Health promotion innovations scale up: combining insights from framing and actor-network to foster reflexivity.

There are numerous hurdles down the road for successfully scaling up health promotion innovations into formal programmes. The challenges of the scaling-up process have mainly been conceived in terms of available resources and technical or management problems. However, aiming for greater impact and sustainability involves addressing new contexts and often adding actors whose perspectives may challenge established orientations. The social dimension of the scaling-up process is thus critical. Building on existing conceptualizations of interventions as dynamic networks and of evolving framing of health issues, this paper elaborates a social view of scaling up that accounts for the transformations of innovations, using framing analysis and the notion of 'expanding scaling-up networks'. First, we discuss interventions as dynamic networks. Second, we conceptualize scaling-up processes as networks in expansion within which social learning and change occur. Third, we propose combining a 'representational approach' to frame analysis and an 'interactional approach' that illustrates framing processes related to the micro-practices of leading public health actors within expanding networks. Using an example concerning equity in early childhood development, we show that this latter approach allows documenting how frames evolve in the process. Considering the process in continuity with existing conceptualizations of interventions as actor-networks and transformation of meanings enriches our conceptualization of scaling up, improves our capacity to anticipate its outcomes, and promotes reflexivity about health promotion goals and means.

Linking process and effects of intersectoral action on local neighbourhoods: systemic modelling based on Actor-Network Theory.

After 25 years of intersectoral practice to increase health promotion resources, there is little scientific literature linking analysis of processes to observation of effects. Applying Actor-Network Theory, this article examines how the effects of intersectoral action are produced and can be attributed to its processes. A prospective multiple case study (2013-2016) was conducted on Neighbourhood Committees (NCs) in Montreal (Canada). Three NCs were studied using four kinds of data: direct observation notes of meetings and events, documents, logbooks and interviews. Systemic modelling of local intersectoral action was used for data collection and analysis. The results show that the transformations in living environments were produced by sequences of a limited number of 'transitory outcomes' that mark the progression of intersectoral action up to its effects. The list of transitory outcomes identified make up three functions in the production of change: (i) network setup and governance; (ii) self-representing and influencing others; (iii) aligning necessary actors and resources. The production of effects follows a systemic model wherein unique configurations of transitory outcomes, adapted to the different contexts where interactions are occurring, represent the change processes that lead to the effects.

Unpacking complexity in public health interventions with the Actor-Network Theory.

This article proposes a sociologically informed theoretical and methodological framework to address the complexity of public health interventions (PHI). It first proposes three arguments in favour of using the Actor-Network Theory (ANT) for the framework. ANT: (1) deals with systems made of human and non-human entities and proposes a relational view of action; (2) provides an understanding of the intervention-context interactions and (3) is a tool for opening the intervention's black box. Three principles derived from ANT addressing theoretical problems with conceptualisation of PHI as complex systems are proposed: (1) to focus on the process of connecting the network entities instead of their stabilised form; (2) both human and non-human entities composing networks have performative capacities and (3) network and intervention shape one another. Three methodological guidelines are further derived: (1) the researcher's task consists in documenting the events that transform the network and intervention; (2) events must be ordered chronologically to represent the intervention's evolution and (3) a broad range of data is needed to capture complex interventions' evolution. Using ANT as a guide, this paper helps reconcile technicist and social views of PHI and provides a mean to integrate process and effect studies of interventions.

Les pratiques de l'action intersectorielle locale pour l'équité en santé : étude du cas Quartier nourricier de la Corporation de développement communautaire Centre-Sud à Montréal.

INTRODUCTION: Afin d'agir sur les inégalités de santé et les ressources locales promotrices de santé, les praticiens et les décideurs doivent être outillés pour pratiquer l'action intersectorielle locale. Planifier et optimiser ces partenariats demeure pourtant un défi en raison du manque de connaissances sur les processus menant à l'atteinte de leurs objectifs - ce qu'ils font et comment. Cette étude documente empiriquement, à l'aide d'une étude de cas, les pratiques de conception de l'action intersectorielle locale dans la démarche Quartier nourricier (QN) à Montréal. MÉTHODES: Une analyse secondaire d'un sous-ensemble des données originales du programme de recherche Valeur de l'action intersectorielle locale a été effectuée. Les données qualitatives sont issues d'une collecte de données prospective ayant suivi l'évolution du système d'action complexe QN entre mars et novembre 2014. Les traces observables de l'action ont été relevées dans des notes d'observation, des documents et des entretiens téléphoniques, puis codifiées dans une matrice chronologique d'évènements critiques et une matrice ordonnée par rôle. L'analyse inductive des matrices a identifié les éléments significatifs pour expliquer le déroulement de l'action. RÉSULTATS: Trois opérations interdépendantes et concomitantes affectent à la fois la relation entre les partenaires et la conception du projet : (a) l'idéation sous contraintes, (b) la négociation de priorités, et (c) la représentation politique. Chaque opération présente un ensemble de pratiques qui font progresser l'action intersectorielle locale. CONCLUSION: Mettre en lumière les pratiques du terrain, en les ancrant dans trois opérations nécessaires pour effectuer des transformations dans les environnements locaux favorables à la santé, permet de guider la planification des stratégies et la conduite des actions pour mener des partenariats intersectoriels. MOTS CLÉS: Action communautaire, action intersectorielle locale, collaboration/partenariats, conception, développement des capacités (y compris les compétences), environnements favorables à la santé, étude de cas, promotion de la santé, réalisme critique, urbanisme/santé urbaine/milieu urbain.

[Diagnostic tool for action in partnerships: foundation, development and validation]. / L'Outil diagnostique de l'action en partenariat: fondements, élaboration et validation.

OBJECTIVES: Intervening on social determinants of health requires that public health stakeholders enter into intersectoral partnerships. The lack of valid tools to evaluate the quality of partnerships is a significant constraint to formulating convincing arguments for this kind of action. In light of this shortcoming, the tool described in this article evaluates processes of collective action based on key aspects of its effectiveness. METHOD: The tool is based on a theoretical model that followed from case studies identifying the conditions associated with quality of partnerships. The tool was developed by operationalizing these conditions into a series of statements, and pretested using the cognitive interviewing method. Construct validity and ecological validity were verified. RESULTS: The tool includes 18 items, with 3 answer choices provided for each item. It is sensitive to variations in judgement. It allows for good convergence among respondents from participating organizations within a partnership; it can also distinguish between partnerships that have difficulty meeting certain conditions and those that do not. The tool is suitable for self-evaluation of partnerships engaged in common projects that involve more than information exchange. DISCUSSION: The tool's validity resides in its validation procedure and in the basic soundness of its theoretical model, which is supported by a number of literature reviews on how partnerships function and their results.

Neighbourhood community life and health: A systematic review of reviews.

Neighbourhood community life has been widely recognized as an important determinant of population health. This systematic review of reviews provides an overview of the evidence for the ecological correlation between neighbourhood community life and population health. Nine databases were searched from 2008 to 2018 in order to identify systematic reviews of studies examining the association between neighbourhood community life and population health in urban neighbourhoods within the Organisation for Economic Co-operation and Development countries. Two reviewers completed selection and data extraction, then assessed the methodological quality of reviews using the Measurement Tool to Assess Systematic Reviews. We identified three high quality reviews and five of moderate quality. The reviews vary in quality of methodology, concepts, and measures. Most of the reviews examined the influence of social cohesion, social capital, and social interactions on health. Reviews found evidence supporting a consistently favourable correlation between social cohesion and physical activity, as well as a favourable trend in the relationship between social cohesion and healthy weight. They also found evidence of a favourable trend in the correlation between social capital and healthy weight. Reviews identified studies supporting a consistently favourable correlation between social interaction and depression. We identify evidence of a positive association between neighbourhood community life and several population health outcomes. Future research should define and conceptualize neighbourhood community life factors and health indicators to improve the comparison between studies and the process of evidence synthesis. This will also enable policy makers to take appropriate decisions.

[Is it possible to sustain health promotion programs in private companies? The case of four Quebec private companies of blue collar workers]. / La pérennisation des programmes de promotion de la santé en entreprise est-elle possible? Le cas de quatre entreprises privées québécoises de travailleurs cols bleus.

OBJECTIVE: Sustained health promotion programmes in the workplace (HPPW) continues to be a public health challenge. This article presents an evaluation of the implementation and sustainability of such programmes in private blue-collar companies in Quebec to shed light on issues specific to this type of setting. METHOD: A multiple case (4 sites), longitudinal (7 years) and interpretive study method was used. The interpretation framework considered that the implementation and sustainability of HPPW in companies are the result of organizational learning in health promotion, determined by the strategies of individuals in a position of control who shape the decisional processes related to these programmes. RESULTS: After seven years of observation, two of the four sites had continued their HPPW, although these programmes were no longer applied within these companies. The health promotion organizational learning processes in both sites were defined according to targeted organizational purposes set by the decision-makers who supported HPPW. However, these gains were largely lost when HPPW were no longer retained as a component of their organizational development strategy. DISCUSSION: The organizational conditions that are conducive to HPPW are difficult to put together and sustain in companies like those in our study. Businesses implement these programmes mainly for the organizational benefits they expect to reap in the short term, whereas improvement in the health of workers in the longer term is not a priority.

[The analysis of complex interventions in public health: the case of the prevention of sexually transmitted infections and blood-borne infections in Montreal]. / L'analyse des interventions complexes en santé publique : le cas de la prévention des ITSS à Montréal.

OBJECTIVES: Based on a theory of intervention as a complex action system, analyze collaboration among partners in Montréal's sexually transmitted and blood-borne infections (STBBI) prevention program to identify main operations problems and possible scenarios for change to achieve better outcomes. METHODS: A descriptive study was conducted using three data sources - public policies and programs, system management documents, and interviews with three types of partners. The results were validated with stakeholders. RESULTS: Five main operations problems affecting the capacity of the system to provide expected services were identified, as well as strategies the partners use to address these. CONCLUSION: Two scenarios for system change to increase its effectiveness in achieving program goals are discussed.

[School readiness and community mobilization: study retrospective in a Montreal area]. / Maturité scolaire et mobilisation communautaire: étude rétrospective dans un quartier Montréalais.

OBJECTIVES: This article presents a modelling of the collective decision-making process by which a community-based population-level intervention transformed the organization of early childhood services in a Montréal community from 2001 to 2006. PARTICIPANTS: Multisectoral players from a childhood/family issue table. LOCATION: The chosen territory is one of the most multi-ethnic and poorest neighbourhoods of Montréal. INTERVENTION: The intervention being examined is Understanding the Early Years (UEY), a Canada-wide initiative aiming to strengthen communities' capacity to use quality information to support the thought process relating to the organization of early childhood services. Twelve Canadian regions took part, including Montréal. RESULTS: The time chart for the collective decision-making process presents the events that significantly influenced the procedure: establishment of an intersectoral working committee, production of a portrait of the neighbourhood, think tank, development and implementation of the Passage maison-école [home-to-school] and Femmes-Relais [relay women] projects, retreats, and inclusion of school readiness as a priority focus area in the neighbourhood's three-year action plan. Also presented are the contextual factors that influenced decision making: the neighbourhood's cooperation and coordination history, the researcher's involvement, financial support and shared leadership. CONCLUSION: The benefits of UEY-Montréal in this territory extended beyond 2006. With respect to current priorities for action in early childhood, this territory is a good example of mobilization for school readiness.

Integrating social theory into public health practice.

The innovative practice that resulted from the Ottawa Charter challenges public health knowledge about programming and evaluation. Specifically, there is a need to formulate program theory that embraces social determinants of health and local actors' mobilization for social change. Likewise, it is imperative to develop a theory of evaluation that fosters reflexive understanding of public health programs engaged in social change. We believe advances in contemporary social theory that are founded on a critique of modernity and that articulate a coherent theory of practice should be considered when addressing these critical challenges.