Evaluating Health Promotion Activities: a selective, annotated bibliography

N.B This paper was added as an appendix to the original technical bulletin, by the ILEP Technical Commission (ITC) in 2007.

Evaluating Health Promotion Activities: a selective, annotated bibliography

 

1. INTRODUCTION

The activities which attempt to inform and educate the general public (or a specific target group, such as people on treatment for leprosy) on health matters are referred to under a number of different headings, including:

  • Health promotion
  • Health education
  • Information, Education and Communication (IEC)
  • Communicating health

These headings are taken to be more or less synonymous and the term ‘health promotion’ will be normally used in this paper.

It is universally acknowledged that such activities can significantly improve health behaviour.  However, there are a number of serious operational problems, which make health promotion a controversial topic within health programmes:

  • Firstly, there is controversy about the underlying aim of health promotion: is it to inform and empower (allow the target audience to make their own decisions about what to do), or is it to persuade and aim specifically at changing behaviour?
  • Secondly, because of the high costs involved, most health promotion programs aim at changing behaviour and are required to produce results, but it has been difficult to evaluate such programmes and demonstrate a measurable effect, in most situations.  Reasons why it is difficult to evaluate health promotion programs include:
    • Health behaviour is itself difficult to measure, so it is equally difficult to show a consistent change in behaviour; evaluation therefore usually looks at self-reported behaviour (people tell the evaluator what they do), or at health outcomes (for example, a programme to teach people affected by leprosy how to look after their feet, could be evaluated by measuring the number and size of foot ulcers over time).  Most health promotion programmes do not have such easily measured health outcomes, so must rely on surveys of self-reported behaviour.
    • Real changes in health behaviour usually take place gradually, over years or even decades and the dynamics may be very different in different segments of the population; for example, changes in smoking patterns have occurred over decades and are very different between men and women, despite a high level of expenditure on anti-smoking programmes in most countries.
    • It is usually difficult to identify a control population, which is similar to the target population, but unexposed to the health promotion activities.
    • Over a period of time, there are many other influences on people’s health behaviour, besides the programme being evaluated; so it is difficult to know what really caused any changes noted.
    • Major health promotion interventions, especially those involving long-running radio or TV programmes, are very costly; even if behaviour change takes place, it is difficult to quantify and thus compare the cost-effectiveness of different approaches.
  • Thirdly, because of the difficulty in determining the effectiveness of different health promotion methods in different contexts, great reliance is placed on the theoretical foundations of how health behaviour is determined and changed.  Thus many health promotion programmes are designed from a theoretical standpoint, rather than from good evidence of efficacy.

In short, health promotion is seen as an essential component of the health services, but it is difficult to evaluate and demonstrate which activities are most cost-effective in any given context.  Because of this complexity and the large body of literature already available, this paper reviews some relevant publications, rather than making new recommendations.

Bibliography

For ILEP members, a starting point in planning health promotion activities is the Technical Bulletin No 13: Planning Health Education Interventions, produced in 1998 by the ILEP Medico-Social Commission.  This is a short paper giving the basic steps and methods of health promotion.

There are many recent textbooks on Health Promotion.  A basic practical guide for use in the field is Communicating Health (Hubley J., 2004 Oxford).  Other textbooks cover the general theory and practice of health promotion. The HIV/AIDS epidemic has led to an increased interest in health promotion and in funding for health promotion interventions.  Large scale use of broadcast media has been studied, for example in the ‘MARCH’ programme.

Similarly, there are a number of textbooks looking at the complex issue of evaluation of health promotion programmes.

For health promotion in leprosy, a Communications Tool Box was published by Novartis and WHO in 2000, which was a very well-produced set of resources to support leprosy-related interventions, particularly at clinic level.  It was reviewed for the ILEP Medico-Social Commission by Dr Andreas Kalk.  A helpful review of knowledge, attitude and practice (KAP) studies in leprosy was written by Siobhan O’Dowd for LEPRA.

References

  1.  ILEP Technical Bulletin No 13. www.ilep.org.uk
  2. Communicating Health.  Hubley J., 2nd Edition, 2004, Macmillan, Oxford
  3. Health Promotion: Disciplines, Diversity and Developments. Bunton R., Macdonald G., 2002
  4. Health Promotion: Philosophy, Prejudice and Practice. Seedhouse D. 2004
  5. Health Promotion: Foundations for practice. Naidoo J., Wills J., 2000
  6. Health Promotion: Planning and Strategies. Tones K., Green J., 2004
  7. Health Promotion: Power and Empowerment. Laverack G., 2004
  8. Health Promotion: Effectiveness, Efficiency and Equity. Tones K., Titford S., 2001
  9. Evaluating Health Promotion programs.  Valente T.W., 2002
  10. Evaluating Health Promotion: practice and methods. Thorogood M., Coombes Y., 2004
  11. Communicating public health information effectively. Eds: Nelson D.E., Brownson R.C., et al. 2002
  12. Modeling and Reinforcement to Combat HIV: The MARCH Approach to Behavior Change. Galavotti C., Pappas-DeLuca K., Lansky A., Am J Pub Hlth, 2001, 91: 1602-1607
  13. Entertainment-Education and HIV/AIDS Prevention: A Field Experiment in Tanzania. Vaughen P., Rogers E.M., et al.  J Hlth Comm 2000, 5(Suppl): 81-100
  14. New Narratives for Africa: Using Stories to Fight AIDS. Galavotti C., Petraglia J., et al. Storytelling, Self, Society, 2005,  1: 25-36
  15. Communications Tool Box, Novartis, 2000
  16. Review by Kalk/MSC, 2000