Evaluating Health Promotion: Why Does Context Matter

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Evaluating Health Promotion Why Does Context
Matter?

• Louise Potvin, PhD
• Chair Community Approaches and Health
  Inequalities
• Université de Montréal
• 2nd Brazilian Seminar on Health Promotion
  Effectiveness
• Rio de Janeiro, May 14th 2008

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Acknowledgements

• Sherri L. Bisset, PhD candidate (U. de Montréal)
  whose thesis provides empirical illustrations for
  this presentation
• Contributors to Health Promotion Evaluation
  Practice in the Americas Values and Research
  (forthcoming). New York Springer.

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Thesis

• Health promotion programs are systems of actions
  that operate as socio-technical networks they
  produce innovations by creating and strengthening
  new linkages between technical devices and local
  actors
• The role of evaluation is to produce knowledge to
  guide future action regarding parts of the
  socio-technical network, in the same or other
  contexts
• Evaluations important role is to document links
  between technical devices, local actors,
  conditions and actions, and changes in local
  context

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Plan

• Programs in context health promotion as a
  socio-technical network
• Program implementation Operating the expansion
  and consolidation of a socio-technical network
• Program evaluation context matters

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Part 1Health Promotion as Socio-Technical
Network
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The Ottawa Charter Two Innovations

• Definition of health
• Health is produced in every day life linked to
  access to local resources/conditions
• Principles of action
• Participation Empowerment legitimacy of non
  expert, local knowledge
• Intersectoral health producing resources are
  accessible through non health sector providers

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A Social Definition of Program

• Programs are social constructions a tinkering of
  previously unrelated (or loosely related), and
  disparate human and non human components
• Knowledge (model of action best practice local
  culture)
• People (staff target population partners)
• Problem (determinants, consequences)
• Technical devices (compound manual meeting
  minutes)
• Activities (meetings courses celebrations)
• Resources (financial material human)
• A mix of local and imported elements
• Need a social process to explain how such
  heterogeneous elements can hold together

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The Actor-Network Theory (ANT)

• Michel Callon Bruno Latour John Law
• Two underlying stories (J. Law)
• Relational materiality  Entities take their
  form and acquire their attributes as a result of
  their relations to other things divisions and
  distinctions are understood as effects. They are
  not given in the order of things 
• Performativity  Entities are preformed in, by,
  and through, those relationships. 

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Socio-Technical Network

• Focus on actions and interactions Both actors
  and networks are outcomes and linked through
  action.
• Actors no ontological rupture between human and
  non-human (technical) entities both are capable
  of agency. Both are defined by, and define, the
  network
• Two orientations of action stabilising existing
  relations and making new connections
• Translation links heterogeneous entities into a
  network

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Socio-Technical Network of Health Promotion
School-Based Nutrition
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Part 2Expansion and consolidation of a
socio-technical network
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Translation

• Operation of linking the networks heterogeneous
  entities
• Ongoing interpretations/reinterpretations by
  actors of their roles and of the innovative
  product, going from their respective interests
  and their power relations and leading to the
  elaboration of compromises
• Four operations
• Problematization
• Interessement
• Enrolment
• Mobilization

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Problematization

• Setting in motion of actors around a provisional
  and minimum project
• Definition of the problem/situation by the
  project or innovation promoters,
• Identification of affected actors, their
  interests and the issues linking them
• Assingment of roles and identities
• HEALTH PROMOTION assigning health meanings to
  non-health entities

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Interessement

• Set of strategies adopted by the various actors
  with a view to
• rallying the other actors around a shared
  objective
• defining their role
• Interessement strategies seek to align actors
  new identities and roles with their interests
• Interessement strategies take shape in material
  devices
• HEALTH PROMOTION actions and artefacts that
  concretely link existing entities with health
  knowledge, partnership agreements,

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Enrolment

• Enrolment occurs when the actors take on a role
  in the network in line with the problematization
• Successful interessement gives rise to
  negotiation which leads to acceptance of a
  precise role enabling the networks consolidation
• HEALTH PROMOTION integration of new
  health-related roles and identities by networks
  entities

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Mobilization

• Mobilization concerns the involvement of a
  critical mass of actors in the action system so
  that innovation becomes relevant, useful,
  indispensable
• Actor mobilization, above and beyond their
  representatives, leads to network extension
• In contrast, the absence of solidity of
  representatives leads to controversies
• HEALTH PROMOTION capacity to displace entities
  and orient their actions in a health-related
  direction

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Translation
PROBLEMATIZATION
INTERESSEMENT
MOBILIZATION
ENROLMENT
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An Example Petits Cuistot-Parents en Réseaux
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Part 3Context and Program Evaluation
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Evaluation and Socio-Technical Networks

• Socio-technical networks are performative they
  acquire reality through action
• Movements in socio-technical networks
  consolidating existing linkages or expansion
  through new linkages
• Evaluation systematic knowledge to inform
  movements for consolidation or expansion of
  network

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Knowledge to Support Consolidating Network

• Focus on the internal context of programs
• Modeling existing entities (numbers, identities,
  roles) their links (strength, meaning), actions
  (number, nature, roles) and controversies
  (nature, solutions translations)
• Methods systematization
• Complementarity of qualitative and quantitative
  information

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Knowledge to Support Expanding Network

• Networks expansion enrolling new entities
  through new or renewed linkages
• Focus on the link between existing network
  (internal context) and external context
• The distinction between external and internal is
  contingent

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Lessons from Health Promotion Evaluation
Practices in the Americas

• Research methods are not  context-neutral 
  evaluation activities are part of a program
  context and there are meaningful linkages between
  evaluation and program
• Innovative evaluation practices strengthen links
  between local context, evaluation and program
• Evaluators have difficulties to reflect on their
  practice beyond the technical aspects of
  cellecting empirical data