Health Promotion International Advance Access originally published online on November 4, 2005
Health Promotion International 2005 20(4):317-319; doi:10.1093/heapro/dai026
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Questioning sustainability in health promotion projects and programs
Associate Editor
"The precise definition of sustainability is still subject to debate. It has no single or universally accepted definition. Like truth and justice, it is not easily captured in a concise definition and means different things to different people"The documented plans of most Health Promotion projects and programs usually contain the word ‘sustainability’. Some even identify specifically what is intended to be sustained, after the project or program funding resources cease. Yet, many plans do not tease out those important aspects of the intervention which are worth sustaining. Nor do they identify whether the intervention itself actually nurtures the processes necessary to ensure the stated intentions have a reasonable chance of being sustained.(Auditor General of Victoria 2004
).
For too long we have paid little attention to what we mean by sustainability in Health Promotion. This has occurred in both developed and developing countries and in small and large projects and programs. We have not reflected thoroughly and regularly on the many health promotion interventions that have achieved some significant degree of sustainability successes, and learnt from them. The landmark North Karelia project in Finland and the many tobacco reduction programs across the world provide a rich source of evidence for such examination and analysis.
How often do we ask—‘Is this action/goal/organisation worth sustaining anyway?’ Perhaps health promotion should focus instead on the evolvement of actions/goals/organisations?
Recently, a number of researchers have sought to interrogate the concept of sustainability in health promotion, and to develop frameworks and guidelines which will assist planners, practitioners, evaluators, managers, organisations and funding authorities. Swerisson and Crisp (2004) provided a thoughtful and practical contribution as they examined the concept of sustainability. They claimed:
"Definitions [of sustainability] are confused; there are relatively few empirical studies. Explanatory models tend to be relatively simplistic and descriptive often failing to consider the substantial literature on learning theory, community action and social policy that has addressed new health related issues".From this rather pessimistic view, the authors go on to propose a typology where there are four levels of health promotion intervention ie: Individual, Organisational, Community Action and Institutional Change. They suggest how sustainability can occur in each of these and what conditions facilitate and inhibit this. Also, they identify the types of things one should look for to examine the evidence of sustainability.p. 124
Earlier, Shediac-Rizkallah and Bone (1998) challenged our thinking about the issue in their insightful and creative paper in the late nineties. They examined indicators of sustainability and proposed three categories for exploration ie: Individual Health Benefits, Institutionalisation Factors, and Community Capacity Attributes.
Recently in a comprehensive analysis, Scheirer (2005) asks ‘Is Sustainability Possible?’ She provides a scholarly examination of 19 empirical health promotion studies and offers a framework adapted from Shediac-Rizkallah & Bone (1998) for probing the evidence of sustainability ie: Aspects of project design and characteristics, Factors within organisational settings, and Factors in the broader community environment. Scheirer found that in 14 of 17 studies, 60% reported sustaining at least one aspect of program content (Scheirer 2005). But is this enough evidence to say sustainability has occurred? Is there such a thing as a sustainability ‘pass mark’ or a ‘minimum threshold’? Who decides this and what values shape the decision?
In a comprehensive review of the sustainability of a state-wide funded secondary school drug reduction program, Harvey (2005) proposed a similar framework for exploring indicators ie: Program aspects, Context (in this case the school setting), and External factors. He identified the very linear process of most program development, where sustainability appeared at the end like a gold star. He claimed that sustainability does not necessarily follow from even successful projects and programs. Harvey makes the plea, as do Swerisson & Crisp (2004), that the rich research literature from other fields must be accessed if we are to be more strategic in designing and then achieving outcomes which would lead to a conclusion about sustainability.
There is considerable momentum building to assist us in planning, implementing and evaluating our projects and programs which seek to address sustainability. Yet, from this brief examination of a few of the more detailed and comprehensive studies, questions about the worth of sustainability are being raised.
Throughout much of the 20th Century it was believed that certain types of physical activity were essential to improving one's health status. Our knowledge of the factors which protect our health or add to our risk emerged over many years from rigorous scientific studies. For example the 'no pain, no gain' approach to physical activity is no longer valid. Evidence has suggested we need different types of physical activities at different stages of our lives. It is not all aerobic, but now includes inner core strength, balance, hand eye coordination, etc. It would have been unwise to sustain many of the inappropriate physical activity interventions that were funded in the last century.
Similarly, our knowledge about appropriate nutrition keeps expanding—as does our knowledge about injury prevention, oral health, sexual health, etc. More recently, we are learning a great deal about what constitutes ‘social and emotional well-being’ and what aspects in our communities, organisations, families and self, contribute to building protective factors for social and emotional well-being.
Knowledge is also increasing about the design, implementation and evaluation of health promotion projects and programs. The excellent work done by WHO, IUHPE and CDC, and the many publications such as the 1999 book 'Evidence of Health Promotion Effectiveness' auspiced by the European Commission and the IUHPE, are providing us with a rich source of evidence about quality health promotion planning and operations. The current Global Programme on Health Promotion Effectiveness, under the joint collaboration of IUHPE and WHO, is continuing to add new knowledge to the way we address health promotion.
Our health promotion work is evolving. It is improving, becoming more effective and dynamic and more questioning. Many of the projects and programs of a decade ago are no longer sustained. The good ones have evolved and used new knowledge to shape their design and actions.
If a project or program is sustained as it was, then it is appropriate to ask the question, why did this happen? Did it not take into account recent evidence about the influences on the particular population's health status, and develop and implement effective strategies for addressing health and related issues? In Drug Education we used to scare the users of what were deemed inappropriate drugs, without examining why the drugs were being used. We blamed the victim if they didn't exercise; eat a balanced diet; practised safe sex, etc. Projects and programs existed in the 1980s and 1990s which took this top down, authoritarian, blaming perspective. Sadly, some are still around. They were, and are, not worth sustaining. The work of Marmot, Wilkinson, Kawachi and many others have challenged us to address the social determinants of health first and not to focus only on behavioural factors. Our understanding of the determinants of health has evolved. We have quite rightly not sustained many health promotion initiatives that were largely individualistic and largely behaviourist.
The question should be asked 'why do we have to document and explain sustainability in order to have many of our projects and programs funded?' Is this an example of legitimising cost shifting by governments and NGO's? Or is it part of our obligation to build the capacity of local groups to take more ownership and be proactive and creative about issues which shape their collective and individual health?
Certainly the Ottawa Charter for Health Promotion has sustained itself for 20 years. But its core building blocks have evolved, been contextualised locally and owned and reshaped by many groups and individuals. Our thinking about actions in sustainability needs more critical reflection and less superficiality. The literature now has some well argued and researched frameworks which reflect more on the evolvement of ideas and actions, to assist us. We need to use them.
REFERENCES
Auditor General of Victoria (2004) Measuring and Reporting on Sustainability. Vic. Govt., Melbourne.
Harvey, G. (2005) An examination of the sustainability of school based program initiatives: The case of "Turning the Tide" in schools. Unpublished Doctoral Thesis, University of Melbourne.
Scheirer, M. (2005) Is sustainability possible? A review and commentary on empirical studies of program sustainability, American Journal of Evaluation, 26 (3), 320–347.[Abstract]
Shediac-Rizkallah, M. and Bone, L. (1998) Planning for the sustainability of community based health programs: conceptual frameworks and future directions for research, practice and policy. Health Education Research, 13, 87–108.
Swerissen, H. and Crisp, B. (2004) The sustainability of health promotion interventions for different levels of social organisation. Health Promotion International, 19 (1), 123–130.
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