Marshall W. Kreuter

Evaluating Community-Based Collaborative Mechanisms: Implications for Practitioners

This article examines the possible reasons why the published literature on community-based coalition strategies offers only marginal evidence that such approaches lead to health status/health systems change. Three possible explanations are proposed: (a) collaborative mechanisms are inefficient and/or insufficient mechanisms for carrying out critical planning and implementation tasks, (b) expectations of health status/health systems change outcomes are unrealistic, and/or (c) Health status/health systems changes may occur but may go undetected because it is difficult to evaluate and demonstrate a cause-and-effect relationship. The implications of each possible explanation are addressed through a review of the literature on stages of coalition building, focusing on key factors for success at each stage. The authors conclude that funders and practitioners may be expecting too much from these increasingly popular mechanisms and may not be asking the right questions when evaluating collaborative activity.

Fighting back or fighting themselves? Community coalitions against substance abuse and their use of best practices.

Ever the optimists (if not positivists), we continue to look to research to vindicate community health strategies in relation to chronic diseases, complex lifestyle changes and social problems, as they were vindicated in earlier decades against communicable diseases. If we had vaccines to deliver against chronic diseases and substance abuse behaviors, perhaps this hopefulness would be justified. The paper by Hallfors et al. in this issue of the AJPM describes an evaluation of the “Fighting Back” substance abuse initiative supported by the Robert Wood Johnson (RWJ) Foundation. They examined the extent to which coalitions attained selected substance abuse goals in 12 “Fighting Back” communities on which they tracked a variety of indicators through much of the 1990s. They employed a prospective design with multiple comparison communities for each coalition community, quantitative and qualitative methods, and thousands of interviews and observations. Despite all these strengths, lending credibility to the authors’ conclusions, some conceptual and methodologic limitations raise the usual doubts that follow randomized and otherwise controlled community trials, especially when they attempt to isolate one component of complex interventions as a causal explanation for success or failure. Other commentaries and analyses have grappled with the methodologic limitations and pitfalls of such research for purposes of studying community-wide interventions or interventions in communities evaluated at the community level. Some have called specifically into question the limitations of “traditional scientific methodology. . .to capture the outcomes of these complex collaborative organizations” called community coalitions. Others have addressed the problem of unrealistic expectations of community strategies in the short term. Our commentary will address some of the conceptual and procedural issues in understanding community coalitions, best practices, and their evaluation in communities. These are not entirely independent of methodological issues of evaluation, but we believe that we must know what we are attempting to measure and evaluate before we can make strategic and scientific decisions on how best to do so. We will comment, then, on two aspects of the evaluation: (1) the complexity-of-interventions issue in evaluating Fighting Back and the isolation of community coalitions as the common starting point in what became widely varied programs across the communities, and (2) the inflated expectations that follow from isolating community coalitions as the independent variable.

The School Health Curriculum Project: Its Theory, Practice, and Measurement Experience

The School Health Curriculum Project(SHCP), initiated over a decade ago to provide a health education curriculum package for elemen tary students, has been widely and variously evaluated. In analyzing studies designed to assess the effectiveness of the SHCP, it was recognized that the measured impact of this project (or any health education intervention) would derive from the adequacy of the theory upon which the program is based, the adequacy of its implementation, and the adequacy of its measurement. Hence, an examination of the theoretical base of the SHCP and its variance in practice was conducted. In addition, a metaevaluation of 24 studies designed to access the effectiveness of the SHCP was completed. Results suggest that the project is effective in influencing health-related knowledge and attitudes. A rationale for future evaluation efforts in school health education is subsequently outlined.

School Health Education: Does It Cause an Effect?

We have tried to raise several issues in this paper. First, schools are very complex systems. It is as difficult to generalize about schools as it is to generalize about the children in them. Second, because of this complexity, any serious discussion of outcomes resulting from any educational program requires a commitment to specificity in problem identification and planning. Third, the current national interest in health promotion, disease prevention and risk reduction has given rise to a greater emphasis on the principles of epidemiologic analysis. This kind of analysis facilitates a focus on outcomes which are, to varying degrees, contributing factors to specific health problems. Fourth, while there are those who fear that this emphasis may compromise the traditional goals of schools, there is clear evidence that the addition of an epidemiologic cause/effect dimension to school health education is consistent both with the tenets of major educational philosophers as well as the goals of health education as stated by scholars in the field. Fifth, the process of decision-making (the assessment of which is admittedly primitive at this point) represents the bridge across which the science of epidemiology can cooperatively join hands with the art of education toward the goal of enhancing the competence of children and youth.

Commentary on the emerging guide to community preventive services from a health promotion perspective

This paper presents the comments of authors Lawrence Green and Marshall Kreuter on the emerging Guide to Community Preventive Services of the Task Force on Community Preventive Services from a health promotion perspective. In terms of the framework, the authors discerned a shift of behavior from its previous position of risk factors to the position of intermediate outcome. This was found to be a refreshing departure from the single-minded focus other professions and sectors have come to expect of the health professions and sciences. The considerable emphasis placed on the intended practitioner and policy-maker audiences has pleased the authors. However, effective implementation can be a challenge to the partners involved in the process. In addition, limitations have been identified in the Task Forces methods. The limitation in the time frame for published studies tends to extend to modest time frames of most grants. This could be addressed by constructing a continuous, interactive system for gathering information about prevention research and practice as part of the infrastructure of the public health system.

State health policy makers: what's the message and who's listening?

This article is based on a white paper commissioned by the Directors of Health Promotion and Education, a national organization representing state health agency directors and practitioners in health promotion and education initiatives. The work reflects an assessment of current understanding of how state-level policy makers receive and use information related to health promotion and chronic disease prevention. Although health education practitioners are routinely encouraged to use policy and environmental change strategies, a systematic approach to communication with policy leaders is not readily available. This work describes the current knowledge of the relationship and offers recommendations for research and practice.

EVIDENCE HIERARCHIES VERSUS SYNERGISTIC INTERVENTIONS

Frieden1 used a “potential health impact” pyramid to illustrate the relative influence each of five categories of interventions could have on public health status. We applaud the compelling case he makes for the bottom tiers having “the greatest potential to improve health”1(p594) because they direct interventions toward structural and socioeconomic determinants of health.

The Dimensions of Health Promotion Applied to Physical Activity

Health promotion is a complementary array of educational and environmental strategies applied in various settings and targeted at selected populations. The few successful and well-described physical activity projects have applied multiple strategies in multiple settings to specific target groups.There is clear and persuasive evidence that regular physical activity improves health. Over the past 20–25 years participation in leisure-time physical activity has increased in Canada, Finland, the USA, and the German Democratic Republic. Unfortunately, more than half the population in each of these four countries remains inactive during leisure time, and total physical activity probably has decreased because of declining activity on the job and for transportation. National physical activity promotion programs need to include both educational and environmental strategies. Regular surveys of physical activity patterns and continued research into the most effective methods to promote regular physical activity are needed.

Are Community Organization and Health Promotion One Process or Two

Goodman and Steckler have contributed enormously in a span of a few years to the qualitative evaluation of community health promotion programs, including their studies for the U.S. Centers for Disease Control to assess the PATCH program. Schwartz and Hoover have put Maine on the national health promotion map with some of the most progressive and innovative programs among state health departments. This teaming of academicians and experienced practitioners has produced a most useful product? We applaud the authors’ eight recommendations, especially numbers 1, 5, and 6. If acted upon by policymakers, these three recommendations alone would surely advance the implementation of effective health promotion programs. We are disinclined to support their recommendation 8, the call for grantmakers or policymakers outside the community to press for institutionalization of new programs inside the communities, for reasons discussed in a previous commentary on their excellent work to develop measures of institutionalization. ~

Report from the AAHE/SOPHE Joint Committee on Ethics

In 1984, the Society for Public Health Education (SOPHE) and the Association for the Advancement of Health Education (AAHE) convened a joint committee to de velop a profession wide code of ethics for health education. The following article is a compilation of the Committees work over two years. The Committees report appears first. It presents the Committees position on how a code of ethics is developed and constitutes guidelines for future refinements in the code. Appendix A is the SOPHE code of ethics produced in 1976. It is included to show the evolution of the code into its current form as presented in Appendix B. Appendix B is the Code of Ethics devel oped by a SOPHE Committee in 1983. SOPHE and AAHE through a joint committee are continuing efforts to develop a code of ethics for the profession of health educa tion. We invite readers reactions to the Code. Comments and questions can be di rected to the AAHE/SOPHE Ethics Committee, c/o the Editors of Health Education Quarterly.