Health promotion challenge conceptions and an alternative evaluation approach
Concepções desafiadoras e uma proposta de avaliação em promoção da saúde
Oswaldo Yoshimi Tanaka
Department of Public Health Practice, University of São Paulo. firstname.lastname@example.org
The current article makes an important contribution to the field of collective health by conducting a broad and in-depth review of the available literature on health promotion, as well as the approaches to its evaluation. Taking a didactic and comprehensive perspective to identify and expound on the various concepts (without categorizing or judging them), the authors allow readers to gain a better understanding of the concepts shaping the field of health promotion.
By presenting health promotion concepts and values with the purpose of situating them in the real, local context, the article facilitates both a grasp of these variables and their analysis (whether as results or context variables), a requisite for a deeper understanding of existing relations in the implementation of health promotion initiatives.
By expounding on and analyzing the various approaches to the evaluation of health programs and services, seeking to identify their respective advantages and disadvantages, the article makes a substantial contribution to expanding the possibilities for utilizing various available alternatives for health promotion evaluation.
The article highlights two expected results of health promotion interventions: the increased autonomy for individuals and groups, aimed at citizens' empowerment, and the search for social equity, aimed at decreasing the social inequalities stemming from macro-policies. The process thus clearly involves a redistribution of powers in the definition of public policies. The strategy of promoting effective participation by various social actors in all the activities and actions aims at the sustainability of the resulting social changes. The inter-sectoral approach is a creative way of formulating the proposal in such a way as to not hold one specific sector accountable for the implementation of actions (or thereby delegating the command over the objectives to a single social actor), and this strategy thus tends to facilitate the process of participation and shared accountability, thereby empowering health promotion initiatives.
As appropriately emphasized in the article, in light of the more comprehensive concept of health promotion, the variables from the local context in which social changes are expected along the lines of increased autonomy and decreased inequalities should be identified in order to serve as the baseline for the evaluation process and for the analysis of such changes, allowing to relate the activities and actions to the observed results.
It thus becomes important to know the prevailing cultural and social patterns and their interrelations, in order to identify which context variables should be known and explored for an analysis of the feasibility of changes deriving from the activities and actions and which are actually part of the changes achieved in terms of autonomy and decreased social inequalities, as emphasized by Mercado (2002).
In relation to the health promotion concept, the article proposes to explore a mix of methodological approaches for evaluating health programs, services, and policies, as proposed by Tanaka & Melo (2001). The authors thus identify important points in the various existing alternatives, outlining the theoretical/conceptual framework and the advantages and disadvantages of each approach presented. The article takes a quantitative/qualitative mix as its methodological option in order to deal with health promotion as both object and subject, based on the concepts presented in the article.
The choice to employ the fourth-generation evaluation focus proposed by Guba & Lincoln (1989), which includes the strategy of effective, negotiated participation by the various social actors involved in implementation (and consequently in evaluation) allows to contemplate two crucial lines of evaluation, namely: 1) the formulation of a contextualized and feasible evaluation question and 2) potentiation of the use of value judgments resulting from evaluation, also used by Tanaka & Melo (2004). Furthermore, by defining inter-sectoral work as the principal thrust for the process of social change in health promotion initiatives, evaluative design should contemplate the analysis of activities in terms of the achievement of the various shared responsibilities defined in the inter-sectoral approach as well as the intensity of this action.
The choice to begin the evaluative design with these two strategies has the advantage of allowing directionality in the formulation of the evaluation question, besides facilitating the identification of contextualized parameters to be used in the evaluation, thus incorporating the more comprehensive concept of increased autonomy and decreased inequalities. This approach thus makes the relationship clearer between the strategies implemented and the results achieved, thereby allowing a more in-depth analysis of the degree and intensity of the relations between the initiatives implemented and the results achieved, fostering knowledge of the conditionality between these variables.
The overall scheme of evaluative design becomes more feasible and provides greater opportunity for participation in the various stages of implementation to the extent that, from the beginning, there is adherence by the various social actors. I reiterate that participation and the inter-sectoral approach empower the establishment of this interrelationship.
Data collection and analysis should thus be based on these intervention strategies, which I consider part of the process as proposed in Tanaka & Melo (2001). When public policies are the focus of evaluation, the basic premise is that there is some type of quantitative information available in the activities and/or actions implemented by health promotion that would serve to analyze the trends in participation and the type of shared responsibility implemented through inter-sectorality. This first quantitative approach to the lines of action will allow one to raise non-explanatory or non-relational "issues" or "questions", yet ones that are sufficient to identify which variables (in the intensity of actions and the commitment to shared responsibility by the various stakeholders) should be collected and analyzed in order to understand to what extent the expected results have been achieved. To understand these types of questions, a qualitative approach is indispensable, not from the perspective of understanding in greater depth, but from the perspective of identifying the relations in the process of constructing the intervention, as well as to identify the influence of increased autonomy and decreased inequalities in achieving the expected results (Creswell, 1994; Tanaka & Melo, 2002).
Thus, by deepening the understanding of the relations, the subsequent stage of analysis of the results will be conditioned by what was found in the evaluation of these interventions, which will facilitate the process of identifying the context variables that should be explored, whether to seek the results achieved or to sort out the variables that may have undergone changes, but which cannot be related to the interventions conducted by health promotion initiatives, as reported by Uchimura & Bosi (2004).
Therefore, the construction of a methodological mix including quantitative and qualitative approaches will be conditioned by given factors, such as the availability and ease of obtaining information and the kind of analysis to be performed.
The quantitative approach can be useful for the analysis of trends or even the speed in the implementation of activities and/or actions. Thus, trends analysis serves as an avenue that allows one to judge the direction of the initiative, to the extent that one expects results indicating that what has been implemented is capable of obtaining the expected result. Nevertheless, in order to understand the scope of the result, it is necessary to understand the meaning and/or intensity with which interactions and/or shared responsibilities have occurred in the implementation of the health promotion initiative. It is therefore necessary to use the qualitative tools in order to inductively provide a critical analysis that is more in keeping with the evaluation questions that have been posed.
This methodological mix could be explored inversely. If we begin with the evaluation question concerning the degree of change provided by the interaction and/or shared responsibility (among the various actors in the inter-sectoral work), by which we could explore through ethnography (Coulon, 1996), inter-actionism (Denzin & Lincoln, 1994), or even constructivism (Spink, 1999) the intensity and degree of change provided by the interaction. Knowing the meaning of the possible scope, we could explore, through a search in the quantitative data, the reach of these interactions in the subject of our actions.
The debate article's argument is reinforced by the experience our team developed in evaluating the Brazilian Program for Humanization of Prenatal and Childbirth Care (PHPN) (Ministério da Saúde, 2004). Although the PHPN is a health program in the classical sense of hospital-based medical care, it raised the challenge of introducing humanization into the provision of services. This qualitative characteristic resulted in the methodological proposal of evaluating this national program using a quantitative/qualitative mix. The initial stage involved an analysis of the available quantitative data in an Internet database, together with the exploration of a specific information system elaborated and implemented to monitor the program and known as SISPRENATAL. Exploration of these data began with the stratification of Brazil's municipalities (or counties) by population and geographic region. By exploring the possible context variables, and mainly the health services supply, it was possible to identify some key evaluation questions for which a more in-depth investigation would be needed in order to understand the respective inter-relations. The methodology proposed for this purpose was thus a qualitative approach. In order to select the real situations and the social actors to be involved, we began with a survey of the universe of municipalities in the country as a whole, which were regrouped based on a certain degree of similarity in relation to the following: either they displayed a health services supply which was not in keeping with the results displayed in the program, or they had a much better performance as compared to municipalities with similar conditions in terms of services supply. It was thereby possible to identify municipalities which, based on the peculiarities of the study variables, might constitute rich "case studies" for a qualitative approach which would allow to identify which other variables were at stake, as well as the meaning of the results. The set of municipalities with these variables was used to select case-study municipalities to become the object/subject of the qualitative study. In each of these municipalities, a case-study methodology was applied using semi-structured interviews and focus groups. This methodological mix allowed us to explore the interrelations among the various social actors in the health care process and to identify the crucial actions and activities in the Program for Humanization of Prenatal and Childbirth Care that would allow for decision-making to enhance the Program and reach the expected results.
Based on the practical application of the mix proposed by the article, it was possible to make the results of the Program's evaluation available, involving aspects of the program's strategy and identification of favorable variables, besides highlighting the context variables that impacted the analysis of the results achieved. The qualitative approach fostered a critical analysis of the various views of the Program on the part of health systems managers, health professionals, and users of the Unified National Health System.
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