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WHO Regional PublicationsEuropean Series, No. 92
Evaluation in health promotionPrinciples and perspectives
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Evaluation in health promotionPrinciples and perspectives
Edited by:Irving Rootman, Michael Goodstadt,Brian Hyndman, David V. McQueen,
Louise Potvin, Jane Springettand Erio Ziglio
WHO Regional Publications, European Series, No. 92
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Part 1Introduction and framework
Introduction to the bookIrving Rootman
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1A framework for
health promotion evaluationIrving Rootman, Michael Goodstadt,
Louise Potvin and Jane Springett
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Table 1.1. Definitions of health promotion
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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 Health, Education, and Welfare, 1979 (19)
A combination of health education and related organizational, political and economic programs designed to support changes in behavior and in 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 (21)
Any combination of health education and related organizational, eco-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 (4) and Epp, 1986 (25)
The process of enabling people to increase control over, and to improve, their health
Goodstadt et al., 1987 (26)
The maintenance and enhancement of existing levels of health through 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
ODonnell, 1989 (28) The science and art of helping people choose their lifestyles to move toward a state of optimal health
Labont & Little, 1992 (29)
Any activity or program designed to improve social and environmental living conditions such that peoples experience of well-being is increased
66
Table 1.2. Definitions of health promotion deconstructed
Source and date Activities(programmes, policies, etc.)
Processes (underlying mechanisms)
Objectives (instrumental outcomes)
Goals(ultimate outcomes)
Winslow, 1920 (2) Organized community effort for the edu-cation of the individual in personal health, and the development of the social machinery
... to ensure everyone a standard of living
... the maintenance or improvement of health
Sigerist, 1946 (1) ... by providing a decent standard of living, good labor conditions, education, physical culture, means of rest and rec-reation
Health is promoted
Lalonde, 1974 (3) ... informing, influencing and assisting both individuals and organizations
... so that they [individuals and organizations] will accept more responsibility and be more active in matters affect-ing mental and physical health
US Department of Health, Education, and Welfare, 1979 (19)
A combination of health education and related organizational, political and eco-nomic programs
designed to support changes in behavior and in the environment
that will improve health
Green, 1980 (20) Any combination of health education and related organizational, political and economic interventions
... designed to facilitate behavioral and environmental changes
... that will improve health
Green & Iverson, 1982 (21) Any combination of health education and related organizational, political and economic supports
for behavior conducive to health
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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-ple to increase control
over the determinants of health
... and thereby improve their health
WHO, 1984 (24), 1986 (4)Epp, 1986 (25)
The process of enabling peo-ple to increase control over [their health]
and thereby to improve their health
Goodstadt et al., 1987 (26) through the implementation of effective programs, services, and poli-cies
The maintenance and enhancement of existing levels of health
Kar, 1989 (27) and the avoidance of health risks by achieving opti-mal levels of the behavioral, societal, environmental, and biomedical determinants of health
The advancement of wellbe-ing
ODonnell, 1989 (28) The science and art of helping people choose their lifestyles
... to move toward a state of optimal health
Green & Kreuter, 1991 (7) The combination of educational and environmental supports for actions and conditions of living
... conducive to health
Source and date Activities(programmes, policies, etc.)
Processes (underlying mechanisms)
Objectives (instrumental outcomes)
Goals(ultimate outcomes)
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issues and debatesDavid V. McQueen and Laurie M. Anderson1
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4Participatory approaches to
evaluation in health promotionJane Springett
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Positivism Hermeneutics
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View of social organization as combinations of similar thingsSurface view
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Emphasis on quantity Emphasis on quality
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Who performs evaluation? External experts Community, project staff facilitator
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When? Usually at programme completion; sometimes also mid-term
Merging of monitoring and evalu-ation; hence frequent small-scale evaluation
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To empower local people to initiate, take and control corrective action
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Personal 1. Physical Growth, activity2. Mental Self-esteem and mood3. Spiritual Meaning of life
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Spiritual Personal values and standards and spiritual beliefs
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Social Relationships with family, friends and acquaintances
Community Availability of societal resources and services
Becoming Practical Home, school and work activities
Leisure Indoor and outdoor activities, recreational resources
Growth Learning things, improving skills and relationships, adapting to life
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7Economic evaluationof health promotion
Christine Godfrey
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Costbenefit analysis Monetary terms Single or multiple effects, not necessarily common to both alternatives
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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
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Health education programme and helmets (20 143 984)
Total social benefits 40 544 770
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Take account of the natureof the issues, level ofintervention required andtime limits
Take account of existingknowledge, attitudes,behaviour, environmentalfactors and organizationalsystems
Have due regard ofapproximate costs, time limitsand social, economic andenvironmental constraints
Determine immediate targetgroups, significant mediatorsand support systems
Determine skills deficit andtraining required
Modify programme ifnecessary
Clarify the health promotionissue or problem
Agree the target groups
Formulate precise programmeobjectives: usually educational,behavioural, environmental ororganizational
Quantify desired outcomewithin given period of time(target setting)
Rewiew possiblemethodological approaches
Agree intervention approach
Determine precise resourcesrequired
Acquire funding and otherresources
Allocate tasks
Pilot-test progamme whereunproven methods are proposed
Execute programme
Evaluate programme
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9Investigating policy
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11Evaluating community initiatives
for health and developmentStephen 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
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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 and objectives of the proposed programme.
Get the participants on board.Set up an evaluation group.Determine what the real health problem is.Establish baseline information.
The importance of spending time on this groundwork cannot be over-emphasized. Involvement of the right people will ensure commitment to the use of the information generated and a good response to any 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 framework for evalu-ation and what ques-tions to ask.
Decide the purpose of the evaluation and who will use the informa-tion.Decide what questions are useful to ask in relation to achieving aims and objectives. Decide from whom to collect information.Decide whether process as well as outcome information is needed.
Take this action before deciding what measures to use. If the objec-tives have been stated clearly, this should be relatively easy. Be clear about the aims of the evaluation; this affects what questions are asked. The main aim is to see whether the activities in the pro-gramme resulted in achieving the stated objectives. Try to look at process as well as outcome.
Step 3. Design the framework for evalu-ation and decide how to measure change.
Decide what to measure and which methods to use.Decide on sample size and target population.Decide when to collect the information.
Good measurement depends on being clear about the issues. Meth-ods should be appropriate to the questions and need not be numeri-cal. Be realistic and honest about limitations of time and money.
Step 4. Collect the data. Make sure data collection is unobtrusive and does not add to partici-pants workload or, if it does, they can see the value of doing it.Make sure participants are still on board.Keep participants informed by regular feedback.Remember that data are not information.
There will be problems of confidentiality and bias. Bias is most com-mon in self-reported behaviour. Problems are smaller if all stakehold-ers have been involved. Participation is a key.
Source: Workplace Task Force report. London, Department of Health, 1993.
Step 5. Evaluate the results to determine the effectiveness of the pro-gramme.
Interpret data in association with the evaluation group, comparing what actually happened with what was expected. Remember that numbers are only indicators of what the world is like.
Data are not information until they have been interpreted. This is best done as a collaborative process, so the participants understand how the results were obtained. Remember the value of so-called soft information, and that some health changes take time to be revealed.
Step 6. Make recom-mendations.
Clarify what is useful.Cover practical changes for immediate implementation.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.
If the participants have been involved in the process, they will already be committed to acting on the findings and be receptive to results
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IntroductionDavid V. McQueen and Jane Springett
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16Evaluation of health promotion
policies: tracking a moving targetNancy Milio
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17Evaluation of countrywidehealth promotion policies:
the Canadian experienceReg Warren, Irving Rootman and Rick Wilson
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