Practitioner opinions on health promotion interventions that work: Opening the ‘black box’ of a linear evidence-based approach

Abstract

While attempts are being made to improve health promotion by following a linear Evidence-Based (EB) approach, the actors involved are aware that the quality of health promotion is not just a matter of supplying ’evidence-based’ interventions to local practitioners, but the result of a situated coproduction process that depends on many factors. This paper explores what constitutes an intervention that works from the perspective of health promotion professionals (HPP), and how, according to them, the development and implementation of interventions should be improved. We interviewed 81 HPPs about the use of 10 health promotion interventions at 30 Municipality Health Services in The Netherlands. The HPPs described an intervention that works as something that produces its intended effects after being realized in a local situation. Interventions are realized by combining elements of a supplied intervention (e.g. a theory, artefacts) with elements that are situated in the local context (e.g. funding, local network). Interventions that are transferred contain implicit assumptions about local contexts, but it is often unclear what precisely constitutes an intervention and what is assumed of local contexts. An intervention that works is a situated configuration of aligned elements. A linear EB approach depends on the realization of the local circumstances in which ’evidence based’ interventions can work. Various strategies are possible for approximating such circumstances, but the core assumption that the configuration that is realized in practice is similar to the ’evidence based’ intervention seems unrealistic for most health promotion in the Netherlands. Under such circumstances, attention should shift from central quality assurance to the system of actors and the distributed actions and heterogeneous learning processes that together add up to interventions that work.

Introduction

During the past decade, attempts to improve health promotion have embraced a linear Evidence-Based (EB) approach (Brug et al., 2010, Cohen et al., 2008, Estabrooks and Glasgow, 2006, Green and Glasgow, 2006, Kelly et al., 2010). The essence of a linear EB approach is to first determine the effectiveness of interventions and consequently promote their use in practice. We have added the term linear to emphasize that this approach is only one of the possible approaches to the use of evidence in practice. A linear approach assumes, implicitly, that interventions are fixed entities that can be moved around while staying the same, and depicts the design and research of interventions at-a-distance as the point-source of the improvement of local practice (Kline & Rosenberg, 1986). Proponents of a linear EB approach describe deviating from this fixed, predetermined entity as less effective and bad practice. In clinical care a linear EB approach appears successful, but attempts to apply it to public health and health promotion have led to a range of problems and challenges, both with determining the effectiveness of interventions and with the use of ‘evidence-based’ interventions in practice (Baranowski, 2006, Green and Glasgow, 2006, Kelly et al., 2010, Rychetnik, 2004). The Center for Healthy Living (Dutch acronym: CGL), which was established in 2008 in the Netherlands, is an interesting example of an attempt to improve health promotion by embracing a linear EB approach (Brug et al., 2010). One of the core tasks of the CGL has been to develop and manage a central (national level) quality assurance structure that recognizes interventions based upon their proven effectiveness. Those involved in the quality assurance structure have emphasized since its inception that to achieve successful health promotion, it is not enough to just supply ‘effective’ interventions to local practitioners. Interventions that work are realized in practice by health promotion professionals (HPP) who combine elements of a supplied intervention with elements that are situated in the local context (e.g. network of intermediaries, funding, competences of HPPs) (Estabrooks and Glasgow, 2006, Green et al., 2009, Kelly et al., 2010). The actions (e.g. designing, learning by testing and doing) that lead to an intervention that works are thus distributed among different actors and the intervention that is ultimately realized in practice is a situated co-production. These insights raise questions that are important for the central quality assurance that lies at the core of a linear EB approach. What actually constitutes the configuration that we refer to as ‘intervention’? How does the ‘intervention’ that is designed and researched at-a-distance, and centrally recognized as effective, relate to what is later supplied to practitioners and to what is ultimately realized in local practice? The answers to these questions are essential for organizations like the CGL that are charged with the task of developing a central quality assurance structure (Abraham et al., 2009, Brug et al., 2010, Dubois et al., 2011, Kelly et al., 2009). This central quality assurance is not a goal in itself, but part of a strategy aimed at contributing to improvement in local practice. A good understanding of what is going on in local practice is essential in finding the best approach to quality assurance and improvement. Though much has been written about how effective interventions should be developed, much less is known about the perspective of HPPs who attempt to make interventions work in practice. The perspective of HPPs is important because these actors play a key role in making interventions work. The aim of this study is to explore what constitutes an intervention that works from the perspective of HPPs, and how, according to them, the development and implementation of interventions should be improved. We explored these questions from a pragmatic perspective, using a case study research design. These issues have a much wider currency than health promotion in the Netherlands. The idea of improving public goods and services, such as health and social services, through central structures for quality assurance has international interest (Berwick, 2005, Kelly et al., 2010). Lessons about how such an approach functions and can be optimized are relevant to all those charged with taking forward an ‘evidence-based’ improvement agenda.

The health promotion system in the Netherlands consists of several organizations at the national and local level. The Public Health Act of 2008 formally assigns the primary responsibility of executing collective prevention to the local municipal governments. Collective prevention should encompass: creating insight into the health status of the population, drafting a local health policy strategy (every 4 years), safeguarding health aspects in policy decisions and contributing to setting up, executing and coordinating prevention programs, including health promotion. By law, every municipality is required to contract the Municipal Health Service (MHS) in their region. Since the decentralization in 2004, the municipalities have full policy freedom in determining the priorities, resource allocation and precise organization of health promotion. There are great differences between the 30 MHSs with respect to the set priorities, the way health promotion is organized, the funding received, the collaboration with local and national organizations and the health promotion activities conducted. This diversity is exemplified by the large difference in the available capacity for health promotion per MHS and the number of citizens for which an MHS works (see Fig. 1). The number of citizens per HPP varies among MHSs from 22,000 to 380,000.

At the national level, the Ministry of Health (MoH) sets broad national priorities and provides task-specific funding for 10 Health Promotion Theme Institutes (TI) that work for specific themes, such as consumer safety, tobacco control and HIV/AIDS prevention (see Table 1, left column). The TIs work at the national level and organize national campaigns, advise the MoH, develop and supply interventions, conduct applied research and support local health promotion efforts. Besides these formal TIs, there are various national organizations, such as the Asthma Fund (Asthma fonds), the Heart Foundation (Hartstichting) and the Foundation for Alcohol Prevention (STAP), that are engaged in health promotion. The Health Care Inspectorate (IGZ) promotes public health through the inspection and enforcement of the quality of prevention measures. In the past, IGZ has reported that health promotion in the Netherlands functioned below expectations. At the request of the MoH, the Center for Healthy Living (CGL) was therefore set up to support health promotion in the Netherlands. One of the core tasks of the CGL has been to develop and manage a quality assurance structure that independently determines which of the developed and supplied interventions are the most ‘effective’ (Brug et al., 2010). The CGL promotes the use of these recognized interventions instead of locally created or other interventions. The IGZ biannually inspects the MHSs and has stated that it will determine the quality of their functioning by assessing the extent to which interventions that are recognized as ‘effective’ by the CGL are implemented. This study is part of a larger project funded by the Strategic Research Fund (SOR) of the Dutch National Institute for Public Health and the Environment (RIVM) and placed at the VU University to assure independence.