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Evaluation of the Implementation of a Health Promoting Health Service Framework: Final Report

Summary

• The ‘Health Promoting Health Service’ project is the central component of the Health Education Board for Scotland’s (HEBS) ‘Health Service’ programme. The aim of the project is to‚ “encourage and promote health promotion as a core element of policies and practice affecting staff and patients”.

• HEBS in partnership with Health Promotion Specialists have developed a resource that provides a framework for such development. The framework offers a range of criteria and indicators that define appropriate and effective arena-based activity.

• An initial draft of this resource was piloted in five case studies and the findings of this process form the basis of this report.

• The framework was consistently seen in a positive light. There were no exclusively negative views; such views were constructive and offered as adjuncts to an initial positive statement.

• There were some concerns over some aspects of the framework: at first sight that it appeared ‘daunting’; that it contained jargon; that its language was too formal; that the trunk and roots of the tree were difficult to operationalise; that the term ‘framework’ reflected a narrow and mechanical emphasis.

• A number of additions were suggested: a summary/rationale section that put the framework in context; the inclusion of worked examples; a ‘layered’ structure that allowed use at varying levels of complexity; access or signposting to ‘toolbox’ resources.

• Beyond the structure of the framework‚ there was evidence that it was being used in different ways across the cases: a range of ‘functional’ uses (as a means of assessing existing provision; ‘looking laterally’ and ‘filling in gaps’ and structuring and controlling activity); and wider ‘holistic’ uses (as a vehicle for broadening the base for health promotion‚ as a vehicle for changing established ‘ethos’)

• The development of a range of specific activities were associated with the framework (e.g. development of patient programmes‚ practice standards‚ handouts‚ posters‚ staff training and activities).

• There was concern over how sustainable progress into further projects and wider organisational features in these areas was. The danger of the framework being used (at best) as a simple project management tool and (at worst) as a means of strict management control was therefore detectable.

• There was no evidence of the framework being used to simply deliver traditional health education activity. In most cases‚ elements of the framework were being used to broaden the scope of topic-based work. There was some evidence of it being applied at an organisational level via staff health programmes and the promotion of organisational communication.

• A range of barriers to implementation were identified including‚ a lack of resources‚ clinical ‘busyness’/contrasting culture‚ a lack of supportive organisational features and health promotion awareness and skills.

• There was considerable evidence that facilitators had excellent relationships with those within the sites and played a crucial role in implementing the framework. Concern was however expressed amongst facilitators that they did not want the sites to become too dependent on them.

• There was some indication that in order to overcome problems in achieving a minimal level of understanding‚ efforts should be made to ensure a basic level of health promotion awareness within all HPHS sites before the relatively advanced ideas contained within the framework are introduced.

 

1. Introduction

1.1. Background to the project

The Health Education Board for Scotland (HEBS) has adopted an ‘arena’ based approach to its activities. Tannahill (1994) describes this as involving‚ “coordinated programmes centred on key arenas for health education” (Tannahill‚ 1994; 7). These include health service‚ schools‚ community‚ the voluntary sector and workplace.

Within the health service programme‚ the HEBS operational plan 1997-1999 identified the ‘Health Promoting Health Service’ project as a central component of development of health promotion activity in health service settings. The specific aim of the project is to‚ “encourage and promote health promotion as a core element of policies and practice affecting staff and patients”.

In this respect‚ HEBS in partnership with a range of Health Promotion Specialists developed a resource that sought to provide a framework for such development within a range of health service ‘settings’ (see appendix 1). The broad aim of this resource is to provide support in the strategic and operational development of health promotion initiatives. The framework offers a range of criteria and indicators that define appropriate and effective arena-based activity (for example‚ ‘environment’‚ ‘partnerships’ and ‘patient programmes’). The intention is to provide a broad‚ flexible and practical resource upon which various health service settings can develop work. An initial draft of this resource that was piloted in five case studies and the findings of this process form the basis of this report.

 

1.2. The general nature of the research

In the broadest of terms‚ this project drew upon work in a number of related fields: from the ‘settings’ literature (Baric‚ 1991‚ 1992); the policy literature (Hawe and Stickney‚ 1997‚ Ziglio‚ 1991) and the alliances/inter-sectoral collaboration literature (Delaney‚ 1994). All have a similar ethos in that evaluation attempts to address changes in broad organisational systems and cultures as well as individual outputs. Additionally‚ within such work‚ efforts have been made to understand in more detail what Ham and Hill (1995) have called the ‘missing link’ of implementation. Finally‚ within this form of assessment‚ the trend has occasionally been towards internally generated and subjective measures of success as well as ‘imposed’ objective measures.

Given that the framework was in a relatively early stage of development‚ as well as accepting the complex circumstances into which it was being introduced‚ the emphasis of this work was directed predominantly towards gaining an understanding of the process of implementation. Mullen et al (1995) sees this as focusing on‚ “the factors influencing adoption‚ successful implementation‚ and maintenance of efficacious health promotion programmes”. In particular‚ the emphasis was on looking at the way that the structure and cultures of the setting affect the nature of implementation. Within this‚ further differences in orientation can be identified. Ziglio (1991) identifies two styles of policy development: rational and incremental. The former sees implementation as a structured and ordered process that can be defined by clear objectives. The latter suggest that achieving such order is unlikely and that evaluation needs to be flexible enough to assess the ‘messiness’ of change. Here‚ the aim was to focus on the local and contested visions of change (Clegowski‚ 1997).

 

1.3. The implications of this broad agenda

The above emphasis on gaining a detailed insight into the implementation of this resource point to the pursuit of three more specific areas of interest:

• the nature and contents of the ‘framework’‚ involving a process that related initial aims‚ objectives and contents of the framework to its actual use; research questions - how understandable was the framework; how applicable was it; how comprehensive was it? etc. (a developmental emphasis)
• the implementation/uptake of the framework in the setting; concerned with ‘ethos’ type indicators and the assessment of process of change and communication; research questions - e.g. what were the factors that facilitated/inhibited implementation‚ what was the function of the framework in this context? etc. (an emphasis on process)
• reviewing the expected outcomes of this implementation (encouraging evidence based practice‚ encouraging communication and collaboration‚ supporting the development of health promotion service specifications and contractual agreements; research questions‚ what impact has the framework had on the nature of health promotion practice undertaken in the setting? (an emphasis on expected outcome).

 

1.4. Specific research aim and objectives

1.4.1. Aim

To identify and critically assess the processes involved in implementing a health promotion framework resource in a range of health service settings.

 

1.4.2. Objectives

1. to assess the prior perceptions of those in the setting on their composition‚ roles‚ potentials in health promotion
2. to assess how understandable and applicable the framework is
3. to make explicit the expectations for the framework from those involved in producing and using it and to relate the actual use of the framework to the original intentions
4. to establish the levels of satisfaction and engagement with the framework
5. to monitor the changing nature and utilisation of the framework
6. to assess expectations regarding the likely outcome of the implementation‚ the establishment of framework and consequence on activity.

 

1.5 The mechanics of undertaking the research

The research was undertaken on a case study basis. Each case contained a named health promotion specialist ‘facilitator’ who had been involved in the development of the framework‚ were acting to promote the use of it and who acted as the most immediate point of contact with the cases. A seconded researcher undertook the HEBS health service programme manager‚ research specialist and the wider Health Promoting Health Service Steering Group generally supported data collection and the work.

 

1.6 Research approach and methods

The focus on gaining in-depth insights into the implementation process suggested the use of a case study approach. Five cases were pursued. Within this‚ data was generated from formal interviews and informal sources (e.g. general observations). The approach was taken forward by two rounds of individual interviews‚ six months apart‚ with members of the five participating pilot sites‚ equivalent to thirty‚ one-hour interviews in total. These were complemented by telephone interviews and the exchange of field reports.

The semi-structured interview schedule was structured in relation to the key points of reference and the main areas of enquiry outlined in the research aims and objectives. Interviews were conducted with three people per site‚ all of who had direct involvement with piloting the framework in their specific area. The first round interviews were used to establish a baseline response of participant’s immediate experience of the framework. The second round interviews focused on subsequent experience of the process of implementation‚ within the context of themes arising from the interviews in round one.

 

1.7 Sampling

Given the need to maintain depth in this work‚ the sample was limited to the relatively limited number of 5 case studies. Sampling done purposively in a way that produced a range of cases; for example‚ different types of health service setting‚ different scales (whole health boards through to smaller units)‚ those adopting different parts of the toolbox‚ etc.) This type of sampling produces data that is generalisable at a theoretical rather than statistical level.

The five pilot sites were selected on the basis of ‘readiness’ and diversity of approach to implementation and use of different aspects of the framework.

Site A: a broad strategic approach to staff health in a hospital setting

Site B: a broad strategic approach to fostering partnerships across a Health Board/Local Authority geographical area

Site C: fostering general health promotion activity in a primary care health centre

Site D: fostering a discrete health promotion project in a hospital ward setting

Site E: using the framework in the support of achieving a ‘baby-friendly’ status within a clinic in a hospital setting.

 

1.8 Assumptions

Before reporting on the work‚ it should be recognised that a number of assumptions underpin the data:

• the cases were initially chosen to access variation and as such the data inevitably reflects these differences
• there exists some fundamental differences in perspectives on‚ for example‚ the nature of the framework and its application‚ both within and between cases that cannot simply be resolved
• as such‚ the reporting does not seek to achieve comprehensive consensus in all issues
• the data reflects subjective views of those within the cases
• the data comes from circumstances that are still emerging (implementation is still in its early stages and progress is slow moving)

 

2. Research findings

2.1 Broad impact of the framework

At a general level‚ there is a significant amount of evidence that the framework has had a tangible impact on health promotion activity within the cases. From a situation where there was little or no planned activity at the first stage interviews‚ all of the respondents at stage two reported developments. These ranged from tangible examples of health promotion activity (specific campaigns‚ training‚ standards development‚ resource production) through to more intangible foundational activities (conducting baseline audits of health promotion activity‚ facilitating an educational process about health promotion‚ nurturing partnerships and generally “learning”).

This immediately highlights a tension that runs through most of the analysis:

• using the framework as a stimulus for specific‚ tangible and (at present) isolated pieces of health promotion activity activity focused‚ project management label‚ discrete‚ desired and relatively easily managed
• using the framework as a wider resource that seeks to establish and nurture foundational features associated with good practice within both health promotion and across the whole organisation process focused orientated at fabric of the whole organisation‚ synonymous with settings ‘ideal’‚ relatively less desired particularly at field level‚ need to be sold more‚ more difficult to manage.

It would be wrong to give preference to any particular application‚ both have utility but are very much dependant on how ‘favourable’ the circumstances are. As will re-enforce later‚ this points to the need for a significant‚ on-going and skilled link between HEBS‚ Local Health Promotion Departments and specific sites that assesses the potential and options at which the framework can be applied.

 

2.2 Specific views on the framework

In general terms‚ the framework was consistently seen in a positive light. For example‚ ‘there’s no doubt that it’s a very‚ very thorough and well researched document and it’s totally applicable to what we’re trying to do…. I find it’s very applicable’. There were no exclusively negative views; such views were constructive and as adjuncts to an initial positive statement. For example‚ a range of statements followed a similar structure:

‘I think the concept of the health promoting health service is so good…and yet it’s not really being sold in the way that it should be‚ because people look at this and just think ‘oh my God’!’

‘I think it’s very useful......at first pass it’s a very daunting document’

‘the more I’ve used the framework‚ then the easier it is the next time that I pick it up and look at it’

‘to have a look at it and think‚ it’s a helluva thick document….on top of everything else to take forward but I think when you do read it‚ it’s a very useful document’

There were varied degrees of consensus over more specific views of the actual framework. A number of consistent views emerged:

• as suggested above‚ a consistent view that the framework appeared at first sight to be ‘daunting’ and excessively long (though see qualifying comment below)

• a consistent view that the framework contained an excessive amount of health promotion jargon. The word ‘jargon’ was used frequently‚ particularly by fieldworkers; for example‚ ‘I would simplify some of that jargon’; ‘there’s quite a lot of jargon written in there and it can be a little bit difficult understanding what is appropriate and what is not’; ‘sometimes the terminology is a little bit off-putting because it doesn’t always relate to your own area’. In more general terms the framework was seen as being ‘too esoteric for practitioners’ and this was linked to the need for the language to reflect an operational orientation. For example‚ ‘it’s not everybody that would understand what it actually means…..how you operationalise it…because basically I’m an operational manager and my job is to look at something and operationalise it’. The full validity of this statement is clearly linked to the issue of who the framework is targeted at and this is discussed in more detail later.

• a consistent view that the language of the framework was unnecessarily formal; for example‚ a respondent felt that it‚ ‘read like a circular’.

• a consistent view that the trunk and roots of the tree were difficult to operationalise and one particular comment reflected that there did not seem to be any connection between the values reflected by the roots and trunk and the detail within the branches; for example‚ ‘I use this bit (the branches) more than the underpinning – the roots of the tree’; ‘The ones in the trunks – mobility‚ empowerment‚ equity – I’m not quite sure that those are as applicable‚ or I don’t use those as much. I certainly do use the branches and would think of every topic within those headings and I find that quite useful’

A range of other comments were offered that were less frequent‚ though are still nevertheless significant:

• the word ‘framework’ was seen to reflect an excessively narrow and mechanical emphasis In contrast to the views expressed above that the framework was insufficiently operational‚ some expressed a contrasting opinion that the framework was too rigid and lacked some ‘softer’ and ‘intangible’ elements. For example‚ ‘if the framework is to influence culture‚ which I think it could do‚ then we need to look at the organisational development element of it a bit stronger’.

This issue is linked to the wider question of how the framework is implemented. Again in contrast to the view that the framework should be narrow‚ specific and prescriptive‚ some felt that a more flexible implementation was preferable. For example‚ ‘I think there is a danger that it could be adhered to very‚ very rigidly by some people as opposed to being a framework…..because it isn’t written as a framework‚ I thought. I thought it was written more as a prescriptive document‚ if you see what I mean. And people will try to follow that rigidly and make sure that they are complying with absolutely everything within the document……and my own view is that it’s been written as an all encompassing framework‚ and it might not be totally appropriate to every single circumstance or every single area and it’s very much horses for courses’

This view was supported by the belief that‚ at certain levels within health service administration‚ imposition is not seen as the most appropriate mechanism of change. For example‚ ‘another thing that worries me a wee bit. I know it’s at pilot stage just now. But we’ve all been through the stages in the past where a document comes from the Centre‚ Trusts have to adopt the document….and little thought is given to as to how it’s going to be adopted and the practicalities and I’ve got this dread that this is adopted as a stratagem "thou shall adopt the strategy!”’.

• (accepting in mind the draft nature of the resource) there were comments that the print size was too small
• (a less prevalent view that) the sections were repetitive
• (a less prevalent view that) the mixed portrait and landscape page layout was inconsistent and confusing

A number of additions/re-structuring were suggested:

• a summary/rationale section that introduced the framework‚ expectations‚ means of use etc.
• worked examples that would provide insights into the overall expectation of the framework and the specifics of the different branches. It was felt that this would be important in making the potential of the framework explicit‚ thus ‘selling’ it. For example‚ both facilitators and field-workers expressed the following consistent statements: ‘until they did a worked example there was still a bit of a cloud of mystery..they’re working on the ground and they don’t want something up there that they can’t hang on to’; ‘she did some worked examples and that helped us..it’s a wee bit vague’; ‘if there were one or two worked examples‚ then I think it would be really helpful. I think everyone has their own ideas about how to even draw up an action plan’
• a ‘layered’ structure that allowed use at varying levels of complexity; for example‚ ‘if it was done in a reference format‚ people can dive in and out….make best use of that. Quite how the two will relate to each other is what we’re trying to establish‚ I think‚ at the moment’.
• specifically‚ access or signposting to ‘toolbox’ resources.

Resolving these technical issues is clearly dependant upon a more fundamental considerations‚ namely the level at which the main emphasis of the framework should be pitched. As will be developed later‚ it was clear from both direct comments from respondents and from the general analysis that the whole framework cannot be structured in a way that is appropriate to all levels of practitioners. To do so would be to stretch and dilute the essence of it. This sentiment is captured in an interesting response from a senior manager within one of the sites‚

‘and I suppose‚ the framework’s broad….. so that all types of people can use it‚ whether they’re on a shop floor‚ or on a ward‚ or whether they’re in the Trust office……and that’s maybe not such a good idea’

Again‚ as will be developed later‚ there were indications that‚ at field level‚ the framework was at worst‚ largely invisible to fieldwork staff‚ the following coming from a manager‚ ‘I don’t think they’re really…..they’re not that much aware of what the framework is…. I don’t think they’re really that interested or bothered’

Alternatively‚ the framework has been used in a relatively ‘functional’ way; associated with broad ‘project management’ rather than the development of wider ‘settings’ resources and specific health promotion activities. For example‚ ‘I’ve found that if you’ve just given them the framework to go and read or to go and look through‚ they would really‚ they don’t seem that motivated or interested. At the end of the day they’re only interested in the final project‚ which I can understand’.

Given that health promotion is more than project management and that there already exists a wide range of generic project management tools‚ a case could be made for targeting the framework at a level above fieldworkers.

Finally‚ as highlighted earlier‚ there exists a strong view that the framework could be perceived as ‘initially daunting’ but that with on-going engagement‚ it became accessible and useful. This tendency will clearly be improved with the production of a more polished final version. However‚ this issue highlights the need to consider the context in which the framework is used and the support provided. If the framework is to be more than a simple tool for project management (see later discussion)‚ a more developed initial context and dissemination process needs to be in place.

 

2.3 Functions of the framework

Beyond the structure of the framework itself‚ there was evidence that it was being used in different ways across the cases. As confirmed above‚ this was inevitable as these cases were initially chosen to reflect different types of practice. The following section reviews the broad ways in which this occurred and offers views on degrees of appropriateness.

There was a range of ‘functional’ uses. The term ‘project management’ was used by a significant number of interviewees and was strongly associated with the framework. For example‚ the situation is constructed that the framework is predicated on a strong foundation of project management’;’I suppose we’ve just been using project management’; ‘it’s just been good project management’; ‘you could say that some of the things would happen anyway without the framework as long as we had good project management’; ‘what they have also done is introduced a project management approach‚ based on a project management method that’s been used in the Trust‚ anyway. So they’ve combined that with this and that has sort of‚ set sort of timescales which is a key thing about delivering a particular project on which perhaps we would need to look at for the framework’

There was however a notion throughout that the framework can potentially provide ‘more’ than basic project management skills. For example‚ ‘as a result of looking at it‚ there has been little small points that we’ve picked up when we’ve reviewed it‚ that we might not necessarily have done had we not used this framework’; ‘but maybe the framework is there to help and support that and to remind you of issues when you go back to it’; ‘at the same time‚ though‚ our senior midwife said we should use the Prince Project……well it’s just a way of planning something too……but then the Prince Project plan was just something like that‚ but it’s not the same (as the framework)’.

More specifically‚ the framework was seen to contribute to the following related functions:

1. As a means of assessing existing provision. There was a strong evidence of the framework being used in a post hoc fashion whereby a range of existing activities were audited and co-ordinated within the branches of the framework. This was done mainly as a mapping exercise without any obligation to add to existing work.
2. As a means of ‘looking laterally’ and ‘filling in gaps’. Building on the audit function described above‚ there was indication that the framework was being used as a means of stimulating thinking on how existing activity could be enhanced by identifying gaps.
3. As a means of structuring and controlling activity. This type of use had a strong sense of being derived from a desire to control staff and activity. It was interesting that all of the sites had developed a range of groups and sub groups that were steering various fragmented and discrete elements of health promotion activity encompassed by the framework. After a process of having ‘broken this up into many little bits’‚ for some‚ the framework was closely associated with the formation of bureaucratic structures‚ [‘we’ve got an operational group‚ there’s a sort of core group and we’ve now formed two operational groups’] and used to set targets and monitor progress towards relatively narrow management goals. This is expressed generally‚ ‘the tasks are written out and there’ll be a date when they’ve to accomplish this task’ and more emotively‚ ‘with the framework‚ well it means I’m able to nag them about it!’.

A wider‚ ‘holistic’ ideal was also expressed that extended beyond the relatively limited and practical focus described above. This theme sought to act at a level above tangible activity and was not dependent on existing health promotion activity.

• As a vehicle for broadening the base for health promotion within the organisation. In a specific sense‚ for many‚ the framework was seen to possess a symbolic ‘kudos’ that was deployed politically in the ‘championing’ of or ‘agitation’ for health promotion values. At a basic level this was done to achieve resources and commitment for health promotion activity and a recognition that this had to be done via a wide base of health service personnel.

For example‚ two separate managers within different sites felt that‚ ‘because you made us a pilot site…..it made people realise that this was an awful lot of work and it can’t just be done by one person‚ or two people….and that we needed lots of people if we want it done’ and ‘the initial reactions round the table here was that we need more people to support in this and we need more management commitment in this…..we haven’t got enough people to take this forward properly‚ and we need more both in here and management and possibly in the community as well…..so that created a hiatus with this particular piece of work‚ because that sort of throws things back a step……which was a good thing in itself in that if the framework has achieved nothing else‚ then one person can’t achieve this by themselves. Then that was a useful thing to have done’. So‚ the involvement of a broader and more senior base of practitioners was sought and achieved. There was evidence that this had been successful in achieving wider involvement at senior level and achieving extra health promotion specific resources.

• As a vehicle for changing established ‘ethos’. More ambitiously‚ the framework was seen by some to express an alternative set of practice values to those already dominant within various health service settings. The following extract reflects this position‚ ‘I think this HEBS thing is good‚ because lots of people now know that certain practices in hospitals should be improved… in our day‚ we accepted the most dreadful practice…you knew that was wrong….why did you accept that…..you see at first they think‚ what a lot of rubbish….we’ve been doing this for 30 years‚ this is rubbish. I want some new ideas. They’re actually beginning to realise that …‚ and things are definitely changing’ .

 

2.4 Outcomes

Specific activities

As suggested earlier‚ at a practical level‚ tangible progress can be detected within cases. In those cases where the framework was put to immediate practical use‚ examples of the development of patient programmes‚ practice standards‚ handouts‚ posters‚ staff training and activities. More broadly‚ there was evidence that partnership development had been enhanced.

In positive terms‚ as a result of the tangible nature of the activity and relatively modest expectations‚ cases where the framework was used in this way showed evidence of immediate and significant progress. There were however concerns around how sustainable this progress was into further limited projects and more importantly wider organisational features. The danger of the framework being used (at best) as a simple project management tool and (at worst) as a means of strict management control was thus detectable. Given the ethos of the framework and the availability of many other project management tools‚ it would be unfortunate for it to be used solely in this way.

Interestingly‚ the cases with the most practical focus had made tangible and significant progress (and that the slowest and perhaps least satisfactory implementation was in the case with the widest and most holistic expectations). Given this undeniable success and not withstanding the recognition that such immediate achievements did contribute to an increased likelihood that the framework could be successful in the longer term‚ it was clear from all involved that was far from being the only or most important expectation associated with the framework. In this sense‚ and with a view to longer-term sustainability‚ it is also important to look at the ways in which the framework is being used.

Focus of activity

The tendency for arena based health promotion to vary in nature and focus has been recognised in the HEBS paper Settings Based Health Promotion: implications for practice and research agendas (1998). In summary it is suggested here that cover five distinct types of activity:

• most conservatively‚ the setting takes on a subordinate role within which traditional health education activities are delivered‚ setting is seen simply as a vehicle that offers access to populations and favourable circumstances for achieving educational goals;

• secondly‚ this specific type of activity (usually topic focused) can be made more sophisticated by drawing on the varied elements the organisation as resources in fulfilling topic oriented aims;

• thirdly‚ there exists activity that still undertakes relatively focused work‚ but does so with distinctly different expectations‚ namely‚ an explicit view to bringing about broader organisational change. In contrast to organisational features having a contributory function as described above‚ in this case‚ specific health promotion projects are used as a vehicle for learning within the organisation and the expectation that significant changes will occur gradually as the result of small low level developments;

• similarly‚ and again drawing upon the ‘organic’ nature of organisations‚ a fourth model places relatively greater emphasis on the development of individuals and groups throughout the organisation through for example‚ staff development‚ training and communication;

• finally and perhaps the most ambitious model uses the notion of the organisation as an entity above the individuals in it and seeks to directly bring about relatively significant changes in the structure and culture. This work tends accept the view that potential for deep and enduring organisational change can only arise from a context where there is the support of those who are relatively powerful. As such‚ the emphasis tends to be more on establishing broad organisational policies and strategies via an inclusive approach involving individuals throughout the organisation.

These features are summarised over:

Table 1. Approaches to settings based health promotion

Type of approach	Nature	Expectations	Indicators	Context/HP relationship
The ‘passive’ model	Health promotion occurs in setting independent of organisational features	Setting is passive; only provides access to participants and medium for intervention	Traditional individual indicators (e.g. knowledge‚ attitude‚ behaviour)	Emphasis on health promotion intervention; no interest in context
The ‘active’ model	Health promotion utilises organisational resources	Setting provides an ‘active’ and more comprehensive resources to fulfil health promotion goals	Traditional individual indicators (e.g. knowledge‚ attitude‚ behaviour)	Emphasis on health promotion intervention; some interest in context
The ‘vehicle’ model	Health promotion seen as a vehicle for organisational change	Health promotion initiatives provide an appropriate means for highlighting the need for broader organisational change.	A mix of project and organisational indicators (interest particularly in the interaction)	Equal emphasis on context and health promotion interventions
The ‘organic’ model	Health promotion equates to organic organisational processes	Organic organisational processes involving communication and participation are inherently linked to health and are thus ‘health promoting’	Organic organisational indicators (e.g. levels of communication and participation; staff development‚ etc.)	Strong emphasis on context; organic development may contain some activities of a ‘health promoting’ nature
The ‘comprehensive’ model	Health promotion equates to comprehensive organisational development	Broad organisational structures‚ cultures and processes are inherently linked to health and are thus ‘health promoting’	Over-arching organisational indicators (e.g. organisational ethos‚ management processes‚ etc.)	Strong emphasis on context; activity occurs independent of health

At present‚ and encouragingly‚ none of the current activity within the pilot sites can be considered to be ‘passive’ in its orientation‚ in that the setting is used solely as a medium for traditional health education. Rather‚ the predominant type of practice falls within the ‘active’ area‚ where the broad resources of the setting (policy‚ training‚ patient programmes‚ etc.) are used to execute relatively focussed health promotion tasks in a more comprehensive. This tends to result in work being focussed around a particular health topic‚ to which the respective branches of the framework are applied. For example‚ ‘one of the specifics that we’ve chosen for the health centre is nutrition’; ‘the one topic that kept coming up no matter what we discussed was nutrition’. Similarly‚ topics of hand washing‚ physical activity‚ and oral health have been identified as focal points. To these are brought the perspective and resources of the framework. This has been done predominantly on a cautious basis‚ one or two elements being applied at one time. There is clearly great concern that the volume of the framework may in practical terms swamp those within the cases; for example:

‘I don’t know whether it just needs a bit of time....and looking at one particular aspect rather than trying to look at the whole framework and apply it to everything‚ all at once…..so I think that becomes very difficult to focus on’

‘if we tried to bring everything in that framework document at the very start‚ the group would have died because it would have been far too much and people would have been very‚ very switched off with the enormity of the project….but now we’re growing into it and we’re quite comfortable…..so maybe we need to make clear‚ again in the framework - and it isn’t quite clear that way......that you don’t have to do everything at once’

‘we started off with staff health…..we’re looking at education in terms of running groups for staff…so I mean‚ we’ve wanted to concentrate on two or three of the branches and I think we’ve maybe picked up now on about five or six. And the thing is as the project starts to expand‚ we find that we’re taking in more and more of the branches that have been identified. That creates its own problems‚ because I think if you get over ambitious with a relatively small group‚ you risk burn out and people get switched off’

‘if you try and take everything in that document and put it into a health promotion strategy you will drown unless you’ve got a whole team of people sitting there ready to rush in who are doing nothing…...and I mean I expressed the view quite clearly that we have to learn to run before we could walk and pick off wee chunks’

At a basic level‚ there was some indication that such activity could result in further work. For example‚ a field-worker expressed the following‚

‘if I could say‚ for example‚ we decided our next programme theme was going to be a campaign on‚ say‚ testicular examination….then I would be happy to look‚ to use the framework to help me set out the project’

However‚ this potential development should mainly be seen in the context of replicating more activity of the same basic nature. Given that such activity was seen as largely separate and additional to existing core work‚ this may explain the concern for overload and the reluctance to expand activity in an uncontrolled way.

There was little explicit evidence that such activity was being explicitly or consciously used to any greater end‚ leading to wider organisational change as would be reflective in the vehicle model. However‚ it must be remembered that: this work is in its relative infancy and one may not have expected such advanced strategies to have developed yet; and that there may have been implicit interaction between specific projects and wider organisational learning.

There was however some evidence of work within the fourth category of ‘organic’ change‚ where a case had approached activity exclusively from within one particular branch‚ usually staff health‚

‘we started off with staff health’

‘we’re taking staff health forward’

‘we’re looking at staff health‚ as it rolls on’

 

2.5 Sequence and structure of implementation

There was significant evidence of respondents being aware of a range of possible approaches to implementing the framework and being conscious of ‘not getting it right’. For some who were using the framework as a means of co-ordinating existing activity‚ there was a concern that they were ‘getting it wrong’‚ that there was ‘something missing’ or that they had ‘done things back-to-front’. For example‚ ‘you weren’t sometimes quite sure if you were using the framework as maybe you should or could’. This issue highlights the significance of the sequencing of implementation and the way in which activity is structured.

In practice‚ the predominant tendency was for the framework to be used in association with existing practice. For example‚

‘as far as health promotion is concerned‚ we do have fairly strict guidelines and protocols to work to‚ so I may well encompass some of the framework‚ but it would have to tie in very closely with what we’re already doing‚ you know‚ with our own protocols and guidelines’

The framework then tended to be applied to retrospectively check on existing practice as either a basic audit tool or to fill in gaps in activity. For example‚

‘so it did work out. We more or less had it all worked out‚ our aims and objectives before we started to look at the framework’

‘so I think having the framework has enabled us to get to these points and have these discussions…..because it’s kind of helped us reflect on some of the things within it’

‘I don’t think we’ve done our projects much differently although certainly it did bring up I would say maybe a couple of things that we maybe wouldn’t have thought about’

‘it has flagged up that we may or may not have thought about…..so maybe we would have been so focused on the project that we wouldn’t have then‚ because I think its quite useful to put the project on one side and then to actually think‚ to reflect‚ I think‚ you have to look at something that’s away from the project‚ that’s maybe talking about‚ it could be anything‚ have you done this‚ have you done that‚ have you thought about this‚ and then you can……and that has been useful’

‘we may well have picked up on project issues if we hadn’t used this framework….but because we used it…. it was sort of coming up right away‚ rather than us just waiting’

‘we didn’t take your document and think now what could we do with this….because in our case….we were on the road to something else already.....this is different from somebody saying‚ oh now what would we do here‚ because I feel that we were on the way....we’d picked something that we had started already.... think the main thing was looking at that tree…..because I had got to the stage where I knew all the things that I wanted to do…then I looked at that tree and I thought well I can get it on to these areas’

A more pointed sentiment was expressed around the need for the framework to take a secondary role to the wider concerns of health promotion‚

‘I think the danger is that people get caught up in trying to make sure that everything fits in with the framework as opposed to getting on with health promotion‚ which after all is the raison d’être for the framework’

‘they wanted at the start of the meeting to talk about the framework document and see how what we were doing fitted with the framework……and I said‚ oh I can understand why you do it‚ but I would prefer at the end of it to sum up and as a catchall use the document to make sure we’ve picked up on things…. I felt we were in danger of making the document the main focus of the meeting‚ which it isn’t.......I mean‚ it shouldn’t be…..the main focus is health promotion’

In contrast‚ there was a feeling that there was something wrong with this pragmatic approach and it could potentially be ‘improper’ and others wanted a greater focus on the framework itself‚ feeling that there were advantages to be gained in doing so; for example‚

‘I think that there certainly is something missing‚ because I do feel that we have done this in a back to front way’

‘we needed to remember….we were not focusing on the framework as such….it wasn’t there in the centre of everything’

‘I think while we’ve had our meetings with them and been discussing the project that’s sort of been more on the project itself rather than the use of the framework’

This tension was also reflected in the question of whether the framework should be seen as a ‘holistic’ resource or one that can be applied to isolated areas. The holistic ethos of settings based activity was voiced as:

‘I’ll need a lot of persuasion to be persuaded that you should break it down’

‘what I’m seeing is people playing with one part of the jigsaw and never getting the whole’

This was tempered by a recognition of the relative difficulty there is in promoting such a view. Most fundamentally‚ some felt that the framework was not of this nature:

‘I don’t think it’s conceptual’

This was associated with the recognition that it was difficult to support such work in the field:

‘well…if you’ve got a real medical model and you’ve to things that must be done‚ and have to be done‚ and very much a checklist type culture‚ then the framework‚ the softer side of the framework around how do we all do that together then‚ how do we consult is lost because as long as you’ve checked your list if that’s the culture you’ve got‚ then that’s the way the framework would be used‚ or that’s the way you could use the framework’

 

2.6 Level of implementation

As is suggested above‚ the cases clearly show the framework being used in a range of different ways. One of the most significant issues to fall out of this consideration is the level at which the resource is targeted. Respondents generally felt that the framework could not encompass too great a range of functions‚ that it had to have a clearer rationale and focus and by implication that its contents‚ ideas and language had to appeal to particular groupings. Building on the notion introduced above of the framework being associated with varied possible functions‚ one can also link this to the range of levels within an organisation that the framework is targeted.

Whilst the evidence here would suggest that‚ at least in the short term‚ the framework has been most successful in achieving change at an operational‚ field-work level‚ it would also appear that there is greatest antipathy to the broader health promotion concepts at this level (as described below in ‘barriers’). In contrast‚ despite the potential for there to be a gap in terminology as reflected in the dislike of health promotion jargon‚ there would appear to be a significant degree of congruence between ‘senior’ staff in the cases and these broader health promotion functions. Whilst the language used may at present be contrasting‚ such individuals were profoundly interested in the wider concerns of‚ for example‚ organisational culture‚ communication‚ partnership development and staff health. These contrasting positions are set out below.

	ranging from
vision of health promotion	reductionist (discrete tangible activities)	holistic (collection of activities and more)
level of action	operational	strategic
function	project management & control	broader ownership via participation
application of the framework	imposed‚ rigid & specific	adopted‚ flexible & responsive
nature of change	incremental & post hoc	rational & prospective

As suggested above‚ whilst being of most immediate value as a means of bringing about incremental change at an operational level‚ there is some indication that: it is practically difficult to encompass such breadth in one framework; shows signs of experiencing hostility; is difficult to sustain (“what next?”) and does not result in change at level that is significant to the organisation.

Given that there is evidence that the subtleties of the framework are generally understood at senior levels‚ it would unfortunate to ‘undersell’ the framework as merely a tool of operational project management. Indeed‚ recognising this additional potential‚ a senior professional talks of the framework having “something more” than a simple planning tool. One would also imagine that given the volume of other such tools‚ the framework would have little long-term impact in this context.

These issue also impact on the application of the framework. There existed two contrasting positions. Those involved in operational activities tended to want a fixed ‘how to’ guide to health promotion activities‚ reflected below‚

‘there wasn’t enough guidelines in here on how you should use the framework and which aspects of it you should use….because it’s kind of off-putting if you look at it‚ and it’s on lots of different pages‚ you don’t always know what you should and shouldn’t be using….and I know that there’s probably lots of flexibility‚ and for the pilot anyway we’re being permitted to use it how we would want it…..but I think‚ you’d feel more secure if you were given more guidelines…..if they gave you examples of‚ well if this was the type of project you’re doing‚ you should really be using blah‚ blah‚ blah’

Others at more strategic levels were happy with a more flexible structure that allowed them the opportunity to build activity that was compatible with their circumstances.

In many ways‚ this is the same issue as was raised in HEBS paper Settings Based Health Promotion: implications for practice and research agendas (1998) - there is a need to gain immediate practical progress that feeds into work at a wider level. As suggested above‚ some were conscious of both ‘old’ incremental and ‘new’ rational approaches and in this sense‚ we could have some faith in the ability of those within cases to make the transition between existing focused activity and original wider interventions.

 

2.7 Barriers to implementation

A range of implementation barriers were identified‚ listed below. Given the significant nature of many of them‚ one should be cautious in suggesting that they can be simply addressed - clearly‚ many of them are of such a profound nature that they are not resolvable. In listing them‚ the intention is not to suggest that they can easily be remedied. Rather‚ they point to broad issues that need to be addressed:

• a lack of resources: as one would expect‚ many cited restrictions in human and financial resources that limited the breadth and speed of implementation‚ reflected here in a small a sample of the comments. In relation to financial resources‚ ‘it’s got to have more money put behind it….otherwise all this is very‚ very difficult……you’re just relying really on people’s goodwill to get a lot of this stuff’; ‘that will be the block if there is no corresponding money because it’s going to take some resources to implement environmental things’. Related to a discussion that will follow later on the nature of facilitator support‚ there were also concerns over a lack of staff to implement the framework‚ for example‚ ‘that there is so much to do…..and for it just to be for one person with Z as a kind of other person‚ come advisor’; ‘I think it could be done much better by somebody with a bit of time‚ really devoted to it….who could get out there and do a little bit. I just can’t’

• clinical ‘busyness’/contrasting culture: associated with above and particularly at a field-work level‚ many felt that they were already overwhelmed with clinical task responsibilities; for example‚ ‘I just don’t feel I’m doing a very good job of it‚ and that’s just purely because I don’t have the time’; ‘I think it may be too big a job for people to do – added on to what they’re doing already’; ‘I thought people not attending at the meetings was due to a lack of interest‚ and It’s not really‚ it’s just that they haven’t got the time’. In seeing time as a resource‚ many said that the major barrier they had in implementing the framework was (a) freeing up staff time for planning meetings and (b) ensuring that all staff could be present together at planning meetings; additionally‚ in a more hostile vein‚ there also existed a view that many did not see health promotion as part of their work ‘culture’

• supportive organisation features: whilst the above was generally couched in terms of individual perspectives‚ another view saw them as a product of collective organisational deficiencies-either due to difficult organisational administration [‘not many people turned up because they were all busy of course‚ this is what happens‚ they’re all busy in their clinical‚ doing their own job‚ or on courses’; ‘there’s a limit to how frequently you can meet up with your staff’] and inter-professional competition and not being able to attain co-operation from a sufficiently wide range of groupings [‘I wrote to all the GPs in the Health Centre…..asking for a nominations…..half the GPs didn’t respond’]

• health promotion awareness and skills: concerns were expressed at the relatively low levels of health promotion awareness and skills within some aspects of the sites-particularly at fieldwork level. This issue is discussed in more depth later within the context of ‘training needs’.

 

2.8 the practical nature of implementation (specifically the role of facilitators)

The issue of implementation needs to be seen in the context of the nature of the relationship between a centrally driven idea and ‘local’ interpretation and implementation. In this sense five major grouping can perhaps be identified as important mediators of the concept: HEBS; Local Facilitators; their wider Health Promotion Department; senior representation in the sites and field-staff. The model of dissemination used in this initial phase of the work involved the development of a resource (the framework) centrally with the support of key individuals from Health Promotion Departments (the facilitators) as vehicles for dissemination to various levels within local sites. There are a number of positive features associated with this model:

• the framework has a significant degree of utility for those in the site (as described above)

• the facilitators have had a central role in implementation and are seen as credible and valuable leaders/resources within the sites

• the facilitators have an excellent relationship with HEBS

These features will form a strong basis for wider dissemination. However‚ despite these positive features‚ the research highlights some current concerns as well as issues that will have to be addressed in future work. Given the complex nature of the framework and the potentially difficult circumstances into which it will generally be introduced‚ there is a broad feeling within the texts that the degree of support required is and will continue to be at a relatively higher level than that first envisaged. This indeed was accepted by a facilitator:

‘I think in terms of using the framework and working on and progressing with the framework‚ there is a need for say somebody like me‚ somebody with specialist health promotion skills to be there and to help with that’

However‚ facilitators also expressed a desire at both stages of interviewing to be ‘less hands on’‚ gradually withdrawing from the work as to allow the sites to be more independent (developing ‘exit strategies’). More specifically‚ there were concerns within the sites that:

• knowledge was concentrated too much within them (‘it’s pretty much me in the driving seat….me the knowledgeable person’); as a result of the need to facilitate rather than drive‚

• progress had been comparatively slow (‘we’ve all expressed the slowness…..in terms of actual getting things up and running…..you could state the pace if you wanted to….but if we did that then that would be a huge commitment to undertake (and) it would also mean that people would tend to be dependent on health promotion for filling role and you couldn’t meet that’)

• that withdrawing would be practically difficult [recognised by both facilitators ‘I think it would easy to take on a bigger role……because people would let you do it if you started leading things. So the difficult thing is to stand back and say‚ to keep the facilitation explanatory role and let people take it themselves’ and others within the sites ‘I would have found it difficult to implement the project using the framework had I not had X’s support and encouragement……that’s what has given me the support that I need……so without that I probably would have been tearing my hair out’]

Most significantly‚ a range of responses from various levels within the sites highlighted the need for facilitators‚ As such‚ this tends to caution against a significant change this relationship. Facilitators were seen to be important in a various respects:

• At the most functional level‚ they provided a “person resource” that prevented practical ‘slippage’ (important given the strongly expressed limitation of lack of resources). This was expressed bluntly by a manager within a site as‚ ‘she’s had somebody in to help her which I think from a human point of view has been very valuable……I think that some health service staff are very needy and they just don’t get that support…..that they’re doing so much‚ and they’re so busy and they don’t always have that human resource or that help’

• More positively‚ as a product of their health promotion skills‚ they were seen as a means of ensuring that a broad health promotion ethos was maintained‚ avoiding any conceptual ‘slippage’. This was expressed in relatively practical terms as ‘I need to be there to keep raising it (health promotion) as an issue’ and more conceptually as‚ ‘ it’s the essence of the ‘health for all’ thing…and I feel that I’m trying to remind myself of those and remind the ward of those‚ in a culture where they’re not used to working with those much yet’

• They provided the opportunity to achieve relatively immediate successes (this was important in that senior representatives in the sites were concerned that if this was not achieved then interest would be lost).

Whilst the existing facilitators were seen as a positive resource‚ the feeling that this base would have to be expanded was expressed. Drawing on the notion that facilitation can probably not be seen as a quick or distanced function and that this will thus call upon a relatively greater amount of specialist resource‚ there was a feeling that the principles of the Health Promoting Health Service should be owned and used by everyone in the Health Promotion Department. Whilst it was recognised that many generic health promotion specialist do not have any specific health service experience and may indeed feel reluctant to become involved in this setting‚ there was a need to widen the base of possible facilitators.

On a wider level‚ there was some expression of a desire for the relationships between the groups identified above to be based less on a chain and more on the notion of an interactive system. For example‚ many in the sites would have liked greater contact with HEBS staff and field-staff in other sites.

 

2.9 Supporting training

The consideration of successful implementation raises the issue of core health promotion awareness and skills within the sites. The feeling that‚ at a structural level‚ the framework contained excessive jargon suggested that some individuals on the ground were having difficulties in dealing with health promotion concepts‚ expressed in the following examples‚ ‘we need a bit more training….very‚ very basic training about health promotion we’ve had seminars but these were at a level that was slightly higher than the understanding within our Trust…. some people aren’t even ready to hear that framework…because they don’t have the basic underpinning of the health promotion; ‘we felt that there was this – it’s difficult to move things forward when there’s this basic gap in knowledge‚ even below that. If people were hearing about the health promoting health service and the branches of the tree and some of the projects we talked about…..but they couldn’t really pin it into health promotion‚ because the gap was there’.

Naturally‚ this was less of a concern in situations where the health promotion activities were relatively specific and tangible‚ though again‚ there was a recognition that greater support was needed in thinking specifically about the framework; for example‚ ‘I’m not sure that one morning’s training was sufficient….I think the initial training was fine and we then needed to go away and have a think about it‚ but I think we could have done with another morning or afternoon session to look at the framework in more depth‚ in relation to the topics that were chosen’.

There were indications from some facilitators that in order to overcome problems in achieving a minimal level of understanding‚ efforts should be made to ensure a basic level of health promotion awareness within all HPHS sites before the relatively advanced ideas contained within the framework were introduced. It should be noted however that this feeling was not consistent across or within all of the sites (see discussion above on the level at which the framework should be pitched).

 

3. Summary: pointers from the literature

The report so far offers a general account of the ways in which the framework was introduced into the five case study sites and the relatively short-term effects that this has had. These insights offer immediate pointers to the ways in which the framework may be advanced in the future. To compliment this and to look to longer-term development‚ I want to broaden this discussion by locating the main issues that have arisen in the wider literature. This includes material that considers:

• the processes involved in developing and implementing policy and programmes (e.g. Hogwood and Gunn‚ 1984; Ham and Hill 1995; Hill‚ 1997; O’Neill et al‚ 1997)

• the nature of general arena/settings based health promotion and its delivery (Grossman and Scala‚ 1993; Dugdill and Springett‚ 1994)

• specific health promoting health service/hospital work (University of Toronto‚ 1999; Scrivens‚ 1995)

The predominant theme that runs through all of this material centres on the nature of change and how (and indeed if) this may be best achieved.

There is an acceptance that a core set of conditions is essential pre-requirements of successful implementation. In a general sense‚ Hogwood and Gunn (1984) for example‚ offer ‘10 pre-conditions of effective implementation’‚ including: that there is sufficient time and resources; that change is based on an accepted ‘theory’ of how the ‘causes’ (the intervention) bring about ‘effects’ (implementation); that there is an understanding of the objectives to be achieved across the whole system; that there is a single implementing agency with authority; and that there is excellent communication amongst all those involved.

Whilst this optimistic and acontextual vision of implementation has been generally discredited in the policy literature as overly optimistic and practically impossible to achieve (Hill‚ 1997)‚ it continues to find some prominence in the health promotion arena/settings literature and practice‚ This can be detected in two ways:

• firstly‚ as reflected in the absence of significant work that specifically and seriously considers the nature of organisational implementation and possible impediments (Grossman and Scala‚ 1993)

• secondly‚ as reflected in the range of simple ‘how to’ guides that define settings based interventions; for example‚ the University of Toronto’s Centre for Health Promotion have recently produced a document‚ Nine Steps to a Health Promoting Integrated Health Systems (University of Toronto‚ 1999) mirrors many of Hogwood and Gunn’s normative statements listed above (e.g. develop a mission based on health promotion values‚ develop a governance structure that reflects these values‚ allocate a minimum budget percentage for health promotion‚ etc.)

We are however beginning to see unease being expressed in the literature with evidence of the ineffectiveness in impacting on settings policy in any comprehensive way (St Leger‚ 1998) and in particular‚ concerns over the potential for ‘ideal’ implementation (Thomas et al 1998).

By resisting the temptation to set prescriptive and ideal expectations of how it should be specifically used‚ the Health Promoting Health Service Framework has already sidestepped many of these ‘theoretical’ problems. There is also evidence that the facilitators are pursuing this ethos on the ground‚ with efforts being made to ‘sell’ the framework and tailor it to the needs of the setting. This position also appears to have practical resonance with those at some levels within the actual cases. Many individuals are clearly appreciative of the fact that the framework does not belittle their professional skills and they welcome the opportunity to use the framework in an active‚ selective and discriminating way. For example‚:

I think there is a danger that it could be adhered to very‚ very rigidly by some people as opposed to being a framework… it might not be totally appropriate to every single circumstance or every single area and it’s very much horses for courses.

This flexibility does however have its drawbacks. Whilst ‘top-down’ imposition may be characterised in the literature as an insensitive and impractical way of bringing about implementation‚ there were many in the field who on the surface would appear to want this type of guidance‚ this tending to occur at a relatively operational level. For example‚

‘there wasn’t enough guidelines in here on how you should use the framework and which aspects of it you should use….because it’s kind of off-putting if you look at it……I think‚ you’d feel more secure if you were given more guidelines’

In a wider sense‚ Ham and Hill (1995) recognise that implementation studies have tended to be either ‘predictive’ giving positive advice on how to secure successful implementation or ‘descriptive’‚ uncovering ‘grassroots’ barriers and both of these traditions are reflected in the current work.

At a descriptive level‚ as suggested in section 2.7‚ there remain many barriers to effective implementation‚ including the existence of ‘competing’ forces within the setting‚ problems of providing sufficient support for change (e.g. training‚ materials‚ consultancy) and limited resources available to specific projects (see O’Neill et al‚ 1997). Similarly‚ the nature of many of the outcomes described in section 2.4 arising from the framework suggest that there are still some difficulties in translating the philosophy of the framework to appropriate tangible activities.

Perhaps conversely and more optimistically‚ there is also evidence that those deploying the framework are trying as best as they can to adhere to more positive and prescriptive principles. For example‚ there are examples of interventions addressing core and priority activity; there is evidence that efforts at gaining and nurturing active participation at various levels within the sites have been successful and there are indications that both formal and informal mechanisms offering training‚ day-to-day support and follow-up are emerging.

More fundamentally‚ whilst many point to a gap in compatibility between health promotion values and those that typically drive various aspects of the health service (e.g. the degree to which the public participate in decision-making‚ how health determinants are constructed‚ the extent to which intersectoral collaboration occurs)‚ there is some evidence of core organisational principles becoming aligned with those of health promotion. O’Neill et al (1997) talk of the notion of ‘non utilitarian preferences’ where the choices and actions of individuals within a setting are made contrary to the ‘rules’ that generally prevail. In some cases‚ there were examples of a tendency for managers using the framework as a vehicle in raising the profile of ‘non-utilitarian’ values. For example‚

‘I’m aware that it’s (the framework) not the only one that’s advocating sort of multi-agency work and partnerships…but these are important to me’

‘I think in terms of the things that I’m most interested in….obviously there’s environmental things‚ staff training and the partnership stuff‚ because you can’t do it on your own‚ and who are you going to be working with to make sure that this happens‚ and obviously policy development…..these are the ones where I think that I’ll be more involved’

One could therefore argue that we are at the start of a process where recognition of the utility of health promotion values is rising.

Beyond the contrasting and isolated positions described above‚ recent literature has tried to reconcile the apparent tension between them (Hill‚ 1997; Ham and Hill‚ 1995). Whilst recognising “a conflict between the desirability of a prescriptive approach and the reality of the need to recognise that implementation involves a complex process of bargaining‚ negotiation and interaction”‚ Ham and Hill (1995; 112-113) end up favouring a position that recognises the utility of “good descriptive analysis” and “normative concerns about rational goal achievement”.

As such‚ two specific positions arise out of this discussion that help suggest a preferred position: firstly‚ that if applied in an insensitive fashion‚ ‘top down’ models of implementation‚ particularly when aimed at expected outcomes tend to be ineffective‚ professional preferring to retain control over decision making; (but) that‚ to some extent‚ they also need to be provided with a broad context and general guidance on how the framework should be used (this process orientation may be more or less prescriptive).

As suggested already‚ part of this problem may be resolved by being more specific about the level at which engagement and implementation occurs‚ specifically that being used as an operational tool throughout the organisation should be avoided. Additionally‚ the development of a preface to the framework that sets a context of how the framework should generally be used would be helpful. This would act as a guiding map‚ whilst avoiding any tendency of being overly prescriptive. This could including for example:

• identifying the possible functions of the framework (‘functional’ and ‘holistic’ uses)
• identifying specific activities and the focus of activity
• considering the sequence and structure of implementation
• considering the levels at which implementation could occur
• identifying support needs (facilitation & training) including a consideration of potential barriers to implementation.

The final point is perhaps the most important. Given that there is a strong expressed need from the field for on-going support (as highlighted in the collection of views contained in sections 2.7‚ 2.8 and 2.9) and recognising that the delivery of this relatively complex notion is in itself an involved and skilled process‚ the need for adequate assistance is stressed. In a wider sense‚ the literature highlights the potential to both over and under-estimate the potential of health promotion change agents within arena/settings based activity and significant problems do clearly exist in striking a balance between activity that acts at a sufficiently profound level within the setting whilst retaining a degree of realism and pragmatism. As such‚ perhaps the most important role that such support would have would be in relation to forming links between the immediate operational needs of health services (perhaps mainly project based health education) and the wider development of whole organisations.

 

4. Specific key issues

1. whilst change is relatively slow‚ there is considerable evidence that the framework is having an impact at various levels in the cases
2. these developments are at both operational and strategic levels
3. the predominant type of activity has been at an operational level‚ concerned with the management and co-ordination of a range of existing health promotion activities
4. in these circumstances‚ change tends to be more immediate though problems are posed in sustaining and widening activity
5. efforts to achieve change at a wider strategic level are less evident‚ slower and the product of a longer term ‘rolling out’ process
6. further clarification is needed on the perceived function of the framework (level of engagement within the setting; activities directed at)
7. it is suggested that the framework should avoid being seen as merely a tool for generic project management of discrete pieces of health promotion activity
8. it is suggested that the framework should be targeted at key senior staff within health service sites and should aim to ultimately promote activity broadly congruous with settings based health promotion
9. the content‚ format and language of the framework are generally seen to be appropriate‚ though there are difficulties in initially engaging with it
10. a context therefore needs to be established that will ensure that engagement within the framework occurs at an appropriate level (see point 8)
11. there is a need for additional work on the framework document (address jargon; develop an introduction that establishes a rationale for the framework; provide worked examples‚ provide signposts to supporting resources)
12. there are still a range of significant barriers to implementation within the cases but that these can be most effectively overcome by involving staff at an appropriately senior level (again see point 8)
13. the facilitators play a crucial role in achieving implementation and there is evidence that this role will have to be maintained at a significant degree over an extended period of time
14. there exists a desire to foster more communication and support between the various parties involved (HEBS‚ lead facilitators‚ broader specialist health promoters‚ senior staff and field-workers within the sites)
15. within this there exists a notion that the implementation of the framework will need to be supported by training at the level of both generic health promotion awareness (a broad level within sites) and more specifically around the nature and function of the framework (with key senior staff within sites).

 

5. Appendix 1

5.1 The framework

The revised version of the HPHS framework was produced after the feasibility study and may be found at http://www.healthpromotinghealthservice.com.

 

5.2 References

Baric L. (1991) Health Promoting Schools Evaluation and Auditing Journal of the Institute of Health Education Vol. 29 (4); 114-16.

Baric L. (1992) Promoting Health New Approaches and Developments Journal of the Institute of Health Education Vol. 30 (1); 6-17.

Clegowski D. (1997) That’s a Good Story‚ But Is It Really Research? Qualitative Enquiry Vol. 3 (2); 188-201.

Delaney F. (1994) Making connections: research into intersectoral collaboration Health Education Journal Vol. 53; 474-485.

Dugdill L. and Springett J. (1994) Evaluation of workplace health promotion: a review Health Education Journal Vol. 53‚ 337-347.

Grossman R. and Scala K. (1993) Health Promotion and Organisational Development: Developing Settings for Health European Health Promotion Series No. 2 WHO Europe/IFF Vienna.

Ham C. and Hill M. (1995) The Policy Process in the Modern Capitalist State Harvester Wheatsheaf‚ London.

Hawe P. and Stickney E. (1997) Developing the effectiveness of an intersectoral food policy coalition through formative evaluation Health Education Research Vol. 12 (2); 213-225.

Health Education Board for Scotland (1998) Settings Based Health Promotion: implications for practice and research agendas presented at HEBS research dissemination event‚ Stirling.

Hill M. Implementation theory: yesterday’s issue? Policy and Politics Vol. 25 (4); 375-385.

Hogwood B. and Gunn L. (1984) Policy Analysis for the Real World Oxford University Press‚ Oxford.

Mullen PD.‚ Evans D.‚ Forster J.‚ Gottlieb N.‚ Kreuter M.‚ Moon R.‚ O’Rourke T. and Strecher V. (1995) Settings as an Important Dimension in Health Education/Promotion Policy‚ Programs and Research Health Education Research Vol.22 (3); 329-345.

O’ Neill M.‚ Lemieux V.‚ Groleau G.‚ Fortin J.P & Lamarche P. (1997) Coalition theory as a framework for understanding and implementing intersectoral health-related intervention Health Promotion International Vol. 12 (1); 79-87.

Scrivens E. (1995) Measuring up The Health Service Journal 6/4/1995; 22-24.

St. Leger L. (1998) Australian teachers’ understanding of the health promoting school concept and the implications for the development of school health Health Promotion International Vol. 13 (3); 223-235.

Tannahill A. (1994) Health education and health promotion‚ From Priorities to Programmes‚ The experience of the Health Education Board for Scotland Health Education Board for Scotland/WHO Regional Office for Europe.

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Acknowledgements

The project would like to thank all those who agreed to be interviewed‚ the facilitators within the sites and the wider Health Promotion Health Service Steering Group.