Section 12. Documenting Health Promotion Initiatives Using the PAHO Guide

Learn how to use the PAHO Guide to document initiatives to improve community health and development.

 

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; individuals, organizations, communities, and institutions working together to create conditions that assure health and well-being for all.

In its simplest terms, health promotion fosters changes in the environment that help promote and protect health. These include changes in communities and systems—for instance, programs that assure access to health services or policies that arrange for public parks for physical activity and spending time with others.

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 the place, such as a municipality or region, or experience such as being young or poor or at risk for a particular outcome.
• Participatory: Health promotion involves the collaboration of all community stakeholders in the selection, planning, implementation, evaluation, and maintenance of health-promoting interventions, policies, and conditions.
• Intersectoral: Health promotion engages all sectors or parts of the community – individual citizens, business, governmental institutions, faith communities, and non-governmental organizations such as health and human service organizations, social and cultural organizations, etc. – in making health-promoting changes in their programs, policies, and practices.
• Sensitive to Context: Health promotion takes into account all relevant aspects of the place and time; including the 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 status in the entire population, with a particular emphasis on the needs of the most marginalized or excluded members of the community.

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 that recognizes that health is not the product simply of medical or other conditions directly related to health, but that it is a comprehensive issue, determined by a complex of social and environmental factors. The Ottawa Charter spelled out these social determinants of 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 several key social determinants that lead to inequities or unfair and avoidable differences in health outcomes:

• Unequal distribution of power, income, goods and services: Some groups of people—for instance, the poor, women, and others of lower social status—have unequal exposures to stressors and health-damaging experiences.
• Social exclusion or marginalization: Some groups of people—for example, indigenous peoples or those experiencing discrimination—have unequal access to social and material support to buffer the effects of stressful conditions.

To promote health equity, the WHO Commission recommends:

• Improving daily living conditions: This involves assuring early childhood education and schooling, including for girls and others denied access. It also involves reducing exposures to harsh conditions, such as environmental toxins and the daily stressors of poor housing, violence, and other living conditions.
• Assuring mechanisms of social protection: This requires that governments adopt policies and build systems that allow a healthy standard of living for everyone.
• Health promotion works on the principle that population health is a product not only of addressing specific health needs, such as assuring primary health care, but also of addressing these broader social determinants. This principle underlies the concept of health promotion, the Guide, and the work of PAHO and other regional offices of the World Health Organization.

What is evidence of health promotion's effectiveness?

In this context, “evidence” refers to an indication that efforts to promote health are working. Establishing an evidence base for health promotion can be a particular challenge:

• Health promotion initiatives are difficult to document: Health promotion engages multiple partners at multiple levels in changing the programs, policies and practices that affect health. It can be challenging to document what is being done to improve health.
• Their complexity makes it hard to see causes and effects: Since multiple factors affect multiple and interrelated outcomes, it is challenging to establish what aspects of a particular initiative resulted in particular outcomes. In this context, evidence may take the form of showing the contribution of multiple environmental changes—such as new programs policies, and practices—on related population-health outcomes.
• Much promising work in developing countries/communities is never documented: The research literature consists largely of reports of work in more affluent countries by researchers who have greater access to resources for research.Thus, many promising health promotion efforts in lower-income communities/ countries are not publicly available.

Global Programme on Health Promotion Effectiveness (GPHPE)

With support from the World Health Organization, the International Union for Health Promotion and Education (IUHPE) launched the GPHPE in 2001. This project has engaged teams throughout the world—including the Working Group of the PAHO Regional Initiative to Evaluate the Effectiveness of Health Promotion—in developing and implementing methods to extend the evidence base. This PAHO Guide for documenting health promotion initiatives is one of the tools resulting from that effort.

What is the PAHO Guide for Documenting Health Promotion Initiatives?

The PAHO Documentation Guide's primary purpose is to create a simple, standard format to help support documentation of health promotion initiatives. Use of the PAHO Guide will expand available indications about whether and how efforts are working to create conditions that promote health and health equity.

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

Much promising health promotion work in the Americas is not documented and the effects of such efforts are not analyzed. The aim of the PAHO Guide is to expand available information on how they are working, including in parts of the world with limited resources for research. Use of the Guide will assist in: (a) describing the health promotion efforts taking place in the Americas and other WHO regions; and (b) analyzing the processes used to promote health that can then be shared with others around the world.

The Guide should also be of benefit to 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 the documentation can contribute to better understanding of what happened, as well as enhanced efficacy or influence among those giving meaning to the effort. Establishing a clear record of what happened, and with what results, can make it more likely that others will help sustain valuable efforts.

Answering the questions posed in the Guide might take some time and thought, but it will be time and thought well spent.  Ultimately, the widespread documentation should contribute to understanding of health promotion initiatives among funders and policy makers, the experience using the Guide should help organizations improve their efforts as well as gain recognition and funding, and documented examples will serve as practical examples which can inform similar initiatives in other countries.

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 will contribute to an evidence base that will help advance the field of health promotion. Improved policies and practice based on this knowledge could help make life better for millions of people throughout the world.
• Using the Guide will contribute to better understanding about what is successful in Latin America and expose the rest of the world to significant health promotion practices in Latin America.
• Contributing information through use of the guide will allow you to connect with others in the field, both in your own and other countries.
• By involving community partners through participatory action research, you can empower participants in your initiative, and engage them in learning new skills.
• Use of the Guide will result in a careful analysis of your effort, help you to better understand your strengths and pinpoint areas to improve, and thereby make your work more effective.
• Documentation will make it possible to communicate what you have accomplished to others, perhaps through websites or journal reports.  As a result, you have a chance to gain international recognition and credibility.
• Describing the accomplishments of your effort can raise your group’s profile.That, in turn, could increase your possibilities for funding and other support.

Who should use the Guide?

The PAHO Health Promotion Documentation Guide is intended for use by any group conducting an initiative aimed at assuring conditions that promote health and health equity. Some documented efforts may be relatively small programs involving a few organizations in local municipalities, while others might cover whole states or provinces, or even whole nations.  Some efforts might target very specific cultural, racial, or ethnic groups, or groups at risk for particular health conditions, such as childhood immunization programs or efforts to promote physical activity or healthy nutrition to reduce risk for diabetes or cardiovascular diseases.

Some of the individuals, organizations, or institutions that might be conducting health promotion initiatives that would be appropriate for inclusion in the Guide include:

• NGOs (non-governmental organizations) or CBOs (community-based organizations) engaged in health and/or human service work.
• Local, state or provincial, or national health or human service agencies.
• Ministers or Secretaries and ministries or departments of health at all levels.
• Community health activists.
• Healthy community, healthy school, and healthy workplace initiatives.
• Faith based communities and or organizations.
• Health Impact Assessment teams.
• Environmental groups.
• Individuals or organizations concerned with providing affordable housing for marginalized individuals and families, including those who are homeless or living in informal settlements.
• Individuals or organizations working to improve health equity and to improve health and quality of life for marginalized individuals or families.
• Those working to change living conditions; for instance, by assuring access to clean drinking water, decent housing, or sanitation

Who in the initiative organization should actually participate in the documentation? It depends. If the work of health promotion initiatives was distributed among many different people – doing different tasks in different sectors of the community – then these key leaders should be involved in documenting and giving meaning to the effort. The dialogue may be facilitated by one or two people close to the effort. The reporter who completes the Guide may simply be an administrator or a good writer who gathers all the documentation from others and puts it in the appropriate form.  In a smaller organization or in a program or effort where one person has her finger on the pulse of the work, it may make the most sense for that person to complete the documentation.  In many cases, a combination of these methods might be used, with different people completing the parts of the documentation with which they are most familiar.

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 the questions, and adding whatever material is necessary to fully describe and analyze your effort, you’ll create the documentation that will make it possible to demonstrate the effectiveness of your work. This will also allow others to reproduce what you did in their situation. In addition, it will help you to understand what you are doing well, and what you 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 how to best answer the questions to pass on the information others might need to replicate (reproduce) it, and to get the most out of the process for your organization.

The Guide is divided into seven parts to obtain information on various aspects of the Health Promotion initiative. We’ll look at each of these parts separately.

CONTACT INFORMATION

This section focuses on documenting the sources of information.

• Submission date: Date on which the questionnaire is being completed/submitted
• Your contact information: Contact information of the person completing the questionnaire
• Lead organization: Contact information for the organization that has primary responsibility for the initiative
• Other partners: Contact information for other organizations, institutions, businesses, etc., involved in or supporting the initiative. The form facilitates five (5) responses. For additional information attach a separate sheet.

PROGRAMME/PROJECT/INITIATIVE SUMMARY

This section gathers basic information on 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 the initiative sets out to do, its main focus. For instance, this might be to increase access to physical activity opportunities, improve access to clean drinking water, reduce exposure to environmental toxins, to reduce highway injuries, increase participation in primary education, etc.
•  Expected outcomes/results: What are the expected outcomes/results of the initiative (both the process and the product of the effort) as appropriate to the initiative.
• Time frame for the initiative: Start date and end date are inserted using the calendar menu which comes up when each field is selected. If the initiative is ongoing and continuous enter the start date and check the ongoing/continuous box. There is a comment box for you to provide an explanation for the responses checked if necessary. This is optional.
• Stage of implementation: Indicate what stage/phase of the initiative is being documented - start up, in progress, or completed.
• Geographic coverage: Select the country in which the initiative is/has been implemented from the drop down field. Check each appropriate geographic division – province/state/region, etc. in which the programme is being implemented and insert in the text field the name(s) of the geographic division.
• Setting: This might include school, community, workplace, etc. where the initiative is being/was conducted. Using the check boxes, check the appropriate setting, check more than one if applicable and state additional setting(s) if appropriate option is not available.
• Brief description: In narrative form, describe the initiative in not more than 300 words (space limited to one page). This is meant to be a summary of the initiative.

GENERAL CONTEXT

Characteristics of the setting:

• This question is divided into section A which aims to capture information on the characteristics of the setting before the implementation of the initiative/programme; and section B which aims to capture information about the setting at this current moment which can be during implementation, or after implementation if completed.

Specific information requested includes:

•  Demography – population characteristics. Here, the demographics of the general population – gender, age, marital status, urban/rural, income level, race/ethnicity, etc. – are called for.  Who are the people you’re working or have worked with?  How do their demographic characteristics (e.g., age, gender, education, income, social status) compare to those of the general population of the community?  How are those characteristics related to the reason you’ve chosen to work with this group?
• Population health profile - life expectancy, infant mortality, diseases or health conditions especially common in the community or society, the threat of epidemics, sanitation, nutrition, unusual positive aspects of population health (exceptional longevity, lack of common medical conditions – hypertension or cardiovascular disease, for example – remarkable lung capacity, etc.), exposure to both human-caused and natural environmental health risks (pollution, parasites). What are the positive and negative aspects of the health of the population you’re concerned with? Are there particular threats to community health or the health of the specific population (e.g., infants and children from disadvantaged communities)? Is the incidence of one or more diseases or conditions particularly high or particularly low? Are there local conditions that present barriers to health promotion (e.g., lack of sanitation, extreme poverty, local customs that support unhealthy practices)? Are there conditions that work in favor of health promotion (e.g., clean environment, sustainable farming practices, good universal health care, and healthy diet)?
• Political context – The nature of the national government, government support for health promotion, political factions in the community or society, or political priorities may all be important to the success of your effort.  What is the character of the local government?  Is health a political priority? Do elected officials ask of a policy option: Is it good for the people’s health? What are the relationships among your population and various others in the community?  What is the history of those relationships? Do they affect the delivery of health services or the possibility of health-promoting conditions for particular groups? Will (does) the political environment affect your effort or decisions about how to conduct it?  If so, how? These and other similar broad political factors might be discussed here.
• Socio economic conditions - The state of the economy, employment and the labor market, economic divisions in the society, economic migration (people moving from rural areas to cities in search of jobs and income, for example, or large numbers of migrants or displaced persons), government support for the poor (food subsidies, housing, income subsidies, etc.), and government involvement in the economy in general.
• Sociocultural – What is the education level, cultural and religious background, norms, and values of the population you’re working with? How do they compare with the community as a whole?  Are there sociocultural factors that make reaching this population difficult?  Are there sociocultural factors that socially exclude or isolate this population, or specifically affect their health and well-being?  Will you (did you) have to change attitudes or social norms in order to make health promotion a priority for this group?
• Citizenship - level of participation – overview of level of participation in community initiatives of the average citizen in the specific area. In the larger context, this might refer to the willingness of stakeholders (those who care about the initiative) to be involved in anything that might draw attention to them. For instance, is the government repressive or likely to be threatened by what it sees as the mobilization of independent groups? It might also refer to stakeholders’ familiarity with the issues and their willingness or their perception of their ability to participate fully. Were all stakeholders involved in the various phases of your effort (or the phase you’re documenting)? If not all, were any stakeholders involved?  Which groups?  What was the mechanism by which stakeholders were involved? Were there barriers to stakeholder involvement, and how were they (or were they not) overcome?

These factors may have a profound effect on how you conduct your effort and how it is received by the population. Because the context can have so much influence on any health promotion initiative, it’s important to describe it carefully, so that others can determine whether a similar initiative might (or might not) work in their situations.

• Why was this initiative started: What influenced the start of the initiative/intervention? Check the appropriate option(s) from the choices given and explain in the text field. If an appropriate option is not available check “other” and explain in the text field.
  • In response to an unmet need. There might, for instance, have been little or no health information available to a particular population or that population may not have access to clean drinking water or healthy food.
  •  In response to a crisis. An accident such as the 1986 meltdown of the nuclear reactor at Chernobyl in Ukraine might demand an effort to address possible health consequences.  The same might be true for a natural disaster, such as the virtual destruction of New Orleans by Hurricane Katrina in 2005, where several feet of polluted water raised enormous health concerns for those (many low-income African Americans) still in the city.
  • In response to an opportunity. A grant became available to address a health issue of importance to the community; for example, a community group might mobilize to address the issue of violence.
  • In response to a political request. A public official, responding to demands of constituents, might obtain political support for a health promotion effort in a particular neighborhood or city. An effort to address community safety, for instance, might be started as an attempt to gain votes just before an election. A particular issue might be raised by publication of an influential report, media coverage of the issue, or public pressure brought to address it.
  • In response to citizen/community action. An individual or group of persons who organized themselves to address a public health issue - e.g., a group of parents who organize a school traffic safety patrol, a community concerned about crime in the neighborhood who organize a community policing group, etc.
  • In response to a funding opportunity. Funds were made available to or through a group to address a health or community issue.
  • Initiated by an individual on behalf of an organization. An individual mobilized a community to pursue an initiative being promoted by a particular organization.
•  Strategies/models or frameworks used in the design of this initiative: Check yes or no if the initiative was guided by any strategies, models or frameworks e.g., Healthy Communities and Municipalities (HMC), Healthy Markets (HM), Health Promoting Schools (HPS). If yes is checked, identify which strategies, models or frameworks and describe briefly, stating which aspects and how the concepts and principles of health promotion informed the initiative.

FINANCING

These questions attempt to determine the investment, source of funds and other resources necessary for the implementation of the initiative. For information on financial resources, please see: Generating, Managing, and Sustaining Financial Resources.

• Budget – Some initiatives will have had a specific budget, others will not. However, try to put a value of what has been invested/spent on the initiative to start it, on an annual basis to maintain its activities, and total amount spent if the initiative is completed.
• Source of funds – Select source(s) of funding and state “other” if option is not available. If received from a donor through project funding, grant or other, please state source and amount received.
• Non financial resources – Resources necessary for the successful implementation of HP initiatives go beyond financial and include non financial resources such as human resources with technical/ training skills etc., and community assets - material, infrastructure, transportation volunteers, in-kind contributions, space, media coverage, etc. Please list what was made available to support the implementation of the selected initiative.
• Adequacy of financial resources – Is (was) your budget adequate to accomplish your goals? If no, please explain the challenges and shortcomings.
• Adequacy of non financial resources – Were the resources that were made available, including community assets, adequate to accomplish the goals of the initiative? If no, please explain the challenges and shortcomings.

PROCESS/ PARTNERSHIPS

The next three questions focus on partnerships

• Key partners and their roles and responsibilities: List the names of all partners that have been/are involved in the initiative, and for each one state the main roles and responsibilities.
• Evolution of partnerships and roles and responsibilities: Indicate whether the partnerships changed over time and if they did describe how they changed over time.
• New partnerships: Indicate whether new partnerships were developed during the implementation of the initiative, and indicate who the new partners were (not the ones involved initially, those that were incorporated for one reason or another during the intervention).

STRATEGIES

These questions aim to capture the strategies used to facilitate the implementation of the initiative. The strategies are primarily the key health promotion strategies outlined in the Ottawa, Caribbean, and Bangkok charters for health promotion:

• Strategies that have/are being used. Select each strategy that was used in implementing the selected initiative. For each selected strategy an additional set of questions needs to be answered to elaborate on the selected strategy. This section will be particularly useful to technical officers implementing HP initiatives as it elaborates on the details associated with each strategy.
  • Participation – Focuses on involving stakeholders/target audience and other partners in decision making, to support implementation, possibly mobilize resources, etc. This is about establishing ‘ownership’ of the initiative by the people in the respective setting.  What did you do to enable people to participate in your project/intervention?
  • Partnerships/collaboration/intersectoral action – How working relationships were forged among various community sectors – government, businesses, organizations, institutions, NGOs, key individuals, faith communities, etc. in order to implement the specific initiative.  What did you do to encourage collaboration?
  • Empowerment/Capacity Building - How did the initiative help people gain more control over the forces that have an impact on their lives? How were people trained or skills built (e.g., cancer detection through self examination, budgeting or life skills shared and knowledge transferred to the persons)?  How were those involved able to get things done and follow through implementing the initiative to bring about the desired outcomes?
  • Public policy – Changing formal policies (laws, regulations, stated policies and procedures) and informal policies (decrees, etc.) that affect the way things are done and thus the development of the people in respect to specific issue being addressed by the initiative. What did you do to change policies or advocate for policy and legislative change?
  • Communications and public relations – Providing information, increasing awareness, obtaining information from target populations and keeping them informed. Also speaks to communication among stakeholders and implementing partners.
  • Advocacy – Refers to ways used to ‘sell’ the ideas of the initiative, convince people to support and provide resources, present information/evidence to inform policy changes, bring about other changes e.g., the way services are provided, physical changes to a structure or physical environment, etc.
  • Building leadership – How were the people who were responsible for implementing the initiative organized?  What formal/informal structures for decision making did you set up? What was your leadership strategy and who was involved in it?  How did you train and bring in new leaders?
  • Creating supportive environments – What did you do to support the community change you wanted to see? What cultural norms did you try to influence and how did you do that? How did you change access to goods and services in order to support individual behaviour changes?
  • Improved access to resources/services -- What policies did you change to enable community members to have greater access to resources and services? What did you do to make community programs easier for people to get to? What did you do to make services more affordable?
• Challenges that the initiative faced – Describe any challenges that the initiative encountered that were not covered under Question 24. Please also include a discussion about what was done to overcome them.
• Actions/strategies that the initiative used – Describe any strategies or actions the initiative used that were not covered under Question 24. Please also include a discussion about how these actions/strategies contributed to the initiative (negatively or positively).

OUTCOMES

• Notable achievements/results/outcomes: List and or describe the main achievements/results and outcomes of the initiative.
• Millennium Development Goals plus: How did (or will) the effort help to achieve the Millennium Development Goals (MDGs)?  Which goal(s) does it address? Select all relevant goals and explain briefly how this was done. The MDG Plus is included and you are asked to select this one if applicable. Since it covers a number of diseases and more importantly risk factors, these are listed and you are requested to check as many as relevant to the initiative.

The Millennium Development Goals.  In 2000, the United Nations Development Programme set out to achieve the eight Millennium Development Goals (MDGs) adopted at the U.N. Millennium Summit in September of that year. These goals, targeted to be achieved by 2015, were agreed on by 189 countries and officially adopted by 147. They are meant to stimulate and coordinate efforts to improve outcomes for the world’s poorest people, those trying to live in conditions of extreme poverty. Although some countries/communities have made great strides toward meeting them, there are few well documented efforts to achieve the MDGs.

The eight Millennium Development Goals (MDGs) are (by 2015) to:

• Eradicate extreme poverty and hunger.  Cut in half the number of people living on less than $1 a day.
• Achieve universal primary education.
• Promote gender equality and empower women.
• Reduce child mortality.  Cut by two-thirds the mortality rate for children under five.
• Improve maternal health.  Reduce the death rate of women in childbirth by three-quarters, and achieve universal access to reproductive health.
• Combat HIV/AIDS, malaria, and other diseases.  Halt and begin to reverse the spread of HIV/AIDS, provide universal access to HIV treatment by 2010.
• Ensure environmental sustainability.  Spread principles of environmental sustainability, foster biodiversity, reduce by half the percentage of people without safe drinking water.
• Develop a global partnership for development.  Establish systems and partnerships that recognize and attend to the needs of developing countries – particularly the poorest – increase development assistance, manage debt, encourage trade, provide access to affordable essential drugs in developing countries, make technology – phones, cell phones, Internet – available.

 MDGs Plus. In recognition of related challenges, many of those working on the MDGs are inclined to add some other important health-related MDGs. The “Plus”was added in recognition of the fact that some countries may have particular needs or problems (violence, chronic diseases, environmental issues) that must be addressed in order to achieve the MDGs, or because of their particular importance to communities.

PAHO’s Efforts to Address the MDGs: The Faces, Voices, and Places initiative. The Pan American Health Organization (WHO/PAHO) has implemented a regional effort to address the health-related MDGs. Known as the Faces, Voices and Places initiative, this was adopted by PAHO in 2006.  As noted in the PAHO Documentation Guide: “This is an effort to build political will at the highest level while at the same time providing technical assistance to address the social and economic determinants of health at the local level. It advocates for the most vulnerable and helps build citizenship with a focus on shared rights and responsibilities. This is achieved through intersectoral and interagency collaboration that unites efforts and commitment toward the achievement of the Millennium Development Goals.”

According to PAHO, the purpose of Faces, Voices and Places is to:

• Respond to the needs of the poorest and most vulnerable communities from the perspective of the social determinants of health.
• Elevate the values of equality and Pan Americanism.
• Synchronize efforts and unify actions and the will to achieve the MDGs.
• Promote the objectives of public health among people and territories.
• Emphasize rights and responsibilities, to ensure sustainable development.
• Consolidate the power of advocacy for the most vulnerable.
• Transition from a focus on poor countries to a focus on people living in poverty.

With its Faces initiative, PAHO aims to encourage “a model of sustainable development that calls for a multiplicity of factors and players at different levels to successfully address the social determinants of health” and the many causes of poverty.

• Changes arising from the initiative: At what level did the initiative bring about change? E.g., behavior or attitudes of individuals? Of groups (e.g., health care providers, policy makers)?  Organizations or institutions? The community? The society? Select as relevant and describe the changes made.
  • Changes at individual level. Increases in the ability of individuals to solve their own problems and meet their own needs. These might include the development of a skilled workforce, the emergence of leadership from within the community, a gain in organizational skills, or individual attitude or behavioural change.
  • Changes in communities. These may include a shift in community attitudes (about alcohol abuse or domestic violence, for instance) or increases in community awareness (about the need for particular services, or the frequency of particular behaviors or events). It may also involve enhanced capacity for community advocacy or mobilization (coalitions, communication networks, community organizing) or democratization (more people involved directly in decision-making, greater participation, emergence of leaders from the community). It may also take the form of new community resources or assets created (health clinics, schools, organizations, clean-water wells, etc.) or community commitment to improvement in the quality of life for everyone.
  • Changes in policy at local, regional, state/province, and national levels.This might include improvement in the infrastructure (roads, utilities, and communication), and changes in organizational policies.
  • Changes at organizational or institutional level.This might include improvements and changes in organizations and institutions (public and private) working at the community level or that are part of the initiative. Examples of such changes could be an increased allocation of resources to issues related to the initiative, the establishment of a new unit responsible for health promotion, assignment of personnel to work on the initiative, institutionalization of participatory methods into work plans, etc.
• Which change was most important and why: Indicate which of the changes made and identified in Question 29 were most important and indicate why.
• Sustainability:  Is the initiative one that requires sustainability (not a project intervention that is specifically time bound)? If it is an initiative to be sustained, indicate whether it has been or not. If not, explain why not; if yes, explain what was done to enable the initiative to be sustained/integrated/ mainstreamed into other activities/processes.
• Evaluation process: Describe how the initiative was evaluated.  How did you gain an understanding of what worked?  How did you find out what needed to be changed?   What information helped you better organize the process, set the timeline, and manage the logistics?  How did you measure your success?  (What outcome measures were used?)  How did you use the evaluation to adjust and improve the effort?
• Main lessons learned: What have you learned, both for the effort as a whole and for each phase (planning, implementation, evaluation, sustainability) – about the efficiency and effectiveness of the processes, methods, and systems you used? What have you learned about the accuracy of your expectations? About the effectiveness of your work in obtaining the desired outcomes? About whether the desired outcomes had the desired results (i.e., were you on the right track?). What have you learned about how you might have conducted the effort better?  Is this effort applicable to other circumstances, or would it only work in your community or one very similar to it, and why?
• Recommendations: What would you recommend to improve this and similar initiatives in the future?
  • Revising the intervention. How would you change the intervention to make it more effective and efficient?  What would you do differently next time?
  • Implications for participatory research. How would you draw more stakeholders and participants into all phases of the process?  Would that be feasible in all phases, given the nature of the effort? Would any of them need training or mentoring, and how would you provide it?
  • Implications for practice. What have you found that would seem to be a best practice, or would help others in trying to achieve outcomes similar to yours?  It is as important to describe here what didn’t work as what did, since eliminating particular methods or approaches can be as helpful as suggesting ones to be used.
• Communication materials, tools, manuals, protocols, etc.: Since one purpose of this exercise is to share experiences and so facilitate the advancement of health promotion initiatives, you are requested to share the material, tools, documents, etc. developed to support this initiative. This will particularly be useful to practitioners as they attempt similar initiatives in their respective countries.
• Photographs: List and attach in a separate file any photographs that tell the story of the initiative implemented.

In Summary

The PAHO Documentation Guide is meant to help you create a record of the whole of your health promotion effort – the process of planning, designing, implementing, evaluating, and sustaining it. It focuses on the context, as well as your methods, results, and the lessons learned.  If you answer the questions in the Guide, you will have a complete picture of what you’ve done, how you’ve done it, and what’s important about it. That documentation will make it possible to pass on what you’ve learned, and to help others create healthy communities.

Contributor

Contributed by the Working Group of the PAHO (Pan American Health Organization) Regional Initiative to Evaluate the Effectiveness of Health Promotion. The Working Group includes World Health Organization (WHO)/PAHO Collaborating Centers: Center for Chronic Non-Communicable Disease Policy (Public Health Agency of Canada); Work Group for Community Health and Development (University of Kansas, USA); Center for Evaluation, Training, and Advocacy in Health Promotion (CEDETES, Center for Development and Evaluation of Public Health Policies and Technologies, University of Valle, Cali, Colombia); Center for Health Promotion Research (Center for Community Health Promotion Research, University of Victoria, Canada); Center for Health Promotion (University of Toronto, Canada); Center for Healthy Cities (Indiana University, USA); Center for Healthy Cities and Health Promotion (CEPEDOC – Center for Study, Research, and Documentation in Healthy Cities, University of Sao Paulo, Brazil); the United States Centers for Disease Control (National Center for Chronic Disease Prevention and Health Promotion); and representatives from the Areas of Sustainable Development and Environmental Health and Health Surveillance, Disease Prevention and Control of PAHO.