health promotion – what kind of phenome- phenome-non are they?
4 H ow can “network effectiveness” in the settings approach of health promotion be
4.6 How can “effectiveness” be defined for the specific case of HPH? specific case of HPH?
Considering the health promotion outcome models introduced in chapter 4.3., the specific network effectiveness model proposed by Brößkamp-Stone (2004), the implicit concepts on network effectiveness, and the strategies to achieve the identified desired effects, as described in the published literature on health promotion networks (compare chapter 4.5), the effective-ness of health promotion networks can be framed as a complex chain of effects, ranging from achieving network establishment and viability to the network’s ability to address the targeted organizations or settings and their relevant environments by specific interventions which should then, in line with outcome hierarchies suggested by Nutbeam (1998), Saan & de Haes (2005), and Spencer et al. (2007), lead to changed structures and processes within these organ-izational settings and, ultimately, bring about better individual health. For the PRICES-HPH evaluation study (compare Dietscher et al. 2011a; Pelikan et al. 2011a), a specific model was developed to guide research along this chain of effects (compare Figure 6 below).
Figure 6: The PRICES-HPH evaluation framework (Dietscher et al. 2011a, Pelikan et al. 2011a)
So as the Brößkamp-Stone model, the PRICES-HPH evaluation model follows a general quality framework. By explicitly referring to Donabedian’s quality paradigm (1966), it distin-guishes, first of all, between structures, processes and outcomes – both for the whole network, and for the individual organizations the network consists of:
On the level of the network, structures refer to the coordination structures and re-sources a network disposes of; processes refer to the specific interventions the net-work has in place; and outcomes may include changes in netnet-work member organiza-tions (especially in the health promotion structures of these), in relevant environments of the network (e.g. the development of supportive legal or financial frameworks for health promotion), and in the network itself (e.g. growth in membership).
On the level of network member organizations, the organizational (health promotion) structures can, as was pointed out, be framed as outcomes (effects) of network inter-ventions. This allows conceptualizing the (resulting) organizational health promotion processes as indirect effects of network interventions (via organizational structures as more direct network outcomes). Individual health, finally, would be the desired out-come of organizational health promotion structures and thus a rather indirect outout-come of network interventions.The PRICES-HPH model acknowledges that effective health promotion interventions need adequate (infra)structures and resources in the first place (a line of thought that is hardly followed in the Brößkamp-Stone model). Thus, the model also relates to the capacity building debate in health promotion (e.g. Hawe et al. 1997; Bell Woodard et al. 2004; compare also chapter 5). In this sense, network structures, in PRICES-HPH, have quite a different notion than in the Brößkamp-Stone (2004) model. In PRICES-HPH, structures include network co-ordination structures, resources and infrastructures, as well as the network’s specific member-ship structures and the technologies in place to support networking. In contrast, the network structures (or features) proposed by Brößkamp-Stone (2004) respectively Alter & Hage (1993)
– i.e. centrality, differentiation, complexity, and connectivity – can, with the exception of size, rather be framed as relational structures only. Their potential interrelations with, and impact on, the network coordination structures and resources, as well as on their processes and desired outcomes, is further analyzed in chapters 6 to 9 on HPH structures, processes, viability and impact on member organizations.
According to the described quality concepts, network structures, then, are understood as impacting on network processes or performance. Here again, a difference exists between Brößkamp-Stone’s notion of processes and the process concept of the PRICES-HPH evalua-tion model. While Brößkamp-Stone, rather generally, distinguishes between coordinative (de-cision-making) and operative network processes, PRICES-HPH differentiates four distinct and theoretically deducted network strategies to achieving desired network outcomes. Follow-ing the principle impacts networks can have on an organization’s self-observation accordFollow-ing to the VOHIM (see chapter 4.3), and in line with the implicit effectiveness concepts in the litera-ture on health promotion networks (see chapter 4.5), PRICES-HPH proposes four main strat-egies of network processes or operation. Two of these are more directly aimed at addressing organizational settings as those entities that usually form setting-oriented health promotion networks.
Strategy 1 (NW-STRAT 1) is about supporting organizational change via the provision of tools, interactive offers, and membership criteria formulated by the network.
Strategy 2 (NW-STRAT 2) aims at empowering staff through education and training.The other two strategies take into account that a given network’s ability to support the de-velopment of health promotion structures and processes in its member organizations depends on frameworks, or contexts, in its relevant environments. Thus, so as in the model by Alter &
Hage (1993), the model takes into account a number of (potential) network-forming factors.
But, in contrast to the Alter & Hage model, the PRICES-HPH evaluation model introduces specific network strategies (NW-STRAT 3, 4) to address these relevant environments in light of their importance for network effectiveness:
Strategy 3 (NW-STRAT 3) aims at further developing favorable conditions for health promotion by seeking coalitions and alliances with relevant partners, and by lobbying – or advocating – for supportive legal, policy and financial frameworks for health promotion.
Strategy 4 (NW-STRAT 4), which is based on the presumption that a general support-ive public opinion will improve the organizational uptake of health promotion by rais-ing the demand for health promotion services and thus strengthenrais-ing the organiza-tional awareness of health promotion as a competitive edge, aims at strengthening public relations (information and communication) about HPH.In addition to the strategies introduced in the original PRICES-HPH evaluation framework, a fifth potential network strategy can be deducted from the accessed literature on health pro-motion networks, i.e. research and the dissemination of research results in the networks. This type of activities can be framed as an auxiliary strategy, supporting the quality of all other net-work strategies. By including this auxiliary strategy as “NW-STRAT 5”, an expanded PRICES-HPH evaluation framework is proposed as follows (compare Figure 7 below):
Figure 7: The expanded PRICES-HPH evaluation framework
Now, on the basis of the described quality understanding of networks, and against the background of sociological systems theory, how can their effectiveness be framed in the con-text of the current research? First of all, in a quality approach, outcome may comprise a multi-tude of effects of given structures and processes – including both intended and unintended outcomes. The first proposal in the development of a specific network effectiveness frame-work, therefore, is to understand the health promotion effectiveness of a network as a specifi-cally selected sub-set of these network outcomes. Although the health gain of patients, staff, and community populations can be defined as the ultimate goal of the settings approach in health promotion, this goal was identified as only indirectly achievable by networks. Therefore, it does not make much sense to include health-related parameters in the observance of net-work effects. Rather, in light of the proposed purpose of health promotion netnet-works in the set-tings approach, i.e. the support of organizational setset-tings in implementing and sustaining health promotion structures and processes (compare chapter 3), the proposal is to observe the health promotion structures (and processes) in place in these organizations (as well as network impacts on relevant environments of the networks and the settings they work with) as the main desired effect of the networks’ operations – or, in other words, as the productive effectiveness of health promotion networks.
In line with sociological systems theory, this productive effectiveness cannot be achieved without the continuous reproduction of a given network. The viability (or sustainability) of net-works – the netnet-works’ reproductive effectiveness – is therefore proposed to be understood as the second specific sub-set of network outcomes to be included in an effectiveness framework of health promotion networks.
Both effectiveness dimensions, the reproductive and the productive effectiveness, have, in the sense of the quality paradigm, to rely on network structures and processes. And, while the quality of structures and processes comprises the entirety of these in a given network, some will be more relevant for network effectiveness than others. Thus, one of the aims of the health promotion network effectiveness framework proposed here is to support the identifica-tion of those sub-sets of network structures and processes that specifically impact on their productive and reproductive effectiveness (compare Figure 8 below).
Figure 8: The health promotion network effectiveness framework
While, according to the proposed effectiveness framework, network structures and pro-cesses interact with each other, and both impact on each of the two effectiveness dimensions outlined in the framework, the proposed hypothesis is that structures are more relevant for the networks’ reproduction, and processes are more relevant for the networks’ production. In order to get a better understanding of the potentially effective sub-sets of effective network structures and processes, chapters 6 and 7 provide introductions to the network structures and processes surveyed in PRICES-HPH.
As outlined, sub-sets of the observed structures and processes would, following the health promotion network effectiveness framework, be expected to impact on the desired sub-sets of network outcomes. Within the PRICES-HPH evaluation study, the two-level approach that gathered data from networks and member hospitals would, in principle, allow for a multi-level structural equation approach to identify the most relevant structures and processes. However, although the 28 network cases PRICES-HPH comprises come up to 90% of the networks that were active at the time of the survey, or 80% of those that officially existed at that time, the small absolute number of cases, and the fact that, in some cases, only a few hospital cases were available per network, does not allow to thoroughly follow this methodological approach.
Therefore, the analyses demonstrated in chapters 8 and 9, which aim at describing the net-works’ reproductive and productive effectiveness, and at identifying the sub-sets of network
structures and processes of relevance for this effectiveness, can only try to approximate a proper path analysis and, in this sense, have to be considered as being of widely explorative character.