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Framework for Evaluating Health Promotion
projects: The Swiss Model for Outcome
Classification in Health Promotion and
Prevention (SMOC)

Committee on Valuing Community-Based, Non-Clinical Prevention
Policies and Wellness Strategies
Institute of Medicine, Washington, D.C. , 5 th December 2011

Brenda Spencer
University Institute for Social and Preventive Medicine, Lausanne
Günter Ackermann
Health Promotion Switzerland




                                                                                                IUMSP
                                               Institut universitaire de médecine sociale et préventive, Lausanne
The SMOC in 2 phrases:
    Ø structured framework offering a common language to
      describe pathways to health
    Ø methodology developed for interactive use integrates the
      perspectives of all stakeholders

    Ø Plan of presentation
       § Why and how was this model developed?
       § What is the purpose and context of its use?
       § What is its theoretical basis and structure?
       § How is the model applied in practice?


                                                                                            IUMSP
                                           Institut universitaire de médecine sociale et préventive, Lausanne
2
The Swiss Model for Outcome Classification in Health Promotion
    and Prevention (SMOC):


    Plan of presentation

    § Why and how was this model developed?

    § What is the purpose and context of its use?

    § What is its theoretical basis and structure?

    § How is the model applied in practice?



                                                                                              IUMSP
                                             Institut universitaire de médecine sociale et préventive, Lausanne
3
Our ever-faithful friend, the black box
                           Why we think our                                 Our
                             activities can                                 goal
                           lead to our goal
     Measures
     applied: What
                   we do                              Improvement
                                                     of a population‘s
     •Projects                                             health
     •Programmes
     •Strategies
     •Policies
                      n.b. output is
                      not outcome!
                                                                                         IUMSP
                                        Institut universitaire de médecine sociale et préventive, Lausanne
4
It’s never so simple…
         Not possible to           Not desirable to
          standardise           standardise measures
           measures                 – adaptation to
                                        context
                                                             What’s more, the
     Measures                                              context changes over
     applied:                                                       time
                                                            Improvement
                                                          of a population‘s
     •Projects                                                  health
     •Programmes                                        Most of these changes
     •Strategies                                         you cannot predict
     •Policies
           And once they’ve           And even if you could, you
          taken place, you’ll           couldn’t control them
             need to take
               different                                                                      IUMSP
              measures                       Institut universitaire de médecine sociale et préventive, Lausanne
5
Various ways to open the
    black box…




                                                                                IUMSP
                               Institut universitaire de médecine sociale et préventive, Lausanne
6
A new solution…………….?




         "Looks like the research boys really came up
                  with something this time."
                                                                                       IUMSP
                                      Institut universitaire de médecine sociale et préventive, Lausanne
7
SMOC Development
    § 2002-2004:    Model Construction
    § 2004-2005:    Feasibility testing & Translation
    § 2005 onwards: Dissemination
          ØGuidelines for use
            http://www.gesundheitsfoerderung.ch/pages/Gesundheitsfoerd
            erung_und_Praevention/Tipps_T ools/ergebnismodell.php

    § 2008: Publication in Health Promotion International
          ØSpencer B, Broesskamp-Stone U, Ruckstuhl B,
           Ackermann G, Spoerri A, Cloetta B. et al. 23 (1): 86.
            http://heapro.oxfordjournals.org/cgi/content/full/dam038?ijkey=
            zQDCckIz8KuMxob&keytype=ref



                                                                                                 IUMSP
                                                Institut universitaire de médecine sociale et préventive, Lausanne
8
The Swiss Model for Outcome Classification in Health Promotion
    and Prevention (SMOC):


    Plan of presentation

    § Why and how was this model developed?

    § What is the purpose and context of its use?

    § What is its theoretical basis and structure?

    § How is the model applied in practice?



                                                                                              IUMSP
                                             Institut universitaire de médecine sociale et préventive, Lausanne
9
Three types of application
                  Situation analysis
     Where is a specific problem to be located?
     How may the problem have arisen?                           Intervention planning
     T o which categories can the factors
     contributing to the development of the         How can the health of the
     problem be attributed and how do they relate   population be maintained or how can a
     to each other?                                 health-related problem be reduced?
     Are there other players that may already be
     having an impact?                              In which categories should the project’s
                                                    objectives be situated and how do the
                                                    objectives interact?
                    Evaluation
     Which factors have contributed in which
     way to maintain health or reduce health-        Applied at three levels:
     related problems in the population?
     In which categories have results                ØProjects
     been achieved and how do these results
                                                     ØProgrammes
     interact?
     What do these results tell us about our         ØStrategies
     hypothesised theory of action?
                                                                                                           IUMSP
                                                          Institut universitaire de médecine sociale et préventive, Lausanne
10
The Swiss Model for Outcome Classification in Health Promotion
     and Prevention (SMOC):


     Plan of presentation

     § Why and how was this model developed?

     § What is the purpose and context of its use?

     § What is its theoretical basis and structure?

     § How is the model applied in practice?



                                                                                               IUMSP
                                              Institut universitaire de médecine sociale et préventive, Lausanne
11
The determinants of health




           Dahlgren G, Whitehead M. Policies and strategies to promote social
             equity in health. Stockholm: Institute for Future Studies; 1991.

                                                                                                        IUMSP
                                                       Institut universitaire de médecine sociale et préventive, Lausanne
12
Theoretical and Methodological
     underpinnings and links
     § Field of Health:
         § Ottawa Charter, 1986
         § Don Nutbeam, 2002; NIGZ Health Promotion Framework
          Saan & de Haes 2005; PRECEDE-PROCEED Green &
          Lewis, 1986; EUPHID Health Development Model for the
          classification of public health indicators Bauer et al., 2006

     § Programmme Theory in Evaluation
         § logic model - “graphic depiction of the relationship between
          the main strategies of a program and associated goals,
          objectives, population(s) of interest, indicators and
          resources” (Hyndman et al., 2001)
                                                                                                 IUMSP
                                                Institut universitaire de médecine sociale et préventive, Lausanne
13
Swiss Model for Outcome Classification
                       Health promotion     Factors influencing          Health                          Health status of the
                        measures (A)      health determinants (B)   determinants (C)                       population (D)



     Infrastructures
                       A1: Development    B1: Health
     services
                       of services        promoting services
                                                                    C1: Physical
                                                                    environment
     Legal system      A2: Advocacy       B2: Public policy
     Administration    Networking         and organisational
     Organisation
     Networks          organisations      practice                  C2: Social
                                                                    environment                                 D:Health
     Groups            A3: Social         B3: Social potential
     Communities
     Population        mobilization       and commitment            C3: Indiv. resources/
                                                                    behavioural patterns
     Individuals       A4: Development    B4: Individual
                       of individual      health-related life
                                                                                                                     IUMSP
                       skills             skills
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
14
SMOC: Levels of outcome (columns)
     and focal points
       Health promotion     Factors influencing          Health                     Health status of
        measures (A)      health determinants (B)   determinants (C)               the population (D)



      Infrastructures, services

      Legal system, administration, organisations                                            Health

      Groups, communities, population

      Individuals


                                                                                                      IUMSP
                                                     Institut universitaire de médecine sociale et préventive, Lausanne
15
Health promotion measures (A)
                        Health promotion      Factors influencing           Health                         Health status of the
     Outcome levels
                         measures (A)       health determinants (B)    determinants (C)                      population (D)


     Infrastructures
                       A1: Development
     services
                       of services

                       A2: Advocacy
     Legal system
     Administration
                       Networking
     Organisation
     Networks
                       organisations                                                                                 Health


     Groups            A3: Social
     Communities
     Population        mobilisation


                        A4:
     Individuals
                        Development of
                        individual skills
                                                                                                                       IUMSP
                                                                      Institut universitaire de médecine sociale et préventive, Lausanne
16
Factors influencing health determinants (B)
                       Health promotion         Factors influencing          Health                          Health status of the
     Outcome levels
                        measures (A)          health determinants (B)   determinants (C)                       population (D)


     Infrastructures
                       A1: Development        B1: Health
     services

                       of services            promoting services


     Legal system      A2: Advocacy           B2: Public policy
     Administration
     Organisation      Networking             and organisational
     Networks
                       organisations          practice
                                                                                                                       Health
     Groups
     Communities
                       A3: Social             B3: Social potential
     Population
                       mobilization           and commitment


     Individuals       A4: Development        B4: Individual
                       of individual skills   health-related life
                                              skills
                                                                                                                         IUMSP
                                                                        Institut universitaire de médecine sociale et préventive, Lausanne
17
B1 Health promoting services
                       Health promotion       Factors influencing   Health determinants                  Health status of the
     Outcome levels
                          measures            health determinants                                            population


     Infrastructures
                        Development of       B1: Health
     services

                           services          promoting services


     Legal system           Advocacy
     Administration
     Organisation          Networking
     Networks
                          organisations
                                                                                                                   Health
     Groups
     Communities
                       Social mobilization
     Population




     Individuals       Development of
                       individual skills
                                                                                                                     IUMSP
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
18
B1 Health promoting services

     § B1-1 Awareness of the service
     § B1-2 Accessibility of the service and reaching of target
            groups
     § B1-3 Use of the service and satisfaction with it
     § B1-4 Sustainability of the service
     § B1-5 Improved professionalism in health promotion



     –     Professionals, mediators
     –     Population

                                                                                                   IUMSP
                                                  Institut universitaire de médecine sociale et préventive, Lausanne
19
B2: Health promoting public policy and
        organisational practice
                       Health promotion       Factors influencing   Health determinants                  Health status of the
     Outcome levels
                          measures            health determinants                                            population


     Infrastructures
                        Development of       B1: Health
     services

                           services          promoting services


     Legal system           Advocacy         B2: Public policy
     Administration
     Organisation          Networking        and organisational
     Networks
                          organisations      practice
                                                                                                                   Health
     Groups
     Communities
                       Social mobilization
     Population




     Individuals       Development of
                       individual skills
                                                                                                                     IUMSP
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
20
B2 Health promoting public policy and
        organisational practice

     § B2-1 Binding engagement of decision-makers and/or key
            persons
     § B2-2 Action-relevant, binding written basis
     § B2-3 Successful organisational changes
     § B2-4 Successful exchange and cooperation




     –    Policy
     –    Organisations

                                                                                                IUMSP
                                               Institut universitaire de médecine sociale et préventive, Lausanne
21
B3 Health promoting social potential
                  and commitment
                       Health promotion       Factors influencing        Health                          Health status of the
     Outcome levels
                          measures            health determinants     determinants                           population


     Infrastructures
                        Development of       B1: Health
     services

                           services          promoting services


     Legal system           Advocacy         B2: Public policy
     Administration
     Organisation          Networking        and organisational
     Networks
                          organisations      practice
                                                                                                                   Health
     Groups
     Communities
                       Social mobilization   B3: Social potential
     Population
                                             and commitment


     Individuals       Development of
                       individual skills
                                                                                                                     IUMSP
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
22
B3: Health promoting social potential
           and commitment

     § B3-1 Existence of active groups focusing on health
            promoting concerns or themes
     § B3-2 Enlisting of new players
     § B3-3 Awareness of the concern by population groups
     § B3-4 Acceptance of a concern by population groups




                                                                                                 IUMSP
                                                Institut universitaire de médecine sociale et préventive, Lausanne
23
B4 Individual health-related life
        skills
                       Health promotion       Factors influencing        Health                          Health status of the
     Outcome levels
                          measures            health determinants     determinants                           population


     Infrastructures
                        Development of       B1: Health
     services

                           services          promoting services


     Legal system           Advocacy         B2: Public policy
     Administration
     Organisation          Networking        and organisational
     Networks
                          organisations      practice
                                                                                                                   Health
     Groups
     Communities
                       Social mobilization   B3: Social potential
     Population
                                             and commitment


     Individuals       Development of        B4: Individual
                       individual skills     health-related life
                                             skills                                                                  IUMSP
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
24
B4 Individual health-related life
     skills


     § B4-1 Factual health-relevant knowledge and capacity to
            act on knowledge
     § B4-2 Positive attitudes towards a health-relevant topic
     § B4-3 New personal and/or social skills
     § B4-4 Strengthened self-confidence regarding a health-
            relevant topic or an activity




                                                                                                  IUMSP
                                                 Institut universitaire de médecine sociale et préventive, Lausanne
25
Health Determinants (C)
                       Health promotion         Factors influencing          Health                          Health status of the
     Outcome levels
                        measures (A)          health determinants (B)   determinants (C)                       population (D)


     Infrastructures
                       A1: Development of     B1: Health
     services

                       services               promoting services
                                                                        C1: Physical
                                                                        environment
     Legal system      A2: Advocacy           B2: Public policy
     Administration
     Organisation      Networking             and organisational
     Networks
                       organisations          practice                  C2: Social
                                                                        environment                                  D:Health
     Groups
     Communities
                       A3: Social             B3: Social potential
     Population
                       mobilization           and commitment            C3: Indiv. resources/
                                                                        behavioural patterns
     Individuals       A4: Development        B4: Individual
                       of individual skills   health-related life
                                              skills                                                                     IUMSP
                                                                        Institut universitaire de médecine sociale et préventive, Lausanne
26
C1 Health-promoting physical
                  environment
                       Health promotion      Factors influencing          Health                          Health status of the
     Outcome levels
                          measures           health determinants       determinants                           population


     Infrastructures
                        Development of        Health promoting
     services

                           services               services
                                                                           C1: Physical
                                                                           environment
     Legal system           Advocacy          Public policy and
     Administration
     Organisation          Networking          organisational
     Networks
                          organisations           practice
                                                                                                                    Health
     Groups
     Communities
                       Social mobilization   Social potential and
     Population
                                                commitment


     Individuals       Development of         Individual health-
                       individual skills       related life skills
                                                                                                                      IUMSP
                                                                     Institut universitaire de médecine sociale et préventive, Lausanne
27
C1 Health-promoting physical
        environment

     § C1-1 Reduction of pollution caused by physical-chemical
            influences
     § C1-2 Conservation and improvement of natural resources
     § C1-3 Health-promoting installations and products




     –    Work place, education, school
     –    Habitation, home
     –    leasure, mobility

                                                                                                IUMSP
                                               Institut universitaire de médecine sociale et préventive, Lausanne
28
C2 Health-promoting social
                  environment
                       Health promotion      Factors influencing          Health                          Health status of the
     Outcome levels
                          measures           health determinants       determinants                           population


     Infrastructures
                        Development of        Health promoting
     services

                           services               services
                                                                     C1: Physical
                                                                     environment
     Legal system           Advocacy          Public policy and
     Administration
     Organisation          Networking          organisational
     Networks
                          organisations           practice           C2: Social
                                                                     environment                                    Health
     Groups
     Communities
                       Social mobilization   Social potential and
     Population
                                                commitment


     Individuals       Development of         Individual health-
                       individual skills       related life skills
                                                                                                                      IUMSP
                                                                     Institut universitaire de médecine sociale et préventive, Lausanne
29
C2 Health-promoting social
        environment


     § C2-1 Social support, social networks, social integration
     § C2-2 Social climate
     § C2-3 Equal access to general social resources




     –   Work place, education, school
     –   Habitation, home
     –   Leasure, mobility

                                                                                                  IUMSP
                                                 Institut universitaire de médecine sociale et préventive, Lausanne
30
C3: Health-promoting individual
           resources and behavioural patterns
                       Health promotion      Factors influencing          Health                          Health status of the
     Outcome levels
                          measures           health determinants       determinants                           population


     Infrastructures
                        Development of        Health promoting
     services

                           services               services
                                                                     C1: Physical
                                                                     environment
     Legal system           Advocacy          Public policy and
     Administration
     Organisation          Networking          organisational
     Networks
                          organisations           practice           C2: Social
                                                                     environment                                    Health
     Groups
     Communities
                       Social mobilization   Social potential and
     Population
                                                commitment           C3: Indiv. resources/
                                                                     behavioural patterns
     Individuals       Development of         Individual health-
                       individual skills       related life skills
                                                                                                                      IUMSP
                                                                     Institut universitaire de médecine sociale et préventive, Lausanne
31
C3: Health-promoting individual
        resources and behavioural patterns

     § C3-1 Health promoting individual skills
     § C3-2 Improved health-relevant behaviour and
                patterns of behavioural




     –   Work place, education, school
     –   Habitation, home
     –   Leasure, mobility

                                                                                               IUMSP
                                              Institut universitaire de médecine sociale et préventive, Lausanne
32
D: Improvement of a population´s health
     and quality of life

     Indicators regarding:

     § Increased healthy life
       expectancy
     § Increased health-related
       quality of life
     § Lower morbidity
     § Less premature mortality




                                                                                   IUMSP
                                  Institut universitaire de médecine sociale et préventive, Lausanne
33
The Swiss Model for Outcome Classification in Health Promotion
     and Prevention (SMOC):


     Plan of presentation

     § Why and how was this model developed?

     § What is the purpose and context of its use?

     § What is its theoretical basis and structure?

     § How is the model applied in practice?



                                                                                               IUMSP
                                              Institut universitaire de médecine sociale et préventive, Lausanne
34
Elderly in the community : situation analysis

                                                           Neighbourhood
                               Health promoting             construction
       Development of              services
          services                                    unfavourable to elderley
                                                      C1: Physical
                                                             pedestrians
                                                      environment
                            Absence of public
                               Public policy and
          Advocacy
         Networking              policy
                                organisational                                        Institutionalisation
        organisations               practice         Social isolation                 Poor Quality of Life
                                                       C2: Social                                 Health
                                                     Loneliness
                                                       environment                    Frailty
                                                     Insecurity
      Social mobilization     Social potential and
                                Low public
                                 commitment
                                 awareness             C3: Indiv. resources/
                                                       behavioural patterns
      Development of          Individual health-           Low physical
      individual skills        related life skills
                            Fear                             activity
                            Resignation


                                                                                                            IUMSP
                                                           Institut universitaire de médecine sociale et préventive, Lausanne
35
Elderly in the community : programme theory

                                                             Apartment rented as
                                   Health promoting         small community centre
         Development of                services
            services         Project Agenda 21 for          C1: Physical garden
                                                             Neighbour
                              community garden              environment
                                                                   activities
          Seek
           Advocacy                Public policy and
      partnerships
          Networking           Joint organisational
                                     project with                                            Elderly live
          organisations        municipality: QoL
                                        practice           Increased social                  independently
                                                             C2: Social                                 Health
                      Residents of                         contact
                                                             environment                     Increased strength
     ProSenectute all ages                                 Intergenerational                 Less depression
         Social mobilization        Social potential and
     community                             Residents       understanding
                      participate in commitment
     development design and            Community group       C3: Indiv. resources/
     project                                created          behavioural patterns
                      construction
        Development of               Individual health-          Increased
                      of garden
        individual skills           related life skills        physical activity
                                 Increased
                                 confidence

                                                                                                                 IUMSP
                                                                Institut universitaire de médecine sociale et préventive, Lausanne
36
Outcome model of a prevention project on obesity in infants

     Development and               Broad dissemination, wide use by
                                        maternal consultants
      Dissemination
                         A1                                   B1
            Development of health
                               High attainment Health promoting services
                                                                       Parental satisfaction, few
                                               of target groups
               promoting services and many coachings
        Acquisition                                                           dropouts                    C1
                                                                                             Health promoting physical
          Tools                      Improved expert skills                                         environment
     Further education
                                                              B2
                         A2         Committed promoting public policy and
                                        Health
           Advocacy, cooperation of consultantsorganizational practice
                   organizations                                                                          C2
     Networking with                                                                     Health promoting social/societal
        pediatrics
                                                        Successful cooperation
                                                                                                   environment                                  D
                                                                                                Improved eating culture                       Health
                                                              B3
                         A3                  Health promoting social potential and
                                                                                          Family meals, slow food, eating without
                                                                                                    distraction/TV,…
               Social mobilization                      commitment
                                                                                                          C3
                                                                                           Health promoting individual
                                                                                               Improved eating behavior
                                                                                           resources and behavioural
                         A4                                   B4                          More fruits, vegetables and salads, less
                                                                                                        patterns
                                                                                       sweets,snacks and sweet beverages. Increased
               Development of                    Health-related Improved
                                                                 life skills                 consumption of sugarless beverages
     Coachings  individual skills                                                                                                           Healthy weight
                                                              educational
      by parent             Improved educational               behaviour
     counsellors                   skills                                                      Increased physical activity
                                                                                        Increased activity outdoors, less computer and

                                                                                                                                               IUMSP
                                                                                                           television


        Measures                Objectives                                                    Institut universitaire de médecine sociale et préventive, Lausanne
37
Outcome model of a prevention project on obesity in infants:
        How many parent counsellors            research questions
               have
     Development and      been reached?
                                Broad dissemination, wide use by
      Dissemination
                         A1            maternaal consultants            Which parents
                                                           B1          can be reached? few
                 How good is the quality target groups services
            Development of health
                               High attainment Health promoting
                                               of
                                                                          Parental satisfaction,
               promoting services and many coachings
        Acquisition
                         of the training?
                                                                                   dropouts                   C1
                                                                                                Health promoting physical
          Tools                                    Do the
                                                        parent counsellors
                                     Improved expert skills                                            environment
     Further education                           have better skills due to the
                                                       B2trainings?
                         A2         Committed promoting public policy and
                                        Health                                                       Was it possible to change
           Advocacy, cooperation of consultantsorganizational practice
               organizations
       Is the networking with                                                                         C2 eating culture of the
                                                                                                       the
                                                                                                                  families?
     Networking with                                                                      Health promoting social/societal
      pediatrics successful?
        pediatrics
                                                      Successful cooperation
                                                                                                         environment                           D
                                                                                                   Improved eating culture                   Health
                                                           B3
                         A3                Health promoting social potential and
                                                                                              Family meals, slow food, eating without
                                                                                                        distraction/TV,…
               Social mobilization                    commitment
     Quality of the               What is the influence on                                        Do children eat
                                                                          T o what extent has C3
      coaching?                    parental attitudes and                                              healthier?
                                                                         educational behaviour eating individual
                                                                                       Health promoting behavior
                                                                                          Improved
                                           skills?                                     resources and behavioural                          Decrease of
                         A4                                B4                  changed? fruits, vegetables and salads, less
                                                                                      More
                                                                                                         patterns
                                                                                         sweets,snacks and sweet beverages. Increased
                                                                                                                                          body weight?
               Development of                    Health-related Improved
                                                                 life skills                 consumption of sugarless beverages
     Coachings  individual skills                                                                                                           Healthy weight
                                                              educational
      by parent             Improved educational               behaviour
     councellors                   skills                                                            More physical activity
                                                                                              More activity outdoors, less computer and
                                                                                                               Are they more
                                                                                                                                              IUMSP
                                                                                                               television

                                                                                                                      active? sociale et préventive, Lausanne
                                                                                                  Institut universitaire de médecine
38
Stakeholder Workshop Process

     § Participation:
        § within stakeholder groups
        § between stakeholder groups

     § Communication:
        § implicit becomes explicit
        § exchange and clarify
        § agree on transparent objectives



                                                                                             IUMSP
                                            Institut universitaire de médecine sociale et préventive, Lausanne
39
Foto




                                                             IUMSP
            Institut universitaire de médecine sociale et préventive, Lausanne
40
IUMSP
     Institut universitaire de médecine sociale et préventive, Lausanne
41
An iterative process…




                                                        but
                                                        nonetheless
                                                        with outputs…



                                                                              IUMSP
                             Institut universitaire de médecine sociale et préventive, Lausanne
42
Overall process leading to the definition of an
     evaluation framework
     Ø Situation analysis
     Ø Programme theory
     Ø Choice of « priority » objectives
     Ø Definition of relevant/key indicators
     Ø Definition of corresponding anticipated values
        § quantitative
        § qualitative


                                                                                          IUMSP
                                         Institut universitaire de médecine sociale et préventive, Lausanne
43
Elderly in the community : possible indicators

                                                              Apartment rented as
                                   Health promoting                 Maintenance of
                                                            small community centre
         Development of                services
            services
                                                                    garden
                                                            C1: Physical garden
                                                             Neighbour
                                                                    Frequency of activities
                                 Project Agenda 21          environment
                                                                   activities
          Seek
           Advocacy                Public policy and
      partnerships
          Networking           Joint organisational
                                     project with                                Elderly live
          organisations          municipality
                                        practice           Level of satisfaction
                                                           Increased social
                                                             C2: Social          independently
                                                                                            Health
                                                           regarding atmosphere
                                                           contact
                      Residents of                           environment         Increased strength
     ProSenectute all ages                                 in neighbourhood
                                                           Intergenerational
                                    Social potential and                         Less depression
         Social mobilization
     community                             Residents       Frequency of contacts
                                                           understanding
                      participate in commitment
     development design and            Community group
                                       Level of              C3: Indiv. resources/
     project                                created          behavioural patterns
                      construction participation
        Development of               Individual health-         Low physical
                      of garden                                         Level of physical
        individual skills           related life skills           activity
                                                                             activity
                                 Increased
                                 confidence

                                                                                                                 IUMSP
                                                                Institut universitaire de médecine sociale et préventive, Lausanne
44
Individual programmes and projects do not
       need to provide evidence of progress from                          Epidemiological data
       C to D:

                       Health promotion     Factors influencing          Health                          Health status of the
                        measures (A)      health determinants (B)   determinants (C)                       population (D)



     Infrastructures
                       A1: Development    B1: Health
     services
                       of services        promoting services
                                                                    C1: Physical
                                                                    environment
     Legal system      A2: Advocacy       B2: Public policy
     Administration    Networking         and organisational
     Organisation
     Networks          organisations      practice                  C2: Social
                                                                    environment                                 D:Health
     Groups            A3: Social         B3: Social potential
     Communities
     Population        mobilization       and commitment            C3: Indiv. resources/
                                                                    behavioural patterns
     Individuals       A4: Development    B4: Individual
                       of individual      health-related life
                                                                                                                     IUMSP
                       skills             skills
                                                                    Institut universitaire de médecine sociale et préventive, Lausanne
45
IUMSP
     Institut universitaire de médecine sociale et préventive, Lausanne
46
Where are we now?
     § Dissemination of use
          § National
          § International
     §   Sustainability/ Integration of SMOC into:
          § further education and training
          § technical support system
          § quality assurance methodology (http://www.quint-essenz.ch/en.html)
          § grant management process
     § Multiple uses and levels of application
     § Creation of web-based community of users
     § Links with systems management
                                                                                                  IUMSP
                                                 Institut universitaire de médecine sociale et préventive, Lausanne
47
Key characteristics of the SMOC
     § Communication and understanding is promoted between
         stakeholders
     §   Provides synthesis of multiple perspectives
     §   Development of common language
     §   Acknowledges complexity
     §   Brings together different forms of evidence from research and
         expert/practitioner knowledge
     § Interventions are developed on a theoretical and evidence-
         based framework
     § Hypotheses regarding change theory are made explicit and
         can be verified: performance AND learning objectives
                                                                                                IUMSP
                                               Institut universitaire de médecine sociale et préventive, Lausanne
48
Thankyou for
     your attention!




                                                         IUMSP
        Institut universitaire de médecine sociale et préventive, Lausanne
49

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Framework for Evaluating Health Promotion projects: The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC)

  • 1. Framework for Evaluating Health Promotion projects: The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC) Committee on Valuing Community-Based, Non-Clinical Prevention Policies and Wellness Strategies Institute of Medicine, Washington, D.C. , 5 th December 2011 Brenda Spencer University Institute for Social and Preventive Medicine, Lausanne Günter Ackermann Health Promotion Switzerland IUMSP Institut universitaire de médecine sociale et préventive, Lausanne
  • 2. The SMOC in 2 phrases: Ø structured framework offering a common language to describe pathways to health Ø methodology developed for interactive use integrates the perspectives of all stakeholders Ø Plan of presentation § Why and how was this model developed? § What is the purpose and context of its use? § What is its theoretical basis and structure? § How is the model applied in practice? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 2
  • 3. The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC): Plan of presentation § Why and how was this model developed? § What is the purpose and context of its use? § What is its theoretical basis and structure? § How is the model applied in practice? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 3
  • 4. Our ever-faithful friend, the black box Why we think our Our activities can goal lead to our goal Measures applied: What we do Improvement of a population‘s •Projects health •Programmes •Strategies •Policies n.b. output is not outcome! IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 4
  • 5. It’s never so simple… Not possible to Not desirable to standardise standardise measures measures – adaptation to context What’s more, the Measures context changes over applied: time Improvement of a population‘s •Projects health •Programmes Most of these changes •Strategies you cannot predict •Policies And once they’ve And even if you could, you taken place, you’ll couldn’t control them need to take different IUMSP measures Institut universitaire de médecine sociale et préventive, Lausanne 5
  • 6. Various ways to open the black box… IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 6
  • 7. A new solution…………….? "Looks like the research boys really came up with something this time." IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 7
  • 8. SMOC Development § 2002-2004: Model Construction § 2004-2005: Feasibility testing & Translation § 2005 onwards: Dissemination ØGuidelines for use http://www.gesundheitsfoerderung.ch/pages/Gesundheitsfoerd erung_und_Praevention/Tipps_T ools/ergebnismodell.php § 2008: Publication in Health Promotion International ØSpencer B, Broesskamp-Stone U, Ruckstuhl B, Ackermann G, Spoerri A, Cloetta B. et al. 23 (1): 86. http://heapro.oxfordjournals.org/cgi/content/full/dam038?ijkey= zQDCckIz8KuMxob&keytype=ref IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 8
  • 9. The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC): Plan of presentation § Why and how was this model developed? § What is the purpose and context of its use? § What is its theoretical basis and structure? § How is the model applied in practice? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 9
  • 10. Three types of application Situation analysis Where is a specific problem to be located? How may the problem have arisen? Intervention planning T o which categories can the factors contributing to the development of the How can the health of the problem be attributed and how do they relate population be maintained or how can a to each other? health-related problem be reduced? Are there other players that may already be having an impact? In which categories should the project’s objectives be situated and how do the objectives interact? Evaluation Which factors have contributed in which way to maintain health or reduce health- Applied at three levels: related problems in the population? In which categories have results ØProjects been achieved and how do these results ØProgrammes interact? What do these results tell us about our ØStrategies hypothesised theory of action? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 10
  • 11. The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC): Plan of presentation § Why and how was this model developed? § What is the purpose and context of its use? § What is its theoretical basis and structure? § How is the model applied in practice? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 11
  • 12. The determinants of health Dahlgren G, Whitehead M. Policies and strategies to promote social equity in health. Stockholm: Institute for Future Studies; 1991. IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 12
  • 13. Theoretical and Methodological underpinnings and links § Field of Health: § Ottawa Charter, 1986 § Don Nutbeam, 2002; NIGZ Health Promotion Framework Saan & de Haes 2005; PRECEDE-PROCEED Green & Lewis, 1986; EUPHID Health Development Model for the classification of public health indicators Bauer et al., 2006 § Programmme Theory in Evaluation § logic model - “graphic depiction of the relationship between the main strategies of a program and associated goals, objectives, population(s) of interest, indicators and resources” (Hyndman et al., 2001) IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 13
  • 14. Swiss Model for Outcome Classification Health promotion Factors influencing Health Health status of the measures (A) health determinants (B) determinants (C) population (D) Infrastructures A1: Development B1: Health services of services promoting services C1: Physical environment Legal system A2: Advocacy B2: Public policy Administration Networking and organisational Organisation Networks organisations practice C2: Social environment D:Health Groups A3: Social B3: Social potential Communities Population mobilization and commitment C3: Indiv. resources/ behavioural patterns Individuals A4: Development B4: Individual of individual health-related life IUMSP skills skills Institut universitaire de médecine sociale et préventive, Lausanne 14
  • 15. SMOC: Levels of outcome (columns) and focal points Health promotion Factors influencing Health Health status of measures (A) health determinants (B) determinants (C) the population (D) Infrastructures, services Legal system, administration, organisations Health Groups, communities, population Individuals IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 15
  • 16. Health promotion measures (A) Health promotion Factors influencing Health Health status of the Outcome levels measures (A) health determinants (B) determinants (C) population (D) Infrastructures A1: Development services of services A2: Advocacy Legal system Administration Networking Organisation Networks organisations Health Groups A3: Social Communities Population mobilisation A4: Individuals Development of individual skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 16
  • 17. Factors influencing health determinants (B) Health promotion Factors influencing Health Health status of the Outcome levels measures (A) health determinants (B) determinants (C) population (D) Infrastructures A1: Development B1: Health services of services promoting services Legal system A2: Advocacy B2: Public policy Administration Organisation Networking and organisational Networks organisations practice Health Groups Communities A3: Social B3: Social potential Population mobilization and commitment Individuals A4: Development B4: Individual of individual skills health-related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 17
  • 18. B1 Health promoting services Health promotion Factors influencing Health determinants Health status of the Outcome levels measures health determinants population Infrastructures Development of B1: Health services services promoting services Legal system Advocacy Administration Organisation Networking Networks organisations Health Groups Communities Social mobilization Population Individuals Development of individual skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 18
  • 19. B1 Health promoting services § B1-1 Awareness of the service § B1-2 Accessibility of the service and reaching of target groups § B1-3 Use of the service and satisfaction with it § B1-4 Sustainability of the service § B1-5 Improved professionalism in health promotion – Professionals, mediators – Population IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 19
  • 20. B2: Health promoting public policy and organisational practice Health promotion Factors influencing Health determinants Health status of the Outcome levels measures health determinants population Infrastructures Development of B1: Health services services promoting services Legal system Advocacy B2: Public policy Administration Organisation Networking and organisational Networks organisations practice Health Groups Communities Social mobilization Population Individuals Development of individual skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 20
  • 21. B2 Health promoting public policy and organisational practice § B2-1 Binding engagement of decision-makers and/or key persons § B2-2 Action-relevant, binding written basis § B2-3 Successful organisational changes § B2-4 Successful exchange and cooperation – Policy – Organisations IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 21
  • 22. B3 Health promoting social potential and commitment Health promotion Factors influencing Health Health status of the Outcome levels measures health determinants determinants population Infrastructures Development of B1: Health services services promoting services Legal system Advocacy B2: Public policy Administration Organisation Networking and organisational Networks organisations practice Health Groups Communities Social mobilization B3: Social potential Population and commitment Individuals Development of individual skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 22
  • 23. B3: Health promoting social potential and commitment § B3-1 Existence of active groups focusing on health promoting concerns or themes § B3-2 Enlisting of new players § B3-3 Awareness of the concern by population groups § B3-4 Acceptance of a concern by population groups IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 23
  • 24. B4 Individual health-related life skills Health promotion Factors influencing Health Health status of the Outcome levels measures health determinants determinants population Infrastructures Development of B1: Health services services promoting services Legal system Advocacy B2: Public policy Administration Organisation Networking and organisational Networks organisations practice Health Groups Communities Social mobilization B3: Social potential Population and commitment Individuals Development of B4: Individual individual skills health-related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 24
  • 25. B4 Individual health-related life skills § B4-1 Factual health-relevant knowledge and capacity to act on knowledge § B4-2 Positive attitudes towards a health-relevant topic § B4-3 New personal and/or social skills § B4-4 Strengthened self-confidence regarding a health- relevant topic or an activity IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 25
  • 26. Health Determinants (C) Health promotion Factors influencing Health Health status of the Outcome levels measures (A) health determinants (B) determinants (C) population (D) Infrastructures A1: Development of B1: Health services services promoting services C1: Physical environment Legal system A2: Advocacy B2: Public policy Administration Organisation Networking and organisational Networks organisations practice C2: Social environment D:Health Groups Communities A3: Social B3: Social potential Population mobilization and commitment C3: Indiv. resources/ behavioural patterns Individuals A4: Development B4: Individual of individual skills health-related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 26
  • 27. C1 Health-promoting physical environment Health promotion Factors influencing Health Health status of the Outcome levels measures health determinants determinants population Infrastructures Development of Health promoting services services services C1: Physical environment Legal system Advocacy Public policy and Administration Organisation Networking organisational Networks organisations practice Health Groups Communities Social mobilization Social potential and Population commitment Individuals Development of Individual health- individual skills related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 27
  • 28. C1 Health-promoting physical environment § C1-1 Reduction of pollution caused by physical-chemical influences § C1-2 Conservation and improvement of natural resources § C1-3 Health-promoting installations and products – Work place, education, school – Habitation, home – leasure, mobility IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 28
  • 29. C2 Health-promoting social environment Health promotion Factors influencing Health Health status of the Outcome levels measures health determinants determinants population Infrastructures Development of Health promoting services services services C1: Physical environment Legal system Advocacy Public policy and Administration Organisation Networking organisational Networks organisations practice C2: Social environment Health Groups Communities Social mobilization Social potential and Population commitment Individuals Development of Individual health- individual skills related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 29
  • 30. C2 Health-promoting social environment § C2-1 Social support, social networks, social integration § C2-2 Social climate § C2-3 Equal access to general social resources – Work place, education, school – Habitation, home – Leasure, mobility IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 30
  • 31. C3: Health-promoting individual resources and behavioural patterns Health promotion Factors influencing Health Health status of the Outcome levels measures health determinants determinants population Infrastructures Development of Health promoting services services services C1: Physical environment Legal system Advocacy Public policy and Administration Organisation Networking organisational Networks organisations practice C2: Social environment Health Groups Communities Social mobilization Social potential and Population commitment C3: Indiv. resources/ behavioural patterns Individuals Development of Individual health- individual skills related life skills IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 31
  • 32. C3: Health-promoting individual resources and behavioural patterns § C3-1 Health promoting individual skills § C3-2 Improved health-relevant behaviour and patterns of behavioural – Work place, education, school – Habitation, home – Leasure, mobility IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 32
  • 33. D: Improvement of a population´s health and quality of life Indicators regarding: § Increased healthy life expectancy § Increased health-related quality of life § Lower morbidity § Less premature mortality IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 33
  • 34. The Swiss Model for Outcome Classification in Health Promotion and Prevention (SMOC): Plan of presentation § Why and how was this model developed? § What is the purpose and context of its use? § What is its theoretical basis and structure? § How is the model applied in practice? IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 34
  • 35. Elderly in the community : situation analysis Neighbourhood Health promoting construction Development of services services unfavourable to elderley C1: Physical pedestrians environment Absence of public Public policy and Advocacy Networking policy organisational Institutionalisation organisations practice Social isolation Poor Quality of Life C2: Social Health Loneliness environment Frailty Insecurity Social mobilization Social potential and Low public commitment awareness C3: Indiv. resources/ behavioural patterns Development of Individual health- Low physical individual skills related life skills Fear activity Resignation IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 35
  • 36. Elderly in the community : programme theory Apartment rented as Health promoting small community centre Development of services services Project Agenda 21 for C1: Physical garden Neighbour community garden environment activities Seek Advocacy Public policy and partnerships Networking Joint organisational project with Elderly live organisations municipality: QoL practice Increased social independently C2: Social Health Residents of contact environment Increased strength ProSenectute all ages Intergenerational Less depression Social mobilization Social potential and community Residents understanding participate in commitment development design and Community group C3: Indiv. resources/ project created behavioural patterns construction Development of Individual health- Increased of garden individual skills related life skills physical activity Increased confidence IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 36
  • 37. Outcome model of a prevention project on obesity in infants Development and Broad dissemination, wide use by maternal consultants Dissemination A1 B1 Development of health High attainment Health promoting services Parental satisfaction, few of target groups promoting services and many coachings Acquisition dropouts C1 Health promoting physical Tools Improved expert skills environment Further education B2 A2 Committed promoting public policy and Health Advocacy, cooperation of consultantsorganizational practice organizations C2 Networking with Health promoting social/societal pediatrics Successful cooperation environment D Improved eating culture Health B3 A3 Health promoting social potential and Family meals, slow food, eating without distraction/TV,… Social mobilization commitment C3 Health promoting individual Improved eating behavior resources and behavioural A4 B4 More fruits, vegetables and salads, less patterns sweets,snacks and sweet beverages. Increased Development of Health-related Improved life skills consumption of sugarless beverages Coachings individual skills Healthy weight educational by parent Improved educational behaviour counsellors skills Increased physical activity Increased activity outdoors, less computer and IUMSP television Measures Objectives Institut universitaire de médecine sociale et préventive, Lausanne 37
  • 38. Outcome model of a prevention project on obesity in infants: How many parent counsellors research questions have Development and been reached? Broad dissemination, wide use by Dissemination A1 maternaal consultants Which parents B1 can be reached? few How good is the quality target groups services Development of health High attainment Health promoting of Parental satisfaction, promoting services and many coachings Acquisition of the training? dropouts C1 Health promoting physical Tools Do the parent counsellors Improved expert skills environment Further education have better skills due to the B2trainings? A2 Committed promoting public policy and Health Was it possible to change Advocacy, cooperation of consultantsorganizational practice organizations Is the networking with C2 eating culture of the the families? Networking with Health promoting social/societal pediatrics successful? pediatrics Successful cooperation environment D Improved eating culture Health B3 A3 Health promoting social potential and Family meals, slow food, eating without distraction/TV,… Social mobilization commitment Quality of the What is the influence on Do children eat T o what extent has C3 coaching? parental attitudes and healthier? educational behaviour eating individual Health promoting behavior Improved skills? resources and behavioural Decrease of A4 B4 changed? fruits, vegetables and salads, less More patterns sweets,snacks and sweet beverages. Increased body weight? Development of Health-related Improved life skills consumption of sugarless beverages Coachings individual skills Healthy weight educational by parent Improved educational behaviour councellors skills More physical activity More activity outdoors, less computer and Are they more IUMSP television active? sociale et préventive, Lausanne Institut universitaire de médecine 38
  • 39. Stakeholder Workshop Process § Participation: § within stakeholder groups § between stakeholder groups § Communication: § implicit becomes explicit § exchange and clarify § agree on transparent objectives IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 39
  • 40. Foto IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 40
  • 41. IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 41
  • 42. An iterative process… but nonetheless with outputs… IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 42
  • 43. Overall process leading to the definition of an evaluation framework Ø Situation analysis Ø Programme theory Ø Choice of « priority » objectives Ø Definition of relevant/key indicators Ø Definition of corresponding anticipated values § quantitative § qualitative IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 43
  • 44. Elderly in the community : possible indicators Apartment rented as Health promoting Maintenance of small community centre Development of services services garden C1: Physical garden Neighbour Frequency of activities Project Agenda 21 environment activities Seek Advocacy Public policy and partnerships Networking Joint organisational project with Elderly live organisations municipality practice Level of satisfaction Increased social C2: Social independently Health regarding atmosphere contact Residents of environment Increased strength ProSenectute all ages in neighbourhood Intergenerational Social potential and Less depression Social mobilization community Residents Frequency of contacts understanding participate in commitment development design and Community group Level of C3: Indiv. resources/ project created behavioural patterns construction participation Development of Individual health- Low physical of garden Level of physical individual skills related life skills activity activity Increased confidence IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 44
  • 45. Individual programmes and projects do not need to provide evidence of progress from Epidemiological data C to D: Health promotion Factors influencing Health Health status of the measures (A) health determinants (B) determinants (C) population (D) Infrastructures A1: Development B1: Health services of services promoting services C1: Physical environment Legal system A2: Advocacy B2: Public policy Administration Networking and organisational Organisation Networks organisations practice C2: Social environment D:Health Groups A3: Social B3: Social potential Communities Population mobilization and commitment C3: Indiv. resources/ behavioural patterns Individuals A4: Development B4: Individual of individual health-related life IUMSP skills skills Institut universitaire de médecine sociale et préventive, Lausanne 45
  • 46. IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 46
  • 47. Where are we now? § Dissemination of use § National § International § Sustainability/ Integration of SMOC into: § further education and training § technical support system § quality assurance methodology (http://www.quint-essenz.ch/en.html) § grant management process § Multiple uses and levels of application § Creation of web-based community of users § Links with systems management IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 47
  • 48. Key characteristics of the SMOC § Communication and understanding is promoted between stakeholders § Provides synthesis of multiple perspectives § Development of common language § Acknowledges complexity § Brings together different forms of evidence from research and expert/practitioner knowledge § Interventions are developed on a theoretical and evidence- based framework § Hypotheses regarding change theory are made explicit and can be verified: performance AND learning objectives IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 48
  • 49. Thankyou for your attention! IUMSP Institut universitaire de médecine sociale et préventive, Lausanne 49