Challenges and approachesChallenges and approacheson evaluation of Health Promotion on evaluation of Health Promotion

EffectivenessEffectiveness

David V. McQueenDavid V. McQueenIUHPE President; Associate Director for Global Health IUHPE President; Associate Director for Global Health

Promotion at CDC, Brazil, May 14, 2008Promotion at CDC, Brazil, May 14, 2008

The Global Programme on The Global Programme on Health Promotion EffectivenessHealth Promotion Effectiveness

A programme coordinated by the International Union for Health A programme coordinated by the International Union for Health Promotion and Education in collaboration with numerous Promotion and Education in collaboration with numerous

international partners.international partners.

Catherine JonesCatherine JonesGPHPE CoordinatorGPHPE CoordinatorDavid V. McQueenDavid V. McQueen

Global LeaderGlobal Leader

International Union for Health Promotion and Education International Union for Health Promotion and Education (contact) cjones@iuhpe.org(contact) cjones@iuhpe.org

GPHPE: Distinguishing aspectsGPHPE: Distinguishing aspects

The GPHPE:The GPHPE: Is a worldwide programme.Is a worldwide programme. Advocates the importance of effectiveness to Advocates the importance of effectiveness to

researchers, practicitioners and decision-makers.researchers, practicitioners and decision-makers. Supports local approaches, given the different Supports local approaches, given the different

stages of the development of the field, and the stages of the development of the field, and the strong influence of social and cultural contextstrong influence of social and cultural context

GPHPE : MonographsGPHPE : Monographs

• *Volume I: *Volume I: McQueen, David V., & Jones, Catherine M., McQueen, David V., & Jones, Catherine M., eds.(2007) eds.(2007) Global Perspectives on Health Promotion Global Perspectives on Health Promotion EffectivenessEffectiveness.  New York: Springer.  New York: Springer

• A critical reflection on the state of health A critical reflection on the state of health promotion effectiveness, issues and questions promotion effectiveness, issues and questions

• Health promotion effectiveness analysed from Health promotion effectiveness analysed from theoretical and practical points of view.theoretical and practical points of view.

• A multi-volume series; now developing Volume A multi-volume series; now developing Volume II addressing emerging areas of interestII addressing emerging areas of interest

Threads to carry from Volume I to Volume IIThreads to carry from Volume I to Volume II

Reaffirming and reflecting on the topic in Volume I Reaffirming and reflecting on the topic in Volume I Taking a focused, strategic approachTaking a focused, strategic approach Capturing the gripping issues of the day to which HP can or Capturing the gripping issues of the day to which HP can or

could contribute morecould contribute more Looking at where theory & practice might better come Looking at where theory & practice might better come

together by understanding the context of interventionstogether by understanding the context of interventions Developing a communications strategy to target a wider Developing a communications strategy to target a wider

audienceaudience Providing a base source document for further work in Providing a base source document for further work in

evaluationevaluation Incorporating capacity building for health promotion Incorporating capacity building for health promotion

evaluationevaluation Providing innovative formats – debate and dialogue- case Providing innovative formats – debate and dialogue- case

historieshistories

GPHPE : Next stepsGPHPE : Next steps

Increasing focus on developing capacityIncreasing focus on developing capacity Enlargement and strengthening of initiativesEnlargement and strengthening of initiatives Increased networking and exchange across globe, Increased networking and exchange across globe, Developing partnerships (e.g. Cochrane PH)Developing partnerships (e.g. Cochrane PH) Focus on methodological issuesFocus on methodological issues Focus on KSTE issues and evidenceFocus on KSTE issues and evidence Focus on broad salient topics, e.g urbanization, Focus on broad salient topics, e.g urbanization,

settings, settings, SDOHSDOH

Consider: Social Determinants of HealthConsider: Social Determinants of Health

The global The global contextcontext for health promotion vis for health promotion vis a vis the SDOH has changed markedly a vis the SDOH has changed markedly

New patterns of communicationNew patterns of communication CommercializationCommercialization Global environmental changeGlobal environmental change Inequities increasing globallyInequities increasing globally

Social Determinants of Health presents Social Determinants of Health presents questions of evidence, Some argue*:questions of evidence, Some argue*:

To manage the challenges of To manage the challenges of globalization, policy must be globalization, policy must be coherent across all levels of coherent across all levels of government, United Nations bodies, government, United Nations bodies, and other organizations, including and other organizations, including the private sector. the private sector. Hypothesis to be Hypothesis to be provenproven

Of course these arguments and assertions Of course these arguments and assertions derive in part from the text of the Bangkok derive in part from the text of the Bangkok

CharterCharterThe Bangkok Charter identifies actions, The Bangkok Charter identifies actions,

commitments and pledges required to commitments and pledges required to address the address the determinants of healthdeterminants of health in a in a globalized worldglobalized world through health through health promotion.promotion.

The Charter affirms that policies and The Charter affirms that policies and partnerships to empower communitiespartnerships to empower communities, , and to improve health and health and to improve health and health equality, should be at the centre of global equality, should be at the centre of global and national development.and national development.

Strategies for Health Promotion in Strategies for Health Promotion in a Globalized Worlda Globalized World

Health promotion has an established repertoire of proven Health promotion has an established repertoire of proven effective strategies (effective strategies (AN ASSUMPTION)AN ASSUMPTION) which need to be which need to be fully utilized. To further advance these strategies, all fully utilized. To further advance these strategies, all sectors and settings must act to:sectors and settings must act to:

AdvocateAdvocate for health based on human rights; for health based on human rights;

InvestInvest in sustainable policies, actions and infrastructure to address the in sustainable policies, actions and infrastructure to address the determinants of health;determinants of health;

Build capacityBuild capacity for policy development, leadership, health promotion for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy;practice, knowledge transfer and research, and literacy;

Regulate and legislateRegulate and legislate to ensure high level of protection from harm to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; andand enable equal opportunity for health and well-being for all people; and

Partner and build alliancesPartner and build alliances with public private, nongovernmental and with public private, nongovernmental and international organizations and civil society to create sustainable actions.international organizations and civil society to create sustainable actions.

HP Commitments to Health for AllHP Commitments to Health for AllThe four key commitments of health promotion are The four key commitments of health promotion are

ultimately questions of evidence and effectivenessultimately questions of evidence and effectiveness

CentralCentral to the global development agenda; to the global development agenda;

A A corcore responsibility for all of government;e responsibility for all of government;

A A key focuskey focus of communities and civil society; and of communities and civil society; and

A A requirementrequirement for good corporate practice. for good corporate practice.

Example: Commitment #1Example: Commitment #1Promotion of Health Central to Global DevelopmentPromotion of Health Central to Global Development

Strong intergovernmental agreements that Strong intergovernmental agreements that increase health and collective health increase health and collective health security are needed. security are needed.

EffectiveEffective mechanisms for global mechanisms for global governance for health are required to governance for health are required to address all the harmful effects of:address all the harmful effects of:

Trade;Trade; Products;Products; Services; andServices; and Marketing Strategies.Marketing Strategies.

Commitment #2Commitment #2Make the Promotion of Health a Core Make the Promotion of Health a Core Responsibility for All of GovernmentResponsibility for All of Government

All governments at all levels must tackle All governments at all levels must tackle poor health and inequalities as a poor health and inequalities as a matter of urgency because health is a matter of urgency because health is a major determinant of socioeconomic major determinant of socioeconomic and political development. and political development.

To ensure this, all levels of government should make To ensure this, all levels of government should make the health consequences of policies and legislation the health consequences of policies and legislation explicit, using tools such as explicit, using tools such as equity-focused health equity-focused health impact assessmentsimpact assessments..

Commitment #3Commitment #3Make the Promotion of Health a Key Make the Promotion of Health a Key

Focus of Communities and Civil SocietyFocus of Communities and Civil Society

Well organized and empowered communities are Well organized and empowered communities are highly effective in determining their own highly effective in determining their own healthhealth, and are capable of making governments , and are capable of making governments and the private sector accountable for the health and the private sector accountable for the health consequences of their policies and practices.consequences of their policies and practices.((AssertionsAssertions))

Civil society needs to exercise its power in the Civil society needs to exercise its power in the marketplace by giving preference to the goods, marketplace by giving preference to the goods, services and shares of companies that exemplify services and shares of companies that exemplify corporate social responsibility.corporate social responsibility.

Commitment #4Commitment #4Make the Promotion of Health a Requirement for Good Make the Promotion of Health a Requirement for Good

Corporate PracticeCorporate Practice

The private sector, like other employers and the The private sector, like other employers and the informal sector, has a responsibility to ensure informal sector, has a responsibility to ensure health and safety in the workplace, and to health and safety in the workplace, and to promote the health and wellbeing of their promote the health and wellbeing of their employees, their families and communities.employees, their families and communities.

The private sector can also contribute to lessening The private sector can also contribute to lessening wider global health impacts, such as those wider global health impacts, such as those associated with global environmental change by associated with global environmental change by complying with local national and international complying with local national and international regulations and agreements that promote and regulations and agreements that promote and protect health.protect health.

The challenge of ‘evidence’The challenge of ‘evidence’

Recognize what we “know” versus Recognize what we “know” versus what we “wish for”.what we “wish for”.

What work needs to be doneWhat work needs to be done What is “inside” the evidence debateWhat is “inside” the evidence debate What is “outside” the debateWhat is “outside” the debate

How to build “good” evidenceHow to build “good” evidence

Distinguish evidence of success from Distinguish evidence of success from evidence of harmevidence of harm

Methodology of deleting vs building Methodology of deleting vs building evidence – reduction vs complexityevidence – reduction vs complexity

Operationalize judgmentOperationalize judgment Distinguish evidence from Distinguish evidence from

effectiveness from evaluationeffectiveness from evaluation

How to build “better” evidenceHow to build “better” evidence

Be reflexiveBe reflexive Methods Follow complexity with the Methods Follow complexity with the

methodsmethods Move away from reductionMove away from reduction Collect more informationCollect more information Assess more interventionsAssess more interventions Be innovativeBe innovative

Distinguish “evidence” of causation and etiology from Distinguish “evidence” of causation and etiology from evidence related to the understanding of evidence related to the understanding of

interventionsinterventions

An example:An example:

““The health of populations is affected by and The health of populations is affected by and is a product of the social determinants in the is a product of the social determinants in the population”*population”*

*This is an etiological statement asserting causation

But what are the components of But what are the components of Social Social Determinants from a HP Perspective?Determinants from a HP Perspective?

LIFELIFESTYLESTYLE: Collective pattern of life conduct: Collective pattern of life conduct LIFE LIFE CONDUCTCONDUCT: Pattern of behavior of an : Pattern of behavior of an

individual in their day-to-day livesindividual in their day-to-day lives LIFE LIFE CONDITIONSCONDITIONS: Patterns of resources of an : Patterns of resources of an

individual or group (including health status)individual or group (including health status) LIFE LIFE SITUATIONSITUATION: Collective pattern of life : Collective pattern of life

conditions conditions LIFE LIFE CHANCESCHANCES: Structural-based probability of : Structural-based probability of

correspondence of lifestyle and life situationcorrespondence of lifestyle and life situation

Adapted from Rutten, A. (1995). The implementation of health Adapted from Rutten, A. (1995). The implementation of health promotion: a new structural perspective. promotion: a new structural perspective. Social Science & MedicineSocial Science & Medicine, , 41(2), 1627-1637.41(2), 1627-1637.

It is all about It is all about

CONTEXTCONTEXT

SOCIOCULTURAL ENVIRONMENT FRAMEWORK

Determinants

SOCIALRESOURCES

Standard of livingCulture and historySocial institutionsBuilt environmentsPolitical structuresEconomic systems Technology

Neighborhood Living Conditions

Community Development and Employment Opportunities

Opportunities for Learning and

Developing Capacity

Community Customs, Norms and Processes

Civic Engagement & Participation

in Decision-Making

Intermediate Outcomes

Health Outcome

Health Promotion, Prevention

and Care Opportunities

PHYSICALENVIRONMENT

Natural Resources

EQUITY ANDSOCIALJUSTICE

.

HEALTHIER COMMUNITIES

The “problem” in The “problem” in understanding the notion of understanding the notion of “context” is our work focus:“context” is our work focus:

Concerned Concerned with CAUSE with CAUSE (i.e. etiology)(i.e. etiology)

MethodsMethods ActionAction TheoryTheory

Concerned with Concerned with CHANGE (i.e. CHANGE (i.e. interventionsinterventions))

ActionAction Concepts and Concepts and

Principles (Values)Principles (Values) MethodsMethods

PH/epi focus Health Promotion

For Health Promotion, Evidence and For Health Promotion, Evidence and Effectiveness are complicated and Effectiveness are complicated and

related termsrelated terms Effectiveness is a broad, loosely defined Effectiveness is a broad, loosely defined

term, generally linked to the notion of term, generally linked to the notion of “outcomes” (tied to causality)“outcomes” (tied to causality)

Notion that effective health promotion Notion that effective health promotion leads to changes in the determinants of leads to changes in the determinants of health is distalhealth is distal

Underlying epistemology of “outcomes” is Underlying epistemology of “outcomes” is complicatedcomplicated

Complexity and Methodology areComplexity and Methodology areIntertwined in Health PromotionIntertwined in Health Promotion

Most community-based health promotion Most community-based health promotion interventions include a complex mixture of interventions include a complex mixture of many disciplines, many variables of varying many disciplines, many variables of varying degrees of measurement difficulty, and degrees of measurement difficulty, and dynamic changing settingsdynamic changing settings

This complexity is increased when the This complexity is increased when the social context is introduced and tied to the social context is introduced and tied to the notion of causality as in the SDOHnotion of causality as in the SDOH

Understanding this complexity requires a Understanding this complexity requires a mixture of complex methodologies and mixture of complex methodologies and considerable time to unravel causal considerable time to unravel causal relationshipsrelationships

A different approachA different approach

Evidence is: Evidence is: Strength of knowledge Strength of knowledge base for what is causally relatedbase for what is causally related

Effectiveness is: Effectiveness is: Agreement about Agreement about translating the evidence to translating the evidence to applicationapplication

Understanding change processes*: where effectiveness meets evidence

High Evidence

Low

High

Low

Effectiveness

Standards Guidance

Political compromise

Experiment

Innovation

Creativity

“Zone of Chaos & Complexity”

Trial & Error

*HAD: modified

Zone of Chaos and Complexity: Zone of Chaos and Complexity: CharacteristicsCharacteristics

Multiple causalityMultiple causalityMultiple settingsMultiple settingsMultiple outcomesMultiple outcomesMultiple actorsMultiple actorsMultiple paradigmsMultiple paradigmsCultural diversityCultural diversityVariation/probabalisticVariation/probabalisticPoliticsPolitics

Irritating IdeasIrritating Ideas

Shared versus unshared variables in Shared versus unshared variables in interventions interventions (epistemology of variables)(epistemology of variables)

Intervention as a problem Intervention as a problem (power corrupts, (power corrupts, empowerment corrupts)empowerment corrupts)

Ethics of interventions Ethics of interventions (planned interventions (planned interventions should do no harmshould do no harm))

““Control” impossible Control” impossible (forces beyond our power)(forces beyond our power)

Naturally occurring interventions Naturally occurring interventions (trump our small, under resourced efforts)(trump our small, under resourced efforts)

Irritating Ideas (continued)Irritating Ideas (continued) Intervention deceit (curb appeal, eyewash)Intervention deceit (curb appeal, eyewash) Evaluation –advisory boardsEvaluation –advisory boards Evaluation reports and analyses not Evaluation reports and analyses not

unbiasedunbiased External policy makers base their External policy makers base their

assessment on evidence in these biased assessment on evidence in these biased reportsreports

External evaluators base their assessment of External evaluators base their assessment of evidence on the biased published reports-evidence on the biased published reports-systematic review of the litsystematic review of the lit

While the focus today has been on SDOH, While the focus today has been on SDOH, because it is the topic of the moment, there because it is the topic of the moment, there

are many othersare many others Each needs to be treated with Each needs to be treated with

reflexivityreflexivity Each needs to be seen as complexEach needs to be seen as complex Each needs to be evaluated in the Each needs to be evaluated in the

Health Promotion contextHealth Promotion context Each needs to be seen in terms of Each needs to be seen in terms of

the notions of evidence and the notions of evidence and effectivenesseffectiveness

What topics in Health Promotion What topics in Health Promotion are doable?are doable?

Given current resourcesGiven current resources Given current HP capacityGiven current HP capacity Requiring new HP capacityRequiring new HP capacity

So what can we do? So what can we do?

We have some initial findings that We have some initial findings that health promotion interventions on health promotion interventions on the social determinants of health the social determinants of health workwork

However, comprehensive and/or However, comprehensive and/or systematic reviews have only been systematic reviews have only been conducted on a few interventions conducted on a few interventions and almost entirely on western and almost entirely on western literatureliterature

Three things that we need Three things that we need

A A better theorybetter theory of evidence and of evidence and evaluation for health promotionevaluation for health promotion

Many ComprehensiveMany Comprehensive evaluationsevaluations of interventions of interventions

Many moreMany more health promotion health promotion interventionsinterventions based on the best based on the best theory of practicetheory of practice

AND, More of your work AND, More of your work represented at the represented at the

- - The 20th IUHPE World Conference on The 20th IUHPE World Conference on Health Promotion and Education to be Health Promotion and Education to be held in Geneva Switzerland, Summer held in Geneva Switzerland, Summer 20102010

The International Union for Health The International Union for Health Promotion and EducationPromotion and Education

The IUHPE aims to connect and support everyone committed to

health promotion and health education wherever they are in the

world.

IUHPE Headquarters2, rue Auguste Comte - 92170 Vanves - France

TEL: 33 1 46 45 0059 - FAX: 33 1 46 45 00 45 - EMAIL: mclamarre@iuhpe.org

More More information:dvmcqueen@cdc.govinformation:dvmcqueen@cdc.gov

The Bangkok Charter for Health PromotionThe Bangkok Charter for Health Promotion in a Globalized Worldin a Globalized World

As developed prior to and during the As developed prior to and during the

6th Global Conference on Health 6th Global Conference on Health Promotion*Promotion*, Bangkok, Thailand August 2005, Bangkok, Thailand August 2005

*Ottawa, Adelaide, Sundsvall, Jakarta, Mexico*Ottawa, Adelaide, Sundsvall, Jakarta, Mexico

Some key conceptsSome key concepts

Links to Ottawa in Links to Ottawa in REDRED Links to key areas of HP work Links to key areas of HP work

YELLOWYELLOW Links to emerging and new areasLinks to emerging and new areas

Bangkok Charter: Scope and Bangkok Charter: Scope and PurposePurpose

The Bangkok Charter identifies actions, The Bangkok Charter identifies actions, commitments and pledges required to commitments and pledges required to address the address the determinants of healthdeterminants of health in a in a globalized worldglobalized world through health through health promotion.promotion.

The Charter affirms that policies and The Charter affirms that policies and partnerships to empower communitiespartnerships to empower communities, , and to improve health and health and to improve health and health equality, should be at the centre of global equality, should be at the centre of global and national development.and national development.

Bangkok Charter: AudienceBangkok Charter: Audience

The Bangkok Charter reaches out to people, The Bangkok Charter reaches out to people, groups and organizations that are critical groups and organizations that are critical to the achievement of health, including:to the achievement of health, including:

Governments and politicians at all levels;Governments and politicians at all levels; Civil societyCivil society;; Private sectorPrivate sector;; International organizations; andInternational organizations; and The public health community.The public health community.

Bangkok Charter: Definition of Bangkok Charter: Definition of Health PromotionHealth Promotion

Health promotion is the process of Health promotion is the process of enabling people to increase control over enabling people to increase control over their health and its determinants, and their health and its determinants, and thereby improve their health. thereby improve their health.

It is a core function of public health It is a core function of public health and contributes to the work of and contributes to the work of tackling communicable and tackling communicable and noncommunicable diseases and noncommunicable diseases and other threats to health.other threats to health.

Addressing Determinants of HealthAddressing Determinants of Health

The global context for health promotion has The global context for health promotion has changed markedly since the development of the changed markedly since the development of the Ottawa Charter:Ottawa Charter:

Increasing inequalities Increasing inequalities within and between countrieswithin and between countries

New patterns of consumption and New patterns of consumption and communicationcommunication

CommercializationCommercialization Global environmental change, and Global environmental change, and UrbanizationUrbanization

Strategies for Health Promotion in Strategies for Health Promotion in a Globalized Worlda Globalized World

Health promotion has an established repertoire of proven Health promotion has an established repertoire of proven effective strategies (effective strategies (AN ASSUMPTION) which need to be which need to be fully utilized. To further advance these strategies, all fully utilized. To further advance these strategies, all sectors and settings must act to:sectors and settings must act to:

AdvocateAdvocate for health based on human rights; for health based on human rights;

InvestInvest in sustainable policies, actions and infrastructure to address the in sustainable policies, actions and infrastructure to address the determinants of health;determinants of health;

Build capacityBuild capacity for policy development, leadership, health promotion for policy development, leadership, health promotion practice, knowledge transfer and research, and literacy;practice, knowledge transfer and research, and literacy;

Regulate and legislateRegulate and legislate to ensure high level of protection from harm to ensure high level of protection from harm and enable equal opportunity for health and well-being for all people; andand enable equal opportunity for health and well-being for all people; and

Partner and build alliancesPartner and build alliances with public private, nongovernmental and with public private, nongovernmental and international organizations and civil society to create sustainable actions.international organizations and civil society to create sustainable actions.

Commitments to Health for AllCommitments to Health for AllThe four key commitments are to make the promotion The four key commitments are to make the promotion

of health:of health:

CentralCentral to the global development agenda; to the global development agenda;

A A corcore responsibility for all of government;e responsibility for all of government;

A A key focuskey focus of communities and civil society; and of communities and civil society; and

A A requirementrequirement for good corporate practice. for good corporate practice.