Using theories of power and place to evaluate community health promotion.

Background: Realist philosophy and methodology is increasingly being explicitly used in the field of integrated care to research the extant context, structure and mechanisms at play, and to design and evaluation interventions. Philosophic realism is the view that entities exist independently of our perception or our theories about them. While the realist philosophy underpins much of modern health and social science, it is only recently that this philosophical approach has been popularised within main stream health and social science literature. Realist research methodology is increasingly being described in research areas that are relevant to the study of integrated care, namely, organisational management, information science, social epidemiology, economics, and health services evaluation. Importantly realist approaches are increasingly being used in mixed method research designs and to elucidate the processes at play in experimental and quasi-experimental studies. Realist researchers seek to explain the underlying “cause” or mechanisms that generate observed phenomenon. The realist understanding of how the world is ontology includes the notion of a hidden or “real” domain where mechanisms generate forces that result in the phenomena which we observe. Realists also view the world as consisting of strata or layers of reality which may interact with other layers to produce new mechanism. This approach is proving useful for studying and developing theory about complex health and social care systems, and then designing and evaluating possible interventions. Over the last number of years a number of realist studies have been presented at the International Foundation of Integrated Care conferences including: realist studies of context and mechanisms; realist design of integrated care interventions; realist synthesis of literature; and realist evaluations of integrated-care interventions. The methodologies, and the dialectical debates, are complex, and therefore, deserving of special consideration within the Integrated Care community. This preliminary workshop will support evaluators and researchers to use realist methods in integrated care and other complex evaluations. Because realist evaluation was initially developed using smaller-scale programs, methods need to be modified for large scale programs, while remaining consistent with underlying methodological principles. The workshop will discuss the value of and the dilemmas involved in using realist methods for large and complex programs, and demonstrate strategies to address the dilemmas. Aims and Objectives: 1- Present and discuss the basic tenants of realist research, design and evaluation as it applies to the large scale and complex programs such as integrated care 2- Discuss the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care Special Interest Group RIC-SIG 3- Modify the scope and purpose of a Realist Research, Design and Evaluation for Integrated Care - SIG Format: Group Discussion Target Audience: Integrated care practitioners and researchers who are familiar with realist research including the current focus on critical realism and realist evaluation Learning and Takeaway: The workshop will define the scope and purpose of a SIG for Realist Research, Design and Evaluation for Integrated Care

Background Community-based health promotion (CBHP) programmes can yield sustainable and transformational changes to complex problems such as intergenerational transmission of social exclusion. However, investments in these projects are held back by lack of evidence on their effectiveness. The realist evaluation (RE) framework is regarded as a promising approach to improve understanding of how programmes generate their outcomes and the way they interact with their context. We look at two CBHP programmes to reflect on how RE can help relate their interventions to their outcomes. Methods We applied the RE approach to: “Football United” a sports for development programmes aiming to support refugee and newly arrived young people and families in their transition into Australian society and to, “Together, health for all in Pays de Redon –Bretagne Sud” a French programme to improve local capacities in addressing the social determinants of health in decision- and policy-making processes. Analyses were conducted on the basis of data collected through semi-structured interviews, documents, observations, etc. Results In both cases, application of the RE perspective highlighted difficulties in identifying the context-mechanism-outcomes configurations that are at the core of the approach. We clarified the definition of mechanism that was initially repeatedly confused with that of intervention/activity. Whereas both programme theories were quite straightforward, they required a whole array of activities critical in shaping the conditions for the implementation of the interventions. Conclusions Our results echo other critics of the conceptual apparatus of the RE approach. While the RE has proven promising in linking CBHP interventions to their outcomes, practitioners still need better tools to grasp the complexity and the dynamic of changes brought on complex systems of actors. Key messages: CBHP programmes can yield sustainable transformational change to complex situations but current evaluation approaches often fail to bring evidence on their effectiveness For the sake of knowledge transfer, theory-based evaluation approaches such as RE also need to capture the broad array of supporting activities of CBHP programmes

Intersectoral Collaboration (ISC) involves multiple sectors working together to tackle complex challenges that no single sector can address alone. In global health, where interconnected issues demand holistic approaches, ISC aligns goals and resources to enhance effectiveness and equity. However, power dynamics within and between sectors can either foster synergy or create tensions, shaping ISC outcomes. This study explores how, why, for whom, in what contexts, and to what extent power dynamics influence ISC in a northeastern state of India. A realist evaluation was conducted in Assam, India. Six Programme Theories (PTs) from a prior realist review were tested and refined through theory-driven realist interviews with 18 stakeholders across different sectors. Data were analysed using Context-Mechanism-Outcome Configurations (CMOCs) to refine PTs, offering a nuanced understanding of how individual, institutional, and contextual factors influence ISC outcomes. A total of 62 CMOCs, grouped into 17 demi-regularities, refined six PTs on power dynamics in ISC. Fair participation fostered empowerment, while proactive leadership enhances motivation, though resource gaps may weaken these effects. Fair resource allocation reduced power imbalances, improving collaboration, whereas hierarchy and unclear roles breed distrust. Personal relationships helped build trust and overcome hierarchy. Findings emphasise that improving ISC requires attention to both structural and relational mechanisms through designing programs that leverage both of these. Given this single-district, qualitative case study, the findings are context-specific to Dibrugarh, Assam, and should be transferred cautiously to comparable settings. Future research could refine programme theories into a middle-range theory, enhancing their transferability to other settings.

This paper presents the results of a systematic literature review on power distribution and power dynamics in multiparty systems. Multiparty systems are underorganized social structures in which power dynamics unfold and impact collaboration effectiveness. We use a theory-driven approach to integrate the empirical literature that explored power differences and dynamics in multiparty systems and we have a two-fold contribution to literature. First, we explore the way power is conceptualized in multiparty systems. Second, we investigate which predictions and propositions of the Social Distance Theory of Power and the Approach Inhibition Model of Power can be used to integrate research on power distribution and dynamics in multiparty systems. We extend the predominantly experimental empirical support of these two theories with insights from the multiparty systems literature. With respect to the way in which power is conceptualized in the multiparty systems literature, our study shows a shift from a possession over resources to a relational perspective on power in the last decades. Moreover, based on the insights of the two psychological theories of power, the study reflects upon the benefits and drawbacks of high versus low power for collaboration effectiveness among stakeholders, pointing towards ways in which facilitators can work with power differences in multiparty systems. Finally, the study points toward directions for future research concerning power dynamics in multiparty systems.

Over the past 30 years health promotion efforts have been targeted at the local level, recognizing that this is the locus of innovative, grassroots efforts to improve the health of the community. Yet addressing the realities of working with local communities is considered to be outside the purview of the public health field; therefore, community-level efforts are ignored. Although we support the recommendations made by the National Expert Panel on Community Health Promotion (1), there are several challenges to be faced in accomplishing these goals. One recommendation made by the expert panel was to promote community-based participatory (CBPR) within and outside of CDC (Centers for Disease Control and Prevention). This approach emphasizes community participation at all stages of and program development, but there are imbalances of power that cannot be dismissed (2). For example, past abuses by researchers, particularly in communities of color, have led many community organizations to act as gatekeepers to protect their constituents. Lack of access to these communities will make it difficult to estimate disease burden and to improve the overall health of the community. Another restriction on community health promotion efforts is the power dynamics between communities and groups such as businesses and policy makers. Initiatives targeting policy and environmental change (e.g., improving access to fruits and vegetables in local bodegas and establishing large grocery stores in impoverished communities) are highly encouraged through programs such as the Racial and Ethnic Approaches to Community Health (REACH) and the Prevention Research Centers. However, many small communities must confront marketing giants such as national food or drink corporations to make a community-wide impact. CDC could help transform these relationships by collaborating with for-profit businesses on health promotion efforts as well as supporting equal partnerships between communities and researchers. These collaborations would deter helicopter research — when the researcher flies (or swoops) into a community and collects and publishes data without leaving anything in return (2). A second recommendation of the panel was to promote a state-of-the-art e-mechanism to share expertise and knowledge about community health promotion. Recent suggests that online information can have a positive impact on consumers' health care. However, for some underserved demographic groups, a divide (a gap in access to digital information) exists (3), despite numerous technologic initiatives to reduce this gap. CDC could provide leadership by identifying the characteristics and needs of digitally underserved populations and allocating adequate resources to address the identified needs. CDC's role could include engaging nontraditional partners, such as information technology corporations and the U.S. Department of Commerce's National Telecommunications and Information Administration, in efforts to initiate new strategies for helping populations gain access to information. More people could then participate with their providers in making important decisions about their health and well-being. Increasing evidence shows that to effectively combat current health problems, focusing solely on changing individual behavior is not sufficient; broader determinants of health must also be addressed (4). The expert panel echoed this point and recommended to shift a measurable part of NCCDPHP's (National Center for Chronic Disease Prevention and Health Promotion's) community health promotion programs to focus on improving living conditions across the lifespan in local communities. However, the panel also recognized that federal health policies do not accommodate this perspective, and therefore recommended that CDC funding be tailored to include a focus on living conditions in communities. Many communities are tackling social, economic, and political issues in an effort to improve their residents' living conditions. However, they are under constant pressure to obtain funding or cease such initiatives altogether. CDC may be able to aid this work in communities by seeking formal agreements with agencies focused on improving people's living conditions (e.g., U.S. Department of Labor, U.S. Department of Housing and Urban Development, U.S. Department of Education). It will take years for community-based interventions to demonstrate that improving living conditions will change behaviors and improve health among residents. As communities address broader social determinants of health, CDC could work with them to measure intermediate outcomes in order to capture the process by which behavior change is accomplished. If communities are held accountable for demonstrating effective public health interventions, then public health leaders and agencies must also be responsive to the realities these communities face as they address complex health problems today and in the future.

In recent years, music‐based interventions have been utilised as a tool for improving public health, reducing inequalities and promoting well‐being of young people. Although some researchers have begun to draw links between music‐related interventions and positive health outcomes, there is little understanding as to how such effects are produced. Realist evaluations—understanding what works, for whom and under what circumstances—are a particularly apt means by which we can open this ‘black box’. In this paper, we use a realist evaluation to assess a community‐based music initiative designed and implemented to support the well‐being of disadvantaged young people in Scotland. In order to gain perspectives on the range of contextual characteristics, mechanisms and outcomes, we collected quantitative and qualitative data in the form of pre‐ and post‐questionnaires, as well as conducting interviews with beneficiaries and stakeholders. Our findings show that the intervention achieved a positive impact on the self‐confidence, well‐being and engagement of disadvantaged young people. This impact was achieved via an approach personally tailored to the individual needs of the young people; and an organisational environment characterised by trust, whereby young people felt safe to express themselves.

Background: Evaluation theory and practice have great potential in catalysing transformative change and furthering decoloniality in [global] health research in Indigenous or formerly colonised societies. Realist evaluation approach can be a good fit for promoting decolonisation due to its strong focus on context and causal mechanisms. Methods: Drawing on the authors’ work on strengthening health research capacity and using the ‘African Research Initiative for Scientific Excellence’ (ARISE) programme as a case study, this paper includes methodological reflections on how the Indigenous realist evaluation was operationalised and stimulated the decolonisation discourse. Results: Findings show that the Indigenous lens adds value to the realist evaluation approach. First, the systematic interrogation of the power structures and dynamics within the programme helped uncover who (partner) has control over what resources and how the partnership perpetuates or reinforces (in)equity. The generative causal question was thus addressed by unearthing the mechanisms (e.g., autonomy/independence, empowerment, and control/ independence) triggered in contexts where there is allyship and shared interests and priorities between Global North and South partners. The ARISE financial support and the Bottom-Up approach (in defining research questions) were identified as a key resource and opportunities within the programme architecture. The Indigenous realist evaluator will play multiple roles, such as identifying appropriate methods—including Indigenous methods—to effectively test and refine the programme theories, judge the programme’s effectiveness, teach/learn about the programme theory, and advocate for actions promoting equity. Conclusion: We conclude that fusing the Indigenous principles with the realist evaluation approach Indigenizes the approach and furthers the decolonisation agenda. We hypothesise that the effectiveness of the Indigenous realist evaluation approach will differ across programmatic and implementation contexts and, therefore, encourage researchers to apply the approach, build evidence on its effectiveness, and further refine it.

Community health promotion offers a potential solution to persistent healthcare challenges, with community health workers playing a pivotal role. The Community Training Institute for Health Disparities (CTIHD) implemented a problem-solving curriculum in Community Health Promotion, integrating a competency-based learning model through two courses: Introduction to Community Health Promotion and Design of an Action Plan for the Promotion of Community Health. Each course comprised ten three-hour sessions, featuring pre/post-tests, evaluations, and a cognitive debriefing. Knowledge change was assessed using pre/post-test scores among 27 community leaders from southern Puerto Rico. Cohort 1 and Cohort 2 demonstrated an overall retention rate of 62.6% and 96.7%, respectively. Although differences in knowledge gained between cohorts and courses weren’t statistically significant, a trend toward increased knowledge was noted. Cohort 1 experienced a 22% knowledge increase in Course 1 and a 24% increase in Course 2. Cohort 2 demonstrated a 41% knowledge increase in Course 1 and a 25% increase in Course 2. The CTIHD’s Community Health Promotion Program has made significant strides in elevating awareness and knowledge, marking a positive step toward reducing health disparities and fostering healthier, empowered communities in southern Puerto Rico.

Background In community health promotion programs (HPP) aiming to improve health and reduce health inequities, health brokers can have a crucial role in building and sustaining intersectoral networks. These networks are pivotal for developing and implementing the HPP. However, the role of health brokers is new and there is little insight into the changes in the networks' size and composition over time and the processes that facilitate brokers' networks. The aim of this study was to map the brokers' network in detail and unravel the barriers and facilitators in network building. Methods To study the brokers' networks in a HPP in a Dutch socioeconomically deprived city district, in October 2017 and November 2019 the Composed Network Analysis (CNA) and the Coordinated Action Checklist (CAC) were used, as part of the action research accompanying the HPP. The CNA provides insight into the size and composition of the network and the CAC explores facilitators and barriers in network building and sustaining. Focus groups with the core network members (n = 6) were held to discuss and interpret results. Results The health brokers' network had expanded from an average of 100 contacts in 2017 to about 140 contacts in 2019. Existing contacts (e.g. social work, welfare work) had been strengthened and new partners, e.g. general practitioners and volunteers joined the network. This resulted in an increased attention for health on the agenda of these organizations and several joint activities as part of the HPP. Facilitators were working on a small scale, informal and formal, and frequent personal contacts. The most important barrier was change of partners. Conclusions The health brokers have been successful in and expanding their networks, putting health on the agenda of network partners and supporting activities. As such, the broker is essential in connecting a diverse range of partners and organizations in an intersectoral network in the city district. Key messages Working on a small scale, and with frequent personal, formal and informal contacts facilitated the health brokers network building and sustaining. A health brokers’ role, being initiator, facilitator and connector is essential for continuation of the community health promotion approach.

This article provides an example of the application of social network analysis method to assess community participation thereby strengthening planning and implementation of health promotion programming. Community health promotion often takes the form of services that reach out to or are located within communities. The concept of community reflects the idea that people's behavior and well-being are influenced by interaction with others, and here, health promotion requires participation and local leadership to facilitate transmission and uptake of interventions for the overall community to achieve social change. However, considerable uncertainty exists over exact levels of participation in these interventions. The article draws on a mixed methods research within a community development project in a vulnerable neighborhood of a town in Denmark. It presents a detailed analysis of the way in which social network analysis can be used as a tool to display participation and nonparticipation in community development and health promotion activities, to help identify capacities and assets, mobilize resources, and finally to evaluate the achievements. The article concludes that identification of interpersonal ties among people who know one another well as well as more tenuous relationships in networks can be used by community development workers to foster greater cohesion and cooperation within an area.

Disciplinary practices on the gendered fat body are a central aspect of weight-loss makeover TV shows; however, they are subtle and hard to identify. I ask how surveillance and control are legitimized as appropriate methods for achieving bodily change in the Finnish makeover shows Jutta ja Superdieetit (Jutta and the Super Diet) and Jutta ja Puolen Vuoden Superdieetit (Jutta and the Half-Year Super Diet) and how the experts reinforce unequal power structures. The ethos of equality is very strong in Finland, which is also apparent in the special construction of the expert as “one of the team”. The research material is examined in light of Michel Foucault’s theories of power and the concept of docile bodies, and as part of postfeminist media culture in which the ideas of “freedom of choice” and “submission as empowerment” are crucial. The choices for the participants of the makeover shows are, however, very limited, leaving just enough freedom so that they accept the power dynamics they are entangled in. I argue that control and surveillance are legitimized as means of helping participants achieve their ideal body and life. Instead of breaking existing power dynamics, the construction of the expert as attentive and caring works to reinforce these structures since discipline is enacted in the “best interest” of the participant. The dynamics of (disciplinary) power are thus subtle and work in a particularly hidden way.

Over 100 project staff, community coalition members, and other representatives from 10 comprehensive community health promotion projects in the western United States were surveyed two years into a three year funding cycle about: (1) the problems or obstacles they judged as preventing successful completion of their current goals and objectives, and (2) future goals and objectives they envisioned for their projects. The key issues confronting respondents were diverse, although issues around the process of implementing community health promotion programs were cited more frequently than issues related to the content of health promotion. When respondents were asked to prioritize Future Goals in the second survey, consensus across communities was obtained despite broad differences in the type of community surveyed and the health problem targeted. This study identifies the common organizational and community development problems faced by newly emerging community health promotion programs and has implications for other communities involved in designing, implementing, and evaluating community-wide health promotion programs.

Background: Non-communicable diseases (NCDs) are the leading cause of death worldwide. However, current evidence regarding the efficacy and cost-effectiveness of community intervention and health promotion programs for NCDs, specifically hypertension, obesity, diabetes, and dyslipidemia, in East and Southeast Asia has not yet been systematically reviewed. We systematically reviewed the literature from East and Southeast Asian countries to answer 2 clinical questions: (1) do health promotion programs for hypertension, obesity, diabetes, and dyslipidemia reduce cardiovascular events and mortality; and (2) are these programs cost-effective?Methods and Results: Electronic literature searches were performed across Medline, Cochrane Library, and Ichushi using key words and relevant subject headings related to randomized controlled trials, comparative studies, quasi-experimental studies, or propensity score matching that met eligibility criteria that were defined for each question. In all, 3,389 records were identified, of which 12 full-text articles were reviewed. Three papers were from Japan, 7 were from China/Hong Kong Special Administrative Region, and 2 were from South Korea. None were from Southeast Asia. Four papers examined the effect of community intervention or health promotion on the incidence of cardiovascular events or mortality. Eight studies examined the cost-effectiveness of interventions.Conclusions: The literature review revealed that community intervention and health promotion programs for the control of NCDs are a cost-effective means of reducing cardiovascular events and mortality in East Asian countries.

The Community Training Institute for Health Disparities (CTIHD) designed a curriculum for a community health promotion program to provide training and enable community members to facilitate community action by empowering individuals with health education, knowledge, and skills to respond to community health needs, specifically to vulnerable communities in Puerto Rico which had already being affected by natural disasters, the COVID-19 pandemic, and migration. A problem-based curriculum design that integrates a competency-based learning model, which included the creation and development of two courses: Introduction to Community Health Promotion and Community Wellness & Health Promotion. Each course consisted of 10 sessions lasting three hours per session. The assessment per session included a pre- and post-test and overall evaluation of the session, and a discussion or practice exercise at the end of the session. Descriptive statistics (frequencies and percentage) were performed to develop the profile of community participants. Central tendency measures (mean and median), and dispersion measures (variance and standard deviation) were used to describe the scores. Twelve (12) community leaders from different southern municipalities of Puerto Rico were recruited. Of these, nine completed the first course and eight completed the second (75% retention rate for Course 1 and 67% retention rate for Course 2). An 18% (difference of 1.2) increase in knowledge was obtained for Course a and a 16% (difference of 0.85) for Course 2. This curriculum enhances communities’ resources, providing their leaders with the necessary competencies to impact health behavior, promote prevention, and become a health promoter within their communities.

IntroductionResearch–practice partnerships (RPPs) are long-term collaborations between research and practice that aim to conduct research that can be used to make practice-based improvements. They intentionally bring together diverse experience in...