outcome.


Program Theory (Chen, 1990, 2005)

The model shows the influence of evaluation through feedback loops (Blank, Löwenbein, 2009)

Main criticisms: Although program theory is based on the theory of open systems, Chen assumes causal relationships within the change model. He considers only evaluation feedback loops and not the ongoing dynamics of the system. The focus lies on the program.


Common change theories (2)

Pawson & Tilley (1997): Realisitic Evaluation Acknowledge the conditions in the

C-box success of implementation depends on

such conditions Interventions must be adopted to

the specific circumstances of a certain organization/system (= program specification)

interventions cannot be standardized Evaluation is the feedback

mechanism that guides program specification and improves the basic intervention concept

Hidden assumption: There is a one best way to

intervene for each system

Context-mechanisms-outcomepattern configurations


Common change theories (3)

Naaldenberg et al. (2008); Hummelbrunner (2008) intervention is

depending on the context (see Pawson & Tilley) and a system of its own (also Pawson & Tilley) but a disturbance in the intervened system, causes resistence as well as new

opportunities

the problem is primarily not how to adapt interventions to systems, but how to make them robust and accepted

interventions need commitment, good planning, persistence the intervened system must be prepared: readiness for change in the system

(Weiner et al. 2008; Kotter 2006) the intervention system needs

– robust methodologies („programme mechanisms“, Hummelbrunner) – learning– partnerships


Intervention as a system in the system

Going deeper into the relation between intervention system and intervened system: Basic paradox: intervention produces new structures/processes by

using old ones (Simon 2007) intervention changes the system and the intervention at the same time „De-paradoxication“ by deconstruction of old structures by new ones (Lewin

(1997; and following Scharmer 2010): defreeze – change – refreeze Defreeze = deconstruction produces readiness for change

Problem awareness, sense of urgency, Luhmann (2000): Change in organizations follows principles of

evolution Variation (= intervention by trial and error) Selection (= reflection on variation and election of suitable) Retention/stabilization (= decision on structural premises regarding variation)




HP agenda setting



HP program adoption



HP implementation

organisationoutput

Results

HP results

A B

D C

2

3

1

4

Programtheory


Program adoption

producevariations

Planning oraction model

Combines the two advices: (1) “Adapt intervention to the system” and (2) “Strengthen the intervention against the system”

Implication for the intervention system: inspire, unleash several variations as add-ons and add-ins - C-box-evolution will “decide” upon what is useful, adequate, appropiate, meaningful …

Implication for evaluation: support reflections on variations and their results that will lead to decisions pro or contra and transfer variations into routines.

reflect on variations

decide on variations

establish variations

Conclusion


Literature

Chen, H.T. (1990, 2005): Theory-driven evaluation. Thousand Oaks, CA: Sage Publications.Hummelbrunner (2008) Response to paper “Systems Thinking” by D. Carbrera et al.: A tool for

implementing DSRP in programme evaluation. Evaluation an Program Planning 31, 311-334.Kotter, J.P. (2007). Leading Change. Why Transformation Efforts Fail. Harvard Business Review, 2Lewin, K. (1997) Resolving Social Conflicts: And, Field Theory in Social Science, American Psychological

Association.Luhmann, N. (2000) Organisation und Entscheidung [Organisation and Decision]. Frankfurt am Main,

Suhrkamp.Maturana, H., Varela, F. Der Baum der Erkenntnis. Die biologischen Wurzeln des Erkennens, Goldmann,

1990.Mintzberg, H. (1979) The structuring of organizations. A synthesis of the research. Prentice-Hall, New

Jersey.Naaldenberg, J., Vaandrager, L. Koelen, M., Wagemakers, A.M., Saan, H., de Hoog, K. (2008) Elaborating

on systems thinking in health promotion practice. Global Health Promotion; 16; 39. Noble, Charles H. 1999 : The Eclectic Roots of Strategy Implementation Research. Journal of Business

Research. S. 120Nutbeam, D. (2006): Health promotion glossary. Health Promotion international.Pawson, R. and Tilley, N. (1997) Realistic Evaluation, London: Sage.Simon F. (2007) Einführung in die systemische Organisationstheorie [Introduction to a systemic

organization theory]. Carl-Auer Verlag, Heidelberg.St Leger, L., Young, I., Blanchard, C., Perry, M. (2010). Promoting health in schools – from evidence to

action. Saint-Denis Cedex: IUHPEScharmer U-Theory; Presencing Institute:

http://www.presencing.com/presencing-theoryu/theoryu_downloads.shtml [25.5.2010]Weiner, B.W., Lewis, M.A, Linnan, L.A. (2008) Using organization theory to understand the determinants of

effective implementation of worksite health promotion programs. Health Education Research, 24, 2, 292-305.


Contact:Dir. PD Dr. Wolfgang Dür, MA

Ludwig Boltzmann Institute Health Promotion [email protected]

Questions for clarification

Creating and Operationalising a Science Base for Implementation Components of

Health Promoting Schools

Louise Rowling, Uni of Sydney, Australia

Oddrun Samdal, Uni of Bergen, Norway

IUHPE Geneve 2010

Introduction• Previous focus of health promoting school (HPS) approach

– Cross-sectoral collaboration between health and education

– Production of guidelines articulating principles – Providing indicators for evaluation

• Focus of presentation – articulate science base of implementation of HPS to fill current gap

– Develop a theoretical understanding of implementation components and their mechanisms

Adelman and Taylor, 2008

Underpinning conceptualisation

• Whole school community approach – system approach

• Organisational development and learning

• Multidisciplinary science base

Methodology• Narrative synthesis of available English-language

literature, 1995-2010, delineating implementation of HPS

• Key words: health promoting schools, implementation, comprehensive approach, whole school improvement/change, school health promotion.

• Implementation of pre-packaged programmes were excluded

• 7 sources were identified that described components of HPS implementation

The components

1) Preparing and planning for school development

2) Policy and institutional anchoring

3) Professional development and learning

4) Leadership and management practices

5) Relational and organisational support context

6) Student participation

7) Partnership and networking

8) Sustainability

1. Preparing and planning for school development – what and why

• What– Readiness, commitment and alignment through

stakeholder involvement– Systematic planning building on existing practices – Identify concrete policies, structures and practices for

the complete implementation approach

• Why: Theoretical base– Programme/planning theory (Green & Kreuter, 2005)

– Implementation theory (Barry, 2005; Elias et al., 2003 )

– Goal commitment and collective efficacy (Whitelaw, 2008)

– Organisational change, school change and innovation (Heward, Hutchins and Keleher, 2007; Hopkins and Jackson, 2003)

Preparing and planning for school development – how and why

• How– Preparing: gain commitment and anchor by identifying

existing supportive structures and practices– Planning: ongoing participation through functioning

representative committee; programme theory based planning model;

• Why: Theoretical and empirical base– Denman, 1999; Green and Kreuter, 2005; Hall and Hord, 2006;

Inchley et al., 2007; Kellogg Foundation, 2004; Leithwood et al., 2007; McBride, 2000; Samdal et al., in press; Samdal, 2008; Spillane, 2006;

2. Policy and institutional anchoring - what and why

• What– Intervention goals match with overall aims and visions

of the school to stimulate ongoing alignment and commitment

– Policy statement on HPS included in school policy plan

• Why: Theoretical base– Organisational change, school change and innovation

(Heward, Hutchins and Keleher, 2007; Hopkins and Jackson, 2003) – Implementation theory (Barry, 2005; Elias et al., 2003 )

Policy and institutional anchoring – how and why

• How– Scaffold school development by anchoring

intervention goals with overall aims and visions of the school through stakeholder involvement

– Policy development and review by: • Identifying existing supporting policies• Formulating policy statement(s) and identifying strategy for

actions and support• Specifying financial, organisational and technical resources

• Theoretical and empirical base– Deschenes et al., 2003; Samdal, 2008

3. Professional development and learning – what and why

• What– Professional development for key implementation staff– Ongoing professional learning for all staff at the school

premises – Core base for building organisational capacity and

individual motivation for change and ensures a whole school approach

• Why: Theoretical base– Organisational change, educational change (Heward,

Hutchins and Keleher, 2007; Hopkins and Jackson, 2003) – Adult learning principles – Professional development (Easton, 2008; Fullan, 2008)

Professional development and learning – how and why

• How– Capacity building– Initial external PD of core team and executives for leadership, – Transfer of knowledge and competence to all staff by trained

staff– School based professional learning for whole staff embedded in

teacher’s work,• Internal sharing of experiences and skill development through a

range of PL strategies – External networking for executive staff and core team

• Why: Theoretical and empirical base– Daft, 1999; Fullan, 1992; 2008; Easton, 2008; Mason and

Rowling 2005; Spillane, 2006; Tjomsland et al., 2009

4. Leadership and management practices – what and why

• What– Balance of leadership and management– Leadership: visionary approach to stimulate readiness

and motivation for change through feedback, encouragement and expectations

– Management: Resource allocation, support structures and administration

• Why: Theoretical base– Social learning theory, social cognitive theory (Bandura,

1998)– Leadership theory (Fullan 2005, 2008)

Leadership and management practices – how and why

• How– Initiate anchoring of visions and aims with priorities – Share decision-making, negotiate directions, understand change

processes, build relationships, build leadership at many levels– Role model and provide opportunities for the staff to share and

reflect on knowledge and experience, give feedback and acknowledge contribution

– Monitor implementation and guide redirections when needed– Celebrate progress and achievements– Ensure appropriate allocation of financial resources and

supportive structures (time etc).

• Why: Theoretical and empirical base– Daft, 1999; Fullan 1992, 2005; Inchley et al., 2007; Larsen and

Samdal, 2008; Samdal et al., in press; Rowling and Mason, 2007, Rowling 2009

5. Relational and organisational support context – what and why

• What– Relational support: climate and culture – Organisational support: structures (including

timetabling), physical environment and fiscal resources

Stimulates motivation and change processes

• Why: Theoretical base– Social learning theory, social climate (Bandura, 1998)

– Organisational capacity (Elias et al., 2003; Flaspohler et al.,

2008; Hopkins and Jackson, 2003)

Relational and organisational support context – how and why

• How– Establish practices for interaction for all school community

members– Nurture reflective behaviours– Pedagogic leadership to create caring environments in

classrooms – Emphasis should be given to relational pedagogy– Scaffolding beneficial teaching schedules, class meetings, and

grouping structures to allow time and opportunities for collaboration

– Modify and create appropriate physical spaces/buildings– Supportive ongoing conditions for professional development and

learning to build capacity .

• Why: Theoretical and empirical base– Boyd, MacNeil and Sullivan, 2006; Cole, 2008; Durlak and Dupre, 2008;

Hall and Hord, 2006; Heward et al., 2007; Hoyle, 2007; MacNeil and Silcox, 2003; Samdal et al., in press

6. Student participation – what and why

• What– Involvement of target group is basic principle of health

promotion (empowerment) – Means and goal to maximize motivation for health and

learning

• Why: Theoretical base– Self-determination theory, agency, initiative (Ryan and

Deci, 2000)

– School connectedness and civic engagement (Simovska and Bruun Jensen, 2009)

– Relational pedagogy (Boyd,, Machnell, and Sullivan, 2006)

Student participation – how and why

• How– Facilitate student active decision-making in school life– Develop teachers’ skills to facilitate this action, putting aside their

views and trusting in young person’s perspectives and advice– Help young people learn they can make a difference to self and

others– Create varying structures to facilitate students’ influence and

participation and invite them to be represented in core team– Ask and listen to students’ perceptions of school needs for

change and enable them to act on their ideas to address them in an inclusive and non judgemental manner

• Why: Theoretical and empirical base– AICAFMHA, 2008; Holdsworth and Blanchard, 2006; Jensen

and Simovska, 2005;

7. Partnership and networking – what and why

• What– Reciprocal partnerships: Stimulates mutual development

and change• Shared vision and decision-making • Efficient use of resources and competence

– Networking facilitates exchange of knowledge and raises consciousness that validates own practices

• Why: Theoretical base– Social learning theory, social climate (Bandura, 1998) – Organisational capacity (Elias et al., 2003; Flaspohler et al., 2008;

Hopkins and Jackson, 2003)

Partnership and networking – how and why

• How– Develop partnerships and collaborative models requiring

readiness, vision, leadership and time, and where appropriate establish contracts including commitment and responsibilities

– Invite parents to contribute and to be represented in core team– Recognise the need for new multi-faceted and clearly defined

roles for professionals– Lateral capacity building through links with other schools by

shadowing and exchange of staff for sharing and learning from each other.

• Why: Theoretical and empirical base– Centre for School Mental Health, 2008; Deschesnes et al., 2003;

Fullan, 2005; Inchley et al., 2007; Samdal et al., in press

8. Sustainability – what and why

• What– “The capacity of a system to engage in the

complexities of continuous improvement” (Fullan, 2005:IX)

– Continued focus on institutionalisation – Needs to be addressed for each component

• Why: Theoretical base– Implementation theory (Barry, 2005; Elias et al., 2003;

Flaspohler et al., 2008; Hopkins and Jackson, 2003)

Sustainability – how and why• How

– Implementing a project so that it becomes part of school priorities and practices

– Monitor performance and evaluate progress, and where necessary, modify existing actions

– Review needs assessment and continue to develop new priority areas

– Continue to anchor initiative in written policies – Ongoing resource allocation – PD and PL for new staff, provide booster sessions for existing staff– Evaluate PL of staff, focussing on teacher and school administrator

behaviour as indicators of system change

• Why: Theoretical and empirical base– Daft, 1999; Fullan, 1992, 2001, 2005; Firth et al., 2008; Inchley et al.,

2007; Larsen and Samdal, 2008; Sabatier, 1997; Tjomsland et al., 2009; Tjomsland et al., 2009; Easton, 2008)

Conclusion• Components are interdependent and

provide balance of specificity and flexibility for whole school community change

• The components provide a basis to enhance the rigour of implementation and evaluation and monotoring for HPS

• Components need to be tested within school specific context and culture by practitioners and researchers

Questions for clarification

Discussion

Questions – Theoretical development -

• How do we measure systems’ change?

• How do we study/capture the process of change in such a way that it can be used to further knowledge in HP practice?

• What research skills are needed?

Questions – Practice development -

• Are the suggested implementation components sufficiently explicit and concrete to facilitate change in schools? – Are there core theoretical links missing?– Is there core practice knowledge missing?

• What practice skills are needed?– How can these be developed?

Date post:	30-Mar-2015
Category:	Documents
Upload:	georgia-barrell
View:	215 times
Download:	0 times

Enhancing the science base for implementation in health promotion as an action strategy for...

Documents