Greater effectiveness in Health Promotion The Dutch Method

Lessons from the Preffi-caseGerard R.M. Molleman PhD.

DirectorNIGZ Centre for Knowlegde and Quality

Management

Overview

1. Context Health Promotion (HP) in the Netherlands

2. Strategies to improve effectiveness in practice

3. Instrument Preffi 2.0 and EQUIHP

4. Stimulating the use of Preffi; capacity building and sustainable use

The Netherlands (2005 data)

• Population: 16.305.526 • included migrants: 3.130.661 • Urbanisation 41,5%• Inhabitants/km2 481• Life expectancy: men 76,2 year

women 80,9 year• Age structure:

– Youth 0 -19 24 % – Adults 15 - 64 61 % – Elderly 65 + 15 %

The Netherlands (2005 data)

• Population: 16.305.526 • included migrants: 3.130.661 • Urbanisation 41,5%• Inhabitants/km2 481• Life expectancy: men 76,2 year

women 80,9 year• Age structure:

– Youth 0 -19 24 % – Adults 15 - 64 61 % – Elderly 65 + 15 %

32,2 million

4

Canada

1. Context Health Promotion (HP) in the Netherlands

Context HP in the Netherlands

• Developing infrastructure since 1962

• 1300 HP-specialists on local level; 70% with a university training

• active professional association

• 4 university-centres HP-oriented

• 6 national institutes on HP-topics• NIGZ : HP in general

Dutch health promotion structure

HS/DCH/94-whoq

40 municipal

12 alc.drug30 mental

57 home care

gp &hospitals

100 thematic

local money insurances fundraising

MINISTERY OF HEALTH, EDUCATION, ETC.

PUBLICHEALTH

HEALTHCARE

ISSUESPECIFIC

DAPHE NIGZ +..

Patient-Org.

TRAININGRESEARCH

Local level

National level

Nationallevel

Trends in HP policy: content

• responsibility HP primarily on the local level: integrated approach through settings (school, community, workplace, etc)

• locally: focus on health inequalities • nationwide: focus on obesity, diabetes,

smoking, mental health• stimulation of local government to pay more

attention to national priorities

Trends in HP policy: strategy:collaboration national and local HP-expertiseNational level: • make syntheses of existing knowledge • make evidence based projects and best

practices available• develop standards and stimulate use of

standards • support local level to make programs tailor made

for the local context• create sustainability for effective HP

– quality system– strengthen leadership– capacity building

Trends in HP policy: strategy:collaboration national and local HP-expertise

Local level• emphasis on implementation and execution

of effective programs

• integrated approaches through settings

• create commitment local government (in health plans)

• stimulate new developments from a local perspective in stead of top down nationally or from research centres

Trends in HP policy: organisation

• investment in HP structure• national quality systems for HP • fostering effectiveness and efficiency of

existing HP-structure • plea for a strong national unit for HP • merge HP/NIGZ with national public

health institute (RIVM)

2. Strategies to improve effectiveness in practice

Different roles for improvement of effectiveness in practice

1. Research !developing and testing evidence based programs

2. Practice!how are they working and use the �effectiveness�

knowledge

3. National institutes! linking practice, research and policy

Research perspective, 1

• focused at rigorously testing the efficacy and effectiveness of preventive interventions.

• aim: large scale dissemination and implementation of only the evidence-based, effective ‘model programs’

This approach has been quite beneficial for advocacy for HP and is widely used

Research perspective, 2

But many ‘evidence-based’ programs :

!have limited effect in terms of objectives, participants and period

!show low or moderate effect size and large variation in efficacy

!are very difficult to implement and investment in implementation is low

!are hardly used in practice

HP-specialists perspective, 1

!develop a lot of projects bottum up

!creative and adapt model-programs

!act fast and visible

!ambitions much higher than capacity

HP-specialists perspective, 2

!not easy to use knowledge about effectiveness

!there are so many new insights

!lack of consensus and standards

!completed their basic training 8 years ago

!HP-specialists hardly read scientific articles

!principles and guidelines are helpful

To improve effectiveness of prevention practice �..

We need a combination strategy:

develop and disseminate evidence-based model programs

!

develop knowledge about effectiveness in practice through principles and guidelines for

effect management

Task national agencyelements of national strategy

!bridging the gap between practice and research

!advocate for evidence-based practice and practice based science

!practice is leading

!develop different support instruments and infrastructure

Reviews

Preffi

Database

What do we know?

What projects are there?

Principles and guideline

Support and advice

NIGZ-Centre for Knowledge and Quality

Training

the Preffi 2.0

PRevention EFFect-management InstrumentOne of the tools to improve the quality of practice

in prevention and health promotion

Aim of the Preffi

To provide to HPTo provide to HP--specialists an instrument specialists an instrument (checklist) for effect management: (checklist) for effect management:

that supports them in improving regularly that supports them in improving regularly the effectiveness of their interventions the effectiveness of their interventions through the use of assessment criteria andthrough the use of assessment criteria andguidelines that reflect recent scientificguidelines that reflect recent scientificknowledge and practiceknowledge and practice--based knowledgebased knowledgeon effect predictorson effect predictors

Development of Preffi• 1993 -1994 IUHPE effectiveness studies • 1993 start effectiveness project• 1994-1995 Preffi 1.0• 1997-1999 implementation Preffi 1.0 • 2000-2002 development Preffi 2.0• 2002 research concept Preffi 2.0• Jan. 2003 launch Preffi 2.0• 2003-2006 implementation Preffi 2.0• 2005 PhD thesis on Preffi• 2004-2005 EU-project GEP• 2006 preparation Preffi 3.0 (internet)all steps in collaboration with practitioners

Format Preffi : Keep it short and simple

" fit on one sheet

" with a maximum of 10 clusters of effect predictors

" mix of scientific- and practice-based knowledge and contextual aspects

" assessment & scenarios for improving interventions

Health PRomotion EFfectiveness Fostering Instrument, Preffi 1.0

Assessment concl. Improvement prior.0. ContextAnalysis1. nature and scope problem2. (behavioral) determinants

Choices (ttic's)3. targetgroup4. target5. interventions6. effective elements7. Management of the projectImplementation8. pre-test9. execution10. Evaluation

Preffi 2.0• new or adapted items• Preffi less linear• more focus on context

• norms for each item• a score form • actions for improvement

What is the problem and itsdeterminants?

What can you do about it?

What are you going to do?

How are you doing it on a large scale?

Does it work?

What is the problem and itsdeterminants?

What can you do about it?

What are you going to do?

How are you doing it on a large scale?

Does it work?

What is the problem and itsdeterminants?

What can you do about it?

What are you going to do?

How are you doing it on a large scale?

Does it work?

Model Preffi 2.0

As an instrument the Preffi consists of �..

•• Users manualUsers manualexplaining its use and instructions for scoring

• The Preffi Questionaire126 assessment questions related to 39 known effect predictors (‘criteria’), including norms

•• Scoring FormScoring Formto assess programs on conditions for effectiveness

• Explanatory guidesummarizing available knowledge and evidence

niet te

beoo

rdele

n

zwak

matig

sterk

Implementatie7 Implementatie

7.1 Keuze voor implementatiestrategie gericht op intermediairen7.1a Wijze van implementeren: top down en/of bottom up7.1b Afstemmen van implementatie-interventies op intermediairen7.1c Geschiktheid van de aanbieder voor intermediairen7.2 Monitoren en genereren van feedback7.3 Inbedden in een bestaande structuur

rapportcijfer

Evaluatie8 Evaluatie

8.1 Duidelijkheid en overeenstemming over de uitgangspunten van de evaluatie8.2 Procesevaluatie8.3 Effectevaluatie8.3a Is (of wordt) er een verandering gemeten?8.3b Is aannemelijk dat de verandering is teweeggebracht door de interventie?8.4 Feedback aan betrokkenen

rapportcijfer

Randvoorwaarden en haalbaarheid1 Randvoorwaarden en haalbaarheid

1.1 Draagvlak1.2 Capaciteit1.3 Sturing door de projectleider1.3a Expertise en eigenschappen van de projectleider1.3b Aandachtspunten voor sturing

rapportcijfer

rapportcijfer over gehele project

korte toelichting: ……………………………………………………………………………………………

…………………………..……………………………………………………………………………………

Toelichting:

Vul bij ieder criterium een score in door een kruisje te zetten in een van de vakjes: sterk, matig of zw ak. De operationalisatie vindt u in het document 'Operationalisering en normering Preffi 2.0'. Mocht u criteria, vragen of termen onduid

Analyse niet te beoordelen

zwak

matig

sterk

2 Probleemanalyse2.1 Aard, ernst en omvang van het probleem2.2 Spreiding van het probleem2.3 Hoe zien de verschillende betrokkenen het probleem?

rapportcijfer

3 Determinanten van (psychische) problematiek, gedrag en omgeving3.1 Theoretisch model3.2 Bijdrage van determinanten aan problematiek, gedrag of omgevingsfactor3.3 Beïnvloedbaarheid van de determinant3.4 Prioritering en keuze

rapportcijfer

Interventiekeuze en -ontwikkeling4 Doelgroep

4.1 Algemene en demografische kenmerken van de doelgroep4.2 Motivatie en mogelijkheden van de doelgroep4.3 Bereikbaarheid van de doelgroep

rapportcijfer

5 Doelen5.1 Doelen sluiten aan op de analyse5.2 Doelen zijn specifiek, tijdgebonden en meetbaar5.3 Doelen zijn aanvaardbaar5.4 Doelen zijn haalbaar

rapportcijfer

6 Interventieontwikkeling6.1 Onderbouwing van de rationale van de interventiestrategie6.1a Afstemming van de strategieën en methoden op doelen en doelgroepen6.1b Eerdere ervaringen met de interventiemethode

6.2 Duur, intensiteit en timing6.2a Duur en intensiteit van de interventie6.2b Timing van de interventie

6.3 Afstemming op de doelgroep6.3a Participatie van de doelgroep6.3b Afstemming op de 'cultuur'

6.4 Effectieve technieken (aanbevolen)Ruimte voor persoonlijke benadering

Feedback over effecten

Gebruik van beloningsstrategieën

Barrières voor gewenst gedrag wegnemen

Sociale steun regelen, omgeving erbij betrekken

Aanleren van vaardigheden

Follow-up regelen

Goal-setting en implementatie-intenties

Interactieve benadering

6.5 Haalbaarheid in de praktijk6.5a Afstemming op intermediaire doelgroepen6.5b Kenmerken van de implementeerbaarheid van de interventies

6.6 Samenhang6.7 Pretest

rapportcijfer

DEVELOPMENT IMPLEMENTATIONScoring form

Cluster Effect predictors(quality criteria)

Questions Norms & scores

Yes / no

Weak

Moderate

Strong

!

Hosman & Molleman, 2003

Assessment scores per Cluster . . . . .

Cluster Effect predictors(quality criteria)

Questions

Theoretical base

Norms & scores

Yes / no

Weak

Moderate

Strong

!

Assessment scores per Cluster . . . . .

Determinants

Impact determ.

Changeability

Priorities and Selection

Cluster Effect predictors(quality criteria)

Questions

Fit to objectives &target population

Norms & scores

Yes / no

Weak

Moderate

Strong

!Assessment scores per Cluster . . . . .

Program development

Duration & intensity

Timing

Involvement of Target group

Fit to culture

Effective techniques

Evaluating a Program with the Preffi 2.0

Evaluation scores

Evaluation Profilescores averaged

by cluster

Planned Improvements

Hosman / Molleman 2003

Checklist8 Clusters

covering39 Criteria

Through

126 questions

Visualize score :

Aspects to improve and actions :make choices !!!

abababab

To be improved Actions

1

2

3

4

Preffi can be used in different ways

1. As an assessment instrument to evaluate the quality of ongoing programs and to identify options for improvement

2. As supportive instrument in developing, or selecting and adapting new programs

3. As an educational instrument in the training and supervision of hp specialists

download: www.preffi.nlthe French version:

www.inpes.sante.fr/preffi/preffi2.htm

Reported benefits of using the Preffi

• attention for effectiveness

• planning more explicit

• more use of scientific models

• clear targets ⇒ evaluation

• more realistic choices

• get in contact with new scientific insights

• higher status for HP

• positive stimulants for quality of projects

Research Preffi 1.0 (1999)Criterion described in project

8090

6390

9480

6173

355252

0 20 40 60 80 100

context

nature/scope problem

determinants

targetgroup

target

intervention

effective elements

management

pretest

implementation

evaluation

% %

Research Preffi 2.0

• Content validity : systematic procedure with review literature, critical dialog with scientific (n=5) and practical advisory board (n=53)

Research Preffi 2.0

• Content validity : systematic procedure with review literature, critical dialog with scientific (n=5) and practical advisory board (n=53)

• Usability of draft version: assessing 4 projects by 35 assessors

1,0 2,0 3,0

CRIT2.1

CRIT2.2

CRIT3.1

CRIT3.2

CRIT3.3

CRIT3.4

CRIT4.1

CRIT4.2

CRIT4.3

CRIT5.1

CRIT5.2

CRIT5.3

CRIT5.4

CRIT6.1A

CRIT6.1B

CRIT6.2A

CRIT6.2B

CRIT6.3A

CRIT6.3B

CRIT6.4

CRIT6.5A

CRIT6.5B

CRIT6.6

CRIT6.7

CRIT1.1

CRIT1.2

CRIT1.3A

CRIT1.3B

CRIT7.1A

CRIT7.1B

CRIT7.1C

CRIT7.2

CRIT7.3

CRIT8.1

CRIT8.2

CRIT8.3A

CRIT8.3B

CRIT8.4

High scores on essential 1.0 items

Average score on Preffi-items

4 price-winningprojects (2002)

Low scores on new 2.0 items

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

1. healthy eating 2. depression

3. safety 4. anti- bullying

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

4,00 5,00 6,00 7,00 8,00

context

problem

determ

t-group

target

interv

implem

evalu

total

1. healthy eating 2. depression

3. safety 4. anti-bullying

Usefulness of draft version Preffi 2.0• Usefulness 7,7

• Focus on diagnostic tool for own projects

• Valuable instrument (91%)• Complete (88%)• Clear (77%)• Complex and time consuming (43%)

• Training is useful

• Time for assessment decrease: 113 min. → 50 min.

Research Preffi 2.0

• Content validity : systematic procedure with review literature, critical dialog with scientific (n=5) and practical advisory board (n=53)

• Usability of draft version: assessing 4 projects by 35 assessors

• Reliability final version: 3 experts and 3 HP-specialists asses 20 projects; Hp-specialists without and with Preffi.

– experts are not a reliable external criterion !!

Reliability of the Preffi 2.0 as assessment tool

• More assessors and more perspectives of assessors are necessary

• Assessment not only on the basis of a written project description but also in a interview with the project coordinator

• Reliability is ameliorated according to concept version:– Total project: 2 assessors– Cluster level from 4 to 3 assessors– Criterium level from 8,1 to 6,4 assessors

• Training is necessary in using Preffi: how to deal with unclarity , strictness of assessment

Quality assurance in Europe

Several tools in European countries

Problems with quality assurance/assessment tools

• No uniform definition, conceptualisation and operationalisation of quality assurance

• Variety of instruments in use – considerable overlap– substantial variation in terms of content and format

GEP-strategy: 3 steps

1. Inventory of existing assessment tools: Identification of 15 guidelines and 17 assessment tools

2. Reaching consensus on assessment tool by two Delphi-rounds & consenus meeting

3. Pilot testing consensus-based assessment tool

Period: April 2004 - June 2005

Partners GEP

22 countries

Eurohealthnet

IUHPE

WHO-HEN

Access-database: form and content

See www.nigz.nl/gettingevidenceClick on ‘products’

EUROPEAN QUALITY INSTRUMENT FORHEALTH PROMOTION (EQUIHP): MODEL

I Framework of HP principles

III Project management1 Leadership2 Planning & documentation3 Capacity and resources4 Participation & commitment/ involvement5 Communication

II Project development & implementation

1 Analysis2 Aims & Objectives3 Target group4 Intervention5 Implementation strategy6 Evaluation

IV Sustainability

See www.nigz.nl/gettingevidenceClick on �products�

4. Stimulating the use of Preffi

capacity building and sustainable use

Focus of the implementation of thePreffi system

• 1300 Health Promotion Specialists: Local level and national institutes

• Development Preffi 2.0

• Relevant others – Researches and teachers– Policy-makers and financial decision makers

– Managers of HP-specialists

• As a structural element In the work processes of HP-specialists

since 1997

since 2000

since 2003

Implementation interventions for HP-specialistst1997-2000-2005

• Announcing the Preffi

• Stimulating use

• Supporting the use of the Preffi

– publications– mailings– lectures – Preffi-award

– lectures– workshops

– handbook– intake workshops– training sessions – inter-vision– advice

Results implementation project Preffi 1997-2000

• 91% is familiar with the Preffi

• 70% has intention to use the Preffi• 40% is capable of using the Preffi• 25% uses the Preffi as part of standard

professional routine

Results implementation project Preffi 1997-2000 and consequences

• Results general implementation-interventions limited

• Specific training useful

• Team-embeddedness important

• But : managers hardly stimulated use of Preffi

→ responsibility professionals

! Awareness

! Invest in training

! Invest in sustainable use of Preffi

Implementation interventions for significant others for HP specialists

• Joint activities with Dutch Professional Association for HP

• Training courses incorporated in HP-program Netherlands School Public Health

• Preffi also used in criteria National Research Board• Involve research community in development Preffi 2.0 • Collaboration with and support from Inspectorate

• Also Preffi-award for the manager with the most attention for Quality of HP

Results Trendstudy HP 2004From the Health Promotion Specialists:

• 78% is intended to use the Preffi 2.0 (1999: 70%)• 57% use Preffi 2.0 more or less regular (1999: 25%)• 74% use not another Quality tool than Preffi or OPUS

Stimulation of the use of Preffi 2.0:

• Use of Preffi in regular team meetings : 16%• Colleagues stimulate use Preffi : 32 %• Manager stimulates use Preffi : 35 %• 51% of HP Specialists is able to use the Preffi next project (1999: 40%)

Interventions for more structural implementation of the Preffi

2002 > Building database of projects in the Netherlands: Structure of the questionnaire derived form Preffi

Interventions for more structural implementation of the Preffi

2002 > Building database of projects in the Netherlands: Structure of the questionnaire derived form Preffi

2005 > National Quality System HP : Preffi is one of the standards in the work process of HP

Interventions for more structural implementation of the Preffi

2002 > Building database of projects in the Netherlands: Structure of the questionnaire derived form Preffi

2005 > National Quality System HP : Preffi is one of the standards in the work process of HP

2005 > Certification system for intervention

Criteria certification system for HP interventions

1. Availability and adequacy of project documentation

2. Quality of the intervention (Preffi-items) 3. Level of evidence: grading system4. Applicability contextual conditions

→ Procedure for scoring method of HP-interventions

Interventions for more structural implementation of the Preffi

2002 > Building database of projects in the Netherlands: Structure of the questionnaire derived form Preffi

2005 > National Quality System HP : Preffi is one of the standards in the work process of HP

2005 > Certification system for intervention

2006> Specific audit-system for HP-projects, in which Preffi is an important part

Conclusions

!In addition to promoting the development and dissemination of evidence-based programs, there is a need for continuous improvement of programs and practice

!This requires evidence-based and practice-based knowledge on the principles of effective programs and implementation

!The PREFFI provides an instrument and a dynamic learning system to improve effectiveness, by linking science and practice

Necessary is also:

• consistent and long term investment in development and implementation of Preffi

• strong HP infrastructure, including quality system

• professional awareness of importance of quality improvement

• investment in capacity building• learning and valuing from effective practice

More information

www.preffi.nl

www.nigz.nl

Here you can also download the summary of the PhD thesis about the Prefi 2.0 and/or an order form