Health Promotion International, Vol. 19, No. 1, 85-94, March 2004
© Oxford University Press 2004. All rights reserved
PERSPECTIVES |
Issues in measuring health promotion capacity in Canada: a multi-province perspective
1Saskatchewan Heart Health Program, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, 2Heart Health Nova Scotia, Dalhousie University, Halifax, Nova Scotia, Canada, 3British Columbia Heart Health Project, British Columbia Ministry of Health Planning, Victoria, British Columbia, Canada and 4Alberta Heart Health Project, University of Alberta, Edmonton, Alberta, Canada
Address for correspondence: Lori S. Ebbesen, Program and Evaluation Officer, Saskatchewan Health Research Foundation, 253-111 Research Drive, Atrium Building, Innovation Place, Saskatoon, Saskatchewan, Canada S7N 3R2, E-mail: lebbesen{at}shrf.ca
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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Significant international progress has been made researching and addressing the economic and social burden of cardiovascular disease, advanced particularly by international conferences and subsequent declarations, and the Canadian Heart Health Initiative (CHHI). The implementation focus of the CHHI on building capacity for heart health promotion is paralleled by efforts to measure capacity. Through the collective experience of Heart Health Programs in Nova Scotia, Saskatchewan, Alberta and British Columbia, critical issues in measuring health promotion capacity are identified and strategies for addressing them are presented. The provincial contexts for the programs vary, as do the conceptualizations of capacity and intervention strategies to build capacity. Yet, despite such differences across provinces, shared issues influencing measuring capacity number many. These include: multiple understandings of terms; evolving understanding of capacity; invisibility of capacity building; detecting change within a dynamic system; staff turnover; time course required for change; attribution for change in capacity; understanding a process through ‘snap-shot’ measurements; lack of existing ‘gold standard’ measurement tools; validity and credibility of instruments; evolving nature of measurement tools; gathering perspectives from multiple levels within organizations; dealing with conflicting perspectives; and managing and disseminating sensitive data. A number of strategies have been devised or adopted to address measurement issues, ranging from adopting participatory processes to the development of monitoring systems. Understanding and addressing issues in measuring capacity deserve attention as they may be potent influences in the dynamic interplay between research and intervention in the process of capacity building in the context of health promotion generally, and/or heart health specifically.
Key words: capacity building; health promotion; measuring capacity
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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The role of capacity building in professional development on individual, community, system and policy levels has been noted in various sectors (Floden et al., 1995
). Over the past decade, the importance of capacity building within the health sector generally, and the field of health promotion specifically, has received increasing emphasis internationally (Hawe et al., 1997; Elliott et al., 1998; Goodman et al., 1998; Casebeer et al., 2000; Crisp et al., 2000; McLean et al., 2000; Smith, N. et al., 2001). Capacity building, and by association capacity, has been conceptualized either vaguely or in a number of ways (Hawe et al., 1997; Smith, N. et al., 2001). It commonly represents a redirection of health promotion activities from population groups to the health system or organizations responsible for health promotion for the purpose of enhancing their ability to develop, implement and sustain health promotion programs and, ultimately, health changes (Hawe et al., 1997; Eades, 2000).
Capacity building in health promotion can be viewed as a means and as an end in itself (Labonte and Laverack, 2001a; Labonte and Laverack, 2001b). Further, capacity building is not a unitary concept. It occurs in multiple domains and consequently four main approaches to capacity building have been identified: top-down organizational, bottom-up organizational, partnerships and community organizing (Crisp et al., 2000). It has been contended that changes in one domain of capacity often have an impact upon another (Crisp et al., 2000). Others extend the argument further to say that capacity is not created to its full potential unless more than one domain has been impacted (McLaughlin et al., 1997).
As a consequence of this shift toward capacity building, a different set of program outcomes for health promotion initiatives is warranted (Hawe et al., 1997). Differing types of capacity indicators for use in health promotion planning and evaluation are useful and required (Labonte and Laverack, 2001a). Changes that occur in the organizational context of the health system itself, and result in lasting and wider health gains, become increasingly important. Yet, the methods of assessing the benefits of building capacity in the health system remain elusive (Potvin, 1996; Hawe et al., 1997), and establishing the links between capacity building and health outcomes is an ongoing research challenge (Crisp et al., 2000). In this regard, principles to guide evaluation efforts in this field have been proposed. Evaluation efforts need to account for the fact that: (i) capacity building is a process that evolves over time; (ii) the organization or community is the target for change and aggregates of individual change may be inappropriate; and (iii) change may occur in unanticipated domains (Crisp et al., 2000). Methods for assessing change in capacity domains are many (Labonte and Lavarack, 2001b). Different measures may be required at different stages of capacity development and a heavier reliance on qualitative research approaches needs to be considered (Crisp et al., 2000). Analysis of the capacity-building process, as well as the evaluation of capacity-building efforts, merit attention (Farquhar, 1996; Johnson et al., 1996; MacLean, 1996).
Capacity building has been clearly articulated and advocated for heart health promotion. For example, the Singapore Declaration (Advisory Board Third International Heart Health Conference, 1998) deals explicitly with creating capacity by developing a heart health infrastructure and the political will to act at international, national and local levels. To that end, the dissemination phase of the Canadian Heart Health Initiative (CHHI) has embraced and operationalized capacity building as its focus.
The CHHI is a multi-phased research and implementation partnership between federal and provincial governments, in which the Heart and Stroke Foundation of Canada and some provincial foundations are major partners. Early phases of this initiative have resulted in Canada-wide cardiovascular disease (CVD) risk surveys (Choiniere et al., 2000; Potvin et al., 2000), and informed understanding of community mobilization regarding heart health through community demonstration projects [Conference of Principal Investigators (COPI), 2002]. The current 5-year phase of the CHHI is devoted to dissemination research in which some provincial projects are explicitly using capacity building as the primary intervention to facilitate the dissemination and delivery of health promotion and prevention programs, policies, activities, services and processes. The implementation focus on building capacity is integrally linked to the research focus on measuring capacity. To varying degrees, the provincial projects broaden the discourse on ‘heart health’, i.e. building and measuring capacity to engage in heart health promotion is connected with, and informs, building and measuring capacity to address other health issues and chronic disease prevention generally.
This paper is designed as a contribution to the growing body of literature on the understanding and measurement of health promotion capacity. It draws on the collective experiences and wisdom of four provincial dissemination phase CHHI projects, from east to west: Heart Health Nova Scotia (HHNS) (Heath et al., 2001), the Saskatchewan Heart Health Program (SHHP) (Ebbesen et al., 2001), the Alberta Heart Health Project (AHHP) (Smith, C. et al., 2001) and the British Columbia Heart Health Project (BCHHP) (Naylor et al., 2001). Pragmatic issues in measuring capacity and an extension of the dialogue on how to address such issues will be described. Researchers from these four provinces engaged in a series of teleconferences and written exchanges from January 2000 to February 2001, to identify issues in measuring health promotion capacity experienced across provinces and to identify viable strategies for addressing these issues.
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BACKGROUND |
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TOPSUMMARYINTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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Within the CHHI, there is recognition that the measurement of capacity is embedded within the conceptualization of capacity, as well as efforts to build capacity. Although some overlap exists, the components of capacity are conceptualized and articulated differently across the provinces (see Table 1). Differences exist among the four provinces regarding goals, project status, and targets for intervention and measurement (see Table 1).
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All four provinces address organizational capacity, and Saskatchewan and Alberta also include individual capacity explicitly. Saskatchewan, Alberta and British Columbia direct intervention and research efforts toward the health authority, district or region, while Nova Scotia directed efforts at community-based organizations, including the health authority.
Intervention strategies differ across the provinces. Nova Scotia used partnership and organizational development (technical support, organizational consultation, action research and community activation) as mechanisms for capacity building, while Saskatchewan offers continuing education, consultation and peer networking. Alberta is in the process of developing their interventions and plans to offer ‘capacity-specific’ educational sessions designed to match the needs of the Regional Health Authorities (RHAs) and opportunities for peer networking. British Columbia emphasizes facilitating the work of champions and enhancing infrastructure, the evidence and policy bases, collaboration and technical expertise.
All four provinces use multi-method designs incorporating qualitative and quantitative research methods to both measure capacity and to understand the capacity-building process. At the time of reporting, Nova Scotia has finished its dissemination phase, while Saskatchewan is in year 5, Alberta year 3, and British Columbia year 4. Despite this backdrop of differences and varying provincial contexts, a number of common issues influencing measurement of capacity were identified.
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ISSUES IN MEASURING CAPACITY |
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TOPSUMMARYINTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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The issues in measuring capacity identified across provinces are not mutually exclusive as many of them interact. Within this list of issues generated, no attempt is made to specify which provinces they apply to and to what extent these issues have been experienced.
Multiple understandings of terms
The lack of a consistent understanding of health promotion and prevention terminology across settings, organizations and individuals presents as a measurement challenge. A shared understanding of health promotion cannot be assumed when exploring health promotion capacity with key informants at multiple levels of an organization and/or across sectors. These informants do not necessarily espouse the same meaning for the same terms. Similarly, understanding regarding ‘heart health’ and ‘heart health promotion’ is a complementary issue. For some respondents, ‘heart health’ implies a disease focus, which they feel is dissonant with a health promotion philosophy. Others find the term too lifestyle oriented and therefore restrictive. This issue of multiple understandings of various terms has implications in the design and format of measurement tools, as well as for data analysis.
Evolving understanding of capacity
The definition and nature of capacity is currently evolving and, therefore, measurement tools—particularly quantitative ones—can be extremely lengthy and complex in order to tap into actual and/or potential dimensions. Consequently, respondent burden becomes a concern.
Invisibility of capacity building
Implicit in health promotion work is citizen empowerment and shared ownership, the achievement of which creates a ‘culture of invisibility’ in health promotion in general, and capacity building in particular (Hawe et al., 1998). This invisibility of capacity building, in turn, presents a difficulty in recognizing, describing and measuring the process. In addition, invisibility challenges attribution of impact of capacity building efforts for individuals and organizations tasked with that mandate.
Dynamic contexts
Measuring health promotion capacity is challenged by the nature of the provincial contexts and capacity building itself. The health system is one that across all of the four provinces is dynamic, and either undergoing or threatening dramatic restructuring. Prominent contextual aspects that have influenced the measurement of capacity include: staff turnover, health system renewal, conflicting perspectives across informants within organizations, conflicting personalities within organizations and between informants and researchers, ‘turf protection’ by health workers in different departments, and organizational staff understanding and valuing the research process.
Organizations are composed of multidimensional systems of their own, and organizational capacity building is, by necessity, a fluid process. Working within diverse organizational systems and with various individuals requires a multi-level, integrated and responsive approach to capacity building, which poses further challenges for measuring capacity.
Time course for change
The long-term outcome for provincial CHHI projects is enhanced capacity that will ultimately contribute to improved health in the population. Organizational and/or individual capacity serve as an intermediate outcome, as do enhanced health promotion and prevention skills, services and programs. The time course for such individual or systems changes to occur (Porras and Robertson, 1987; Goodman et al., 1996) is a challenge to projects with set timeframes, such as the provincial Heart Health projects. Our collective focus on organizational change within a 5-year research project tempers our ability to actualize and measure noticeable changes at the organizational level, let alone at the population health level.
Building trust and dealing with sensitive issues
It has been important to establish and/or develop further a trusting relationship between researchers and organizational or community representatives to ensure high quality data. Initially in particular, researchers had to combat the perception that exploration of capacity infers or refers to performance appraisal. Equally as important is the longitudinal nature of the research. The provincial research protocols are designed to explore a process of capacity building and therefore require multiple connections over time. The relationships underlying these multiple connections depend on trust and are a mediating factor that cannot be underestimated (Cameron et al., 1996; McLean et al., 2001).
Finally, understanding the process of capacity building necessitates an exploration of facilitators and barriers. Events, factors or circumstances influencing health promotion capacity at an organizational level may pertain to sensitive, personnel or organizational issues. The development of appropriate questions and the subsequent documenting and sharing of such sensitive information without breaching confidentiality or the trust that has been established poses a research challenge.
‘Snap-shot’ measurements
Health promotion capacity building is a process of, for instance, increasing knowledge, improving skills, creating infrastructure, and garnering human and financial resources. The extent to which this process can be tracked and closely monitored varies across provinces; however, all face the challenge of capturing nuances and developments as they unfold. Quantitative instruments are marred as they provide ‘snap-shots’ in time. Although qualitative interviews allow the exploration of critical events or milestones, they count on accurate and comprehensive recall of informants, sometimes months after a particular occurrence.
Validity and reliability of quantitative measures
As mentioned, the conceptualization of capacity continues to evolve and there is no ‘gold standard’ tool to measure heart health promotion capacity. Establishing criterion validity is therefore compromised. In the absence of a definitive tool, the four provinces have drawn on and adapted existing tools, and created new instruments to suit respective needs, introducing questions of validity and reliability. Are we measuring what we purport to measure? Are our instruments reliable?
External validity, the generalizability of findings to and across populations of subjects and settings, is difficult to reach because each project is context specific. Psychometric testing of quantitative surveys used in the provinces is challenging due to the relatively small sample sizes.
Attribution for change in capacity
Realizing the investment and ‘dose’ of CHHI efforts are embedded within a much broader capacity-building context; a further aim of the provincial Heart Health projects is to understand and evaluate their respective contributions to the process of capacity building. The extent to which this is possible, indeed desirable, poses a potential threat to measuring capacity. The process for building health promotion capacity in the four provinces is participatory. The organizations and individuals who are ‘recipients’ of the capacity-building interventions are integrally involved in developing, planning and evaluating the process. If the principles of participatory action research and health promotion are adhered to, then ‘others’ take ownership and embrace the work as their own. This is both a positive aspect of the process and an outcome; however, identifying both the successful elements of the capacity-building strategy and the independent contributions of the Heart Health projects becomes complex. In addition, the internal validity of the CHHI projects is threatened by a number of other external factors that contribute to capacity building. For instance, extreme volatility in the health care system, changes in health promotion funding, and testing of and maturation in instrumentation challenge the provincial projects to conclude that the interventions (independent variable) are responsible for changes in health promotion capacity (dependent variable).
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ADDRESSING MEASUREMENT ISSUES |
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TOPSUMMARYINTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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A number of strategies and means were devised or adopted in the CHHI provincial projects to address these issues in measuring capacity. Not infrequently, a single strategy addresses more than one of the measurement issues described. Conversely, a single issue may be addressed by multiple strategies. These strategies, displayed in Table 2 and described below, range from adopting participatory processes to the development of monitoring and feedback systems to assess inputs, throughputs and outputs of the research projects.
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Research processes, including the development of survey tools and interview guides, have been participatory, utilizing extensive consultation within and across provinces. The participatory processes help to combat mixed understandings of health promotion, heart health and capacity through ongoing discourse and prolonged engagement. The participatory nature of the projects, where researchers and participants are working together to operationalize key constructs and develop and implement instruments, helps to build common understanding of terminology. In addition, the measurement tools used in these four provinces are designed to serve two purposes: education as well as data collection. Introductory statements, questions, and sections of surveys and/or interview guides position or clarify heart health promotion issues and the conceptualization of capacity, thereby addressing the mixed understanding of these two areas. In this way, both the research processes and tools serve in and of themselves as interventions in building health promotion capacity (Cameron et al., 1996
; COPI, 2002). The importance of acknowledging and collecting data about a variety of contexts related to capacity and capacity building is also highlighted by the provincial experiences. The dynamic nature of the health system challenges the measurement, and for that matter the building of heart health promotion capacity. The provinces regard an understanding of the larger environment influencing health promotion capacity as an integral component of the research. We are investigating and then providing a rich description of context—national, provincial and organizational—in order to situate findings and facilitate transferability across settings.
Quantitative and qualitative research methods inform different aspects of capacity measurement, i.e. changes in capacity and the process through which such changes occur, respectively. Each of the four provinces incorporated mixed methods research designs to capture both health promotion capacity at certain points in time, as well as the evolution of capacity over time (Farquhar, 1996; MacLean, 1996). The use of mixed methods permitted the results of one means of data collection to add to or to guide the other. For instance, survey results have informed questions for interview guides and vice versa. As the projects unfold, a heavier reliance has been placed on qualitative data-gathering strategies, as they are judged as more amenable to health practitioners engaged in the research and more appropriate for exploring the process of capacity development (Crisp et al., 2000).
The CHHI, a long-standing and well respected initiative within these four provinces, offered an important condition for success in the measurement and building of capacity in the form of prolonged engagement with communities and organizations involved in heart health promotion. The nurturing of relationships established in previous phases and in other community-based research has facilitated access to organizations and individuals within the health system and in other sectors. The nature and quality of researcher and practitioner relationships facilitates research processes (Cameron and Best, 1987; Cameron et al., 1996). The need to develop provincial credibility as research teams has been minimized due to the history and contributions of previous Heart Health phases, and other experiences in community-based research. The maintenance of this credibility is fostered through open and transparent research processes, ongoing dialogue, and the action–reflection orientation of the projects (where findings are continually used to inform the capacity-building process). At the national level, the established and developing network of Heart Health representatives has been a catalyst and a resource, as it has provided the opportunity to build on collective wisdom and experience.
Content validity of quantitative measures measuring capacity across provinces is high. Many of the scales embedded in survey instruments have been created based on theory ‘borrowed’ or adapted from other valid tools (Isreal et al., 1994; Prochaska et al., 1997; Hawe et al., 1999). Each consecutive province has had the opportunity to build upon the work of previous provinces. Moreover, each province has taken the time to focus test, field test and/or pilot test instruments in their own context. More recently, the Alberta Heart Health Project has addressed construct validity testing directly using factor analytical techniques. The construct validity of their scales has proven to be highly satisfactory with psychometric testing, providing clear evidence of sound scales. Furthermore, the internal reliability of the scales has also proven to be highly acceptable with Chronbach's alphas of 
0.66 for all scales.
Ensuring the trustworthiness of qualitative data is a parallel consideration in the assessment of capacity in the four provinces, and is comparable to the assessment of the validity and reliability of quantitative measures. Trustworthiness has been enhanced in the projects through triangulation, participatory research processes, member checks, peer debriefing and prolonged engagement. More specifically, two forms of triangulation have been adopted in the Heart Health projects. First, methodological triangulation is being practiced. Each of the four provinces has adopted multiple methods of data collection, including surveys, in-depth interviews, document review and participant observation, to understand the complex phenomena of capacity and building capacity. The mix of qualitative and quantitative methods of data gathering provides the projects with strong research designs that allow for a more valid measure of capacity, and a fuller understanding of capacity building for health promotion, within and across organizations and individuals. Secondly, researcher triangulation, the independent and collective review of data by more than one researcher thereby enhancing the credibility of the findings, is a strategy being used.
Processes adopted in each of the provinces invite participation in the research processes. As noted previously, pilot testing of instruments, participant observation, conducting Think Tanks to clarify and contextualize issues, and the development of joint intervention planning committees are examples of ways in which participants in the dissemination phase have been engaged in the process.
Member checks and peer debriefing among multiple researchers add further to the credibility of research findings (Lincoln and Guba, 1985). Data, analytical categories, interpretations, conclusions and implications for action are tested with members of those stakeholder groups from whom the data were originally collected and subsequently revised accordingly.
Also contributing to trustworthiness is prolonged engagement, which allows researchers to: learn the organizational or community culture; test for misinformation introduced by distortions either of self or of the respondents; clarify differing perspectives; and build trust. It permits identification of those characteristics and elements in the situation that are most relevant to the problem or issue being pursued, to focus on them in detail and to track them closely as they unfold (i.e. understand the process of capacity development).
Exploring the contributions of capacity-building interventions generated by the Heart Health projects has been accomplished and informed through: (i) the development of monitoring systems that track both participation (‘reach’) and number and type of interventions (‘dose’); and (ii) intervention-specific evaluations. Such efforts honor the dynamic nature of capacity building and identify process indicators thereof. They illuminate important markers of success in the development of capacity, the change process, and tease out facilitators of, and challenges to capacity building. Monitoring systems and intervention-specific evaluations help to assess the independent contributions of the Heart Health projects and are critical to the development of knowledge in this area.
Finally, a willingness to be creative and flexible in research design is an integral part of measuring capacity. Given the dynamic context and system, and the process of building capacity, the appropriateness of research designs that rely on repeated measures with instruments developed at the outset needs to be re-examined. Appropriately so, instruments in these four Heart Health projects have evolved based upon feedback, ongoing analysis and context, and as understanding of capacity itself has matured. For instance, the first surveys of health organizations in all provinces were considered a baseline of health promotion capacity. Subsequent rounds of surveys conducted in these provinces shifted focus to address changes in capacity and to examine more fully issues highlighted in early research data, therefore necessitating revisions to the instruments.
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SUMMARY REMARKS |
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TOPSUMMARYINTRODUCTIONBACKGROUNDISSUES IN MEASURING CAPACITYADDRESSING MEASUREMENT ISSUESSUMMARY REMARKSREFERENCES |
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Health promotion capacity is receiving international attention and is still an evolving concept. An understanding of its various components or elements continues to develop; the CHHI is making a noteworthy contribution in this regard. The dissemination phase of the CHHI builds capacity for heart health promotion through integrated multi-sector and multi-level implementation, and is paralleled by efforts to measure capacity. As has been noted, understanding and addressing issues in measuring capacity deserves further attention as it may have potent influences in the dynamic interplay between research and intervention in the process of capacity building, multiplying health gains and, ultimately, health system reform (Hawe et al., 1997
; Casebeer et al., 2000; Elliott et al., 2000). Through broadening the discourse on heart health and drawing on international health promotion capacity literature and efforts, lessons learned through the CHHI about capacity building and measurement extend beyond heart health and beyond national borders. This paper draws on the collective experiences and wisdom of four provincial CHHI Projects (HHNS, SHHP, AHHP and BCHHP) to describe issues in measuring capacity and to extend the dialogue on how to address such issues. It illustrates the intriguing and important balance of ‘art’ and ‘science’ embedded within these research initiatives. Scientific rigor is intricately blended with the art of flexibility, adaptability and garnering meaningful participation in and through the research processes.
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ACKNOWLEDGEMENTS |
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The authors acknowledge the contributions of the Heart Health teams in each of the four provinces, in recognition of the collective wisdom upon which this paper is based. Funding for our projects has been provided nationally by the Canadian Institutes of Health Research, provincially by the Nova Scotia Department of Health, Saskatchewan Health, Alberta Health and Wellness, and British Columbia Ministry of Health, and, in Saskatchewan, the Heart and Stroke Foundation of Saskatchewan.
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 N. Hanusaik, J. L O'Loughlin, N. Kishchuk, J. Eyles, K. Robinson, and R. Cameron Building the backbone for organisational research in public health systems: development of measures of organisational capacity for chronic disease prevention J. Epidemiol. Community Health, August 1, 2007; 61(8): 742 - 749. [Abstract] [Full Text] [PDF]
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E. W. Nam and K. Engelhardt Health promotion capacity mapping: the Korean situation Health Promot. Int., June 1, 2007; 22(2): 155 - 162. [Abstract] [Full Text] [PDF]
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M. B. Mittelmark, M. Wise, E. W. Nam, C. Santos-Burgoa, E. Fosse, H. Saan, S. Hagard, and K. C. Tang Mapping national capacity to engage in health promotion: Overview of issues and approaches Health Promot. Int., December 1, 2006; 21(suppl_1): 91 - 98. [Abstract] [Full Text] [PDF]
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 K. L. Robinson, M. S. Driedger, S. J. Elliott, and J. Eyles Understanding Facilitators of and Barriers to Health Promotion Practice Health Promot Pract, October 1, 2006; 7(4): 467 - 476. [Abstract] [PDF]
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 L. Barrett, R. C. Plotnikoff, K. Raine, and D. Anderson Development of Measures of Organizational Leadership for Health Promotion Health Educ Behav, April 1, 2005; 32(2): 195 - 207. [Abstract] [PDF]
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J. Catford The Bangkok Conference: steering countries to build national capacity for health promotion Health Promot. Int., March 1, 2005; 20(1): 1 - 6. [Full Text] [PDF]
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 M. B. Mittelmark, E. Fosse, C. Jones, M. Davies, and J. K. Davies Mapping European Capacity to Engage in Health Promotion at the National Level: HP-Source.net Promotion & Education, March 1, 2005; 12(1_suppl): 33 - 39. [PDF]
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 R. C. Plotnikoff, D. Anderson, K. Raine, K. Cook, L. Barrett, and T. R. Prodaniuk Scale Development of Individual and Organisation Infrastructure for Heart Health Promotion in Regional Health Authorities Health Education Journal, January 1, 2005; 64(3): 256 - 270. [Abstract] [PDF]
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D. Anderson, R. C. Plotnikoff, K. Raine, K. Cook, C. Smith, and L. Barrett Towards the development of scales to measure 'will' to promote heart health within health organizations in Canada Health Promot. Int., December 1, 2004; 19(4): 471 - 481. [Abstract] [Full Text] [PDF]
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