Community health promotion : facilitating and evaluating coordinated action to create supportive environments

Introduction Community programs to promote health have been launched all over the world and fit well with Dutch policy that emphasizes the participation of all citizens in all facets of society. However, researchers, practitioners, and policy makers report uncertainty about how to implement and evaluate health promotion programs. In particular, the social environment of health is still overlooked and underexposed due to a lack of consensus on concepts relating to the social environment of health, a lack of information on interventions that bring about social change, and a lack of feasible methods and tools. Consequently, the effectiveness of health promotion may not be evaluated under all relevant headings. Methods The aim of the studies reported in this thesis was to gain the required knowledge to contribute to the development of methods, tools, and theory to facilitate and evaluate community health promotion. Case studies have been selected that are guided by action research or in which action research was part of the research activities. Methods, tools, and theory have been developed, piloted, and evaluated simultaneously and iteratively in the Eindhoven program Working on Healthy Neighborhoods and the Healthy Lifestyles program in Amsterdam. Based on these case studies and the experiences in other Dutch community health programs, factors that are important in community health promotion were identified and a framework to facilitate and evaluate the social environment of health was developed. Based on the factors and the framework a Checklist for Coordinated Action was developed and assessed for usability in six different partnerships: a national program, an academic collaborative and four local partnerships. Results In the Eindhoven program the participatory action research facilitated the restart and continuation of the program, the achievement of intersectoral collaboration, the initiation of community participation, and other accompanying research. In the Amsterdam program, participatory approaches facilitated the participation of 15% of the target population at the desired level in the different phases of the program. The factors important in community health promotion are representation of relevant societal sectors, discussing aims, objectives, roles and responsibilities, communication infrastructure, visibility and management. These factors helped to develop a framework and guidelines which offer operational variables of participation and collaboration and thereby provide common ground for researchers and practitioners. The developed Checklist for Coordinated Action facilitates and evaluates partnerships that differ in context and level, phase of the program and topics addressed. Conclusion The thesis has revealed that action research methods and tools are valuable because they fit community health promotion, they generate actionable knowledge for relevant stakeholders, and they are essential and complementary in capturing and assessing the full effects of a community health promotion intervention. Scientific quality is assured by the use of different verification techniques and scientific criteria. Participation is of cardinal value as it contributes to health and serves multiple purposes in health promotion programs. Systematic learning processes can make participation manageable, and research activities are a proper way to facilitate those learning processes. Nonetheless, the potential of participation has not yet been harnessed. Participation thrives in principle-based programs: programs that are characterized by the co-generation of knowledge by involved stakeholders in a flexible and tailored way. To further develop and harvest the full benefit of participation and principle-based programs, researchers are challenged to broaden their research paradigm, practitioners are challenged to foster and coordinate principle-based programs, participation and learning processes and policymakers are challenged to stimulate and support science and practice. By participating and collaborating supportive social environments for health can be created