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Research in Brief 14: The Health Promoting Health Service (HPHS) - what is needed to develop effective and sustainable health promotion practice within the health service?

Introduction

The significance of context or ‘settings’ for the development and delivery of health promotion programmes (eg. in cities‚ schools‚ hospitals‚ workplaces) is a central feature of health promotion practice (Whitelaw‚ 2001). The settings approach‚ together with the European Health for All targets‚ have been described by the World Health Organisation as cornerstones of the modernization of public health in that both aim to reorient health policy priorities from a risk factor approach to strategies that address the determinants of health and empower people to participate in improving the health of their communities (Kickbusch‚ 2003).

The health service has been a key setting for the delivery of health promotion programmes in Scotland over the last ten years. HEBS developed the Health Promoting Health Service Framework‚ a tool to promote and guide the development of consistent standards in health promotion practice in this setting. In 2001‚ Dr Claudia Martin from Scottish Health Feedback was commissioned to evaluate the value and utility of this framework in developing effective and sustainable health promotion practice within the health service context.

The Health Promoting Health Service (HPHS Framework)

The HPHS Framework was developed by HEBS in partnership with health promotion specialists and representatives from NHS Trusts and Boards in Scotland. It comprises guidelines to support the planning‚ development‚ implementation and auditing of health promotion practice within health service settings.

The HPHS Framework is illustrated in the form of a tree where the roots represent the major determinants of health and the trunk represents the underpinning principles of empowerment‚ participation‚ equity and sustainability. The branches depict the eight domains required for effective and sustainable health promotion practice:

• communication and co-ordination
• working in partnerships
• the environment
• policy development
• health promotion programmes
• staff health
• training and development
• research and evaluation.

Pilot implementation sites

Following revisions to the HPHS Framework in response to the findings of an earlier feasibility study (Whitelaw‚ 1999)‚ the use of the Framework was evaluated in relation to health promotion practice already underway in nine health service sites across Scotland. A common feature across the sites was the involvement of non-health promotion specialists with varying degrees of health promotion experience. All the pilot sites were required to participate in the external evaluation and to identify and monitor health related outcomes. The health promotion activities being developed and delivered by the nine participating sites were:

1. Co-ordination and integration of health promotion activity across a locality (Acute Trust and LHCC)
2. Improving staff health within an Acute Trust
3. A depression awareness project within a Primary Care Trust
4. Exercise classes for older people living in a remote rural location (LHCC)
5. Improving young people’s access to sexual health services (NHS Board)
6. A home medication delivery service for older people (primary care)
7. A ward-based head and neck cancer awareness project (Acute Trust)
8. An exercise initiative for patients and staff within a forensic psychiatry unit (Mental Health Directorate)
9. Development of a Trust-wide health promotion strategy including patient and staff programmes

In addition to the HPHS framework‚ the following support was made available to the pilot sites:

• Access to specialist health promotion advice and expertise provided by a health promotion facilitator from the local health promotion department
• A HPHS Network convened by HEBS which brought together all those the participating projects and included regular meetings and workshops
• Access to training opportunities‚ including HEBS six-day Promoting Health course
• M&E advice and support provided by the external evaluator
• Financial support from HEBS (between £500 and £3000) matched by the local ‘host’ NHS organization (to fund attendance at meetings‚ Steering Groups‚ administrative support‚ etc).

The contributions of the HPHS Framework to improving health promotion practice was evaluated by exploring the following questions:

• How was the framework used in each of nine local implementation sites?
• What were the support needs of teams involved in health promotion activities?
• Did the use of the framework and associated support influence individual learning and organizational change? In what ways?
• Did the use of the framework contribute to improved health outcomes? In what ways?

Improvements in health promotion practice were examined in relation to the effectiveness and sustainability of health promotion activities‚ the co-ordination and integration of health promotion work at both individual and organizational levels‚ and organizational approaches to health improvement.

To address the above questions‚ the evaluation comprised the following elements:

• Case studies of all nine implementation sites‚ including visits to the pilot sites‚ meetings and interviews with project teams and the project leaders over the course of the two year evaluation managers. The case studies were a vehicle for observing and documenting the processes of implementation‚ over time‚ in each of the pilot sites.
• Two surveys of the use of the HPHS Framework by health promotion specialists and others outwith the pilot sites. The surveys provided “snapshots” of the wider awareness and use of the Framework.
• Providing support to projects on monitoring and evaluation (including training days and project-specific advice) to contribute to information on short-term outcomes
• A summative evaluation at the end of the pilot implementation phase using a questionnaire survey of project workers and managers to capture project workers’ perceptions of the impact of their participation in the pilot on their own and their organizations’ learning
• The collation of financial information relating to expenditure of HEBS funding for the pilot sites.

The evaluation spanned a three-year period from June 2001 to June 2004 with regular feedback to the Evaluation Sub-Group that contributed to the review and interpretation of findings. Through these review meetings‚ the focus of the evaluation shifted from assessing the impact of the HPHS Framework on health promotion practice to a much broader concern to capture and differentiate between the wider contextual factors and specific change mechanisms that were influencing the development of effective health promotion practice in the pilot sites‚ of which the HPHS framework came to be seen as just one small element.

Use of the HPHS Framework

Access to additional funding was for some projects a stronger incentive for participation in the pilots of HPHS implementation than access to the Framework. At the outset‚ the HPHS Framework was not really understood by many of the non-specialist staff involved‚ not found to be easy to use and seen as largely irrelevant. This was for several reasons: their involvement in health promotion was additional to their largely clinical duties; their knowledge and understanding of health promotion concepts was weak‚ there was often only patchy or non-existent skilled support from a facilitator‚ and organisational awareness of‚ or commitment to‚ such endeavours was lacking. At a later stage‚ and with skilled health promotion facilitation available and training in place‚ the Framework came to be understood and used more. When asked to reflect on the influence and impact of using HPHS framework on their individual learning and development‚ most of those involved in the pilot projects identified a real shift in their thinking‚ knowledge and skills. It provided a sense of identity‚ coherence‚ and a focus for the health promotion projects‚ individually and collectively‚ through the HPHS Network meetings. With greater confidence‚ support and experience‚ for most the Framework became increasingly relevant‚ useful and effective and came to be used to inform activities on a continual basis.

Although the projects had access to a range of support mechanisms‚ both locally and from HEBS‚ two-thirds felt that they received the support they needed to carry out the work‚ but the rest of the projects experienced‚ at best‚ patchy or inconsistent support and‚ at worst‚ no support. Almost all of the project workers attended Network meetings organised by HEBS and everyone found them to be very or quite useful. Half of the project respondents were very positive about the support they received from their managers. However‚ support from their local health promotion department and their own organisation was less consistently provided. Despite the provision of support with monitoring and self-evaluation‚ limited information on short-term outcomes was obtained.

The contributions and impacts of the HPHS Framework on the wider NHS organizations were less visible‚ but apparent nevertheless. The areas of greatest impact were reported as involvement of staff and patients in the work‚ in general awareness raising about health promotion and the HPHS Framework within the organization and communicating about the health promotion projects being undertaken.

The expectation that the HPHS pilot sites would be influential not only within their own organizations and localities‚ but also in the wider NHS‚ was largely unrealized within the timescale of the evaluation. Awareness and use of the HPHS framework was very low beyond health promotion professionals‚ all of whom knew about the HPHS framework and three-quarters of whom had used it. Among Public Health Practitioners‚ 44% were not aware of HPHS in 2002‚ declining to 33% in 2004‚ but a very small proportion (5-7%) had used it. Low usage of the tool in the wider health service squared with early observations of the pilot sites which suggested that the HPHS framework itself was often not being used by non-specialist health service staff either a planning tool or conceptual guide for health promotion activities in the early stages. The assumption underlying the initial evaluation question was that the guidelines could in itself lead to more effective health promotion practice by influencing the understanding of practitioners‚ by influencing organizations’ commitment to health promotion‚ and by influencing the wider policy agenda. Little evidence was found to support this.

Developing effective and sustainable health promotion practice - necessary conditions

Given the lack of empirical evidence to support a linear relationship between use of the HPHS framework and improved health promotion practice and outcomes‚ the evaluation question was re-formulated to examine what nexus of conditions are required for effective health promotion practice and what part the HPHS framework might play in this. The key factors that were eventually identified as contributing to effective health promotion practice‚ and in which the HPHS framework can be effectively used‚ included:

• Leadership and advocacy within a project team and/or the organization
• An organizational strategic commitment to health promotion and health improvement work
• Access to and acquisition of health promotion competencies
• Access to skilled support and funding for health promotionactivities
• A critical mass of people within the organization who “understand” the principles of health promotion (and HPHS)
• The extent to which the NHS organization is responsive to the wider policy agenda around health improvement‚ reducing health inequalities‚ partnership working etc.
• Access to guidance on good practice (e.g. HPHS Framework)

The diagram below shows a revised model of the necessary pre-conditions for effective health promotion practice‚ within which the HPHS Framework is but one factor within a much wider nexus of influences.

Conclusions

The evaluation clearly shows that the HPHS framework is not a resource for non-specialists to simply use as a stand-alone‚ off-the-shelf device if health promotion knowledge‚ understanding and skills for health promotion are limited. A considerable amount of individual learning and infrastructural support needs to be in place prior to its effective use by non-specialist health service practitioners. It is therefore unrealistic to simply ‘roll out’ the HPHS framework across the NHS in Scotland as a tool for supporting effective health promotion practice.

The HPHS framework in itself is of marginal importance to the implementation of effective and sustainable health promotion practice in the health service. If effective and sustainable health promotion practice is to be achieved‚ there is a range of other factors and conditions that need to be addressed as essential pre-requisites. These conditions and resources may be more fully realized within the contemporary context of organizational change as health boards develop as public health organizations and health services are re-oriented towards health improvement goals.

The HPHS Framework was developed as a tool to support non-specialist health service practitioners to improve the health promoting elements of their work and to encourage and support a more coherent organisational approach and commitment to health promotion. Since the Framework was developed‚ the role of the health services in public health in Scotland has been strengthened and‚ non-specialists are expected to engage in health improvement‚ in particular community and school nurses‚ pharmacists and Allied Health Professionals. In addition‚ Community Health Partnerships are being developed‚ bringing together resources within localities. These developments emphasise the need to build capacity in primary care and community settings amongst non-specialists for whom health promotion will be an integral part of their job. The HPHS Framework could contribute to that effort since the evaluation demonstrated its value if introduced in a timely and appropriate manner. At the very least‚ it has value as a quality assurance tool that facilitates better health promotion practice within the NHS. At best‚ use of the HPHS framework is part of a repertoire of resources that contribute to a sea-change in organizational approaches to health promotion activity.

References

Kickbusch‚ I. (2003) The Contribution of the World Health Organization to a New Public Health and Health Promotion. Am J Public Health‚ March 1‚ 2003; 93(3): 383 - 388.

Whitelaw‚ S. (1999) Evaluation of the Implementation of a ‘Health Promoting Health Service’ Framework. Edinburgh‚ HEBS‚ May 1999.

Whitelaw‚ S. (2001) ‘Settings’ based health promotion: a review. Health Promotion International‚ Vol. 16‚ No. 4‚ 339-353‚ December 2001.

Evaluation Sub-Group

This research was commissioned and managed by the Health Education Board for Scotland (now Health Scotland) with the advice and expertise of members of the Evaluation Sub-Group:

Ann Kerr‚ Programme Manager: Health Service‚ HEBS/Health Scotland

Erica Wimbush‚ Head of Research & Evaluation‚ HEBS/Health Scotland

Dr Sandy Whitelaw‚ University of Glasgow Crichton Campus

Find out more

A full report‚ entitled ‘Evaluation of the Health Promoting Health Service Framework: Final report’ by Claudia Martin of Scottish Health Feedback (now Scottish Centre for Social Research) is available at www.healthpromotinghealthservice.com and www.hebs.com/research/cr. If you would like more information or have any comments‚ please contact Health Scotland’s Research Officer (research.officer@hebs.scot.nhs.uk) quoting reference number 2001/2002 RE004.