Health Promotion International Advance Access originally published online on July 22, 2006
Health Promotion International 2006 21(4):274-283; doi:10.1093/heapro/dal026
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Determinants of health promotion action: comparative analysis of local voluntary associations in four municipalities in Finland
Department of Public Health, University of Helsinki Finland 1 The Karolinska Institute Medical Management Centre, Stockholm, Sweden and Faculty of Medicine, Bergen University Norway 2 Department of Public Health, University of Helsinki and Folkhälsan Research Center Helsinki, Finland 3 University of Turku, Department of Public Health and Folkhälsan Research Center Helsinki, Finland 4 National Public Health Institute Helsinki, Finland 5 Department of Public Health, University of Helsinki, Finland and The Karolinska Institute Medical Management Centre Stockholm, Sweden
Address for correspondence: Nina Simonsen-RehnPO Box 4100014 University of HelsinkiFinlandE-mail: nina.simonsen-rehn{at}helsinki.fi
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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The World Health Organization makes a case for the importance of voluntary organizations in promoting health at local levels. The purpose of this paper is to contribute to understanding which factors explain local voluntary associations (LVAs) participation in health promotion in local contexts. It does so through (i) identifying indicators that represent determinants of health promotion action which were reported by LVAs and by (ii) comparing their actions with these determinants. The data reported are from a questionnaire survey of all registered LVAs in four municipalities in Finland. Principal component analysis revealed four determinants of health promotion action. Four factors in the final multivariate model explained over half of the variance of LVAs engagement in health promotion action: competence, values ‘healthy’ and also opportunities and municipality. There is some evidence to support a model of health promotion action which has not been tested empirically in relation to these types of organization. More detailed studies of determinants of health promotion action are needed to shape strategies in local communities.
Key words: community participation; health promotion; local voluntary organizations
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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The World Health Organization has called for the involvement of voluntary organizations in promoting health at local levels (WHO, 1986
, 1998). In the Scandinavian countries, the role played by the voluntary sector in the core areas of welfare has been limited. Instead culture, recreation and trade union activities have dominated (Helander and Sivesind, 2001; Lundström, 2001). Yet, many community organizations are interested in action for health, regardless of their main activities (Trojan et al., 1991): in a Finnish study, 76% of the responding local voluntary associations (LVAs) felt that their work had a positive impact on the health and well-being of people living in the municipalities (Simonsen-Rehn et al., 2004). This study considers the role of LVAs in health promotion and possible factors which influence their activities in this subject. In Finland the major form of nonprofit organization is the association. LVAs constitute the lowest level in the highly structured associational sector.
Community action and participation
Theories or models about communal action for health and change in communities include diffusion of innovation, community organization and community building (Nutbeam and Harris, 2004). For identifying determinants of health promotion action, ‘community building’ concepts are useful. One way of conceptualizing the ‘potential to act’ is ‘community capacity’ (Baker and Teaser-Polk, 1998), regarded as a key factor influencing community health promotion efforts (Goodman et al., 1998; Merzel and D’Afflitti, 2003). According to Goodman and colleagues the dimensions of community capacity include participation, leadership, skills, resources, values, history, networks and sense of community (Goodman et al., 1998).
Zakus and Lysack have identified a number of predisposing conditions for community participation in health: community priority to health issues, a political climate which supports community participation, a sociocultural and political context which supports both awareness and discussion of issues affecting individual and community well-being, knowledge and skills, and successful experience with earlier community participation (Zakus and Lysack, 1998).
From another field, Bandura has extended the conception of human agency in social cognitive theory to collective agency, and put forward the concept of ‘collective efficacy’ (Bandura, 1998, 2004). According to this view, people's belief in their collective efficacy to accomplish social change plays a key role to health promotion.
Health promotion
This study investigated the LVAs’ role in health promotion and factors influencing this work. In addition to the literature above, the research drew on the following theories and principles to identify determinants and which health promotion actions of the LVAs to investigate.
Health promotion is in the Ottawa Charter (WHO, 1986) defined as ‘the process of enabling people to increase control over, and to improve, their health’. Health is seen as a resource for every day life, a positive concept emphasizing social and personal resources, as well as physical capacities. By health promotion action is in this study understood the LVAs reported action to promote healthy lifestyles, mental well-being and social support.
Rütten and colleagues proposed a multilevel health promotion model based on a general model, ‘logic of events’, presented by the Finnish philosopher von Wright (von Wright, 1976; Rütten et al., 2000). According to this framework, the determinants of action can be described in terms of ‘values’, ‘competence’ and ‘opportunities’. We find that this model, consistent with a socioecological perspective, is one way of summarizing the present knowledge on community action for health.
Empirical data about voluntary organizations health promotion actions
Little is known about the role of local voluntary organizations in health promotion and factors influencing these kinds of action. Finnish local governments have a high degree of autonomy and responsibility over local conditions and health policy guidelines. Consequently, knowledge about the roles played be the voluntary organizations in this context is important [cp. (Helander, 1997)]. There is also a need to make theory explicit in health promotion research and especially theories of multilevel influences that are embedded in the concepts and principles of the Ottawa Charter (Dean, 1996).
In this paper, data from a study of LVAs in four municipalities in Finland is used to document their health promotion actions and to develop the theoretical understanding of determinants of health promotion action in local contexts.
This study had the following objectives:
- Identifying factors which would represent the determinants of health promotion action reported by LVAs in four municipalities in Finland.
- Comparing the actual health promotion actions of the LVAs with the proposed determinants of health promotion action.
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DATA AND METHOD |
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TOPSUMMARYINTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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Health promotion actions and determinants of action were investigated by postal questionnaire surveys to four municipalities in Finland in 2002 (n = 457) which also included other questions (Simonsen-Rehn et al., 2004
). The questionnaires were addressed to all registered LVAs in the four municipalities studied (the freedom of association is secured in the Constitution Act, but only registered associations have legal capacity). The response rate was 40% (182) ranging from 45% (WM) to 34% (SWM) across municipalities. The LVAs were classified into seven categories based on their names: associations for (i) culture and recreation 30%, (ii) business, professionals and politics 24%, (iii) public health 17%, (iv) sports 10%, (v) patients 10%, (vi) retired and elderly people 7% and (vii) other 1%. There was no statistically significant difference between the municipalities concerning the mix of types of associations. The number of members was on average 153 (median 85) and the number of persons taking part in organizing activities on average 22 (median 10). Of the associations, 13% had paid employees.
Health promotion action: measures, scale construction
Fourteen questions about health promotion were asked on a 14-item scale: six items assessed promotion of healthy lifestyles (acting for promoting physical exercise, promoting healthy diet habits, reduction of smoking, reduction of alcohol abuse, prevention of drug abuse/distribution and sexual education), three items assessed promotion of mental well-being (acting for developing personal abilities, strengthening self-confidence and promoting subjective well-being) and five items assessed social support (material, practical, knowledge, emotional and spiritual).
Respondents rated each item on a five point Likert scale (ranging from ‘not at all’ to ‘very much’) to indicate whether and to what extent they were engaged in health promotion action. The health promotion action scale was constructed by sum-scoring and then dividing the sum-score by the number of items defining the scale (70% of the items had to be answered). The internal consistency of the scale was good (Cronbach's alpha 0.89). The health promotion action scale was dichotomized into high versus low groups, using the median as cutoff point.
Determinants of health promotion action: measures, factor analysis and scale construction
Questions based on items that previous literature proposed as of potential importance to community action for health were asked. The items were listed on five point Likert scales indicating to what extent respondents agreed with the statements or to what extent the items where part of their priorities. The categories ranged from ‘not at all agree’ to ‘fully agree’ or ‘not at all’ to ‘very much’. For this study, the 12 items to represent the determinants in the multilevel health promotion model (Rütten et al., 2000) were submitted to principal component analysis (PCA; extraction criterion: Eigen value >1). One of the items was constructed as a sum-score of six statements, indicating whether the voluntary association cooperated with different municipal authorities (sum-score ranging from 0 to 6). To be compatible with the other items, the continuous sum-score was then transformed to a five point scale (the classes being 0, 1, 2, 3–4, 5–6 cooperation partners). The PCA produced the identification of the structure presented in Table 1. Four factors were found empirically: one factor each for opportunities and competence, while two dimensions were identified for values, labeled values ‘healthy’ and values ‘vulnerable’.
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Using this structure, four scales were constructed by sum-scoring and then dividing the sum-score by the respective number of items defining the scales (one missing item per scale was allowed). The internal consistency of the scales was sufficient (for Cronbach's alphas, see Table 1). The scales were dichotomized into high versus low groups, using medians as cutoff points.
Further statistical analyses
Differences in health promotion action categories and explanatory variables (values ‘healthy’, values ‘vulnerable’, competence, opportunities and municipality) were investigated using cross-tabulations and Pearson Chi-square tests. Differences in proposed determinants of health promotion action were also investigated across municipalities. Associations between the variables were examined with Chi-square tests and Phi-coefficients. Proposed determinants of health promotion action were assessed using univariate and multivariate binary logistic regression models. The determinants were entered one by one to determine which variables make unique contributions. The analyses were performed with SPSS 12.0.1 for Windows.
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FINDINGS |
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TOPSUMMARYINTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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Variations across municipalities
Table 2 shows the proportion of LVAs reporting high participation in health promotion action across municipalities and across the proposed determinants: values ‘healthy’, values ‘vulnerable’, competence and opportunities. Participating in a high degree in health promotion action was more prevalent in the groups valuing ‘healthy’ and ‘vulnerable’ more highly, and in the groups reporting high competence and opportunities (p
0.001). The differences in frequencies of high participation in health promotion action between municipalities was not statistically significant (p = 0.07).
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The proportions of LVAs belonging to the ‘high groups’ in the proposed determinants of health promotion action across municipalities are presented in Table 3. There were no statistically significant differences between municipalities.
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Bivariate correlations
As Table 4 shows, the associations between the variables in the intended model were all positive, and, with one exception, statistically significant. The correlation (Phi-coefficient) between health promotion action and proposed determinants vary from 0.46 for values ‘healthy’ to 0.27 for values ‘vulnerable’. Associations between the proposed determinants range from 0.14 to 0.41, being highest between opportunities and the three other determinants.
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Logistic regression analyses for health promotion action
The univariate model of health promotion action and determinants are presented in Table 5. Health promotion action was clearly associated with the proposed determinants. LVAs rating their competence, values and opportunities as high were more likely to take actively part in health promotion action. There were no statistically significant differences between SM (reference) and the other municipalities concerning LVAs actions in health promotion.
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In the multivariate analyses of health promotion action in Table 6, opportunities, competence and values ‘healthy’ were all statistically significant correlates of health promotion action. The association between values ‘vulnerable’ and health promotion action disappeared when competence (Model 2) was brought in to the model. Values ‘vulnerable’ could be removed from the multivariate model without a significant decrease in model fit. In the final model (Model 5), the odds of reporting high participation in health promotion action were about six times higher for LVAs reporting high competence (OR = 6.31, 95% CI = 2.39–16.67) and valuing ‘healthy’ to a high degree (OR = 6.61, 95% CI = 2.71–16.14), than for LVAs reporting low competence and low value ‘healthy’ scores. Further, the odds for reporting high participation in health promotion action were four times higher for LVAs reporting high opportunities (OR = 4.13, 95% CI = 1.69–10.11) than under conditions of low opportunities. There were no statistically significant interactions between opportunities, competence and values ‘healthy’. The odds for LVAs in SM reporting high participation in health promotion action were lower than for LVAs in EM and WM, when opportunities, competence and values ‘healthy’ were controlled for. The factors in the final model (Model 5, Figure 1) explained 52% of the variance of health promotion action (Nagelkerke pseudo-R2 = 0.52).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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A key finding was that factor analytical techniques revealed four composite indices of determinants of health promotion action in our data on LVAs. The labeling of these determinants built on the determinants described in the multilevel health promotion model (Rütten et al., 2000
), which is based on von Wright's model ‘logic of events’ (von Wright, 1976). All proposed determinants were associated with LVAs engagement in health promotion action. The final model on determinants of LVAs health promotion action (Figure 1) includes four variables that explain over half of the variance. Besides the determinants in the multilevel health promotion model, also municipality had an influence on health promotion action. The general model of von Wright's, as adapted by Rütten and colleagues, has been found to be a valuable conceptual framework at different levels of action, and we assume that the model is also applicable to the organizational level of voluntary associations [e.g. (Rütten et al., 2000, 2003)]. This study gives some empirical confirmation for this assumption.
In the study sample of LVAs, valuing ‘healthy’ and perceiving competence were statistically the most significant factors associated with health promotion action. LVAs valuing ‘healthy’ and perceiving high competence were much more likely to engage in health promotion action than LVAs valuing ‘healthy’ to a low degree and perceiving low competence. This supports earlier findings about relationships between organizational capacity and the priority given to certain aspects of health in organizations (public health agencies) with actual implementation of activities (Riley et al., 2001). However, the study measure of ‘competence’ was based on the LVAs own assessment.
The effect of values ‘vulnerable’ on health promotion action disappeared in the multivariate model. This might partly be due to the study's construction of the health promotion scale, which consisted of three parts including promotion of healthy lifestyles as well as social and mental well-being. Commitment to promoting life-quality of the ‘vulnerable’ groups perhaps involves more social and psychological ‘interventions’ than promotion of healthy lifestyles. However, lifestyle changes have an impact on health also in older people, and the building of a healthier society is dependent in part on action against aging stereotypes (Ory et al., 2003).
LVAs reporting a high level of opportunity were much more likely to engage in health promotion action than voluntary associations reporting a low level of opportunity. Opportunities are regarded as an important component for the dynamics of the ‘logic of events’ model: changes of external situations create new opportunities (von Wright, 1976; Rütten et al., 2000). A partnership approach and normative and/or policy change interventions to strengthening the resources for health have been widely advocated [e.g. (Gillies, 1998; Zakus and Lysack, 1998; Merzel and D'Afflitti, 2003)]. Our results support the use of these strategies. Theoretically, the possibility to participate in decision-making and have influence over decisions concerning health and well-being also lead to empowerment (Israel et al., 1994), which could imply a better competence for health promotion action. In our data, the correlation between competence and opportunities was quite strong, but according to the results of the logistic regression analysis, no indication for mediating effects between the determinants could be found. The odds ratio for competence stayed quite stable when bringing opportunities into the model. Moreover, no significant interactions between the determinants were found. These questions merit further studies.
Nearly 60% of the LVAs in EM and WM engaged in comprehensive health promotion action compared to below 40% in SM and SWM. When controlling for competence, values ‘healthy’ and opportunities in the logistic regression model, the voluntary associations in EM and WM reported engaging in more health promotion action than the LVAs in SM. Differences in action could be a response to variation in local conditions. The municipalities in this study are quite similar regarding the population (number varied from 7444 to 11 981 in 2002), its age structure and health, so this does not seem to explain the difference. EM and WM are more urban with higher population density (169/161 persons/km2), whereas SM and SWM belong to ‘densely populated areas’ with lower population density (45/44 persons/km2). An urban environment might be a more fruitful ground for health promotion action.
Differences in action in the municipalities could also be a response to variation in health policy that was not reflected in our assessment of opportunities. In applying purchasing to health promotion, it has been pointed out that health promotion cannot be left to the health sector alone (Ziglio et al., 2000). Commitment to health promotion requires that health is high on the agenda of policy-makers (WHO, 1986). In SM, only 14% of the political decision-makers were of the opinion that emphasis on health promotion was of importance in making the choice of service provider (Laamanen et al., 2005), which could imply a somewhat low interest for the issue. Local governments have a decisive role in shaping opportunities for different actors to engage in health promotion (Gillies, 1998). Future studies could address these questions more specifically, taking also community history (Goodman et al., 1998) and organizational empowerment (Laverack and Wallerstein, 2001; Laverack, 2003) into consideration.
Methodological considerations
The response rate of 40% was considered sufficient for the purpose of the study. In earlier studies concerning voluntary associations in Finland, response rates have varied between 42 and 54 percent (Helander and Pikkala, 1999; Helander, 2004). A higher response might have been achieved with a shorter than 15 page questionnaire with many open-ended questions. Also, the questionnaire was sent to all registered LVAs in the municipalities, regardless of their main activities. It is assumed that voluntary associations with no or little interest in health were the ones who did not respond in a higher degree, but no analysis of respondents was carried out to confirm this. The study reached associations with address-information in the Register on Associations, which was about half of the registered associations. Approximately half of the voluntary associations in the register are active (Rönnberg, 1999).
Due to the cross-sectional design, conclusions about directions of influence cannot be made. In the multilevel health promotion model (Rütten et al., 2000) reciprocal associations are assumed, so that competence and opportunities enable action and action improves competence and changes opportunities. Also strong relationships between the determinants are assumed, for example, so that, opportunities affect action directly, but also through affecting values. A longitudinal design and path analyses could give additional information on the direction of influence between variables and accordingly also suggestions for ways to engage LVAs in health promotion.
The principal component analysis performed to identify composite indices associated with health promotion action yielded a four factor structure with Cronbach alphas ranging from 0.66 to 0.87. The four factors were considered to expose face validity. There were four cases with studentized residuals greater than 2.00 and although two of the cases had big residuals (5.15, 6.85), the odds ratios were high and the factors in the final model explained over 50% of the variance of reported health promotion action. The Hosmer–Lemeshow test for goodness-of-fit yielded p=0.518 in the final model, decreasing from p=0.839 when bringing the dummy-coded municipal-variable into the model. These statistical tests indicate that the model is a good characterization of the associations between the replies to the questionnaire.
Important factors overlooked in our analysis were for example resources and support from the municipality. Due to the small sample, more determinants could not be analyzed in the regression model (Peduzzi et al., 1996). The items used to assess health promotion action, opportunities and competence address principles expressed in the Ottawa Charter, i.e. a broad view on health, cooperation, participation and empowerment of the community. The items used to assess values address the voluntary associations focus in health promotion on different target groups in the community. It should be observed that associations between determinants and action, as we assessed them, could reflect consistency in perception rather than their role as the determinants of action. Further scale development using other items and a bigger sample is needed to bring more insight into the determinants of LVAs’ action in health promotion.
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CONCLUSIONS |
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TOPSUMMARYINTRODUCTIONDATA AND METHODFINDINGSDISCUSSIONCONCLUSIONSREFERENCES |
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Responses by LVAs to a questionnaire survey found factors which were associated with engagement in health promotion action. These were the LVAs’ perception of their competence and commitment to health promotion values, reflected in wanting to support harmonious development of children and youth, improving life-quality of adults and relieving the negative effects of unemployment. Further, the results indicate that policies in municipalities can create opportunities which enable LVAs to participate in health promotion action.
The results showed differences between the municipalities indicating that there are other important determinants of LVAs health promotion action in addition to competence, opportunities and values ‘healthy’.
The analysis also found some empirical support for a reported model of health promotion action which has not been tested empirically on these types of organization. The study was able to develop an empirically based model of the determinants of health promotion (Figure 1) and contribute to evidence-based theory in health promotion.
More detailed studies of determinants of health promotion action are needed to shape strategies in local communities like municipalities.
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ACKNOWLEDGEMENTS |
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The study was supported by the Academy of Finland (grant no. 105 189), Samfundet Folkhälsan i Svenska Finland and the Jahnsson Foundation (grant no. 5088).
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