Annemarie Wagemakers

Elaborating on systems thinking in health promotion practice

Health and well-being are the result of a series of complex processes in which an individual interacts with other people and the environment. A systematic approach ensures incorporation of individual, ecological, social and political factors. However, interactions between these factors can be overlooked within a systematical approach. A systemic approach can provide additional information by incorporating interactions and communication. The opportunities of a systems thinking perspective for health promotion were investigated for this paper. Although others have also made attempts to explore systems thinking in the field of health promotion, the implications of systems thinking in practice need attention. Other fields such as agricultural extension studies, organizational studies and development studies provide useful experiences with the use of a systems thinking perspective in practice. Building on experiences from these fields, we give a theoretical background in which processes of social learning and innovation play an important role. From this background, we derive an overview of important concepts for the practical application of a systems thinking perspective. These concepts are the structure of the system, meanings attached to actions, and power relations between actors. To make these concepts more explicit and reduce the theoretical character of systems thinking, we use an illustration to elaborate on these concepts in practice. For this purpose, we describe a health promotion partnership in The Netherlands using the concepts structure, meaning and power relations. We show how a systems perspective increases insight in the functioning of a partnership and how this can facilitate processes of social learning and innovation. This article concludes by identifying future opportunities and challenges in adopting systems thinking for health promotion practice. A systems perspective towards health promotion can help projects reaching a more integral and sustainable approach in which the complex nature of health promotion processes is supported. Practical applications of systems thinking are necessary to adapt this perspective. (Global Health Promotion, 2009; 16 (1): pp. 39—47)

Community health promotion: A framework to facilitate and evaluate supportive social environments for health

The evaluation of community health promotion designed to create supportive social environments for health is still in its infancy. There is a lack of consensus on concepts, a lack of information on interventions that bring about social change, and a lack of feasible methods and tools. Consequently, the effectiveness of community health promotion may not be evaluated under all relevant headings. Therefore, this study aims to contribute to the evaluation of change in the social environment by presenting a framework. On the basis of the relevant literature we describe the relation between social environment and health predicting mediators. We selected participation and collaboration as core concepts in moderating the social environment of health because these terms give insight into the actual dynamics of health promotion practice. We synthesize the results into a framework with operational variables and offer four guidelines on how to apply the framework: use the variables as a menu, set specific aims for social change processes, use an action research approach, and triangulate data. The framework and guidelines enable the start-up, facilitation and evaluation of social change and learning processes and provide common ground for researchers and practitioners to improve the practice of their professions.

Coordinated action checklist: a tool for partnerships to facilitate and evaluate community health promotion

Coordinated action through partnerships is a core approach in community health promotion to deal with the multidimensionality of today’s health and societal issues. The number of partnerships is increasing. However, facilitation and evaluation of partnerships is hampered by the lack and/or non-use of feasible tools. As a consequence, health promotion through partnerships is not optimally facilitated and evaluated. This article describes the development and piloting of a tool and guidelines to facilitate and evaluate coordinated action in community health promotion. The initial development of the tool was based on relevant literature, a conceptual framework to support social environments for health, and an inventory of existing tools. Appreciative inquiry principles contributed to the formulation of items. The result, a checklist for coordinated action, was further developed and assessed for usability in six different partnerships: a national program, an academic collaborative and four local partnerships. Results of the checklist were cross-checked and discussed with partners. Piloting the checklist resulted in a feasible tool helpful to partnerships because of its ability to generate actionable knowledge. The checklist enables the facilitation and evaluation of community health promotion partnerships that differ in context and level (both local and national), phase of the program and topics addressed. Cross-checking and discussing results with partners and triangulation with interview data increases the reliability of the results of the checklist. Piloting in multiple cases contributes to the checklist’s external validity.

Participatory approaches to promote healthy lifestyles among Turkish and Moroccan women in Amsterdam

Although it is recognized that community health promotion succeeds or fails by level of participation, effectiveness and benefits of community programs are underestimated, because participation is seldom monitored and evaluated. In the Dutch “Healthy Lifestyle Westerpark” program in Amsterdam, participation was both the main working principle and the main goal. Between 2003 and 2006, the Municipal Health Service (MHS) carried out a qualitative study on the background of overweight in Turkish and Moroccan women aged 25 to 45 years and on possibilities for promoting health with and for the target group. The aim of the program was to increase the womens participation and to evaluate participation levels in all phases. The research aim of this paper is to contribute to the development of participatory methods. Needs assessment and intervention development phases resulted in implementation of aerobic lessons and nutrition interventions. In the evaluation phase, participation levels were measured using Prettys typology in focus groups. Results show that women appreciate participating in the program. Increase in physical activity was not measured. Womens knowledge about healthy food increased, women changed behavior by buying healthier food ingredients and women continued to participate. Participatory approaches facilitate participation at the desired level in the different phases of the program. Participatory approaches are time-consuming but worthwhile. Prettys typology is useful to measure degree of participation, although methods can be improved and the meaning of participation should be reconsidered. The added value of this article is twofold: 1. it demonstrates that participatory methods and tools both facilitate and evaluate participation, and 2. it shows how to evaluate the degree of participation. (Promot Educ, 2008; 15 (4): pp. 17-23)

Citizen Science for public health

Abstract Community engagement in public health policy is easier said than done. One reason is that public health policy is produced in a complex process resulting in policies that may appear not to link up to citizen perspectives. We therefore address the central question as to whether citizen engagement in knowledge production could enable inclusive health policy making. Building on non-health work fields, we describe different types of citizen engagement in scientific research, or ‘Citizen Science’. We describe the challenges that Citizen Science poses for public health, and how these could be addressed. Despite these challenges, we expect that Citizen Science or similar approaches such as participatory action research and ‘popular epidemiology’ may yield better knowledge, empowered communities, and improved community health. We provide a draft framework to enable evaluation of Citizen Science in practice, consisting of a descriptive typology of different kinds of Citizen Science and a causal framework that shows how Citizen Science in public health might benefit both the knowledge produced as well as the ‘Citizen Scientists’ as active participants.

Alliances in the Dutch BeweegKuur lifestyle intervention

Objective: BeweegKuur (Exercise Therapy) is a Dutch lifestyle programme in which participants are referred by a general practitioner (GP) to a lifestyle advisor. To support participants, regional and local alliances are established. The present study explored the successes and challenges associated with collaboration processes in local BeweegKuur alliances. Design: A qualitative explorative study. Setting: The Netherlands Institute for Sports and Physical Activity (NISB) initiated the Building BeweegKuur Alliances project to support local alliances. The BeweegKuur intervention is implemented by over 30 regional and about 150 local alliances throughout the Netherlands. Method: 12 in-depth interviews were held with coordinators of the alliances, and four focus groups were held with regional and local alliance partners. Results: Collaboration within the alliances is perceived as successful in integrating prevention and care. Challenges include the participation of sectors such as the local municipality and the sports sector, and the transition of BeweegKuur participants to local sports facilities. Conclusion: This study identifies three general conditions for successful coordinated action: (a) flexible protocols and management that allow for contextual adaptations; (b) making successes and challenges visible using facilitating methods and tools; and (c) time and funding to overcome differences of culture between different sectors, and to build trust.

Actiebegeleidend onderzoek ter bevordering van intersectorale samenwerking en bewonersparticipatie De ervaringen met het wijkgezondheidswerk in Eindhoven

SamenvattingGGD Eindhoven is in 1999 gestart met het project ‘Wijkgezondheidswerk’ in twee zogeheten impulsbuurten. Doel van het project is het reduceren van sociaal-economische gezondheidsverschillen in beide buurten. Daartoe zijn, gezamenlijk met organisaties werkzaam in de buurten, verschillende activiteiten opgezet en uitgevoerd, voor en ook met de bewoners.Het project is dankzij subsidie van ZonMw omlijst met onderzoek. Vanuit de Universiteit Wageningen is gedurende drie jaar actiebegeleidend onderzoek uitgevoerd tot 2002.Het resultaat is dat intersectorale samenwerking is gegroeid en inzichtelijk is gemaakt. Ook de bewonersparticipatie is op gang gekomen. Hoewel wijkgezondheidswerk top-down geïnitieerd is, is het project gaandeweg steeds meer bottom-up gedragen. Het actiebegeleidend onderzoek heeft een faciliterende rol gehad in het overwinnen van de startproblemen, de voortgang van het project en de afstemming tussen de praktijk en de verschillende onderzoeken. Actiebegeleidend onderzoek kan gezien worden als een interventie die bijdraagt aan intersectorale samenwerking en bewonersparticipatie en daarmee sociaal draagvlak genereert.AbstractParticipatory action research within the communitybased intervention project ‘Wijkgezondheidswerk’ In 1999, the Municipal Health Service (MHS) in Eindhoven started the community-based intervention project ‘Wijkgezondheidswerk’ in two deprived neighbourhoods. The aim of the project was to reduce socialeconomic inequalities in health. To achieve this aim, the MHS, in collaboration with organisations working in the neighbourhoods, initiated several activities with and for inhabitants. ZonMw provided funding for the accompanying research activities. The Wageningen University carried out the participatory action research during three years, up to 2002. The project has been succesful in establishing intersectoral collaboration and initiating community participation. Although ‘Wijkgezondheidswerk’ started top-down, during the program it became more and more bottom-up. The participatory action research enabled to deal with problems at the start of the project, to continue the project and to attune programme practice and research. Participatory action research can be seen as an intervention which facilitates intersectoral collaboration and community participation, thereby gerenerating social support.

Amsterdam’s STI/HIV programme: An innovative strategy to achieve and enhance the participation of migrant community-based organisations

Objective: The STI/HIV prevention programme in Amsterdam aims to improve the sexual health of Amsterdam residents of African, Antillean, Aruban and Surinamese origins. The programme strategy is to achieve and enhance the participation of migrant community-based organisations (CBOs) in sexual health promotion through a grant scheme and by providing support to CBOs in developing, implementing and monitoring STI/HIV projects within their own communities. This evaluation focussed on identifying obstacles and successes of the CBO projects, assessing the organisation of the programme and examining the level of CBO participation. Design: Multi-method qualitative approach based on a community-based research framework, including document analysis, 37 semi-structured interviews with CBO representatives and Public Health Service (PHS) professionals and participant observation. Setting: Amsterdam, The Netherlands. Results: In total, 76 CBOs participated in the programme, and 110 diverse and culturally specific projects were developed. The CBOs appreciated participation in the programme, but did not necessarily perceive their participation to be at a high level. The multiple roles fulfilled by the PHS coordinator and the capacity of both the PHS and the CBOs were crucial for success. Conclusion: This study shows that the strategy to achieve and enhance participation by CBOs in combination with grant schemes is efficient for developing and implementing STI/HIV projects, provided that there is on-going support to develop, implement and monitor projects. In assessing the effectiveness of the programme, a number of challenges lie ahead, especially regarding the continuous monitoring of projects and assessing programme impact on sexual health.

Evaluation Design for Community-Based Physical Activity Programs for Socially Disadvantaged Groups: Communities on the Move

Background As interventions are not yet successful in substantially improving physical activity levels of low socioeconomic status groups in the Netherlands, it is a challenge to undertake more effective interventions. Participatory community-based physical activity interventions such as Communities on the Move (CoM) seem promising. Evaluating their effectiveness, however, calls for appropriate evaluation approaches. Objective This paper provides the conceptual model for the development of a context-sensitive monitoring and evaluation approach in order to (1) measure the effectiveness and cost-effectiveness of CoM, and (2) develop an evaluation design enabling the identification of underlying mechanisms which explain what works and why in community-based physical activity programs. Methods A cohort design is proposed, based on multiple cases, measuring impact, processes, and changes at each of the distinguished levels. The methods described in this paper will evaluate both short- and long-term effects, costs, and benefits of CoM. Results Testing of the proposed model began in October 2012 and is on-going. Conclusions The design offers a valid research strategy for evaluating the effectiveness of community-based physical activity programs. Internal validity is guaranteed by the use of several verification techniques such as triangulation. The multiple case studies at the program and community levels enhance external validity.

Evidence in gezondheidsbevordering

SamenvattingOm de kwaliteit van gezondheidsbevordering te waarborgen, groeit de vraag naar evidence-based interventies. Tot nu toe wordt evidence opgevat en toegepast zoals in de medische wetenschappen gebeurt, waarbij het gaat om het vaststellen van het effect van een geneesmiddel of behandeling. Deze vorm van evidence blijkt in gezondheidsbevordering vaak problemen op te leveren omdat dit soort evidence geen rekening houdt met de context. Dit bemoeilijkt de interpretatie van de resultaten en het gebruik van de uitkomsten.In dit artikel wordt een overzicht gegeven van soorten evidence waaronder typen die wel rekenschap geven van de context. Deze contextgevoelige soorten evidence zijn beter bruikbaar voor de kwaliteitsborging van gezondheidsbevordering. Het genereren van contextgevoelige evidence vereist echter andere onderzoeksmethoden en kwaliteitscriteria. Ook het combineren van soorten evidence is nog een onontgonnen terrein.AbstractEvidence in health promotionDutch policy makers, professionals and researchers are searching for ways to improve the efficiency, quality and long-term sustainability of health promotion by promoting evidence based health promotion. This refers to the use of information derived from formal research and systematic investigation to identify the most effective health promotion actions to address health issues in given contexts and populations. However, the term “evidence-based” remains a confusing concept. We consider how and why the evidence-based health promotion movement developed and we discuss what types of evidence are available. Various initiatives have resulted in further quality improvement of the health promotion field but also face a number of bottlenecks. These bottlenecks are difficulties with the RCT-design, the time lag, the neglection of the role of context and the fact that dissemination of described effective interventions are not automatically implemented in practice. The current strategies of policy makers and intermediaries show a preference of descriptive analytical and impact evidence (context-free evidence) above theoretical, implementation and stakeholder evidence (context-sensitive and informal evidence).