Section 12. Documenting Health Promotion Initiatives Using the PAHO Guide

Introduction: What is Health Promotion?

Health promotion is defined by the World Health Organization (WHO) as “a process of enabling people to increase control over their health.” This idea is put into practice using participatory approaches, with individuals, organizations, communities, and institutions working together to create conditions that support health and well-being for all. 

In its simplest terms, health promotion fosters changes in environments and systems that help promote and protect health. These may include, for example, programs that improve access to health services or policies that support public parks and other spaces for physical activity and social connection. 

Health promotion involves a particular way of working together. It is:

• Population-based: Health promotion considers health in terms of the whole population; that is, all the people who share a place, such as a municipality or region, or an experience or characteristic, such as being young, experiencing poverty, or experiencing increased risk for a particular outcome.
• Participatory: Health promotion involves the collaboration of community stakeholders in the selection, planning, implementation, evaluation, and maintenance of health-promoting interventions, policies, and conditions.
• Intersectoral: Health promotion engages different sectors of the community – community members, businesses, government institutions, faith communities, and nongovernmental organizations such as health and human service organizations and social and cultural organizations – in making health-promoting changes in their programs, policies, and practices.
• Sensitive to Context: Health promotion takes into account relevant aspects of the place and time, including history, demographics, past experience, geography, culture, politics, economics, social structure, and other important factors.
• Multi-level: Health promotion operates at many different levels – individual and relationship, organizational, community, and broader system – to achieve population-health goals.

The ultimate goal of health promotion is the continued improvement of health-related conditions and health across the population, with particular attention to people and communities experiencing marginalization, exclusion, or other barriers to health.

Social Determinants of Health—Ottawa Charter and the WHO Commission on Social Determinants of Health

A WHO conference in Ottawa, Canada, in 1986 adopted the Ottawa Charter, a document recognizing that health is not simply the product of medical care or conditions directly related to health. Rather, health is influenced by a complex set of social, economic, and environmental conditions. The Ottawa Charter identified these fundamental conditions and resources for health:

• Peace
• Shelter
• Education
• Food
• Income
• A stable ecosystem
• Sustainable resources
• Social justice
• Equity

In its final report in 2008, the WHO Commission on Social Determinants of Health focused attention on social conditions that contribute to inequities – unfair and avoidable differences in health outcomes. These included:

• Unequal distribution of power, income, goods, and services: People and groups with fewer economic, social, or political resources may experience greater exposure to stressors and health-damaging conditions.
• Social exclusion or marginalization: Some groups – for example, Indigenous Peoples and people experiencing discrimination – may face barriers to social, economic, and material resources that can protect and promote health.

To promote health equity, the WHO Commission recommends:

• Improving daily living conditions. This includes supporting early childhood development and education, expanding access to schooling for people who face barriers, and reducing exposure to harmful conditions such as environmental hazards, inadequate housing, violence, and chronic stress.
• Strengthening social protection. This includes policies and systems that help make a healthy standard of living possible for everyone.
• Health promotion works on the principle that population health is a product not only of addressing specific health needs, such as access to primary health care, but also of addressing broader social determinants. This principle underlies health promotion and continues to inform the work of WHO, PAHO, and other public-health organizations.

What is evidence of health promotion's effectiveness?

In this context, “evidence” refers to information indicating whether and how efforts to promote health are working. Establishing an evidence base for health promotion can present particular challenges:

• Health promotion initiatives can be difficult to document. Health promotion may involve multiple partners working at multiple levels to change programs, policies, practices, environments, and systems. Capturing the full range of what is being done can be challenging.
• Their complexity can make cause and effect difficult to determine. Multiple factors may contribute to multiple, interconnected outcomes, making it difficult to attribute a particular result to one part of an initiative. Evidence may therefore include information showing how multiple environmental, program, policy, and practice changes contributed to population-health outcomes.
• Promising work in lower-resource settings may be underdocumented. Published research has often reflected settings and institutions with greater access to research funding, evaluation capacity, and publication opportunities. As a result, useful health promotion experience from communities and countries with fewer research resources may be less visible in the published literature.

Global Programme on Health Promotion Effectiveness (GPHPE)

The PAHO Documentation Guide grew out of an earlier international effort to strengthen the evidence base for health promotion. With support from WHO, the International Union for Health Promotion and Education (IUHPE) launched the Global Programme on Health Promotion Effectiveness in 2001. Teams from different parts of the world, including the Working Group of the PAHO Regional Initiative to Evaluate the Effectiveness of Health Promotion, worked on methods for documenting and assessing health promotion practice. The PAHO Guide discussed in this section was one of the tools that resulted from that effort.

What is the PAHO Guide for Documenting Health Promotion Initiatives?

The PAHO Documentation Guide's primary purpose is to provide a simple, standard format for documenting health promotion initiatives. The Guide can help create a clearer record of whether and how efforts are working to create conditions that promote health and health equity. 

The original PAHO Documentation Guide, developed in 2010, takes the form of a seven-part questionnaire asking for information about a health promotion effort. (For a copy of the PAHO Documentation Guide, please see Tool #1.) 

Much promising health promotion work may never be formally documented or analyzed. The Guide was developed to expand available information about how health promotion initiatives work, including efforts in places where research and evaluation resources may be limited. Its use can help: (a) describe health promotion efforts taking place in the Americas and other regions; and (b) analyze the processes used to promote health so that useful lessons can be shared. 

The Guide should also benefit those using it. Systematic reflection on practice can lead to the refinement of methods and new ideas for improving the initiative. Engaging community partners as participants in documentation can contribute to a better understanding of what happened and strengthen the influence and capacity of people involved in the effort. Establishing a clear record of what happened, and with what results, can also help others understand and support valuable work.

Answering the questions posed in the Guide may take time and thought, but that reflection can be useful. Thorough documentation can help funders, policymakers, practitioners, community members, and researchers understand health promotion initiatives; help organizations improve their own work; and provide practical examples that can inform similar efforts elsewhere.

Why should you use the Guide?

Answering the questions in the PAHO Documentation Guide will take time for those involved in the initiative, including interviews with stakeholders who have a perspective on the effort. You are busy enough already trying to support this and other activities, so why take the time to create this record of your health promotion initiative? 

There are, in fact, a number of good reasons to use the Guide, including:

• Using the Guide can contribute to the evidence base for health promotion. Sharing what has been tried, how it was implemented, and what happened can help practitioners and policymakers learn from experience.
• Using the Guide can contribute to a better understanding of health promotion practice in the Americas, including work in Latin America and the Caribbean that may otherwise receive limited attention in international literature.
• Documenting and sharing information can help you connect with others in the field, in your own country and elsewhere.
• By involving community partners through participatory action research or other participatory methods, you can strengthen participants' skills, knowledge, and influence in the initiative.
• Use of the Guide can result in a careful analysis of your effort, help you to better understand your strengths and identify areas for improvement, and thereby strengthen your work.
• Documentation makes it possible to communicate what you have accomplished to others through reports, websites, publications, presentations, or other formats.
• Describing the accomplishments of your effort can raise your group’s profile and may strengthen opportunities for funding, partnerships, or other support.

Who should use the Guide?

The PAHO Health Promotion Documentation Guide is intended for use by groups conducting initiatives aimed at creating conditions that promote health and health equity. Some efforts may be relatively small programs involving a few organizations in a local community, while others may cover whole states or provinces, regions, or nations. Some initiatives may focus on particular cultural, racial, ethnic, geographic, or other populations, or on groups experiencing increased risk for particular health conditions.

Individuals, organizations, or institutions conducting health promotion initiatives appropriate for documentation might include:

• NGOs (nongovernmental organizations) or CBOs (community-based organizations) engaged in health and/or human service work.
• Local, state or provincial, regional, or national health or human service agencies.
• Ministries, departments, or other government agencies responsible for health.
• Community health advocates and organizers.
• Healthy community, healthy school, and healthy workplace initiatives.
• Faith-based communities and organizations.
• Health Impact Assessment teams.
• Environmental organizations and groups.
• Individuals or organizations working to increase access to safe and affordable housing, including for people experiencing homelessness or living in informal settlements.
• Individuals or organizations working to improve health equity and the health and quality of life of people and communities experiencing marginalization or other barriers.
• Those working to improve living conditions, for instance by increasing access to clean drinking water, safe housing, sanitation, transportation, healthy food, or other resources important to health.

Who in the organization should actually participate in the documentation? It depends. If the work of the initiative is distributed among many people doing different tasks in different sectors of the community, then people with knowledge of those different parts of the effort should be involved in documenting and interpreting it. The discussion may be facilitated by one or two people close to the effort. The person who completes the Guide may be an administrator or a skilled writer who gathers information from others and puts it into the appropriate form.

In a smaller organization, or in an initiative where one person has their finger on the pulse of most of the work, it may make sense for that person to coordinate the documentation. In many cases, a combination of these approaches will work best, with different people contributing to the portions they know most about.

How do you use the Guide?

As explained earlier, the PAHO Documentation Guide takes the form of a questionnaire rather than a manual. By answering its questions and adding whatever material is needed to fully describe and analyze your effort, you can create a record of what was done, why it was done, and what happened. This can help others determine whether lessons from your initiative might be adapted or applied in their own settings. It can also help you understand what is working well and what may need to change to improve community health. 

In this section, we’ll look at the questions the Guide asks to help you describe and document your work. The focus is on answering them in a way that provides useful information to others while also helping your organization reflect on its own experience. 

The Guide is divided into seven parts that gather information on different aspects of a health promotion initiative. We’ll look at each separately.

CONTACT INFORMATION

This section focuses on documenting the sources of information.

• Submission date: The date on which the questionnaire is being completed or submitted.
• Your contact information: Contact information for the person coordinating or completing the documentation.
• Lead organization: Contact information for the organization with primary responsibility for the initiative.
• Other partners: Contact information for other organizations, institutions, businesses, agencies, community groups, or others involved in or supporting the initiative.

PROGRAMME/PROJECT/INITIATIVE SUMMARY

This section gathers basic information about the project and provides an overview of the initiative.

• Title/Name of Initiative: By what name is the initiative known?
• Purpose(s) or objective(s): What does the initiative set out to do? What is its main focus? For instance, an initiative might aim to increase opportunities for physical activity, improve access to clean drinking water, reduce exposure to environmental hazards, reduce traffic injuries, increase participation in education, or address another condition affecting health.
• Expected outcomes/results: What outcomes or results does the initiative expect to achieve, including both changes in the process and changes in conditions or outcomes?
• Time frame for the initiative: When did the initiative begin? When is it expected to end? If it is ongoing, indicate that and provide any useful explanation.
• Stage of implementation: Indicate whether the initiative is in start-up, in progress, completed, or ongoing.
• Geographic coverage: Describe the country and the state, province, territory, region, municipality, neighborhood, or other geographic areas in which the initiative is being implemented.
• Setting: This might include a school, community, workplace, health care setting, faith community, public space, or another setting where the initiative is being or was conducted.
• Brief description: In narrative form, provide a concise summary of the initiative.

GENERAL CONTEXT

Characteristics of the setting:

• This portion of the Guide asks you to describe the setting before implementation and again during or after the initiative. Comparing these descriptions helps show what conditions were present at the beginning and what may have changed over time.

Specific information requested includes:

• Demography – population characteristics. These may include age, sex or gender, household or family characteristics, urban/rural location, income, race and ethnicity, education, and other relevant information. Who are the people involved in or affected by your initiative? How do their characteristics compare with those of the larger community, and how are those characteristics related to the reason for the initiative?
• Population health profile – life expectancy, infant and maternal health, diseases or health conditions of particular concern, sanitation, nutrition, environmental exposures, and positive indicators of health and well-being. What are the strengths and concerns related to the health of the population? Are there particular health challenges affecting specific populations? Are there local conditions that create barriers to health promotion, such as inadequate sanitation, severe poverty, environmental hazards, violence, lack of access to care, or other conditions? Are there existing conditions or community assets that support health promotion?
• Political context – The nature of government, public support for health promotion, political priorities, and relationships among groups may all affect an initiative. Is health a priority for decision-makers? How do government policies and relationships among different groups affect access to services or health-promoting conditions? Will the political environment influence your work or decisions about how to conduct it? If so, how?
• Socioeconomic conditions – The state of the economy, employment and the labor market, economic inequality, migration or displacement, social protection, housing, income support, and other economic conditions that may affect the initiative and the people involved.
• Sociocultural context – What are the educational, cultural, religious, linguistic, and social characteristics of the population you’re working with? Are there social or cultural conditions that create barriers to participation or health? Are there strengths, traditions, relationships, or community practices that can support the effort? Do particular norms or expectations need to be addressed in order to promote health?
• Community participation – The original Guide refers to this dimension as “Citizenship.” In contemporary use, it can be understood more broadly as the extent to which community members and stakeholders are able and willing to participate in community initiatives. Were stakeholders involved in the different phases of the effort? Which groups participated? How were they involved? Were there barriers to participation, and if so, how were they addressed?

These factors may have a profound effect on how you conduct your effort and how it is experienced by the community. Because context can influence any health promotion initiative, it’s important to describe it carefully so that others can judge whether and how lessons from your initiative might apply in their own settings.

• Why was this initiative started? What influenced the start of the initiative or intervention?
  • In response to an unmet need. For instance, a population may have limited access to reliable health information, clean drinking water, nutritious food, safe housing, health services, or other resources.
  • In response to a crisis. An industrial or environmental disaster such as the 1986 Chernobyl nuclear accident might demand an effort to address health consequences. The same could be true of a natural disaster such as Hurricane Katrina in 2005, when flooding, contamination, displacement, and disrupted services created major health concerns.
  • In response to an opportunity. A new partnership, funding opportunity, policy change, or other opening may make it possible to address an important community health issue.
  • In response to a political request. A public official responding to constituent concerns or other political priorities may support a health promotion effort. An issue may also gain attention through an influential report, media coverage, community advocacy, or public pressure.
  • In response to community action. Community members may organize themselves around an issue – for example, parents organizing a school traffic-safety effort or residents organizing to improve safety in their neighborhood.
  • In response to a funding opportunity. Funding may become available to address a health or community issue.
  • Initiated by an individual on behalf of an organization. An individual may help mobilize a community around an initiative supported or promoted by an organization.
• Strategies, models, or frameworks used in the design of the initiative: Identify whether the initiative was guided by any established strategies, models, or frameworks, and briefly describe how their concepts or principles informed the initiative.

FINANCING

These questions attempt to determine the investment, sources of funding, and other resources necessary for implementing the initiative.

• Budget – Some initiatives have a specific budget and others do not. Try to estimate the value of what has been invested or spent to begin the initiative, what is required on an annual basis to maintain it, and the total investment if the initiative has been completed.
• Source of funds – Identify the sources of funding and, where useful, the amounts received through grants, contracts, public funding, donations, or other sources.
• Nonfinancial resources – Resources necessary for successful health promotion extend beyond money. They may include people with technical or training skills, community knowledge and relationships, facilities, transportation, volunteers, donated materials, in-kind contributions, meeting space, media coverage, and other community assets.
• Adequacy of financial resources – Was your budget sufficient to accomplish your goals? If not, explain the challenges or limitations.
• Adequacy of nonfinancial resources – Were available resources, including community assets, sufficient to accomplish the initiative’s goals? If not, explain what was missing or inadequate.

PROCESS/PARTNERSHIPS

The next questions focus on partnerships.

• Key partners and their roles and responsibilities: Identify the partners involved in the initiative and describe their primary roles and responsibilities.
• Evolution of partnerships and roles and responsibilities: Did partnerships or responsibilities change over time? If so, describe how and why.
• New partnerships: Were additional partners brought into the initiative after it began? Who were they, and what led to their involvement?

STRATEGIES

These questions aim to capture the strategies used to carry out the initiative. The original Guide draws largely on health promotion strategies reflected in the Ottawa, Caribbean, and Bangkok charters.

• Strategies used. Identify the strategies used in implementing the initiative and describe how each contributed to the work.
  • Participation – How were community members, intended participants, and other partners involved in decision-making and implementation? What did you do to create meaningful participation and shared ownership of the initiative?
  • Partnerships/collaboration/intersectoral action – How were working relationships developed among different community sectors – government, businesses, organizations, institutions, NGOs, community leaders, faith communities, and others – in order to implement the initiative? What did you do to encourage collaboration?
  • Empowerment/capacity building – How did the initiative strengthen people’s ability to influence the conditions affecting their lives? What knowledge or skills were developed? How did participants and partners increase their ability to carry out the work and pursue desired outcomes?
  • Public policy – What formal policies, laws, regulations, organizational procedures, or informal practices affecting the issue were addressed? What did the initiative do to advocate for or help bring about policy change?
  • Communications and public relations – How did the initiative provide information, increase awareness, gather information from the people and communities involved, and maintain communication among stakeholders and implementing partners?
  • Advocacy – What approaches were used to build support for the initiative, encourage people and organizations to provide resources, present evidence to inform policy, or bring about changes in services, systems, or the physical environment?
  • Building leadership – How were people responsible for the initiative organized? What formal or informal structures for decision-making were established? What was your leadership strategy, who participated in leadership, and how were new leaders supported or developed?
  • Creating supportive environments – What did you do to create conditions that support the community change you wanted to see? Did you address social norms, access to resources, organizational practices, or features of the physical environment?
  • Improved access to resources/services – What changes helped community members gain better access to resources and services? What was done to make programs easier to reach, use, afford, or navigate?
• Challenges the initiative faced – Describe important challenges encountered during the initiative and what was done to address them.
• Additional actions or strategies – Describe any other actions or strategies that were important to implementation and how they affected the initiative, positively or negatively.

OUTCOMES

• Notable achievements/results/outcomes: List or describe the main achievements, results, and outcomes of the initiative.
• Contribution to broader development goals: The original 2010 PAHO Guide asked how an initiative contributed to the Millennium Development Goals (MDGs). Because the MDG period ended in 2015, contemporary documentation should instead consider whether and how the initiative contributes to the United Nations Sustainable Development Goals (SDGs) and other relevant current health and development priorities.

From the Millennium Development Goals to the Sustainable Development Goals

The original PAHO Documentation Guide was developed during the period of the Millennium Development Goals, eight international development goals adopted in 2000 with a target date of 2015. References to the MDGs in the original Guide should therefore be understood in their historical context.

In 2015, United Nations member states adopted the 2030 Agenda for Sustainable Development and its 17 Sustainable Development Goals (SDGs), which took effect in 2016. The SDGs build on the earlier MDGs but address a broader range of social, economic, environmental, and health conditions.

For current documentation, an initiative can identify the SDGs to which it contributes. SDG 3 specifically addresses health and well-being, but health promotion can also contribute to goals related to poverty, food and nutrition, education, gender equality, clean water and sanitation, employment, inequality, sustainable communities, climate, peace and institutions, partnerships, and other determinants of health.

The original Guide also discussed PAHO’s Faces, Voices and Places initiative, adopted in 2006, as an example of a regional initiative connected with the MDGs and social determinants of health. This should now be understood as a historical example from the MDG period rather than as the current global development framework.

Current PAHO health promotion work is aligned with the 2030 Agenda and emphasizes health equity, social participation, intersectoral action, healthy settings, and action on the social determinants of health.

• Changes arising from the initiative: At what levels did the initiative contribute to change? Consider changes involving individuals, groups, organizations, communities, policies, systems, or broader social conditions. Describe the changes and the available evidence supporting them.
  • Changes at the individual level. These may include increased skills, knowledge, confidence, leadership, problem-solving ability, or changes in attitudes or behavior.
  • Changes in communities. These may include a shift in community attitudes around issues such as harmful alcohol use or domestic violence; increased awareness of community needs or strengths; stronger coalitions, communication networks, or organizing capacity; broader participation in decision-making; development of community leadership; creation of new community resources or assets; or increased commitment to improving quality of life.
  • Changes in policy at local, regional, state/provincial, or national levels. These might include new or revised policies, improvements in infrastructure, or changes in organizational procedures and practices.
  • Changes at the organizational or institutional level. These may include increased resources devoted to the issue, establishment of a new health promotion function or unit, assignment of staff, stronger partnerships, or incorporation of participatory approaches into routine organizational practice.
• Which change was most important and why? Of the changes identified, which were most significant, and why?
• Sustainability: Does the initiative need to continue in order to maintain its benefits? If so, what was done to sustain or integrate the work into ongoing programs, policies, organizations, systems, or community practices? If it was not sustained, why not?
• Evaluation process: Describe how the initiative was evaluated. How did you learn what worked and what needed to change? What information helped you organize the process, set timelines, and manage implementation? What process or outcome measures were used? How were evaluation findings used to adjust and improve the effort?
• Main lessons learned: What have you learned from the effort as a whole and from its planning, implementation, evaluation, and sustainability? What did you learn about the methods and systems you used, the accuracy of your expectations, and the effectiveness of the initiative? What might you do differently? Which lessons might apply in other settings, and which depend strongly on your particular community or context?
• Recommendations: What would you recommend to improve this or similar initiatives in the future?
  • Revising the intervention. How would you change the intervention to make it more effective, equitable, accessible, or efficient? What would you do differently next time?
  • Implications for participatory research. How could you involve more stakeholders and participants in the different phases of the process? What support, training, or mentoring might be useful?
  • Implications for practice. What approaches appear particularly useful for others pursuing similar outcomes? It is just as important to describe what did not work as what did, since knowing what to avoid or modify can be as useful as knowing what to repeat.
• Communication materials, tools, manuals, protocols, etc.: Identify materials developed to support the initiative that could help others understand or adapt the work, where sharing them is appropriate.
• Photographs and other documentation: Identify photographs or other appropriate materials that help tell the story of the initiative. When sharing images or information about participants, follow applicable consent, privacy, and confidentiality requirements.

In Summary

The PAHO Documentation Guide was developed to help practitioners create a record of the whole of a health promotion effort – its context, planning, design, implementation, partnerships, strategies, outcomes, evaluation, sustainability, and lessons learned. If you answer the questions in the Guide carefully, you can develop a detailed picture of what was done, how it was done, what changed, and what others might learn from the experience.

Although the original Guide was developed in 2010 and contains some references that reflect that period – particularly the Millennium Development Goals – its central purpose remains useful: helping practitioners document and reflect systematically on health promotion practice so that lessons can be shared, initiatives can be improved, and useful approaches can inform work in other communities.

For contemporary use, historical fields should be interpreted in light of current health and development frameworks. In particular, the Sustainable Development Goals and the 2030 Agenda have replaced the Millennium Development Goals as the current global development framework.

Contributor

Originally contributed by the Working Group of the PAHO (Pan American Health Organization) Regional Initiative to Evaluate the Effectiveness of Health Promotion, with participation from WHO/PAHO Collaborating Centers and other public-health partners. The organizational names and affiliations in the original contributor statement reflect the institutions involved at the time the Guide was developed.