Health Promotion International Advance Access published online on April 11, 2008
Health Promotion International, doi:10.1093/heapro/dan008
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Article |
Using health promotion outcomes in formative evaluation studies to predict success factors in interventions: an application to an intervention for promoting physical activity in Dutch children (JUMP-in)
1Department of Epidemiology, Documentation and Health Promotion, Municipal Health Service Amsterdam, Amsterdam, The Netherlands 2 EMGO Institute and Department of Public and Occupational Health, VU University Medical Centre, Amsterdam, The Netherlands 3Communication and Innovation Studies, Social Sciences Group, Wageningen University, Wageningen, The Netherlands
* Corresponding author. E-mail: mjurg{at}ggd.amsterdam.nl
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SUMMARY |
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JUMP-in is a systematically developed intervention aimed at promoting physical activity among primary school children. It is a joint project involving different authorities and entails six school-based programme components. Measuring effects of such an intervention is a complex challenge. A common problem is the lack of valid instruments to measure physical activity and its determinants. In addition, it usually takes years to find improvements in physical activity and related constructs like weight and fitness, or even in causal factors. For this reason different authors advocate for the establishment of ‘health promotion outcomes’; (i) health literacy, (ii) social action and influence and (iii) healthy public policy and organizational practice. It is presumed that these health promotion outcomes lead to changes in determinants, behaviour and finally in health. Insight in these health promotion outcomes and information about input and through-put are important in discussing the impact and output. The formative evaluation study of the JUMP-in pilot shows the health promotion outcomes of the intervention. The health promotion outcomes ‘social action and influence’ and ‘healthy public policy and organizational practices’ were found to be positive. By measuring the presence of the conditions to achieve ‘health literacy’, it became clear that more attention must be paid to implementation in the future. Based on the health promotion outcomes, we expect that JUMP-in will be an effective intervention in the future.
Key words: health promotion outcomes; formative evaluation; physical activity
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONFUNDINGREFERENCES |
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In the Netherlands, overweight among children is an important public health issue. In 1987, 4% of children were overweight. In 1997, this rate has increased to 10% of the children (Hirasing et al., 2001
), and in 2004 15% of Dutch children aged 5–14 years were indicated to be overweight (van den Hurk et al., 2006). Other developed countries have identified similar increases. One of the major causes of obesity is a caloric imbalance, due to ingestion of more calories than are required for energy. Physical activity is one of the greatest contributors to the use of body energy (Ball et al., 2001). Although it is generally recommended that children should be physically active at a moderate level of intensity for at least 60 minutes every day (Kemper et al., 2000), many children do not meet this recommendation. A national study from Zeijl et al. (Zeijl et al., 2005) found that 29% of the Dutch children aged 10–12 years reported to meet this recommendation. This percentage is even lower among children in large cities (De Vries et al., 2005).
Various interventions are aimed at promoting physical activity among children (Sallis et al., 1993; Davis et al., 1995; Donnelly et al., 1996; Harrell et al., 1996; Pate et al., 1997; Gortmaker et al., 1999; Nader et al., 1999; Müller et al., 2001; Sahota et al., 2001; Robinson et al., 2003; Going et al., 2003; Pangrazi et al., 2003; Veugelers and Fitzgerald, 2005). Only a few showed (moderate) effects (Davis et al., 1995; Harrell et al., 1996; Nader et al., 1999; Müller et al., 2001; Pangrazi et al., 2003). The observed low effectiveness of interventions on physical activity may be attributable to a weak intervention design or programme implementation (Rossi and Freeman, 1993; Koelen and van den Ban, 2004). It may also be due to difficulties in research design, especially the lack of reliable and valid instruments to measure physical activity among children (Brug et al., 2005; Campbell et al., 2005). For example, the cognitive requirements for completion of a questionnaire about physical activity are high for (young) children (Sallis et al., 1999). Also, more objective measurement methods, such as the accelerometer, have disadvantages: they are expensive, children forget to wear the metre or they act differently wearing them.
In addition to the challenge of assessing and demonstrating behaviour change, it usually takes a long time before improvements in physical activity and related constructs such as weight, fitness or even in causal factors can be observed. For this reason, different authors advocate, to establish ‘health promotion outcomes’. Health promotion outcomes represent those personal, social and structural factors that can be modified in order to change the determinants of health (Nutbeam, 1996; 2000). Insight in health promotion outcomes explains the relation between implementation, capacity and efficacy of the intervention program. They represent the most immediate results of health promotion interventions. At the personal level, these outcomes are related to changes in health literacy, at the social level to social action and influence, and at the structural level to healthy public policy and organizational practice (Nutbeam, 2000; Nutbeam and Harris 2004; Saan and De Haes, 2004a). ‘Health literacy’ refers to personal, cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information to promote and maintain good health (Nutbeam, 2000). ‘Social action and influence’ describes the results of efforts to enhance the actions and control of social groups over the determinants of health (Nutbeam, 2000). Finally, ‘healthy public policy and organizational practices’ are the result of efforts to overcome structural barriers to health—typically the outcome of political advocacy and lobbying which may lead to legislative change (Nutbeam, 2000). Generally, it is assumed that these health promotion outcomes are conditional for changes in determinants of behaviour, in actual behaviour, and finally in health.
In order to contribute to the prevention of overweight and inactivity in children, JUMP-in had been started in 2002 in Amsterdam. JUMP-in is a systematically developed intervention, aimed at promoting physical activity among primary school children. It is a joint project involving municipal authorities (Municipal Health Services, Department of Social Development of Amsterdam and city district departments), primary schools and local sport clubs. The pilot JUMP-in was accompanied by an effect evaluation (Jurg et al., 2005; Jurg et al., 2006) and a two school years during formative evaluation. This article describes a formative evaluation study, using these health promotion outcomes as indicators for success of the JUMP-in project.
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METHODS |
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TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONFUNDINGREFERENCES |
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JUMP-in programme design
To overcome weak intervention design, the JUMP-in programme has been systematically designed, based on the Intervention Mapping protocol (Bartholomew et al., 2001
), and using theoretical input from the Theory of Planned Behaviour (Ajzen, 1988), a model of physical exercise and habit formation (Aarts et al., 1997), the Precaution Adoption Process Model (Weinstein and Sandman, 1992), the ecological model of Pikora et al. (Pikora et al., 2003) and the Service Quality Model (Parasuraman et al., 1985). The JUMP-in project entails six programme components: school sports activity, a pupil follow-up system, in-class exercises (The class moves!®), lessons aimed at amongst others increasing awareness and self-efficacy (Choose your card!), a parental information service, and an Activity Week. A brief description of the JUMP-in programme components is provided in Frame 1. | Frame 1: Description of the components of the JUMP-in programme School sports activities Easy school exercise activities are offered in or near to the school premises in order to offer the children easily accessible facilities for exercise. As far as possible, use is made of the normal local range of activities and of existing exercise activities in the area, the school at large and of after school child care. Pupil follow-up system
The physical education (PE) teacher monitors the pupils in order to stimulate pupils in a structured way in their development in the areas of sport and physical activity and in attaining the physical activity recommendation for youth (i.e. at least 60 min of moderate-intensity physical activity on most, preferably all days of the week, including twice weekly activities that aim at increasing or maintaining physical fitness (Kemper et al., 2000 The class moves! ® (De klas beweegt!®) This is a programme that ensures that during normal lessons and exercise breaks, exercises for relaxation and posture will be done, all of which will be adjusted to the sensor-motor development process of the child. Teachers need to be trained to use ‘the Class Moves! ®’. Choose your Card! This is a newly developed game approach that works with assignment cards for use in the class and at home. The method is especially aimed at raising consciousness on the importance of physical activity and one’s own activity behaviour, self-efficacy, social support, planning skills and parents. Teachers need to be trained to use ‘Choose your Card!’. The cards are used to prepare for an activity week and are linked to an exhibition. Parental information service A group meeting in which the importance of physical activity and sports for children and the role played by parents in supporting and stimulating such activity in their children is emphasized. The group meeting is organized by school and can be given in the parents’ own language by specially trained information officers. Activity Week In the Activity Week, some components of JUMP-in are brought together. Parents play an important role in this week. Some examples of activities in this week are: a sport and activity exhibition where products of Choose your Card are presented, exercise activities and exercise days during the week, a joint warming-up session for parents and children and a sport market where parents and children meet local sport clubs. In this week, the parental information service is available most of the time.
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Organization
Two city districts were recruited for participation, districts A and B. Both districts had the same characteristics; the population mainly was characterized by a lower socio-economic status and the districts were comparable in terms of availability and access to sports facilities. In each district, two intervention schools were selected. Sports clubs located in the recruited city districts were approached for participation. In each district, the sports coordinators and the physical education (PE) teachers from the schools collaborated in physical activity management teams. The frequency of meetings depended on the phase of implementation and on encountered problems. The PE teachers were responsible for the coordination of JUMP-in within the schools. The sports coordinators were responsible for the coordination between the schools and assisted in the organization of school sports activities. The physical management teams were coached by a steering group, represented by project leaders of the municipal health service and the city department of sports and recreation. This steering group had meetings with the school director about the planning and introduction of different programme components. The physical activity management teams and the steering group met every 2 months. In these meetings, some programme components were fine-tuned, the implementation processes were discussed and advice and experience were exchanged.
Data collection
The formative evaluation was conducted during two whole school years in which the pilot took place (September 2002–June 2004), and focussed on the health promotion outcomes ‘healthy literacy’, ‘social action and influence’ and ‘healthy public policy and organizational practice’. Data were collected by three different methods. First, school teachers were asked to complete a structured questionnaire. The questionnaires were distributed by the PE teacher [response rate was 43% (n = 20) in the first year and 55% (n = 26) in the second year]. Secondly, an independent researcher conducted semi-structured interviews of 1 hour or more with members from the steering group, the sports coordinators from the city districts, the staff member for Sport and Recreation of district B and the leader of the local Sport Service of district A. Thirdly, documentary analyses were conducted on the project plan and on the minutes of meetings. The interviews and questionnaires took place at the end of both school years, while the document analyses were conducted throughout the two school years.
Measured variables
‘Health literacy’ was not measured directly but focused on the presence of the conditions to achieve ‘health literacy’. To achieve health literacy among children and the school team members, it is firstly important to have programme components that are sufficient and of good enough quality to bring about changes in for example knowledge, attitude and skills. With regard to health literacy, thorough content of the programme components is necessary. All programme components were carefully chosen and developed on the basis of theories and models. It was the task of the PE teachers and the school teachers to implement parts of the programme. The PE teacher received instruments such as the pupil-follow-up system and school sports activities. They also received an introduction or training how to use the instruments. These contributed to promote physical activity in an efficient way. School teachers were trained to stimulate the determinants of physical activity by using the programme components The class moves!® and Choose your card! Thus, in theory the programme was well designed, and it can be expected that it has the potential to achieve changes in determinants such as knowledge, attitude and self-efficacy. Secondly, efficient implementation is essential to improve health literacy (Tones, 1996). Therefore, the formative evaluation concentrates on the quality of the programme components and the implementation. Documentary analysis of the project plan provided information about the quality of the intervention design and the content of the programme components. An important criterion for quality was the use of relevant theories and models when choosing or developing programme components, because this makes it conceivable for determinants such as knowledge, attitude and skills to change (Bartolomew et al., 2001). Moreover, attention was paid to the implementation plans. The actual implementation was verified during the semi-structured interviews. Examples of questions in this regard were: ‘Which successes have been achieved after two years JUMP-in?’, ‘What has been changed in the planning in the past year?’ and ‘Which factors facilitated and/or impeded the implementation?’. The questionnaires for schoolteachers contained questions related to the implementation. An example of such a question was: ‘I teach the exercises of the calendar: ...’. The seven answer categories ranged form ‘never’ to ‘more than once a day’.
Participation, collaboration and support are the keywords attached to ‘social action and influence’. Support was assessed among teachers by two statements in the questionnaire: ‘I am encouraged to take an active part in the project’ and ‘I feel as if my school is working as a team on this project’. The statements could be answered from five categories, ranging from ‘I completely disagree’ to ‘I completely agree’. Also, the PE teachers, sports coordinators and project leaders were asked about support, participation and collaboration in the semi-structured interviews. Examples of questions were: ‘To what extent did you receive support during the implementation?’, ‘To what extent did you feel commitment to the project as an employee from.?’ and ‘What is your opinion about the collaboration during the project?’.
Changes in ‘healthy public policy and organizational practices’ support the continuation of the intervention, and relate to changes in law, rules or financial plans. These aspects were included in the semi-structured interviews and document analyses. In the interviews PE teachers, sports coordinators and project leaders were questioned about their plans for continuation of JUMP-in in the next years and about the role they would play themselves in the future. In addition, the respondents were asked under which conditions successful implementation of JUMP-in could be achieved and which factors impeded or facilitated the embedding of JUMP-in in healthy public policy or organization. Also, document analyses of minutes and e-mails provided information.
Data analyses
The SPSS 9.0 statistical package was used to obtain descriptive statistics (frequencies and means) from the quantitative data of the structured questionnaires.
The semi-structured interviews were recorded and transcribed. During the interview, notes were made by the interviewer. Subsequently, the transcriptions of the interviews, the interview notes and the notes from the document analyses were organized by topic, recoded, summarized, analysed and finally described. This document was added to the results from the questionnaires.
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RESULTS |
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Health literacy
Comprehensive implementation is necessary for the achievement of health literacy. Table 1 shows an overview of the extent and duration to which programme components have been implemented. The programme components ‘school sports activities’ and ‘the activity week’ were implemented without complications. As to the implementation of the programme components ‘parental information service’, ‘the class moves’, ‘choose your card’ and ‘pupil follow up system’ had to struggle with impeding factors, especially in city district B. Impeding factors were: a fully booked school year (first year), work load of teachers (first and second year), lack of interest in project information among teachers (first year) and deficiency of hierarchical authority by the PE teacher (first and second year). The PE teacher was expected to organize the implementation in the school setting. Without formal authority, the PE teacher could not carry out this task. Lack of skills among PE teachers to coordinate the implementation of the school program components and to coach sport trainers was also an impeding factor (first and second year). In addition, due to a delay in the development of some programme components (Choose your Card! and the Pupil Follow-up System), implementation of these components were delayed as well. Strong facilitating factors were effort and commitment of project members, experiences with sport exercise activities and an existing network between schools and local sport service. Extensive recruitment of parents through different channels and the use of trained and experienced instructors explained the successful implementation of the parental information service.
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Social action and influence
The participation and effort of the PE teachers, sports coordinators and staff members was good. They were involved in the development and planning phases from the beginning of the project and they were convinced of the potential effects of the intervention. Participation of school teachers, however, was less. Encouraging school teachers to participate seemed to be rather difficult, and had to be restarted for every new programme component. Factors impeding participation mainly related to inefficient and insufficient communication about the project, which led to differences in expectations and lack of clarity about tasks and responsibilities. The school teachers felt that they were not informed in time, which led to resistance to join the project. Moreover, they felt to have had insufficient preparation time. Adjustments of instructional presentations consistent with the teachers’ terminology, goals and needs appeared to be important to encourage the teachers to participate. Forty percent of the responding school teachers in the first year and 43% in the second year experienced support of their superiors.
All respondents (school teachers, PE teachers, sport coordinators, staff members and the steering group) reported that the strength of JUMP-in was dependent on the cooperation between the city districts, schools and sports clubs. ‘Absence of guidelines about how to fulfil the set of tasks’ impeded the cooperation mainly, while ‘an existing network or past contact’ and ‘the effort and commitment of the project members’ facilitated the collaboration. After 2 years, JUMP-in succeeded in creating a working collaboration in city district A. City district B had to manage with fewer facilitating factors; they had a smaller existing network and the project members were less committed to the project. Nevertheless essential steps are being taken (see healthy public policy and organizational practices) that will also lead to structural collaboration in this district in the future.
The PE teacher, sports coordinator and staff members of both district mentioned that they felt supported by their superior. However, they also mentioned that they encountered less intensive support by the steering group in the second year. By deliberately reducing the intensity of support in the second year, the steering group wanted to explore (i) the required support, (ii) realistic and functional set of tasks and (iii) the feasibility of a self-supporting and independent organization. This trial of less intensive support resulted in a reduction of implementation of some programme components in the second year.
Healthy public policy and organizational practices
One of the goals of JUMP-in was to embed the project, if it appeared to be successful, into the regular school programmes and policies. The creation of prerequisites was crucial for structural embedding in policies, e.g. structural employment of physical activity managers and PE teachers to fulfil the management tasks. The formative evaluation showed that it took 2 years to achieve these changes in healthy public policy. It became clear that especially ‘absence of guidelines about the set of tasks’ hampered the process of embedding JUMP-in into policy. Examples of factors that facilitated embedding were ‘effort and commitment of project members’ and ‘project targets that were aligned with those of the involved organisation’.
However, based on the experienced success, all schools decided to continue and embed JUMP-in into their policy. The city districts made their policies align with JUMP-in, and they reserved money and human resources to make a continuation of JUMP-in possible.
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DISCUSSION |
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Different authors argue for measuring health promotion outcomes as ‘health literacy’, ‘social action and influence’ and ‘healthy public policy and organizational practices’, because these outcomes can be measured in the short term and give an indication about expected successes for the near future (Nutbeam, 2000
; Saan and De Haes, 2004b). The formative evaluation of JUMP-in showed overall positive results on two of the three aspects: ‘social action and influence’ and ‘healthy public policy and organizational practices’.
Participation, support and collaboration were obtained and facilitated the implementation. Consistent with other studies, involvement was an important facilitating factor for participation (Iedema, 2000; Sahota et al., 2001). Using participation, support and collaboration as indicators for the health promotion outcome ‘social action and influence’ provided lessons for the future. For example one should be aware of the importance of informing school teachers in the early phase and know that participation among them can be facilitated by tailoring instructional presentations to the teachers’ terminology and, more important, to their goals. Also other authors (e.g. Milio, 1997; Wallerstein, 2000; St Leger, 2001; Koelen et al., 2001; Mendes and Akerman, 2002) mentioned the necessity of paying attention to each others’ goals. District B did not succeed in creating a working collaboration in two years, which can be explained by a smaller existing network at the beginning of the project and less commitment of the project members. Nevertheless, essential steps were taken that will lead to structural collaboration in the future. It has been recognized that creating collaboration and intensive participation may take years (Mercx, 2002; Weijters and Koelen, 2003; Ronda et al., 2004).
Furthermore, the health promotion outcome ‘healthy public policy and organizational practices’ indicates positive future expectations for JUMP-in. After two years, all intervention schools and participating city districts experienced JUMP-in as a success. This lead to adaptation of both city district- and school policies, rules and financial plans and increases the chance of structural embedding and health benefits on the long term. With regard to the condition to achieve health literacy, some results have been attained as well. The programme itself is systematically designed and based on theory, and therefore has the opportunities to bring about change in physical activity and its determinants. Nevertheless, some impeding factors during implementation may lead to a lower level of health literacy than expected. Health literacy will be achieved in the future if more attention is paid to implementation. Based on the results achieved at the social action level and the policy level, we expect that JUMP-in will be an effective intervention in the future.
It is important to note some limitations of the present study. First, the respondents were interviewed only at the end of the school year. Extensive evaluation of all programme components at different time points would be helpful to evaluate activities that had been ended in the past, such as skills training and information meetings for teachers. But this also would increase the workload of the project members to an unacceptable level. The use of invalidated questionnaires is another possible limitation. However, the results of the questionnaires were always combined with results of other methods (triangulation). A third limitation is the low and possibly selective response of the school teachers questionnaire. Possibly, the teachers who responded to the questionnaire were more committed to the project or the project goals. Finally, one can question whether measuring variables such as ‘health literacy’, ‘social action and influence’ and ‘healthy public policy and organizational practices’ are feasible when not defined in detail. For the future usage, it is important to operationalize these variables more specifically, especially when we use these health promotion outcomes as indicators for the extent of success of an intervention. In addition, using existing instruments to measure these variables makes it possible to compare different health promotion programs. Examples of useful instruments are Pretty’s ladder of participation (pretty, 1995), the participation measurement instrument of Rifkin (Rifkin et al., 1988; Koelen and van den Ban, 2004) or a combination of both instruments, as used by Koelen and Vaandrager (Koelen and Vaandrager, 1995), is also an option.
In conclusion, measuring ‘health promotion outcomes’ provides valuable information about the processes of both collaboration and implementation. Insight is given into the barriers and facilitators during the implementation as well as in the discrepancy between the planned and the actual implementation, i.e. it reduces change on type III error. The formative evaluation helped to make an estimate of expected future effects of JUMP-in by measuring ‘health promotion outcomes’. But equally important, research on health promotion outcomes offers possibilities to optimize the JUMP-in intervention and organization in such a way that effectiveness should be increased and long-term effects can be expected. At this moment, JUMP-in is disseminated across a larger area in the Amsterdam region, accompanied by a continuous formative and summative evaluation.
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FUNDING |
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This study was supported financially by Public Health Fund (Fonds OGZ) and Ministry of Health, Welfare and Sport.
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