Health Promotion Programs: Planning, Implementation

• Lecture is about planning, implementation, and evaluation of health promotion programs

Learning Objectives

• Define Planning
• Elucidate the concept and steps involved in planning of health promotion programs
• Explain the concept of monitoring and evaluation with regard to health promotion programs
• Develop health promotion planning using the "PRECEDE-PROCEED" model

Definition of Planning

• The process of making anticipatory decisions about what needs to be done
• Includes how it has to be done
• Includes with what resources
• Planning engages in a process or procedure to develop a method of achieving a specific end
• Planning is central to both health education and health promotion

Health Program Planning

• A systematic process for assessing health needs within a community
• Factor identification influences health
• Selection of appropriate interventions for disease prevention and health promotion
• Health education/Health promotion planning can be:
• Program planning
• Communication Planning
• Session Planning

Purposes of planning

• To match resources with a specific problem
• To enable the best use of limited resources
• To avoid duplication and wasteful expenditure
• To help in problem prioritization
• To develop the best course of action

Principles of Planning

• It should be based on careful analysis of the situation through research
• It should relate to the basic needs and interests of concerned people
• It should be planned with the people involved in its implementation
• It should have the fullest utilization of the existing resources
• It should be flexible enough to meet long term situations
• It should be a continuous process, given new problems can arise as old ones are solved
• It should be achievable, considering such factors as finance, personnel, and time
• Trained personnel should be utilized for preparing the plan

Planning Process/Steps

• Planning a health promotion program is a multistep process
• It involves sequential steps where each step builds upon the previous one

Steps in Planning Health Promotion Programs

• Assess needs
• Identify problem and prioritize
• Set goals and objectives
• Develop implementation strategy
• Implement
• Evaluate
• Determine future need

Models for Planning Health Promotion Programs

• Different kinds of planning models guide the planning process
• Examples: PRECEDE-PROCEED, MATCH, PATCH, SMART
• Models provide structure and organization in the planning process

PRECEDE-PROCEED Model

• PRECEDE-PROCEED is often used and well-known
• Developed by Lawrence Green and Marshall Kreuter
• PRECEDE was created in the early 1970s to serve as the diagnostic part
• PROCEED was created in the 1980s to serve as the implementation and evaluation part
• PRECEDE
• P = Predisposing
• R = Reinforcing
• E = Enabling
• C = Constructs
• E = Educational/Ecological
• D = Diagnosis
• E = Evaluation
• PROCEED
• P = Policy
• R = Regulatory
• O = Organizational
• C = Constructs
• E = Educational &
• E = Environmental
• D = Development

Phases of PRECEDE

• Phase 1: Social Assessment
• Phase 2: Epidemiological Assessment
• Phase 3: Behavioral and Environmental Assessment
• Phase 4: Educational and Organizational Assessment
• Phase 5: Administrative and Policy Assessment

Phase 1: Social Assessment

• It seeks to subjectively define the quality of life for individuals or a population
• Includes self-assessment of the needs and aspirations of the target group
• Identifies social problems that impact quality of life
• Quality of Life is the final outcome of Phase 1

Social Assessment conceptualizes health as:

• Instrumental/functional value: a means to achieve goals and lead a productive life
• Ultimate value: a means of being happy, joyful, and satisfied
• Also consider needs and types of needs

Needs

• Perceived Needs: What is felt by the people
• Normative Needs: What is felt by an expert; actual needs
• Comparative Needs: Equity or equality

Sources of Data during Social Assessment include

• Primary data - quantitative data via survey
• Primary data - Qualitative data via interview using Focus Group Discussion (FGD) and Individual Depth Interview (IDI)
• Secondary data - existing records and/or pre-collected data

Indicators of social assessment include

• Unemployment
• Crime
• Violence
• Absenteeism
• Decreased productivity
• Job insecurity
• Internal peoples displacement
• War
• Overall quality of life

Phase 2: Epidemiological Assessment

• Using literature review, determine health issues associated with the desired quality of life
• Includes identifying morbidity, mortality, risk factors, disability, incidence, and prevalence of disease
• The data is objective, and often comes from secondary sources

Setting Priorities Based on Phase 1 and 2

• Identifying social and health problems occur during phases 1 & 2 of the PRECEDE portion of the model
• It is critical to set the priority among these issues

Reasons For Identifying Priority

• Resources are limited
• Problems are numerous
• It is not possible to address every area that requires attention
• Approaches used to set priority
• Basic Priority Rating (BPR) quantifies the process of prioritizing the problems
• Magnitude of problem
• Seriousness of the problem
• Urgency of problem
• Apply standard measures like prevalence, incidence, mortality, and morbidity to compare issues

Setting goals and health objectives for Phase 1 and 2

• Goals reduce the burden of disease or health concern
• Objectives reduce the prevalence of disease or health concern in a set population by a specific time
• Broad goals and vision are developed from the social Diagnosis

Phase 3: Behavioral and Environmental assessment

• Involves determining and prioritizing behavioral (personal) and environmental factors
• Factor are linked to health problems identified in Phase 2 and indirectly related to Phase 1
• Personal cause is here and should be operationalized vulnerability (ex: pregnant women.)
• Behavioral assessment is analysis of behavioral links to problems identified in the epidemiological or social diagnosis
• Environmental assessment is a parallel analysis of factors in the social and physical environment other than specific actions

Example of Behavior and Environment assessment

• Malaria (outcome) is caused by
• An absence of stagnant water (environmental),
• Not properly using Insecticide Treated Nets (ITTN), or staying out at evening (behavioral)
• Pregnant women or children under five (personal)

Prioritizing Behavioral Factors

• Determine the importance and changeability of certain behaviors

Considerations for Importance include:

• Evidence linking it to the health problem
• How prevalent/widespread it is

Considerations for changeability include:

• Evidence that the behavior can be changed
• How deep-rooted it is in culture
• Review of past experience
• Whether it is still in the developmental stages

Behavioral prioritization matrix

• Quadrant type is determined by changeability and importance
• More changeable/more important = High priority
• Less changeable/more important = Innovative program
• More changeable/less important = Low priority
• Less changeable/less important = No program
• Behavioral objectives are created from Quadrants I & II

Setting objectives for phase 3 of PRECEDE

• Once identified, objectives for each behavioral and environmental causes will be written (SMART)
• Objectives provide direction and need to be useful in the evaluation process with clear and measurable accomplishments

Elements of a well written objective

• What
• Who
• When
• How much

Types of Objectives

• Hierarchy of learning objectives can be created, by complexity, effort and time.
• Awareness objectives
• Knowledge objectives
• Attitude objectives
• Skill development objectives
• 3 Distinct types
• Behavioral objectives
• Environmental objectives
• Outcome/program objectives

Phase 4: Educational & Organizational Assessment

• Causal factor identification related to the Behavioral and Environmental causes of ill health from PRE phases
• Factors that must be changed to initiate and sustain behavioral and environmental changes identified in Phase 3
• Involves assessment of Predisposing, Enabling, and Reinforcing factors
• Predisposing Factors: awareness, knowledge, attitude, beliefs
• Enabling Factors: availability, accessibility, skills, laws
• Reinforcing Factors: families, peers

Establishing priorities within 4th Phase

• Prioritizing is done by determinants of behavioral and environmental changes
• Priorities are based on importance and changeability

Importance estimated in:

• Prevalence: How widespread or frequent the factor is
• Immediacy/urgency: How compelling or urgent the factor is
• Necessity: The factor must be in place to ensure change

Rating factors in terms of changeability

• Knowledge is easier to change
• Beliefs
• Attitudes (harder)
• Values (hardest)
• Learning and resource objectives in this phase

Learning and Resource Objectives

• Predisposing factors are related to learning objectives
• Reinforcing factors are related to learning objectives
• Enabling factors are related to resource objectives

Phase 5: Administrative and Policy assessment

• Concerns administrative and organizational concerns prior to program implementation
• Includes assessment of resources, budget development and allocation, development of implementation timetable, organization and coordination with others
• Analysis of policies, resources and circumstances prevailing organizational situations that could hinder or facilitate the development of the health program Policy assessment
• SWOT analysis is used to analyze strengths, weaknesses, opportunities and threats

Note

• Along with phases of PRECEDE part (especially phases 3 and 4) its recommended also to use other behavioral theories or models that help indent behavioral, environmental and educational factors affecting health and behaviors
• Determine which model is appropriate

PROCEED Part (4 Phases)

• Phase 6: Implementation
• Phase 7: Process Evaluation
• Phase 8: Impact Evaluation
• Phase 9: Outcome Evaluation

Phase 6: Implementation

• Implementation is the act of converting program objectives into actions through policy changes, regulation and organization
• It requires identification of intervention strategies
• Planners determine most appropriate means to reach goals and objectives

Considerations for Planner During Phase 6

• Set of activities that would permit the most;
• Effective means to a desired outcome
• Efficient means related to resource utilization in a responsible manner
• Multi-activity intervention are more likely to have a greater effect on a population
  • Health communication and health education strategies
  • Health policy and reinforcement strategies
  • Health engineering strategies
  • Community mobilization strategies
  • Other strategies such as advocacy

Health Communication Strategies

• All forms of intervention include some form of communication
• Achieve many goals and objectives
• Highest penetration rate of all intervention strategies
• Very cost effective
• Integral component of program planning
• The core of health promotion inventions
• May include interventions like social marketing

Health Policy Reinforcement Strategies

• Include executive directives, laws, policies, regulations, procedures and regulations
• Activities because they are required to guide individual or collective behaviors
• Applied when other strategies fail
• Examples: Prohibiting smoking in public places

Health Engineering Strategies

• Designed to change the structure or the type of service or system of care
• Designed to improve promotion services
• Creates forced choice
• Examples: Restructuring health systems and services

Community Mobilization Strategies

• A participatory capacity-building through which community, individuals, or organizations plan, carry out and evaluate services and activities
• Group or community behavior change is successful when everyone in the group does the same
• CM influences norms, beliefs and cultures to bring about social change
• Most Health Promotion intervention areas require community participation for collective action
• Helps build ownership and sustainability

Advocacy

• Influences key decision makes and opinion formers for change to policies and practice
• Actions designed to gain support for a particular health goal Advocacy is directed at influencing policy, laws, regulations and funding at both private and public corporations

Implementing the Plan requires an action plan

• Logic model: A plan that shows the relationship among components [resources, outputs, outcomes]
• Gantt Chart: A plan that shows a timeline or project timeline

Implementation: Logframe Definitions

• Goal: main overall objective the project will achieve framed as a sustainable improvement in human conditions
• Objective: changes or results that need to be achieved to make impact on problem
• Output: is the project interventions or sets of activities, needed to achieve objectives
• Activity: actions carried out as part of the intervention
• Input: are the resources used to carry out an activity

Putting plans into action

• Piloting the program
• Phrasing the program in small segments
• Initiate the entire program at once

Phases 7-9: Monitoring and Evauation

• Process evaluation: measurements of program activities to ensure quality service delivery
• Impact evaluation: measurable effects, leading to program outcome
• Outcome evaluation: Long-term, ultimate goals of a program

Evaluation of program

• It determines if the specified goals and objectives have been met
• It determines how it has been achieved
• systematically and objectively investigates relevance, effectiveness and impact of services
• Effectiveness is what has been achieved
• Efficiency deals with resources invested.

Reasons to Undertake an Evaluation

• Assess results, and determine if objectives have been attained
• Justify use of resources
• Improve assist future planning by creating knowledge
• Improve our practices
• Determine efficiency and effectiveness
• Win credibility and support
• Inform other health promoters

Types of Evaluation

• Formative evaluation includes a combination of measurements used to improve program delivery
• Summative evaluation combines measurements and judgements that conclude impact and outcome

Standards of Evaluation

• Utility: ensures information need of users
• Feasibility: realistic, diplomatic and frugal
• Propriety: ensure the evaluation is ethical
• **Accuracy:**reveal and convey the technical aspects of promotion