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Aims: To investigate the place and validity of effective process in evaluating health promotion practice in nursing and, in doing so, develop a specific model for this purpose.
Background/rationale: The failure of many nurses to provide successful health promotional programmes is underpinned by a distinct lack of evaluation research activity. Without this type of activity, health-related nursing practice remains limited in its scope and nature. This article seeks to redress this situation by proposing a specific evaluation model that assists the nurse in their attempts to include evaluative research activity in future health promotion practice.
Method: This article draws on existing literature to develop an evolving theoretical perspective for health promotion practice in nursing. The proposed model was developed from this perspective.
Conclusion: Evaluation is an essential activity for any health promotion programme. Failure to include it in practice ensures that attempts to conduct health promotion are usually rendered ineffective and unsuccessful. Evaluation models are valuable tools that nurses can incorporate routinely into existing frameworks of practice, alongside other models of health education/health promotion, such as planning models. The development of this model is intended to enable nurses to review their current practice and offer a further framework for those who wish to extend their current health promotion repertoire.
When it comes to devising health promotion and health education programmes, nurses are advised to take into account all of the processes involved. Planning, implementation and evaluation are all essential components of health promotion programmes. I have devised several process models for planning and implementing health education and health promotion practice to aid nurses in using a structured and systematic approach to their health promotion activity (Whitehead 2001a, 2001b). The planning and implementation stages of any health-related programme are vital for ensuring successful outcomes. Effective planning and implementation allows nurses to look ahead towards the most appropriate evaluation activity. The planning and implementation phases of a health promotion programme, however, are only part of the process and therefore should always be monitored and followed up by an evaluation phase. Not to do this would in most cases invalidate what had gone on previously, as well as provide no real means with which to measure the position, validity, outcomes or success of health promotion/health education programmes as they progress.
When conducting health promoting or health educational activity, most nurses do not usually take into account all of the constituent parts of a programme process. It is most likely to be the planning phase that receives the most attention. It is rare to see evidence of evaluative process in nursing-related health promotion practice. This might well explain the dearth of nursing literature offering effective examples of health promotion programme process, especially with regard to evaluation. This article seeks to highlight the need routinely to evaluate all health-related activities, alongside all of the constituent parts of the processes of health promotion/health education programming. Consequently, I have sought to develop an evaluation process model (discussed later) that assists the practitioner in further developing their health programming.
I have argued elsewhere (Whitehead 2001c) that one of the problems for nurses working in the field of health-related activity is that they might be unable to conceptualize the differences between health education and health promotion as distinct processes. I do not wish to compound this problem but, from now on, will use ‘health promotion’ as a generic term that includes health education, even though the two paradigms are contextually different. What is mostly referred to in nursing as health promotion activity would often more appropriately be termed ‘traditional health education’ (Whitehead 2001c). This being said, regardless of the type of approach or intervention, all health-related programmes require an evaluative component.
According to Kiger (1995), health promotion evaluation is a planned and continuous process that is carried out with regard to stated health criteria that may involve measurement. Similarly, Tones and Tilford (1994) state that it is a process that is primarily concerned with assessing health-related activity against values and goals in such a way that the results contribute to future decision-making. Health promotion evaluation is viewed as a research approach in its own right that involves assessing the capacity and/or performance of an intended action for health improvement, in terms of its effectiveness and efficiency [Health Education Board for Scotland (HEBS) 1999]. It is conducted for three overarching reasons: accountability, future programme development and knowledge-building.
Downie et al. (1996) suggest that there are essentially two main types of evaluation in health promotion. First, there is evaluation that involves assessing an activity in terms of specific aims or objectives (outcome assessment/evaluation). Essentially, this refers to the measurement of ‘what has been achieved’ and necessitates that the researcher refers back to the original programme objectives. MacDonald (1998, p. 188) sees it slightly differently and states that outcome evaluation ‘deals with the changing interplay between procedures and resources while the target problem is being addressed.’Tones (2000) suggests that the limitation of outcome evaluation is that it provides no insights into what actually occurred during the programme, but only the end product. The second evaluation approach is concerned with measuring an activity against a standard that may or may not be related to the specific objectives of the activity (process assessment/evaluation). This approach focuses more on ‘how the intervention has been achieved’. Process assessment therefore may not necessarily consider only the success rates of health promotion programmes, but also the processes of how this is achieved, how it is measured and at what cost. It is primarily directed at resources and procedures. Tones (2000) argues that the weakness of this approach is that, whilst it allows the evaluator to understand the dynamics of programme delivery, it does not necessarily provide illumination. In this context, illumination provides the means by which the researcher can predict if an intervention has been successful or not, as well as why this is the case. When process and outcome evaluation are combined, the evaluation focuses on monitoring the process of change that occurs as the result of a health intervention as well as the factors that facilitate or prevent desired changes (HEBS 1999).
Process and outcome evaluations are not the only types of evaluation that can be used in health promotion programming, although they are the most common. Kiger (1995) adds the element of structure, ‘structural evaluation’ relating to the organizational and human resource influences on any health programme. Developmental, impact and transfer evaluation processes are also worthy of mention (HEBS 1999).
Developmental evaluation refers to assessment of the feasibility of a new programme and tests the effectiveness of a new approach. Impact evaluation is the assessment of short-term immediate impact of a programme. Transfer evaluation is the assessment of replicability of programme processes and outcomes, and their transferability to other settings or populations. For those interested in finding out more about evaluation research strategies and processes, there are several generic contemporary texts and sources (Pawson & Tilley 1997, Scott & Weston 1998, HEBS 1999, Owen & Rogers 1999, Robson 2000, Schalock 2000).
In health promotion evaluation, the term ‘assessment’ and ‘evaluation’ are commonly used to mean the same (MacDonald 1998). In the nursing process, however, assessment and evaluation are discrete components of its process, which could be potentially confusing for nurses. This being said, Lindsey and Hartrick (1996) are particularly critical of the nursing process as a means to facilitate health promotion activity. Therefore, it might be appropriate for nurses to question and examine the validity of adopting in their health promotion practice nursing processes adopted for other purposes.
The often controversial and contested nature of what constitutes health promotion practice has led to a situation whereby clear evidence as to what counts as best practice and outcomes needs to be provided. Health professionals need to produce convincing evidence that health promotion actually does work. According to Naidoo and Wills (2000), health promotion is an ‘uncertain business’ and there are no guarantees that the outcomes of programmes will deliver what is anticipated or required of them. They add that evaluation is vital to ensure the on-going survival and viability of health promotion. Similarly, Downie et al. (1996) argue that if health promotion practice is to advance in a consistent and effective manner, then its future is dependent on sound evaluation. The World Health Organization (WHO) suggests that, at present, the field of health promotion lacks the appropriate infrastructure to develop expertise in health promotion evaluation research (WHO 1998). Without this evaluative activity, there are concerns that health promotion may fail to reconcile those who commission the resources that are needed to ensure its continuation (Learmonth & Mackie 2000). For some time now, health-related strategies have had to survive on the basis of short-term, insecure funding arrangements. On a positive note, it appears that some progress is being made in health promotion evaluation research. Wright (1999), for instance, argues that encouraging progress has been made in the last few years in developing appropriate health promotion evaluation rationales.
According to Downie et al. (1996), there are several reasons why health practitioners must evaluate health promotion programmes. For instance, they need to assess the level and extent to which programmes have and are achieving their objectives, as well as ensuring efficient and cost-effective use of resources. Health promotion evaluation also informs the development of programme methodology, ensures that ethical practice is adhered to and helps to assess the place of health promotion activity in relation to its overall efforts to achieve health gain. There are two reasons for evaluating health promotion programmes in the first place (Everitt & Hardiker 1997). First, there is the need to generate evidence about the practice or programme being monitored. Second, there is a need to make judgements on how good practice and programmes are.
In line with the reasons offered thus far to evaluate health promotion strategies are the emerging rationalization agendas of the health services. The current economic climate in the United Kingdom National Health Service (NHS), accompanied by recent radical quality-related reforms, has led to increased interest in monitoring health promotion initiatives (Naidoo & Wills 1999, Learmonth 2000, South & Tilford 2000). Raphael (2000) and Bartholomew et al. (2001) highlight the timely emergence of an increasingly high profile for health promotion evidence and evaluation, given the heightened presence of evidence-based practice. The evidence-based approach, however, has been criticised by health promotionalists because it often advocates the use of bio-scientific and positivist frameworks (Green & Tones 1999, South & Tilford 2000, Lazenbatt et al. 2001). Furthermore, evidence-based practice may be aligned purely with performance management and cost-saving exercises, which are not usually priorities of health promotion programmes (Learmonth 2000). Evaluating cost-effectiveness alone can be short-sighted, yet is a measure that is favoured by many managers and administrators. Whilst measuring the cost effectiveness of health promotion programmes provides a valid means for justifying their existence, these programmes can lead eventually to increased costs if one considers, for instance, increased longevity in populations.
Another important thing to remember about the advantage of evaluating programmes of activity is that it allows practitioners to design and implement new ones. They can learn from the strengths and weaknesses of previous programmes. Reviewing previous programmes then becomes an integral part of health-related work as practitioners become more conversant with evaluative techniques. Kiger (1995) observes that nurses who evaluate their health promotion programmes also demonstrate their willingness to show accountability for their success or failure. This helps to avoid the situation where the failure of health promotion programmes is attributed purely to failure of clients to comply or perform as expected.
Many nurses' health promotion practices are governed by biomedically determined criteria. Downie et al. (1996) highlight the limitation of observing a health state as the baseline and then measuring deviations from this, ultimately focusing on ill-health rather than positive health measurement. Biomedical and epidemiologically driven health outcome measures are particularly problematical when formulating health promotion evaluation evidence. Hepworth (1997) identifies that health outcomes-based research has traditionally focused on epidemiological variables that measure morbidity and mortality rates at population level. Tones (2000), however, states that epidemiological indicators should never be used to assess health promotion programmes. There is a growing unease about the use of biomedical models of health in health promotion activities and scepticism about the benefit of their health interventions, especially in relation to what interventions they count as ‘successful’ (Browne 2001). Biomedical models of health focus on medically determined negative indicators and outcomes of health, such as ill-health, illness and disease states, as opposed to broader determinants of health such as client social well-being. In looking to widen its focus to include community-based empowerment programmes that stress positive notions of health, health promotion is seen to be increasingly at odds with the biomedical/preventative position. There is a growing recognition that health promotion programmes that target whole communities are more effective in improving the health status of individuals (Sanson-Fisher et al. 1996). Unfortunately, Skinner (1995) stresses that most nursing models tend to favour ‘traditional health education’ approaches, rather than health promotion ones, and that they predominantly relate more to individualistic biomedical than community-based approaches. Davies and Macdonald (1998) highlight the particular dilemma that health promoters face in the paradigm war between what should be evaluated from a biomedical public health position vs. a wider health promotion position. Nurses may find themselves torn between these two positions because of the systems that predominate in their workplaces. It is, however, possible to introduce some balance to this situation by identifying a range of approaches within health-related process models (Whitehead 2001a, 2001b).
The fact that many of the wider-reaching health promotion strategies of today focus on evaluating the outcomes of emancipatory and enabling community empowerment programmes is a particular dilemma for nursing. Some argue that if health-related strategies do not include socially empowering or enabling activities, then they cannot be considered health promotional at all (Macdonald & Davies 1998, Tones 2000). Where nurses are involved in wider-reaching health promotion programming, they have expanded their health-related repertoire beyond current traditional health education techniques, to include activities such as social education programming, critical consciousness-raising, agenda-setting, political advocacy and working with mass media organizations (Sanson-Fisher et al. 1996, Tones 2000, Whitehead 2000). This expansion of practice is not easy where biomedical frameworks predominate.
An examination of the literature reveals only a few examples of nursing-focused health promotion evaluation strategies (Macleod-Clark & Maben 1999, Ashley et al. 2001, Lazenbatt et al. 2001, Twinn 2001, Bolman et al. 2002). These examples are not, however, representative of established and everyday practice by grass-root nurse researchers. This state of affairs is perhaps indicative of the fact that any attempt to incorporate health promotion evaluation techniques into practice, without a sound understanding of their nature and processes, will usually render them completely ineffective. According to Tones (2000, p. 229),
To critically evaluate the effectiveness and efficiency of any [health promotion] programme which is theoretically and methodologically unsound is either naïve or cynical and certainly renders a major disservice to health promotion.
Evaluators should be completely conversant with evaluation models and techniques before they attempt to implement them in practice. This will not be easy for individual nurses if they are not supported by colleagues and given the appropriate time, resources and training to conduct such activities. Shiroyama et al. (1995) observe that the quality of health promotion evaluation will remain debatable unless appropriate training of key health professionals becomes widespread.
Evaluation research differs in its overall scope from general research activity. It is typically concerned with assessing the processes and outcomes of the achievement of predetermined goals, while general research has a far wider range of purposes (Tones & Tilford 1994). Despite this, the fact that large-scale health promotion research usually involves sophisticated and complex methods should not deter committed health practitioners. Ewles and Simnett (1999) suggest that even modest methods of evaluation can be used routinely.
Traditionally, a positivist approach to evaluation of health promotion programmes has predominated. At the same time health service agendas have been dominated by and driven by biomedical frameworks of health care delivery. The traditional optimum research design in the field of medicine, in particular, has been the randomised controlled trial (RCT). Inevitably, this design has been blindly applied to health promotion research. This situation has been strongly challenged by many in the field of health promotion (Sanson-Fisher et al. 1996, Hepworth 1997, Speller et al. 1997, Britton et al. 1998, Learmonth & Watson 1999, Ashley et al. 2001). Indeed, even the WHO (1998, p. 6), argues that the use of RCTs in most cases is an ‘inappropriate, misleading and unnecessarily expensive’ method of evaluating health promotion programmes. Personal health experience is seen to be an essential component of health promotion activity and therefore it is ideologically unsound to reduce people to mere objects in health promotion evaluation (Raphael & Bryant 2000).
It has become evident that no single method of evaluation is appropriate for all situations. More recently, there has been a drive to define and develop alternative methodologies to RCTs and systematic reviews and, in particular, qualitative methods of inquiry (Learmonth & Cheung 1999). This said, not every quantitative method imposes restrictions and it would be a mistake to reject any of them out of hand. Instead, it might be more useful to acknowledge a realistic evaluation approach that adopts a postempiricist viewpoint, which is not simply driven by method or measurement, nor performed solely for the benefit of science, but for practitioners, programme participants and the public (Pawson & Tilley 1997). Similarly, Owen and Rogers (1999) argue that the postpositivist perspective of emergent realism assumes that evaluators are able to use a combination of systematic methods in order to describe the existence of an ‘external reality’. Flexible modes of incorporating both quantitative and qualitative evaluative methods are now being recognized as a sensible way forward. Oakley (2001, p. 28) puts it well:
What is important is that we leave behind the killing fields of the paradigm war and enter the more humane and kinder territory of combining methods and approaches in order to answer focused questions about how health promotion initiatives can enhance the quality and quantity of people's lives.
It is suggested here that action research frameworks are particularly useful in health promotion evaluation programmes (Hepworth 1997, WHO 1998, Learmonth 2000, Tones 2000). For example, I have recently completed an NHS Executive-commissioned Our Healthier Nation health promotion study that used a participatory action research (PAR) methodology to investigate osteoporosis prevention activities (National Health Service South-West Regional Office 2002). All research designs can be considered as long as they avoid the narrow parameters discussed previously. Learmonth and Mackie (2000) demonstrate the usefulness of a meta-evaluation methodology that measures effectiveness across a range of health promotion activities and different types of evaluation techniques.
Perhaps the most appropriate indicator of a relevant health promotion evaluation method is that good evaluation reflects the values of the activities that are to be measured (MacDonald 1998, Smart 1999). Rolls (1999) argues that health promotion activities need to be evaluated in their own terms and not underpinned by different criteria and values than those on which they are based. For instance, Wass (2000) suggests that community action and policy change activities are not amenable to pure quantitative analysis methods. After all, subjectivity in health promotion research cannot be eliminated simply through attempts to control it (Everitt & Hardiker 1999). In the case of community action strategies, participatory styles of evaluation, which include the views of participants, are far more appropriate.
Evaluation strategies should also seek to avoid cutting corners. Sanson-Fisher et al. (1996) state that there is huge pressure on health promotion evaluators to use quick and simple evaluation methods and that this, in turn, affects their level of scientific rigour. Scientific rigour, however, is not the exclusive domain of longitudinal quantitative research methods, nor does it always fit with a participatory research methodology. Whilst health promotion aims to empower individuals and communities, the scientific rigour of some research is often dis-empowering and nonparticipatory (Macdonald & Davies 1998, Peersman 2001). Designing health promotion programmes around an evaluation strategy rather than the other way around is desirable.
Outcome-orientated evaluation tends to be favoured where the objectives are evidence-focused and effectiveness is an important facet of the programme (Wimbush & Watson 2000). Even here, Wass (2000) suggests that quantitative evaluation techniques may not always be the most appropriate. Tones (2000), on the other hand, suggests that process evaluations are a useful ‘adjunct’ to evaluations that are primarily quantitative in nature, providing a limited degree of illumination. Process evaluation, it appears, does lend itself to both quantitative and qualitative methodologies and is not the exclusive domain of any one approach. A focus on outcome alone limits the opportunity to learn valuable lessons about the approach itself (Downie et al. 1996). Evaluators could look beyond the traditional and dominant paradigm through adopting the most appropriate methodology for the task at hand, and seeking to implement integrative and pluralistic evaluation methods that synthesize the best aspects of evaluation models (Peersman et al. 1999, Robson 2000). Nutbeam et al. (1990) also suggest that a combined approach to evaluation is best. Using outcome and process evaluation together is seen to be useful. Britton et al. (1998) particularly recommend the use of quantitative outcome evaluation combined with qualitative process evaluation. Similarly, the WHO (1998) suggests that process evaluation, combined with short- and long-term outcomes, provides the best range of information for evaluating health promotion programmes. The process approach could be used in the early stages of programme development and throughout its course, whilst outcome evaluation comes into its own towards the latter stages when repeatability and replicability are being monitored.
Health promoters are increasingly required to design evaluation strategy models that can be applied to health promotion programmes (Fraser et al. 1995, MacDonald 1998). The model put forward here (Figure 1) is an example of a stage process model that represents a mostly linear sequence of events to be addressed in order to ensure that health promotion evaluation is as effective as possible. Any evaluation sequence, however, must be cyclical if it is to succeed because this facilitates redefining and setting new goals and the reformulation of any unmet outcomes. The evaluation phase of any health promotion programme should simultaneously be seen as both the end stage and beginning stage of the programme process. As an essential activity in its own right, evaluation has a potential role at all stages of health programme provision (Owen & Rogers 1999). The importance of evaluation is further emphasized when we consider that it can also be used to inform the design of future initiatives, once again highlighting the importance of the cyclical process (Downie et al. 1996).
| [Help with image viewing] [Email Jumpstart To Image] | Figure 1 An evaluation model for nursing health promotion programme activity. |
Essentially, this model commits the nurse to addressing the determinants of their evaluation in an ordered, sequential and structured way. The initial stages of the evaluation cycle require that practitioners plan exactly what they need to measure and how they will specifically go about this. Pirie (1999, p. 134) states that the key to effective health promotion evaluation is ‘clear thinking about the purpose of the evaluation’. Indicators, process and outcome measures will need to be known. A wide range of health indicators exists, but they are mainly represented by health profiles (descriptive quantitative accounts of differing aspects of health) and health indices (the aggregate of different aspects of health performance into a single value). Difficulties in determining appropriate indicators for measuring success highlight the need for appropriate definitions of anticipated outcomes (Twinn 2001). Perhaps the most commonly used ‘performance’ indicators are the three Es –effectiveness, efficiency and efficacy. Effectiveness is the extent to which a programme has met its intended objectives, efficiency is a measure of ‘relative’ success and efficacy is used interchangeably with both effectiveness and efficiency (Tones 2000). Equity can be added to these terms as a measurement of the capacity of a programme to be accessed by participants.
The early stages of this model are aimed at identifying the process and purpose of the evaluation strategy. Alongside these outcome indicators, most programmes need to ascertain to what extent attributes such as knowledge, attitudes, beliefs, motivations and values will play a part. Other factors that are considered in the early stages of evaluation are who is going to perform the evaluation and in which context and setting the evaluation will take place. The evaluation team decides whether all key stakeholders are to be represented. Pluralistic evaluation, where all stakeholders' views and interests are represented from the beginning, represents a far more favourable position evaluation activity (WHO 1998). The research activity might be set in the community, institutional or organization context or a mixture of these.
When nurses come to decide what evaluation method they could use, they are presented with a number of options. Outcome and process evaluation methods are specifically highlighted because they represent the most commonly used methods. Where the model identifies other approaches, these indicate a variety of other less common options, some of which have been identified earlier in this account and include context evaluation (Twinn 2001). At this point, the nurse has already determined if they are going to use a single method or a combination. Following this, are the logistical and resource implications of conducting evaluation research. All the time nurses are being guided by the model through a comprehensive planning phase that eventually leads to the implementation and final evaluation of the programme. Success is often measured in terms of outcomes met, although this does not mean that not meeting the intended outcomes equates to an unsuccessful programme. Outcomes may change or success may be measured in terms of lessons learned. Alternatively, the meeting of all intended outcomes might equate to a completed programme that is then terminated. Process outcomes may be different again.
This model is limited to the extent that it only offers a brief indication of the types of activity that represent each component of a complex and resource-intensive process. Nurses, once conversant with the overall evaluation process, are then advised to study each stage in further depth and familiarize themselves with the wide variety of available methods.
Evaluating health promotion programmes is far from straightforward and difficulties can be encountered at all stages (Downie et al. 1996, Pirie 1999). The fact that there is still active debate about what actually constitutes appropriate evaluation in health promotion compounds the problem (Scott & Weston 1998). For some nurses these issues will be enough to prevent them from using such methods. For others, they will merely highlight the challenges ahead and offer a position from which to begin. Either way, Lazenbatt et al. (2001) acknowledge that an understanding of evaluation methodology is essential for nurses and that nursing must develop a health promotional ‘evaluative culture’ for the future. Undertaking detailed evaluation of a health promotion programme is not easy for any nurse, but a systematic and sequential approach to health promotion processes that routinely includes evaluation activity will help to address this dilemma. The model presented in this article has been designed as a process model that can assist nurses in identifying the stages and factors that they are most likely to encounter and could consider in their attempts at implementing health promotion evaluation.
The intention of health promotion evaluation is that it assesses activities in the light of intended goals and values, so that the outcomes can contribute to future decision-making and programme-setting. Without this insight it is difficult for practitioners to effectively contribute to the health promotion/health policy agenda. With this in mind, it is timely that nurses determine their own health promotion agendas for the future through their own evidence of effectiveness and efficiency. Effective planned evaluation offers tangible evidence of what has been achieved and thereby offers nurses confidence and satisfaction in relation to their health promotion role (Kiger 1995). Nurses are encouraged here to raise their health promotion profile by engaging in concerted evaluation research strategies and appropriately disseminating their findings. It is hoped that the model presented in this article will further aid those that participate in such activity.
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Keywords: health promotion; evaluation; evaluation research; health education
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