Capstone Project- JOHNS HOKPINS MEDICINE

Introduction

This article represents the second of two (see Frankish et al., 2006) articles that present a concep- tual framework of health promotion in primary health care (HP in PHC) settings. The framework has five domains (values, structures, strategies, processes and outcomes). Frankish et al. (2006) present the foundational values and structures that serve to create a supportive environment for health

promotion. The latter three domains are the focus of the present article.

We argue that health promotion deserves greater attention in primary health care settings. Treatment alone is unlikely to have marked effects on health inequities that underlie many health conditions. Many jurisdictions and health professionals now recognize that a reduction in health inequalities and a closing of the gap in health status requires greater integration of HP in PHC (Keleher, 2001; Ministry of Health, New Zealand, 2003).

Health promotion research in primary health care often focuses on only one or two of many compon- ents. This further contributes to the maintenance of diverse and fragmented perspectives. It is critical to identify/define the terms/concepts underpinning

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© 2006 Edward Arnold (Publishers) Ltd 10.1191/1463423606pc286oa

Building on a foundation: strategies, processes and outcomes of health promotion in primary health care settings Glen Moulton Institute of Health Promotion Research, University of British Columbia, Vancouver, BC, Canada, James Frankish Institute of Health Promotion Research, Faculty of Graduate Studies, Department of Health Care and Epidemiology, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada, Irving Rootman Faculty of Human and Social Development, University of Victoria, Victoria, BC, Canada, Carol Cole and Diane Gray Institute of Health Promotion Research, University of British Columbia, Vancouver, BC, Canada

Jurisdictions around the world have articulated the need for the development of an inte- grated health care system with an increased emphasis on primary health care that incorp- orates the principles/practices of health promotion. Over the past century, the medical model has been the default model of care in many countries, and yet treatment alone is unlikely to have marked effects on health inequities or health status. This article presents and discusses three fundamental dimensions (strategies, processes and outcomes) of health promotion in primary health care (HP in PHC) settings. We argue that the three dimensions are founded on the values and structures of health promotion (Frankish et al., 2006). Our work is based on a comprehensive literature review, validation by key informants and a national survey of Canadian primary health care settings. We suggest that the strategies (types of interventions), processes (client and community centred care), and desired health promotion outcomes (intended or unintended results) need to be better articulated and understood. Identification and discussion of the domains of HP in PHC settings is a crucial first step. It is a step toward the subsequent identification of related indicators and measures of health promotion that can be used for planning, implementation and evaluation of important health promotion initiatives.

Key words: health care reform; health inequities; health promotion; indicators; popu- lation health; primary health care; standards

Received: May 2004; accepted: December 2005

Address for correspondence: Glen Moulton, Institute of Health Promotion Research, University of British Columbia, Room 411, LPC Building, 2206 East Mall, Vancouver, BC, Canada V6T 1Z3. Email: [email protected]

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HP in PHC. We do so by differentiating it from the more predominant disease focused model. By oper- ationalizing the breadth, depth and diversity of HP in PHC, settings may be able to develop and sustain it. This change requires a philosophical paradigm shift and practical implementation. For definitions of primary health care and health promotion, read- ers are referred to Frankish et al. (2006).

Research design

This research project consulted broadly, using quali- tative and quantitative methods, to construct a con- ceptual framework for HP in PHC that distils the most salient characteristics from dozens of possi- bilities. It included an extensive review of the pub- lished literature in scholarly journals, and grey literature, including policy documents and reports. We employed a Delphi technique by convening experts to seek input on relevant characteristics of HP in PHC.We also sought input from focus groups held in four Canadian cities. Finally, we undertook a national survey of primary health care settings to examine the perceived level of importance and reported activity that professionals and adminis- trators attributed to the characteristics of our con- ceptual framework. Our conceptual framework was refined with each successive research phase. The characteristics within the five domains (values, structures, strategies, processes, and outcomes) were modified until no other aspects of health promotion could be identified for inclusion. Complete details on our research design is provided in Frankish et al. (2006).

Key domains and characteristics of HP in PHC

Health promotion comprises multiple, intercon- nected concepts that can be incorporated into the practice of primary health care settings.

Frankish et al. (2006) describes the philosoph- ical values that provide the foundation for health promotion. They also highlight how these values should manifest in structures that create a support- ive environment for health promotion. Our focus is to build on Frankish et al. (2006) by presenting the remaining three domains (strategies, processes, outcomes).

The strategies (types of interventions) and pro- cesses (client and community centred care) are important to the outcomes that health promotion initiatives may achieve in primary health care set- tings. Strategies are specific types of interventions. Processes describes aspects of providing client- centred care through interpersonal relationships. Finally, outcomes are the intended or unintended results of the strategies, processes and structures. The synergy between the first four components leads to desired health promotion outcomes.

None of the dimensions within the five domains are unique to health promotion per se. Health pro- motion is unique precisely because it is an amalgam of values and practices that enhance health. The information provided exemplifies the breadth of the subject area. Practitioners and decision makers may require additional information to acquire suf- ficient depth of knowledge.

This article builds on these values and structures. Below, we outline the strategies, processes and out- comes that may be expected to arise out of these foundational values and structures.

Strategies Multifactoral causes of illness and disease

necessitate a multifactoral approach to health pro- motion. We see three complimentary approaches to health promotion (Birse, 1998). The first is the medical or preventive medicine approach that is directed at improving physiological risk factors. Next, the behavioural or lifestyle approach is directed at improving behavioural risk factors, such as smoking and physical inactivity. Finally, the socio- environmental approach is concerned with the totality of health experiences and the factors that help to maintain or improve health (including risk conditions and psychological risk factors). This approach targets the determinants of health in one’s physical and social environment.

These approaches differ in how health is viewed, how health problems are defined, what interven- tions are implemented, and how effectiveness is measured. They are most effective in terms of long- term outcomes when a combination of such strat- egies is used concurrently, and at several levels within a setting and with external partners (Swaby and Biesot, 2001).

Despite the apparent widespread acceptance of a socio-environmental (eg, population health)

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perspective held by many working in health pro- motion, most health promotion activity continues to be preventive and lifestyle oriented through the provision of health information/education, screen- ing and early intervention. These are valid strat- egies. But, they are insufficient and ineffective on their own and they do not harness the full potential of health promotion to positively affect individual and community health.

A health promotion approach seeks to expand the focus of attention beyond the individual. Clients of primary health care may be individuals, families, groups, communities and populations. Health pro- motion is more than a specific programme (add-on to existing health services) or a single strategy or aggregate of individual strategies. It demands a multifaceted reorientation and incorporation of a range of services and intervention strategies that meet people’s immediate needs and also address social and economic conditions. Group and com- munity strategies are fundamental to health promotion.

Empowerment is a fundamental value of health promotion and in keeping with health promotion’s focus of enabling individuals. If the strategies employed are not enabling or empowering to indi- viduals and communities, then it is not health promotion. Community empowerment involves individuals acting collectively to gain greater influ- ence and control over the determinants of health and the quality of life in their community. Health professionals generally have more power (status, legitimacy, access to or control over resources) than their clients (Labonte, 1994). It is important that health professionals do not remain the locus of con- trol, but rather are an enabling agent. Empowering individuals or groups requires access to decision making, skills and knowledge to effect change. People cannot achieve their fullest health potential unless they are able to take control of those things that determine their health.

Individual strategies The individual level of care is fundamental to

our health system. Primary care interventions are generally episodic and brief. They occur between an individual and a health care provider, typically a physician, and health promotion strategies are consequently short term, such as giving advice for smoking cessation or distributing health education pamphlets. Some practitioners see this as the full

extent of health promotion (Swaby and Biesot, 2001). The individual is targeted for change rather than the social or environmental conditions that underlie the illness or disease. Individual focused strategies are not unique to health promotion. A health promotion approach, however, focuses on the individual in the context of their community, such as vaccinations targeted towards hard to reach populations, and includes the provision of ancillary services. Individual oriented health promotion strategies include personal life skills, psychological counseling, health education (and information), self care, referrals, home visits, and preventive inter- ventions (eg, screening), individual risk assess- ments (for body weight, diet, activity levels), and immunizations (for tetanus, measles, polio and influenza).

Individual oriented strategies have not been successful in meeting the needs of the most vulner- able in society. Health promotion seeks to redress inequalities in health status. Need and demand for primary care are clearly divergent, with those in greatest need of an intervention being the least likely to receive it. The inequality of provision has led to inequity of uptake, and should be remedied by appropriate targeting and tailoring of pro- grammes (Davis et al., 1996).

Group strategies Group strategies typically refer to groups small

in number, generally fewer than 20 participants. These groups generally focus on life conditions of their members. They are where people begin to forge new identities in supportive relationships. Group strategies include group counseling, cap- acity building, outreach, self-help/mutual aid, and social support. Issues addressed may include drug and alcohol dependency, adolescent health, or men- tal health.

Community strategies Community strategies are those that will affect

the broad community and population (whether or not they directly participate) through social and environmental change. The groups that benefit the most from community level strategies are the ones at greatest risk of ill health, and often, the most difficult to reach through conventional approaches. Community strategies include community develop- ment/community economic development, healthy public policy (eg, economic and regulatory activities

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involving financial and legislative incentives or dis- incentives focusing on price, availability, restrictions and enforcement, such as modifying consumption of tobacco and alcohol through increased taxation, and restrictions on advertising), health communication (eg, health fairs, social marketing, mass media strat- egies), coalition building, advocacy (eg, direct pol- itical lobbying, media advocacy), and supportive environments.

Organizational strategies Organizational strategies are targeted at the

health setting itself, and its practitioners (see struc- ture section).

The range and content of the various strategies is vast. It can include any combination of medical conditions, determinants of health, lifestyle/behav- ioural issues and/or population groups (eg, age, gender, ethnicity). Strategies implemented in a primary health care setting will differ based on the needs of the population. In an inner city area, the strategies for community members may address poverty, homelessness, addictions problems, while in a rural area, services may include farming or fishing safety and addressing the needs of an aging population. Formulating health promotion strat- egies involves selection and prioritization since intervening on a multitude of problems while con- tinuing to provide high quality primary health care services is challenging. It is possible, however, to pursue a strategy collectively, with shared initia- tives, while also pursuing individual professional objectives.

Process Health promotion is a process with the aim of

enabling people to take action to improve their health. Health promotion is not something that is done on or to individuals; it is done with and by people, either as individuals or groups. Process characteristics are related to the client centred delivery of health promotion and address inter- personal issues between clients and practitioners. Below, we identify the process related characteris- tics in our conceptual framework.

Proactive approach In addition to addressing the ‘presenting symp-

toms’ and immediate health needs of clients, health

promotion practice requires organizations and staff to be proactive (rather than simply reactive) in service delivery by addressing underlying health issues of individuals and their community (eg, housing, social support, economic status). The most vulnerable members of a community have the greatest need for health promotion and the most limited capacity, thus the need to be proactive.

Individualization and choice People have the right and responsibility to be

active partners in making decisions about their own health. Health promotion services are offered in a manner that enables individuals to take more control of their health. However, people cannot be reliant upon resources they do not have. Providers need to assess participants’ readiness to change, lived reality, and cultural traditions. The provider may advocate for the client if necessary or liaise with other professionals and agencies as needed.

Mutual learning Health promotion encourages clients to be

involved in planning and making decisions about their own health care. There is a sharing of informa- tion and options on a variety of health related issues and a reduction of power differentials between providers and clients. Both the process and out- comes of health promotion should be educational and capacity building for both clients and providers.

Respectful communication Good rapport between clients and health pro-

fessionals must meet expectations and standards of privacy, confidentiality, informed choice, empathy, honesty, sensitivity, accountability, trans- parency, openness, integrity, and equity (Howard Research and Instructional Systems, 2000). Inter- personal processes ensure the client has sufficient time in meeting with health professionals, and the practitioner is skilled, informed, credible and non-judgmental.

Meaningful participation Health promotion involves clients and commu-

nity members in meaningful ways in the planning, implementation and evaluation of health-related activities or services. It is not feasible or practical to seek public involvement in every decision. However, the active participation of clients and the wider community remains central to health

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promotion and the related social model of health. The intent is to increase capacity at the personal and community levels, to strengthen social con- nectedness, trust and competence and to thereby address health problems. Community participa- tion extends from professionally driven, top-down models seeking to respond to community input via surveys or a community representative on an insti- tutional board, to bottom-up approaches with full community ownership of health programmes, including decisionmaking and programme imple- mentation. Specific tasks and priority issues must be approached in a genuine planning and mutual identification process.

Outcomes The final domain of our framework pertains to

the outcomes of health promotion. We define a health outcome as a change in the health of an indi- vidual, group or population that is attributable to an intervention or series of interventions. It demon- strates to funders and policymakers that the pro- gramme had an impact. Assumptions around what interventions will impact the health of populations are reasonably easy to generate, however, the paths of causation to (ill) health are highly complex and not easily measurable. Proving a causal connection between activities and improved health is even more difficult. A health promotion approach is not part of a simple linear process in which there is a direct causal relationship between an interven- tion(s) and an outcome. This lack of obvious causal- ity wrongly results in uncertainty and doubt about health promotion’s effectiveness.

There are numerous, practical challenges to at- tributing health outcomes to health promotion interventions. Therefore, evaluation and outcomes are often difficult to address at the practice level (Adams et al., 2001). In order to measure changes, baseline information (ie, benchmarks) and appro- priate measurement tools are needed, but most systems are not readily available for tracking evalu- ative data. Regional reports may be published on some indicators, or pre-post data may have to be collected. Tracking high risk populations presents even more difficulties. There is also a lack of resources for undertaking sufficient and appro- priate evaluations. Some managers and health professionals are also unrealistic about what can be achieved over the life of a relatively short-term

project. Others often do not (believe they) have the capacity to carry out such functions, nor do they believe it is their responsibility to measure health outcomes of a particular health promotion inter- vention any more than they should be expected to measure the effectiveness of drugs they prescribe.

Outcomes require considerable time to accrue, and short timelines create significant challenges in assessing quality in a definitive way. Three years or less is too short for establishing new programmes in community health, especially health promotion programmes. It may be as long as five to ten years before the full impact of an intervention is realized and there is a measurable impact (Howard Research and Instructional Systems, 2000). It is also difficult to track all costs associated with pro- grammes, especially if more than one organization is involved.

There is an unrealistic expectation that health promotion initiatives will adopt experimental research designs that have been developed for med- ical research. Such designs are deficient as an evalu- ation tool for complex and multidimensional activities. Randomized control trials are best suited for simple interventions, and are not appropriate for evaluating many health promotion strategies, such as working for policy change or community action, when outcomes may not be amenable to statistical analysis (Victorian Department of Human Services, 2000).

Often, governments and funding bodies expect health promotion to be evaluated to a much greater extent than is expected of the rest of the health sys- tem. Some concern has been expressed that health promotion is being set up to fail by being required to demonstrate its impact on people’s health over a short period of time and after relatively minor interventions. If outcome criteria revolve around whether or not a project is easily measurable, spe- cific and achievable within a short funding cycle, it may do little in the long term to improve health by reducing health inequalities or addressing causes of poor health. The more easily it can be measured the more insignificant it may be in improving the health of communities.

The conundrum is that the most powerful forms of health promotion action are those that are long term, and the least easily controlled or measured by conventional means. If health is broadly defined to include psychosocial dimensions, then outcomes should also include these aspects. However, the

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search for outcomes may narrow the definition of what constitutes health promotion.

Both qualitative and quantitative research, and evaluation play a crucial role in improving quality and accountability in primary health care. Clearly defined programme goals and objectives, from which the evaluation flows, are critical. These goals and objectives must be prioritized so that the evalu- ation resources can be tailored to the identified priorities. The measurement of outcomes should be slowly integrated, and commensurate with requisite resources.

For HP in PHC we may have to be satisfied that ‘quality’ can only be approximated, not quantified. A template of possible outcomes is listed in Table 1. The outcomes are categorized at the individual, organizational and community levels. These out- comes may be distal, intermediate or immediate. The measurement of intermediate or immediate outcomes may be more realistic than measuring distal outcomes for most settings.

Discussion

Despite the call for health promotion and disease prevention in the Declaration of Alma-Ata and the appeal for the reorientation of health services in the Ottawa Charter, the prevailing models of health care throughout the world are still primarily curative. Curative care still predominates over preventive and developmental activities, such as health promo- tion. In most countries, primary care tends to be limited to the most basic provision of curative and preventive services (eg, diagnoses of illnesses, refer- rals, and vaccinations) (Anderson et al., 2001). Most health care systems are in fact illness care systems. The role of health promotion in health care reform has been minor or insignificant in many jurisdictions (Ziglio et al., 2000). Reform of primary care in many countries has involved more refinement (ie, tinker- ing) and rhetoric than substantive changes (Marriott and Mable, 2000). For instance, Canada’s primary care system has been described as ‘so much innov- ation, so little change’ (Hutchison et al., 2001).

The underlying values and strategies of HP in PHC remain as valid today as when they were alluded to in the Alma-Ata Declaration and the Ottawa Charter, and many of the burdens that gave rise to these seminal documents have yet to be overcome. There is still tremendous potential

for primary health care to tackle present day, worldwide challenges through the incorporation of health promotion. Political, social and economic crises have reduced the access of many people to health care. Demographical trends that have pri- mary health care implications include urbanization, aging populations, population growth, the preva- lence of chronic diseases, sedentary behaviour, drug resistance (eg, antibiotics), drug abuse, civil violence, AIDS and other emerging diseases, and environmental disasters. These problems threaten the health and well being of hundreds of millions of people throughout the world.

Implementation of a health promotion approach in primary health care has been characterized by heterogeneity and discontinuities. At the conceptual level, health promotion and primary health care have been subject to interpretations that reflect divergent political and health perspectives. While principles of primary health care and health promo- tion have been included in many strategic planning documents, there remains considerable diversity in the models of primary health care being used. Where the implementation of primary health care is incomplete or is not delivering expected results, shortcomings are attributed to a lack of practical guidance on implementation, poor leadership, insuf- ficient political commitment, inadequate resources, and unrealistic expectations placed on this model of care (World Health Organization, 2003). In some countries, financing constraints have also impacted on the level of technical support to peripheral staff and on the development of referral and communi- cation systems. Failure of primary health care to reach priority populations, such as the poor and other disadvantaged groups, also stems from com- plex socioeconomic and political factors. Most national health systems are coming under increas- ing scrutiny with a concern for containing costs, improving quality, and encouraging cooperation and balance between the private and public sec- tors. Taken together, the above issues and the eco- nomic and social pressures on primary care have resulted in missed opportunities for cumulative, incremental change involving health promotion. While sudden and major changes in primary health care delivery are unlikely (and undesirable), sig- nificant incremental change around health promo- tion is possible.

Some 25 years after the Alma-Ata Declaration, health ministers in many countries have called for

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a renewed commitment to the goal of ‘health for all’ and endorsed the adoption of a health promo- tion approach in primary health care as a strategy for reducing the world’s persisting inequities in health (PAHO, 2003). All countries need to iden- tify ways to better incorporate a health promotion perspective within existing infrastructures and to make appropriate adaptations. A renewed com- mitment to health promotion and primary health care has great potential to guarantee the right to health for all citizens, while giving priority to the health of the least privileged groups and to redu- cing inequalities in health. A continued reliance on hospitals and advanced technologies does little to address health inequities or to improve popula- tion health. When compared to secondary and ter- tiary care, primary care is less intensive in its demand for both capital and labour and is less hierarchical in organization. Therefore, it is inherently more adaptable and capable of responding to changing societal needs.

Several countries have launched efforts to reorganize their primary health care, including increased reliance on regional health systems and strengthening human resources. Primary health care has contributed to greater social participation, introduction of new providers, such as community health workers, integration of services provided by different sectors, and extension of community out- reach and intersectoral activities. Efforts are being made in some countries to enhance participation of rural communities and a sense of ownership.

The next set of challenges pertains to defining whose role and responsibility improved implemen- tation of HP in PHC is, and enhancing the capacity the health system to address it. There are continu- ing issues to further develop the evidence base for primary health care, and the creation of relevant measurements and indicators need to be addressed in policy, practice and research.

Taken together, the two articles (Frankish et al., 2006; Moulton et al., 2006) provide a theoretically and empirically grounded conceptual framework for HP in PHC. Their five domains (values, struc- tures, strategies, processes, outcomes) have high levels of both face and construct validity. There is a need to build on this work by creating consensus indicators or ways of measuring each characteris- tic. Equally, there is an urgent need to establish standards or definitions of success for each indicator of a given characteristic. Judd et al. (2001) provide

examples of nine approaches to setting standards in the evaluation of community based health pro- motion programmes. It remains to be determined whether such measures and standards would have predictive validity and utility in terms of predicting improvements in health status, health behaviours and use of health/social services.

The mechanisms by which people come together, interact and take action to promote their health should also be strengthened. There is a need to give added emphasis to locally integrated approaches to community development and to concentrate on the needs of disadvantaged populations. Policy and design interventions that promote rights to access, social justice and equity need to be improved. Primary care has inherent barriers that prevent providers from incorporating a more comprehen- sive approach. Building capacity for providers, organizations and bureaucrats to develop HP in PHC is crucial. Health promotion action also requires the involvement of people outside the health sector, beyond individuals that describe themselves as ‘health’ workers.

Conclusion

For settings and jurisdictions seeking to incorp- orate HP in PHC, we offer the present conceptual framework to assist them. We argue that in order for health promotion to come to fruition, its char- acteristics must be clear and broadly understood. More importantly, we must be able to identify clear measures that can be implemented on a sus- tained and comprehensive basis. We argue for the creation of a vision that makes the values, struc- tures, strategies, processes and outcomes of health promotion more explicit. This vision may con- tribute to better dialogue among stakeholders and the negotiation of a new set of shared norms and standards, and broader engagement in health pro- motion initiatives.

Our overall goal is to improve the health of indi- viduals and communities by improving the quality and quantity of health promotion that occurs. This goal can only be achieved through clear criteria for HP in PHC settings and the rigorous collection and evaluation of data associated with such criteria. Only then will health promotion achieve greater prominence in primary health care. We believe that health promotion reflects widely held community

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values. Further, evidence suggests that many citi- zens would endorse a movement toward more col- laborative structures, strategies, and processes in our health care system. The outcomes of health promotion also highlight the need to balance the great strengths of our ‘illness care system’ with the strengthening of a parallel, integrated health pro- motion system that would maximize individual and community health, now and in the future.

Acknowledgements

The authors would like to thank the Health Reform Working Group of the Canadian Consortium for Health Promotion Research, the research co- investigators, the advisory committee, the focus group participants, and all others who contributed in many ways to the completion of this article. This work has been made possible by a grant from The Canadian Institutes of Health Research.

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