435463
2012
GHP19110.1177/1757975911435463EditorialGlobal Health Promotion
Editorial What is the ‘best’ health promotion action to take? Suzanne F. Jackson1
Health promotion is about taking action, doing something to change the lives of individuals, communities or whole societies. For the most part, health promoters are doers, people who work with others at any level to figure out how to solve problems. Lots of activity is taking place all over the globe but very little ends up in published literature, and many practitioners have to ‘reinvent the wheel’ when good practices to fit their situation probably already exist. How does a practitioner in a low- or middle-income country (LMIC) get information about a best practice in health promotion? I believe there is a chain of factors involved. •• Access – How do you get information about practices that are culturally appropriate, in your language, in a form you can understand and use? •• Quality – How can you be sure that the practices you find that have been evaluated in a rigorous way are applicable to your setting, culture or community? What changes if you want to use a participatory approach? •• Contributions – How can you, as a practitioner, write up or communicate the practices you are using to others when you have no resources or time to meet high evaluation standards for rigour, when English is not your first language, and when you do not get support for writing up your results? Each of these points connects to the process of editing and producing a journal in the health promotion field. On the positive side, the process of producing a peer-reviewed journal article about an intervention guarantees some degree of quality. Articles that have been published have met some standards for the quality of the evaluation design and the reader can rely on this when selecting published practices for replication. However the tiny
fraction of evaluated practices that appear in journals require that the practitioners involved had the time and resources to do the evaluation and probably they had an opportunity to collaborate with researchers or universities. Such resources are often available only for short periods of time, focus attention on ‘new’ practices rather than support for ongoing work, and are not accessible for the majority of health promoters working on the front lines. By the time something is published, it may be at least five years since the evaluation took place. Given the rapid evolution of research, best practices of the 1990s are being superceded by better practices in the 2000s. One of the best sources of information about best practices is the systematic review. This process relies on the existence of published articles, with evaluation designs that meet high standards, produced in language(s) known to the reviewers (usually English). Systematic reviews are usually biased toward quantitative research designs and exclude high quality qualitative evaluation designs. Health promotion interventions can be participatory in nature, use multiple strategies operating at multiple levels in multiple sectors that reinforce or interact with each other, result in multiple outcomes, and change the context that is the focus for ‘control’ in randomized trials. All of these aspects present challenges to evaluators and reviewers. When the literature available for systematic reviews is mostly from Western countries and following randomized control trial (RCT) designs, the relevance and cultural transferability to LMIC contexts can be challenged. I have been involved in three initiatives aiming to find best practices in health promotion – one at a national level in Canada, one with the Pan-American Health Organization (PAHO) in the Americas, and one with the World Health Organization (WHO). In each case, the task has been to find evaluated health promotion
1. Editor-in-Chief, Global Health Promotion. Email: [email protected]
Global Health Promotion 1757-9759; Vol 19(1): 3 –4; 435463 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975911435463 http://ghp.sagepub.com Downloaded from ped.sagepub.com at Universitaet Osnabrueck on April 15, 2015
S. F. Jackson
4
interventions with quality research designs and in all three cases, systematic reviews yielded few results. •• In Canada, the criteria for inclusion on the Chronic Disease Prevention and Health Promotion Best Practices Portal (CBPP) have been broadened to include criteria for both qualitative and quantitative study designs, and attempts have been made to capture and distinguish innovations that have not completed formal evaluations (http://cbpp-pcpe.phac-aspc.gc.ca/). •• In a long term project with PAHO, I have been part of a team developing a mechanism to enable practitioners in Latin America to share their interventions by using a documentation template. It is structured to allow practitioners to fill in details about their work even if it has not been formally evaluated. Entries are reviewed before posting and there is the possibility of follow-up interviews to fill in more details. Eventually the entries will be searchable on a range of special key words and the hope is that best practices can be derived once a critical mass of cases is in the database (http://new.paho.org/hpd/). •• At WHO, a group of authors with expertise in different public health topics were tasked with finding health promotion interventions specifically in LMIC meeting Cochrane Collaboration standards for quality of design (http://www.cochrane.org/). Even in Canada, there were very few evaluated Canadian interventions that could be included in the CBPP. Canada is a country with training for practitioners in evaluation, a culture of requiring evaluation processes with most programs, resources for evaluation, and English as a common language. Many practitioners use up their evaluation time preparing reports for their funders which never end up being published in any form. Imagine the challenges for a LMIC where there is no culture of evaluation, little knowledge of how to do evaluation among practitioners, different worldviews on what matters, and other working languages than English. At each stage in this process, there are barriers for those in low- and middle-income countries. If you are a practitioner in rural Africa, how do you find out about possible interventions when you
have limited access to computers, no local library, and do not understand English very well? In addition, how do you conduct evaluations of your work to contribute to a database when you don’t have enough resources to operate the program properly? Is the requirement for ‘best’ practices a ‘Western’ idea where investors want to make sure they are investing in something that works? There are lots of actions that take place all over the world by very capable practitioners recognizing the context, language, customs, and what matters to people. From a Western perspective, one could argue that what is missing is information about causality and connections that have been gleaned through Western scientific research. However, there are non-Western ways of framing problems and taking action. How do we get beyond a focus on Northern / Western definitions and paradigms of good practice to include exciting developments in other parts of the globe? How do we recognize other worldviews of what constitutes success? How do we incorporate advances in evaluation approaches that do a better job of assessing multi-level, multi-sectoral, contextaltering health promotion interventions? It is encouraging to know that more health promoters are interested in doing evaluations and using evidence in their practice. Evaluators are more interested in identifying new approaches to evaluation and broader criteria of evaluation design quality. However, relying on articles published in journals to improve practice is a slow process. We need faster mechanisms to share information in underserved areas. I think that technologies emerging over the next few years will enable practitioners to get access to information summaries from reliable sources describing health promotion interventions that have met some standards of quality (not necessarily the highest). Hopefully, future technologies will remove language barriers and enable a richer exchange of ideas across many cultures. There is still a need for journals, such as Global Health Promotion, to continue to publish high quality evaluations and systematic reviews. But, in keeping with new technologies, we should also be looking at different ways to contribute to the rapid exchange of intervention mechanisms across cultures and contexts with a mid-range of quality standards.
IUHPE – Global Health Promotion Vol. 19, No. 1 2012
Downloaded from ped.sagepub.com at Universitaet Osnabrueck on April 15, 2015
2012
GHP19110.1177/1757975911435463EditorialGlobal Health Promotion
Editorial What is the ‘best’ health promotion action to take? Suzanne F. Jackson1
Health promotion is about taking action, doing something to change the lives of individuals, communities or whole societies. For the most part, health promoters are doers, people who work with others at any level to figure out how to solve problems. Lots of activity is taking place all over the globe but very little ends up in published literature, and many practitioners have to ‘reinvent the wheel’ when good practices to fit their situation probably already exist. How does a practitioner in a low- or middle-income country (LMIC) get information about a best practice in health promotion? I believe there is a chain of factors involved. •• Access – How do you get information about practices that are culturally appropriate, in your language, in a form you can understand and use? •• Quality – How can you be sure that the practices you find that have been evaluated in a rigorous way are applicable to your setting, culture or community? What changes if you want to use a participatory approach? •• Contributions – How can you, as a practitioner, write up or communicate the practices you are using to others when you have no resources or time to meet high evaluation standards for rigour, when English is not your first language, and when you do not get support for writing up your results? Each of these points connects to the process of editing and producing a journal in the health promotion field. On the positive side, the process of producing a peer-reviewed journal article about an intervention guarantees some degree of quality. Articles that have been published have met some standards for the quality of the evaluation design and the reader can rely on this when selecting published practices for replication. However the tiny
fraction of evaluated practices that appear in journals require that the practitioners involved had the time and resources to do the evaluation and probably they had an opportunity to collaborate with researchers or universities. Such resources are often available only for short periods of time, focus attention on ‘new’ practices rather than support for ongoing work, and are not accessible for the majority of health promoters working on the front lines. By the time something is published, it may be at least five years since the evaluation took place. Given the rapid evolution of research, best practices of the 1990s are being superceded by better practices in the 2000s. One of the best sources of information about best practices is the systematic review. This process relies on the existence of published articles, with evaluation designs that meet high standards, produced in language(s) known to the reviewers (usually English). Systematic reviews are usually biased toward quantitative research designs and exclude high quality qualitative evaluation designs. Health promotion interventions can be participatory in nature, use multiple strategies operating at multiple levels in multiple sectors that reinforce or interact with each other, result in multiple outcomes, and change the context that is the focus for ‘control’ in randomized trials. All of these aspects present challenges to evaluators and reviewers. When the literature available for systematic reviews is mostly from Western countries and following randomized control trial (RCT) designs, the relevance and cultural transferability to LMIC contexts can be challenged. I have been involved in three initiatives aiming to find best practices in health promotion – one at a national level in Canada, one with the Pan-American Health Organization (PAHO) in the Americas, and one with the World Health Organization (WHO). In each case, the task has been to find evaluated health promotion
1. Editor-in-Chief, Global Health Promotion. Email: [email protected]
Global Health Promotion 1757-9759; Vol 19(1): 3 –4; 435463 Copyright © The Author(s) 2012, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975911435463 http://ghp.sagepub.com Downloaded from ped.sagepub.com at Universitaet Osnabrueck on April 15, 2015
S. F. Jackson
4
interventions with quality research designs and in all three cases, systematic reviews yielded few results. •• In Canada, the criteria for inclusion on the Chronic Disease Prevention and Health Promotion Best Practices Portal (CBPP) have been broadened to include criteria for both qualitative and quantitative study designs, and attempts have been made to capture and distinguish innovations that have not completed formal evaluations (http://cbpp-pcpe.phac-aspc.gc.ca/). •• In a long term project with PAHO, I have been part of a team developing a mechanism to enable practitioners in Latin America to share their interventions by using a documentation template. It is structured to allow practitioners to fill in details about their work even if it has not been formally evaluated. Entries are reviewed before posting and there is the possibility of follow-up interviews to fill in more details. Eventually the entries will be searchable on a range of special key words and the hope is that best practices can be derived once a critical mass of cases is in the database (http://new.paho.org/hpd/). •• At WHO, a group of authors with expertise in different public health topics were tasked with finding health promotion interventions specifically in LMIC meeting Cochrane Collaboration standards for quality of design (http://www.cochrane.org/). Even in Canada, there were very few evaluated Canadian interventions that could be included in the CBPP. Canada is a country with training for practitioners in evaluation, a culture of requiring evaluation processes with most programs, resources for evaluation, and English as a common language. Many practitioners use up their evaluation time preparing reports for their funders which never end up being published in any form. Imagine the challenges for a LMIC where there is no culture of evaluation, little knowledge of how to do evaluation among practitioners, different worldviews on what matters, and other working languages than English. At each stage in this process, there are barriers for those in low- and middle-income countries. If you are a practitioner in rural Africa, how do you find out about possible interventions when you
have limited access to computers, no local library, and do not understand English very well? In addition, how do you conduct evaluations of your work to contribute to a database when you don’t have enough resources to operate the program properly? Is the requirement for ‘best’ practices a ‘Western’ idea where investors want to make sure they are investing in something that works? There are lots of actions that take place all over the world by very capable practitioners recognizing the context, language, customs, and what matters to people. From a Western perspective, one could argue that what is missing is information about causality and connections that have been gleaned through Western scientific research. However, there are non-Western ways of framing problems and taking action. How do we get beyond a focus on Northern / Western definitions and paradigms of good practice to include exciting developments in other parts of the globe? How do we recognize other worldviews of what constitutes success? How do we incorporate advances in evaluation approaches that do a better job of assessing multi-level, multi-sectoral, contextaltering health promotion interventions? It is encouraging to know that more health promoters are interested in doing evaluations and using evidence in their practice. Evaluators are more interested in identifying new approaches to evaluation and broader criteria of evaluation design quality. However, relying on articles published in journals to improve practice is a slow process. We need faster mechanisms to share information in underserved areas. I think that technologies emerging over the next few years will enable practitioners to get access to information summaries from reliable sources describing health promotion interventions that have met some standards of quality (not necessarily the highest). Hopefully, future technologies will remove language barriers and enable a richer exchange of ideas across many cultures. There is still a need for journals, such as Global Health Promotion, to continue to publish high quality evaluations and systematic reviews. But, in keeping with new technologies, we should also be looking at different ways to contribute to the rapid exchange of intervention mechanisms across cultures and contexts with a mid-range of quality standards.
IUHPE – Global Health Promotion Vol. 19, No. 1 2012
Downloaded from ped.sagepub.com at Universitaet Osnabrueck on April 15, 2015
