HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 3 © Oxford University Press 2004. All rights reserved.
The Eat Well SA project: an evaluation-based case study in building capacity for promoting healthy eating
1Centre for Health Promotion, Women's and Children's Hospital, Adelaide, Australia, 2Department of Public Health, Flinders University Adelaide, Australia, 3Health Promotion SA, Department of Human Services, Adelaide, Australia, 4South Australian Community Health Research Unit, Flinders Medical Centre, Bedford Park, Australia and 5Paul Laris and Associates, Henley Beach, Australia
Address for correspondence: Alison Smith, Centre for Health Promotion, Women's and Children's Hospital, Adelaide 72 King William Rd, North Adelaide SA 5066, Australia, E-mail: smitha{at}mail.wch.sa.gov.au
SUMMARY
The term ‘capacity building’ is used in the health promotion literature to mean investing in communities, organizations and structures to enhance access to knowledge, skills and resources needed to conduct effective health programs. The Eat Well SA project aimed to increase consumption of healthy food by children, young people and their families in South Australia. The project evaluation demonstrated that awareness about healthy eating among stakeholders across a range of sectors, coalitions and partnerships to promote healthy eating and sustainable programs had been developed. The project achievements were analysed further using a capacity-building framework. This analysis showed that partnership development was a key strategy for success, leading to increased problem-solving capacity among key stakeholders and workers from education, child care, health, transport and food industry sectors. It was also a strategy that required concerted effort and review. New and ongoing programs were initiated and institutionalized within other sectors, notably the child care, vocational education and transport sectors. A model for planning and evaluating nutrition health promotion work is described.
Key words: capacity building; health promotion; nutrition
INTRODUCTION
The Eat Well SA project
Eat Well SA was developed in 1996 in response to the (former) South Australian health promotion foundation outsourcing a statewide nutrition project. The beginnings of the project, including its intellectual origins, have been described elsewhere (Coveney et al., 1999
). Briefly, the project's goal was to increase the consumption of healthy food by children, young people and families in South Australia. The objectives were to increase the availability and promotion of healthy food in settings where children, young people and their families live, are cared for, educated and spend their leisure time, and to increase community knowledge and awareness of healthy food choices (Smith, 2002).
Strategies were developed to improve public policy, create supportive environments for healthy eating, support community action and develop personal skills informed by the Ottawa Charter (Baum, 2002). Six areas for strategy development and implementation were selected for the first 3 years:
- Improving the food supply in rural South Australia;
- Improving food service and promoting healthy eating in child care settings;
- Promoting awareness in the school community of the environmental and health impact of eating;
- Promoting awareness of links between food, health and the environment;
- Supporting community food activities for low-income and non-English-speaking groups; and
- Promoting fruit and vegetable consumption.
As nutrition is an issue that is affected by the work of many sectors, the project approach was to put nutrition and food issues onto the agenda of other agencies and sectors. Inter-sectoral and inter-agency partnerships were developed to increase awareness about nutrition issues among a range of agencies and to increase service providers' capacity to support community action (Coveney et al., 1999).
Capacity building
Use of the term ‘capacity building’ has increased in the health literature. It first made an appearance in the mid-1970s as a way of discussing the importance of training and development in the context of health service reform (Anon, 1975). It was not until the mid-1990s, however, that the term became commonly used in the health promotion context. Since that time, the idea of building capacity has found its way into Australian health promotion and public health strategic statements at the local, state and national levels (National Health and Medical Research Council, 1996; National Public Health Partnership, 2001; NSW Health Department, 2001).
At its broadest, most general level, capacity building refers to the ability of an initiative or program to build upon, or add value to, existing resources to promote effective, efficient, sustainable outcomes. More specifically, capacity building in health promotion is about investing in existing communities, organizations and structures to enhance access to the knowledge, skills and resources needed to conduct effective health programs (Jackson et al., 1994). It is also about increasing the capability to choose the most appropriate methods or actions (Kickbusch, 2001).
The benefits of capacity building have been discussed elsewhere in relation to community development (Maton, 2000), program effectiveness (Schwartz et al., 1993), program evaluation (Brazil, 1999), and training and education (Young, 1999). This literature suggests that building capacity has a number of potential gains for health promoters, health service funders and communities.
Hawe et al. have described the three dimensions of capacity building (Hawe et al., 1997). These are: (i) health infrastructures or service development; (ii) problem solving capability of organizations and communities; and (iii) program maintenance or sustainability.
‘Health infrastructure or service development’ creates the organizational culture required to deliver effective health promotion programs. Organizational capacity is achieved by developing health promotion skills and knowledge in the workforce, by incorporating health promotion goals into the organization's strategic directions and leadership, and by committing adequate human, financial and information resources (NSW Health Department, 2001). Development of health promotion capacity is necessary for health services to provide a full range of early intervention, preventive, health promotion and therapeutic services.
Organizations and communities require ‘problem-solving capabilities’ as a basic component of undertaking community empowerment and organizational development work (Labonte and Laverack, 2001; Laverack and Wallerstein, 2001). Capacity building here refers to the ways in which health promotion agencies contribute technical, administrative, evaluation and other expertise, which will assist efforts to influence conditions that affect health and development (Fawcett et al., 1995). If successful, the resulting relationship, whether this be with organizations or communities, allows not only for immediate problems to be addressed, but also for new ones to be effectively tackled through the development of key problem solving skills (Hawe et al., 1997).
‘Program maintenance and sustainability’ through capacity building refers to the extent to which work initiated by one agency is taken on by the same or another agency or network of agencies as their core business. Capacity building in this area relies on the ability of health promoters to sustain a program's focus of activity. This can be enhanced by ensuring that both project (and evaluation) design and implementation are developed through a participatory approach between funders, service providers and communities (Shediac-Riskallah and Bone, 1998).
Investment is also required to achieve these types of capacities. First, the investment of resources, whether in terms of staff, funding or information access, is crucial for successful capacity building. Secondly, capacity building requires specific (though not necessarily formal) training and education. Finally, the institutionalization of initiatives allows organizations or communities to invest in health promotion activities as part of their core business.
The aim of this article is to describe the evaluation outcomes of the Eat Well SA project, to analyse further the evaluation results using a model of capacity building, and to propose a planning and evaluation model for building capacity for healthy eating at a local or regional level.
EVALUATION METHOD
An external evaluation of Eat Well SA (Laris et al., 2001) was undertaken during 2000. Qualitative and quantitative data were collected, analysed and reported based on a framework of key questions. These were designed to assess: (i) process (e.g. what happened, who was reached and what methods were effective?); (ii) impact (e.g. what changes were observed in terms of food service, knowledge, awareness and policy development?) (Hawe et al., 1990); and (iii) generative impact (e.g. changes in organizational relationships and in the context for promoting healthy eating) (Pawson and Tilley, 1997).
In order to answer these key questions from a wide range of sources, four methods were used to collect data for the evaluation. One hundred and sixty-five project documents were analysed, including plans, minutes, reports, terms of reference, project materials and evaluation reports. Interviews were undertaken with 50 key informants, identified from a list of key partners and stakeholders. Project staff were also interviewed about all areas of involvement. Three focus groups were undertaken with 16 people, including two groups of grant holders and one group of project partners. A telephone survey was conducted of 180 respondents from a sample of 300 people selected from the project newsletter mailing list. They represented the broader target group the project was trying to reach. The survey data were collected about project recall and perception of support provided by the project (Laris et al., 2001).
The outcomes of the project described by the evaluation were analysed further, to investigate and describe the type of capacity developed by the project. Project outcomes were categorized using the framework described by Hawe and colleagues (Hawe et al., 1997; NSW Health Department, 2001). The program logic model (Weiss, 1998) was then applied, to propose an evaluation model based on the type of capacity building developed by the project.
RESULTS
The evaluation described the project as using awareness raising, partnership development and implementing collaborative action across all six strategy areas of the project. Methods used for increasing awareness included a campaign promoting fruits and vegetables, dissemination of pamphlets and newsletters, a conference, a cookbook, a literature review and a research study. Eat Well SA formed coalitions with agencies from the health, migrant health, community services, vocational education, schools education, child care, research, community health, rural health and primary producer sectors. The project supported the development and maintenance of partnerships. These supported the provision of small grants to schools and community organizations working with non-English-speaking and low-income groups to increase their access to healthy food, to plan development of vocational training for child care cooks and to provide resources for early childhood services (Smith, 2002).
Project achievements
The contribution of the project to increasing consumption of healthy food among children, young people and families by awareness raising, problem solving and development of sustainable programs is shown in Table 1. The telephone survey found that three-quarters of targeted workers were aware of the project, while between one-third and one-half reported receiving support from Eat Well SA for their work promoting environmentally friendly food, hygienic and safe food, and nutrition. These activities raised awareness of the project among key stakeholders and developed their readiness to be involved in other activities.
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Eat Well SA was found to have successfully formed significant and effective partnerships and relationships with 50 organizations, in each of the six strategy areas of the project. The project was found to have contributed to improving the context for promoting healthy eating in South Australia through relationship building, collaborative planning and advocacy across the breadth of food and nutrition issues, thereby increasing capacity, knowledge and skills among a broad range of workers.
Tensions related to differing values were found when working collaboratively with other organizations. One example was the tension between a community development paradigm and a professional nutrition paradigm. In another case, a partner organization stated that work requiring environmental expertise undertaken by project nutrition staff would have more appropriately been contracted out.
Five new projects and formal partnerships were developed, which garnered funding across several areas. In addition, training of child care cooks and improving rural and remote freight transport have been institutionalized into the work of the vocational education and transport sectors, respectively (Table 1).
Type of capacity developed
Specific activities in each dimension are summarized in Table 2. The Eat Well SA project ‘infrastructure’ included recruitment of a staff team of between two and three members, with administrative and practical support from the Women's and Children's Hospital, Adelaide, the auspicing organization. Support for the project's capacity to develop, implement and evaluate projects was provided by the funder, a management group, reference groups, working groups, formal partnerships, consultants and steering committees, many of which included representation from consortium member organizations.
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The Eat Well SA project facilitated the development of ‘problem solving capabilities’ through the development and coordination of partnerships and coalitions (Table 2). The evaluation results found that partners strongly appreciated the partnerships developed by the project, as a unique and valuable contribution to promoting healthy eating. These provided avenues for people from different agencies and organizations to share their skills and perspectives and to work together. Newsletters, professional development workshops and inter-agency forums also supported skills development. In addition, community capacity was supported through information dissemination strategies (e.g. a parent newsletter distributed through child care centres), provision of 28 small grants to community-based organizations and schools, and through the implementation of grant projects in the community.
‘Program sustainability’ was enhanced by the commitment of project partners, for whom the outcomes sought were part of their core business. Three types of program sustainability have been identified: first, activities were institutionalized in the business of other sectors; secondly, new programs were developed jointly and owned by all partners; and thirdly, funds were sourced to develop new programs in partnership with service delivery agencies.
Evaluating capacity building
A model for planning and evaluating a capacity-building project situated within a health promotion group in a statewide health service is shown in Figure 1. Based on the capacity-building model developed for the project, this model is built around awareness raising and advocacy, gaining commitment from key stakeholders, joint development of new strategies followed by implementation, and joint development and implementation of sustainable programs and policies. Information dissemination was used as an awareness-raising activity, but also as a catalyst for action, which led to sustainable outcomes and capacity building.
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Activities to support these outcomes are also shown in Figure 1. These include gathering and disseminating information, identifying key stakeholders, allocating resources to coalition development work (including staff time), seeking financing from funding agencies, facilitating activities, and providing leadership (NSW Health Department, 2001
) and nutrition and health promotion expertise. Capacity-building outcomes are used to develop indicators of increased capacity, from which performance indicators for the project are developed in different project areas. DISCUSSION
Capacity building was found to be a useful framework for analysing this health promotion project. Partnerships have been suggested to be vitally important in increasing capacity to address health issues, as many health problems are outside the influence of the health sector (NSW Health Department, 2001). Research has shown that stronger relationships between agencies and a greater allocation of resources to health promotion are desirable for future collaborative action. In addition, partnerships need to support a learning culture and increased problem-solving capacity to tackle difficult issues, through providing opportunities for exchange of skills between workers from different sectors (McGlone et al., 1999). Partnership development also requires a high level of clarity about the purpose of the partnership and the role of the participating organizations (Tasmania Department of Community and Health Services, 1999). The Eat Well SA evaluation indicated that relationships and willingness to collaborate along with problem-solving capacity were developed through effective partnerships, which require ongoing review and evaluation.
Hawe et al. (Hawe et al., 1997) point out that an appreciation of capacity building could better inform decisions about health program investment. They suggest that decisions be guided by attention to return on investment in terms of size of health gain on the one hand, and sustainability of outcomes on the other hand. For example, it might make sense to invest in health programs that show modest health gains but have engaged other stakeholders to take on the issue, and demonstrate high potential to tackle other health problems. These considerations seriously challenge traditional views of program success, which have been understood in terms of individual changes in health status.
Indeed, also challenged are the evaluation methodologies that are employed in assessing program success. Hence, capacity-building indicators have been developed to evaluate the process and impact of the project. The project evaluation utilized the idea of evaluating generative changes in the context within which the project was working (Pawson and Tilley, 1997) which allowed capacity building changes in relationships to be described by the evaluation. This evaluation approach is important because a narrower focus on behaviour change would have failed to appreciate the value added to the project and the field of public health nutrition through attention to capacity building.
Shediac-Riskallah and Bone suggest that institutional strength of the host organizations is positively associated with program sustainability (Shediac-Riskallah and Bone, 1998). In the case of the Eat Well SA project, the host organization (Women's and Children's Hospital, Adelaide) has a strong focus on health promotion through the development of its strategic plan and the employment of a management-level health promotion director. The host organization provides a well developed organizational structure to sustain the project (Hawe et al., 1997; McGlone et al., 1999), including accommodation, facilities and a management system. The project also employed nutrition professionals who were able to develop partnerships with community and government agencies at a statewide level, an opportunity not available to many nutritionists operating within the often local geographic constraints of the organizations in which they work (McGlone et al., 1999).
CONCLUSIONS
This research shows that understanding the capacity-building effects of health promotion projects provides clarity about outcomes and planning and evaluation methods. The Eat Well SA project developed a useful model for undertaking sustainable, intersectoral, collaborative work to promote healthy eating, which can also be used by other organizations to address other nutrition issues. The hard issues like improving food security of vulnerable groups require continued development through local and statewide partnerships and actions. The project's evaluation framework requires further development in order to establish project outcomes in health and social terms.
ACKNOWLEDGEMENTS
We would like to acknowledge the following members of the consortium that developed the project: Liz Kellett, Kate Thomson, Anne Johnson and Giordana Cross. Members of the project evaluation working group (Adrian Heard, Alison Shanks, Angela Littleford, Giordana Cross, John Coveney, Patricia Carter, Peter Baghurst and Richard Cooke) provided direction and advice to the project evaluation team of P. L., G. J. and A. S., who undertook the evaluation work from which the information in this paper was sourced. Giordana Cross provided comments on an earlier version of this paper. Eat Well SA, a statewide nutrition project of the Women's and Children's Hospital Adelaide and Flinders University (Adelaide), was funded by the Department of Human Services, South Australia.
FOOTNOTES
A.S. and P.C. were previously Eat Well SA Managers.
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