Lenneke Vaandrager

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.

Psychometric properties of the OLQ-13 scale to measure Sense of Coherence in a community-dwelling older population

BackgroundWith the ongoing demographic shift, the quality of life and health promotion among older individuals are becoming increasingly important. Recent research suggests that Sense of Coherence positively affects quality of life. Hence, a valid and reliable measurement of Sense of Coherence is pivotal. The 13-item Orientation to Life Questionnaire (OLQ-13) can be used to measure Sense of Coherence. The purpose of the present study is to assess the psychometric properties, validity, and reliability, of the OLQ-13 in community-dwelling individuals, aged 65 and older.MethodsThe OLQ-13 scale was administered as part of a healthy aging project for non-institutionalized people aged 65 years and older. Internal consistency and reliability were assessed by means of inter-item and test-halves correlations and Cronbachs alpha. Construct validity was explored using cluster analysis and exploratory factor analysis (n = 703) and tested using confirmatory factor analysis on a separate subset of individuals (n = 658). Item face validity was investigated by means of 12 semi-structured interviews.ResultsThe reliability and the validity of the OLQ-13 in this population of non-institutionalized individuals aged 65 years and older was ambiguous, at least partly due to the poor performance of two items (b and d), which was confirmed by results from the qualitative part of this study. The psychometric properties of the proposed OLQ-11, obtained by deleting the two items, were better. In particular, the interpretation of exploratory factor solution improved. Whereas the underlying theoretical constructs could not be linked to the exploratory analyses of OLQ-13, this was to some extent possible in OLQ-11. The superior validity of OLQ-11 over OLQ-13 was supported by the better model fit in the confirmatory factor analysis.ConclusionsThe present mixed-method study suggests the proposed OLQ-11 as a more suitable instrument for measuring Sense of Coherence than the OLQ-13 in a population of ageing individuals. This study confirms that the validity and reliability of OLQ-13 may differ substantially in different populations.

Aging Populations’ Everyday Life Perspectives on Healthy Aging: New Insights for Policy and Strategies at the Local Level

Population aging makes policy makers face the challenge of supporting people as they age. Strategies designed to promote healthy aging should take the viewpoints of this target group into account. To strengthen interventions on healthy aging, this study aims to investigate how aging individuals experience healthy aging in their locality. A salutogenic background is used to ensure a broad perspective on health. Data collected from 79 in-depth interviews (using an appreciative inquiry approach) in the Netherlands were analyzed for interviewees’ experiences on healthy aging. Results indicate that healthy aging is perceived within the context of everyday life, and interviewees who are content with their health often have an assets-based and positive view on health. Often, however, interventions and facilities address isolated health themes, and such an approach does not match well with these perceptions. Framing interventions positively in terms of assets, resources, and everyday life may increase their effectiveness.

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.

Culture in salutogenesis: the scholarship of Aaron Antonovsky:

Aaron Antonovsky wrote extensively, although disjointedly, about the roles of culture in salutogenesis. This paper provides a synopsis of his work in this arena. A literature review identified those of his English language writings in which culture was a subject, and relevant text segments were analysed using an inductive followed by a deductive method. Using thematic network analysis, text segments were sorted inductively by open coding and then analysed. This was followed by deductive text segment coding guided by the constructs of the salutogenic model of health. The analysis revealed that Antonovsky had an expansive interest in the roles of culture in salutogenesis. His writings included attention to the role of culture in: (a) shaping life situations; (b) giving rise to stressors and resources; (c) contributing to life experiences of predictability, load balance and meaningful roles; (d) facilitating the development of the sense of coherence and (e) shaping perceptions of health and well-being. Antonovsky’s writings about culture were sometimes conjectural, as well as being obviously influenced by his life experience in the USA and then in Israel, and by the spirit of the times in which he lived. However, he also drew extensively on his own and others’ empiricism, leading him to view culture as an integral aspect of the salutogenic model of health. The present analysis provides salutogenesis scholars with a roadmap of Antonovsky’s reflections, ponderings and conclusions about culture in the context of salutogenesis. It provides assistance in the form of an overview of Antonovsky’s treatment of culture in the context of salutogenesis.

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)

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.

Neighbors Connected: the interactive use of multi-method and interdisciplinary evidence in the development and implementation of neighbors connected

Neighbors Connected is a community-based intervention in the Netherlands. It helps the active older people to organize social activities for their less active older neighbors, facilitated by practical and financial support from the Community Health Service. The intervention is the outcome of a combination of semi-structured interviews with the older people, with organizations for older people and with local policy-makers, epidemiological data and interactive discussions, all of which support the notion that engaging in social activities is a way to enhance healthy ageing within the community. The use of different sources of evidence resulted in a comprehensive picture and actionable local knowledge.

Beyond bridging the know-do gap: a qualitative study of systemic interaction to foster knowledge exchange in the public health sector in The Netherlands

BackgroundDespite considerable attention currently being given to facilitating the use of research results in public health practice, several concerns remain, resulting in the so-called know-do gap. This article aims to identify the key tensions causing the know-do gap from a broad perspective by using a systemic approach and considering the public health sector as an innovation system.MethodsAn exploratory qualitative design including in-depth semi-structured interviews was used, with 33 interviewees from different actor categories in the Dutch public health innovation system. The analyses employed an innovation system matrix to highlight the principal tensions causing the know-do gap.ResultsSeven key tensions were identified, including: research priorities determined by powerful players; no consensus about criteria for knowledge quality; different perceptions about the knowledge broker role; competition engendering fragmentation; thematic funding engendering fragmentation; predominance of passive knowledge sharing; and lack of capacity among users to use and influence research.ConclusionsThe identified tensions indicate that bridging the know-do gap requires much more than linking research to practice or translating knowledge. An innovation system perspective is crucial in providing information on the total picture of knowledge exchange within the Dutch public health sector. Such a system includes broader stakeholder involvement as well as the creation of social, economic, and contextual conditions (achieving shared visions, building networks, institutional change, removing financial and infrastructural barriers), as these create conducive factors at several system levels and induce knowledge co-creation and innovation.