For many years now, the dominant approach to health care has been to see disease as being caused by a specific agent and to believe that medical intervention such as immunization, antibiotics or surgery will rectify the problem. This approach has been successful in many ways, especially in the area of infectious diseases, but it may be reaching the limit of its effectiveness. One of the things that we have learned from the technological age in medical care and health services is that we are unable to “buy health”. However, it may well be within our means to promote better health and quality of life. We believe that what is necessary at this stage, especially in Canada, is the development of comprehensive health promotion pilot projects which will provide an opportunity to use program models intended to assess health status and bring about the necessary lifestyle/health/behaviour changes. We can no longer afford to devote all our efforts to raising awareness; we must move into the areas of health promotion intervention and action.
Choosing Areas for Support
When either public or private organizations are considering funding and/or undertaking projects relating to health promotion, they will be faced with several choices. First, there is the need for research and development.
Research could include:
1. Evaluating different techniques for assessing health status.
2. Evaluating different techniques for bringing about lifestyle change.
3. Developing program process models, which contain clearly defmed methodologies for working with groups of people to apply the tools that research and development have provided.
It is also necessary to develop procedures for applying assessment tools, applying the techniques for behaviour change, and assessing their effectiveness on an operational level, in business and industry.
When companies are considering support of health promotion they may be wise to consider funding an in-house program model. This may be the most advantageous way to support and advance health promotion in their own businesses or industry as well as the community at large.
*Note: These criteria were developed as part of Mr. McQueen’s presentation at the Second Grantors’ Conference of The Canadian Centre for Philanthropy.
Evaluating Health Promotion Programs
The following are characteristics of a sound health promotion program: a) The target group should be clearly defined. We know that programs designed to work on distributed individuals or masses of people are extremely expensive and need to be tremendously sophisticated.
b) The health promotion program should include some type of evaluation tool.
It may be, for example, a health risk/hazard appraisal that is made before and after the health promotion program is run.
c) The health promotion program itself should be clearly defined. It should have an assessment stage, a developmental stage and an implementation stage. The assessment stage should be designed to study a target group, assess its health status, and identify health stresses that are in operation. Second, there should be a mechanism for developing a plan of action tailored to this target group which will address the items identified in the assessment stage. Third, there should be a clearly defined process of implementation which allows the programs to be implemented in the target group so as to provide long-range effectiveness.
d) Motivation and participation are two key indicators of potentially successful health promotion programs. I would suggest that members of the target group can be motivated through cost sharing and time sharing, so that, if it is an employee program, both employee and employer are giving up some of their time and paying some of the cost.
e) Health promotion programs appear to be most successful when they are selfsupporting. That is to say, when the target group is identified, its health status assessed and a program developed in co-operation with the participants, then people who are part of the target group should be trained to perpetuate it. It is not sufficient to set up a program that brings about behaviour change on a temporary basis. The behaviour change must be sustained through in-house trainers and support groups.
f) Retention is another factor which should be considered. The intention of a program should be to retain as many people as possible and to extend this retention over a lifetime.
g) I would also recommend that health promotion programs allied with hospitals offer the best prospects for success. If hospitals can also ally themselves with a community education institution, the strengths of both of these institutions will be of immense value in any health promotion program.
In general, a good health promotion program should have the potential to reduce disease and also to improve health through lifestyle behaviour change and encouragement of individual assumption of responsibility for health and improved quality of life.
Mistakes to Avoid
Consideration of a number of criticisms directed to current health promotion programs may prove helpful:
a) Over-enthusiasm can be detrimental. Sponsors and leaders of health promotion projects should be aware of this. In a corporate and/or business environment already full of pressures, health promotion does not need to become one more.
b) Credibility is lost when a program of comprehensive health promotion overemphasizes the physical aspect.
c) Avoid flashy showpieces. Programs do not need to be designed around extensive, expensive physical facilities.
d) “Elitism”—concentration on one set of employees, particularly “white collar” employees reduces benefits. The initial program may be directed to a target group with which one anticipates a high degree of success but once success is proven with one group of workers the intention should be to move on to the entire population of the organization.
e) Institutions wishing to support health promotion programs should be leery of supporting programs which are purely recreational. These are programs which are designed to improve fitness, stop smoking, improve nutrition, etc., but have no evaluation or documentation system for assessing health status change among the participants. Without this evaluation and documentation, they are simply recreational programs that will not necessarily contribute to the actual promotion of health.
f) Be wary of investing without investigation. One of the most comprehensive documents produced by a funding agency is Viewpoint: Towards a Healthier America, a summary report on health issues and related program activities of the Kellogg Foundation. This document has a very comprehensive listing of the criteria for health promotion and disease prevention proposal review that the Kellogg Foundation uses. This foundation has also associated itself with the Health Services Research Center at the University of North Carolina at Chapel Hill. We would suggest that organizations wishing to move into the health promotion field should ally themselves with some similar institution which has become knowledgeable in the field of health sciences, particularly in health sciences education and health promotion.
g) The effectiveness of health hazard/health risk estimation tools which try to identify behaviours and use laboratory data and non-invasive diagnostic clues to predict illness and reduce the risk through health promotion programs remains to be proved. Health promotion programming of this type which intends to use tools which can be administered through the mail or in a shopping plaza should be considered less than adequate. If the goal is to evaluate and document behaviour change, more sophisticated tools will need to be used. If however, the health promotion project is only to raise awareness, the administration of any tool may be useful. Raising awareness can be very useful when it is followed up with counselling, programming, and support groups designed to help individuals reduce their health risks or health hazards. The more sophisticated tools can also be very useful in carrying out an evaluation of the effectiveness of programs is bringing about behaviour change.
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Chairman, Allied and Community Health Programs, Health Sciences Division, Humber College of Applied Arts and Technology, Toronto.
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