Chapter 19 Planning health promotion interventions
We have seen in Chapter 18 how needs assessment and targeting may be carried out, and the importance of carrying out this process and being clear about the context in which this is done. This chapter builds on the discussion of the first stage of planning – needs assessment – in Chapter 18. Firstly, definitions of planning are given and the reasons for planning discussed. Planning at different levels, from broad strategic planning through project planning to small-scale health education planning, is considered. The Ewles & Simnett (2003) and PRECEDE–proceed models (Green & Kreuter 2005) are reviewed in detail. Quality and audit issues and how this relates to planning are then considered.
Planning is one of those terms which is used in many different ways. Other related terms are used in equally imprecise ways, so that often the same activity is labelled in different ways by different people. There are no hard and fast rules about the way terms are used, but the following definitions are presented as a means of clarifying the differences between related activities. These are the definitions we shall be using in this chapter.
Judy has been given a remit to develop a health promotion programme with the aim of reducing the suicide rate. Her health authority’s policy includes a commitment to equal opportunities. She decides her priority will be unemployed people, who are known to be at increased risk of suicide. She consults with stakeholders. Judy’s objectives are: (1) to set up a support group for unemployed people; and (2) to provide specialist counselling services. Her strategy is to network with existing community groups, and to recruit and train volunteer counsellors.
Reasons for planning
Health promoters usually have no problem in finding things to do which seem reasonable. Work areas are inherited from others, delegated from more senior members of the workplace or demanded by clients. It is possible to be kept very busy reacting to all these pressures, and planning health promotion interventions may seem a luxury or a waste of time. However, there are sound reasons for planning health promotion or being proactive in your work practice:
Planning takes different forms and is used at different levels. It may be used to provide the best services or care for an individual client, as in the nursing process, or planning may be for group activities, such as antenatal classes. Planning may also refer to large-scale health promotion interventions targeted at whole populations.
The degree of formality of the planning process also varies. When planning a one-to-one intervention, the process is informal and may involve no one else. Planning for a group intervention may involve liaising with other professionals as well as the target group, to find out what their aims and objectives are and what sorts of methods and resources are available and acceptable. A written plan may be produced to act as a guide and a statement of agreed outcomes and methods. Planning a large-scale intervention will usually involve more long-term collaborative planning. Often a working group (or taskforce or local forum) will be established early on to identify interested groups and gain their support and expertise. A written plan will usually be produced, outlining not only objectives and methods but also a timescale of what is to be achieved when; funding details and a budget; who is responsible for which tasks; and how the intervention will be evaluated and the findings reported back.
There has been much greater emphasis on systematic planning in recent years due to a need for greater economic accountability, more focus on targets and their achievement, and the need to include evidence as part of project development. It is particularly important for practitioners to be clear about the rationale for interventions, the goals and the approach adopted.
Health promotion planning cycle
Planning involves several key stages or logical stepping stones which enable the health promoter to achieve a desired result. The benefit is being clear about what it is you want to achieve, i.e. the purpose of any intervention. Planning entails:
Some planning models are presented in a linear fashion. Others show a circular process to indicate that any evaluation feeds back into the process, as illustrated in Figure 19.1. This seemingly rational and simple approach describes how decisions should be made. It does not take into account that there may not be agreement on objectives or the best way to proceed and that in real life, planning is often piecemeal or incremental. There is no grand design, but circumstances dictate many small reactive decisions.
Figure 19.1 suggests that the planning cycle begins with a needs assessment through which the programme’s focus and any specific target groups may be identified. The underlying causes and contributory factors that led to the problem and the areas that will need to be addressed are then identified. Figure 19.2 shows how understanding the effects of a problem can help to identify indicators and desired outcomes from an intervention. Turning the problem, in this case antisocial activity by young people in a neighbourhood, into a positive statement gives a purpose for the intervention. Addressing the causes of the problem identifies outputs and activities. The aims and objectives can then be clearly stated. This provides a number of options for intervention and at this point many other issues come into play such as resource availability, capacity and potential obstacles. These issues will then be considered alongside any evidence of effective interventions. The actual intervention or programme and its methods can then be selected. The practicalities of implementation will need to be explored and the evaluation and monitoring plans put in place. This simple model can be applied to all levels of planning activities, from large-scale strategic planning, to middle-scale project planning and small-scale interventions with clients.
Strategy tends to be used as an umbrella term to cover a broad programme. It may therefore have several different objectives and projects. Practitioners often do not start with a blank sheet and have to work in a wider policy context where issues are determined nationally. For example, all primary care trusts are required to have a strategy to tackle obesity. Strategies may be local as well as national and involve many stakeholders. A stakeholder analysis helps to identify relevant partners and their interests regarding the issue. For example, local area agreements (LAAs) require consultation between statutory and voluntary agencies and local populations to draw up agreed plans to promote health in a defined locality. LAA plans include:
Developing a local obesity strategy
To ensure the long-term commitment of all stakeholders and to try to develop a robust action plan, an extensive consultation process has been undertaken within Torbay during the development of this strategy. Opinions have been sought with regards to both the prevention and management of obesity from stakeholders and members of the general public living in Torbay. Furthermore, a resource mapping exercise has also been undertaken. Alongside the mapping of current practice and the recording of both public and stakeholder opinion regards priorities for action, the evidence for the effectiveness of a broad spectrum of interventions was researched at length. This, alongside local and national policy, was used to help prioritise potential actions. Furthermore, those actions known to have evidence of effectiveness reaching those individuals at greatest potential risk were given largest priority … Work to improve the health of the population is by no means the sole responsibility of the health service and increasingly local responsibility for the health of communities is being shared between the agencies that make up Local Strategic Partnerships (LSPs) and with the communities themselves (Torbay Care Trust 2006).
Project planning is a smaller-scale activity and refers to planning a specific project which is time-limited and aims to bring about a defined change. Examples of small-scale health promotion projects include a project to raise the awareness of university students about meningitis, a project to train school nurses in presentation skills and a project to map safe routes to school for young children.
The working group would need to involve a variety of partners in order to maximize its effectiveness. You might have identified representatives from the local authority, mass media, occupational health services covering workplaces, primary health care practitioners, mental health practitioners, teachers and youth workers, licensed victuallers, magistrates, the police service and voluntary agencies dealing with alcohol-related problems. The success of this strategy will depend on the different partners working together to achieve aims.
The start of the project is agreement that the project should take place, its overall aims and the allocation of a budget to support the project. Often the start is signalled by the formal adoption of a project proposal, indicating that an organization has given support for the development and implementation of a project. Specification means setting objectives and quality criteria for how the project is to be delivered. Setting objectives is considered in more detail below. Quality and audit are discussed later in this chapter. Design is the detailed planning of the training intervention. A Gantt chart (set out as an example in Figure 19.3) is a useful tool to use at this stage. A Gantt chart plots tasks and the people responsible for these tasks against a timescale in which these activities need to be undertaken. It portrays in a graphical form the interdependence of project tasks and how each single task contributes to the whole. Implementation is the project activity, e.g. training sessions. Evaluation, review and final completion report on project outcomes and assess whether objectives have been met. It is useful to have a time lag between completing the project and the final review in order to assess long-term as well as immediate outcomes.
The strategy outlined in Activity 19.4 includes a project centred on training GPs and practice nurses to identify problematic use of alcohol at an early stage. This project, which is part of the overall alcohol reduction strategy, would require careful and detailed planning, including: