Reorientation of health services: enablers and barriers faced by organisations when increasing health promotion capacity

Health promotion plays an important role in maintaining and improving the overall health of the population. Health promotion is defined as ‘the process of enabling people to increase control over their health and its determinants, and thereby improve their health’¹. Approaches that are multi-strategic and guided by the Ottawa Charter for Health Promotion¹ have been effective in improving healthy lifestyle behaviours and in reducing the risk of developing non-communicable diseases.² By specifically improving diet, physical activity levels and eliminating tobacco smoking it is estimated at least 80 per cent of all heart disease, stroke and type 2 diabetes and over 40 per cent of cancer would be prevented.²

An individual’s health is determined not only by their behaviours but also by their circumstances and environment.³ Health promotion approaches focus on strengthening the skills and capabilities of individuals, groups and the broader population as well as influencing the social, environmental and economic determinants of health.¹ To address the environmental, social and economic determinants, health promotion approaches are implemented across several organisational settings both within and outside of the health sector. Health services are recognised by the World Health Organization as a key setting for health promotion and include hospitals, primary health care, community health and public health organisations.⁴

Primary healthcare organisations are important providers of health promotion approaches. They are the first point of contact for individuals, families and the community with the healthcare system.⁵ Four out of five Australians will see a primary healthcare professional at least once a year.⁶ The links between health promotion and primary health care were defined in the Declaration of Alma-Ata.⁷ Primary health care is a key setting for the promotion of healthy behaviours, identification of risk factors for ill health and the treatment of illness.⁸

In Australia, the health status and life expectancy of Aboriginal and Torres Strait Islander peoples is much lower than that of the general population.⁹ The higher mortality rates for preventable chronic diseases is well documented.¹⁰ In response to this health inequity, Aboriginal community controlled health services (ACCHS) emerged in the early 1970s to improve access and provide culturally appropriate health care.¹¹ ACCHS are primary healthcare organisations that provide holistic, comprehensive and culturally appropriate health care, planned and managed by boards elected from the local Aboriginal community.¹¹ The philosophy of community control is consistent with health promotion theory, which states that the health status of Aboriginal people can only be improved by local Aboriginal people controlling healthcare delivery in their community.¹¹

Both mainstream primary healthcare services and ACCHS face many known challenges in the delivery of health promotion. Short-term funding cycles, lack of commitment to long-term evaluations, inconsistencies in practices, and the contested meanings of health promotion by decision makers continue to hinder the effective implementation of health promotion approaches.^2,12 Additionally, managing both treatment and health promotion roles can be challenging for primary healthcare providers. The broader health promotion role may be neglected if an individualistic approach that focuses solely on the immediate treatment needs of the client is taken. This individualistic approach to health care and emphasis on health education alone may influence decision makers within the health service to prioritise short-term targets of health care at the expense of long-term targets that support improved health outcomes.¹²

With the emergence of health-promoting healthcare settings in the 1990s, health promotion practitioners have focused on building health promotion capacity through infrastructure that includes staff, skills, resources and workplace structures to address health problems more effectively.¹³ Others have focused on building capacity to sustain the effects of health promotion programs and build problem-solving capacity through partnerships at an individual, community and organisation level to better address health problems.^14,15 Work done by Hawe and colleagues,¹⁶ NSW Health Department,¹⁷ and later supported by Judd and Keleher,¹⁸ identified specific organisational structures and processes that can strengthen health promotion capacity within an organisation. Organisations need workforce capability, organisational support through resource allocation and collaborative approaches, and structures to utilise opportunities and skill sets to deliver effective health promotion approaches.¹⁶ Systems thinking linked with change processes have been used at organisational levels to identify system supports and influencing mechanisms such as policies, inter-relationships, resources and organisational values.¹⁹ The health promotion capacity building framework identifies five key components required to build capacity: organisational development, workforce development, resource allocation, leadership and partnerships.¹⁷ The framework acknowledges the interdependency between the components and has guided health promotion capacity building work, particularly in Australia, since the early 2000s.²⁰

The health promotion capacity building framework¹⁷ identified areas that can be strengthened to embed health promotion within an organisation. However, when reorientating health services it is important to understand the challenges of implementing change into practice. This review aimed to identify the common enablers and barriers these organisations face and to explore the experiences health organisations, in particular Aboriginal and Torres Strait Islander organisations, had when increasing their health promotion capacity.

A systematic search of peer-reviewed articles was conducted using electronic databases including APAIS, APAFT, CINAHL, Current Contents Connect, Medline, ProQuest Central, PsycARTICLES, PsycINFO, Scopus, Social Sciences Citation Index, the Cochrane library, Google Scholar and the Australian Indigenous HealthInfonet. Further articles were sourced from hand searching of reference lists from articles identified through the database search.

Search terms (MeSH and text words) were defined by the outcome of interest ‘health promotion’; the change effect which included terms such as ‘capacity building’, ‘organisational innovation’, ‘organisational change’ and ‘organisational development’; and the health organisational setting using terms such as ‘primary health care’, ‘public health administration’ and ‘community health services’. Given the particular interest in exploring health promotion in Indigenous healthcare settings, ‘Indigenous’ and ‘Aboriginal and Torres Strait Islander’ search terms were also used. However, no relevant articles were found. The Australian Indigenous HealthInfonet database was then searched and one relevant article was found.

Only articles published in English between 1990 and March 2014 were included. The rationale for the start year was that health promoting health settings were first discussed in the early 1990s. The dates of publication for articles in the full text review ranged from 1992 to 2014. To ensure articles described enablers and/or barriers for building organisational health promotion capacity within a health organisation were found, articles were only included if they focused on a health care–settings approach and discussed the factors that facilitated or hindered an organisation’s ability to increase their health promotion capacity. Both qualitative and quantitative studies were included to obtain a broader understanding of this area.

Articles were excluded if: (i) health promotion capacity was aimed at collectively increasing a coalition’s or group of partner organisations ability to undertake a combined health promotion approach; or (ii) the content was general in nature and an organisation’s experiences were not used as examples of how health promotion capacity was affected.

Titles and abstracts were independently reviewed for topic relevance. Four hundred and sixty-five articles were found. After the removal of duplicates (n = 340) a total of 125 articles were then reviewed for relevance. Following a full-text review, 100 articles were excluded, leaving 25 relevant articles to be included in the review. Figure 1 summarises the article selection process.

Fig. 1.  Search strategy.

Twenty-five articles met the inclusion criteria. These articles described health promotion capacity building initiatives in Australia, Canada, United States of America, Africa, China, United Kingdom, Sweden and the Solomon Islands, with the majority of papers from Australia (n = 8) and Canada (n = 8). The organisational settings included primary health care, community health, hospitals and public health organisations. Table 1 summarises the studies discussed in this review.

Table 1.  Summary of relevant literature
BI, brief intervention; CCI, community capacity index; CI, confidence interval; n, number in sample; NHS, National Health Service; OR, odds ratio; PAR, participatory action research; QI, quality improvement; SNAP, smoking, nutrition, alcohol and physical activity; US, United States; WHO, World Health Organization

There were three main ways the articles identified the enablers and barriers to increasing health promotion capacity. First, health organisations implemented specific capacity building interventions, such as workforce training and leadership development, and assessed the enablers and barriers when implementing these interventions. Second, health organisations implemented a new program in their organisation and included in their evaluation the impact of organisational enablers or barriers. Lastly, articles reported on what the health promotion workforce perceived were the enablers and barriers to health promotion practice. Across all studies common themes were identified.

To increase organisational health promotion capacity, management support,^18,20–33 a skilled and knowledgeable workforce,^34–38 external specialist assistance,^{18,24,32,34,35} resource allocation,^20,22,27,31 leadership^{26,27,29,31,33,39,40} and access to external partners to work on health promotion approaches^21,25–27 were the most commonly reported enablers. Management support was reported in two ways: first, the line manager’s influence on work practice; and second, the influence of the organisation’s ethos and practice. Key features of these enablers are outlined in Table 2.

Table 2.  Summary of enablers for increasing health promotion capacity within healthcare organisations

The most common reported barriers for an organisation aiming to increase health promotion capacity were: lack of management support;^20,26,37,38 lack of dedicated health promotion staff;^25,26,30,41 staff who lacked skills or confidence in health promotion;^25,30,39,42 competing priorities;^{25,28,29,37–39,41,43} and a lack of time and resources allocated to health promotion activities.^29,30,37,41 A summary of these barriers is presented in Table 3.

Table 3.  Summary of barriers found when increasing health promotion capacity within healthcare organisations

This literature review has demonstrated that, very few studies have comprehensively reviewed building health promotion capacity within a health organisation. Most of the included studies focused on specific areas such as training for the workforce, leadership development or delivery by staff of a new health promotion program. The majority of the articles (n = 15) referenced the work of Hawe and colleagues¹⁶ and/or the NSW Health Department capacity building framework for health promotion to guide their interventions. Interestingly, all enablers and barriers identified in the 25 articles reflected at least one of the five areas of this framework (organisational development, workforce development, resource allocation, leadership and partnerships).

There was consistency in the literature regarding the importance of health promotion work in improving overall health outcomes and the challenges faced by health organisations to achieve this. Many authors acknowledged the challenges of the political environment, through changing priorities, access to resources and long-term funding.^{18,22–24,26,32,35,38,41}

Only one study related to an Indigenous health service.⁴² This study examined the organisation’s capacity to conduct brief interventions with clients. The enablers and barriers identified were consistent with other studies in this review.^{25,28,30,38,39,41,43} Brief intervention by itself is a single strategy health promotion approach. The narrow focus of evaluating a single strategy, and that only one study was found, highlights the limited knowledge in this area. Further and more comprehensive research is required to understand the enablers and barriers to increasing health promotion capacity in Indigenous health organisations.

Methodological limitations were present in all of the studies identified in this review. Many studies included a small sample size (less than 25 participants), and selection bias was present in most studies. This is particularly relevant for quantitative studies. Selection bias is expected in qualitative research designs due to purposive sampling, which was required here to ensure those involved in health promotion approaches were included in sharing their experiences. With these limitations the findings may only be generalisable to the relevant organisational context. However, the enablers and barriers identified were common across the studies and despite these limitations there are several key findings that can be explored further: management support, leadership, external specialist assistance, skilled staff, partnership work, resource allocation, and the challenge of competing work priorities in health organisations.

Management support was the most commonly reported enabler and barrier. Management support was often referred to as the line manager’s role. Managers are leaders for the direction of the work team and translate strategic direction and policies into activity. However, their influence is limited by organisational constraints such as political agendas, funding and reporting requirements. Organisational policies supportive of health promotion practice can limit the influence of these constraints.

Only a few studies identified managers’ perspectives on the enablers and barriers to health promotion capacity.^26,30,33 The majority of studies reported the enablers and barriers from a practitioner’s point of view.^{18,21–25,33,37,38} As managers were identified as gatekeepers to many of the enablers and barriers to health promotion practice within an organisation, further exploration of the supports required to assist the management role would be useful.

Managers were identified as crucial for providing leadership within the organisation about health promotion practice. The ability to assess readiness for change and to motivate and support new ways of working was identified as an important leadership skill.^26,29,33 Additionally, staff who model good health promotion practice can lead a change in practice throughout the organisation,³³ demonstrating that the influence of leadership in this process is not solely the responsibility of managers.

There were several interventions where external specialist assistance was provided and valued by the participants when evaluated.^{18,24,32–35} Access to expertise outside the organisation during and after the change process was important. One-off, short-term assistance such as training would not embed the skills and systems learned without support to translate this into practice.

A skilled workforce is essential for effective health promotion practice.²¹ This was identified in studies that addressed the need to improve knowledge and skills through training^{24,26,27,31,33,34,37,38} and by practitioners who identified that health promotion knowledge and skills were required to effectively deliver health promotion approaches.^{25,29,36,39,40,42} While this finding is not necessarily surprising, the frequency with which it was mentioned in the studies highlights its importance.

Partnerships can achieve greater health outcomes than an individual organisation can do on its own. Working in partnership combines resources and expertise to address a health issue of concern. A practitioner’s skills in partnering with external stakeholders, and the organisation’s ability to work in partnership, increases the organisation’s own health promotion capacity.^21,25–27 For partnership to occur there needs to be openness and commitment from the organisation to allow staff to build robust relationships.

The strength of an organisation’s commitment to health promotion can be measured through its allocation of resources. This includes dedicated staff to work on health promotion programs^{20,22,25,26,30,31,41} and financial support for resources needed to develop, deliver and evaluate health promotion programs. In an environment where additional funds for prevention work are not available, understanding how best to utilise existing resources is essential.

Influencing quality improvement processes to support health promotion practice can increase an organisation’s health promotion capacity.^24,29,32,33 The process of adhering to and reflecting on practice through quality improvement reviews can be a driver for improving practice where incremental standards for health promotion practice have been articulated. Continuous quality improvement processes have been used effectively to sustain improvements in Aboriginal and Torres Strait Islander primary health care settings.^44,45 Combining this with a focus to assess health promotion practice has been shown to build an organisation’s confidence in identifying health promotion improvement strategies and actions.⁴⁶ Further work is underway to assess how this confidence will impact on organisational health promotion capacity.⁴⁶

Many health organisations provide both treatment and health promotion services. If other priorities are deemed more important, a health promotion and prevention focus can be lost.^{28,29,37–39,41,43} This could be due to lack of dedicated resources for health promotion approaches, lack of management support, or health promotion not being identified as a priority in the organisation’s strategic focus. In primary healthcare organisations that are clearly involved in both treatment and health promotion work, it would be useful to explore further how this challenge is addressed in a resource-poor environment.

Reorientating health services to increase health promotion capacity requires systematic change within the organisation. The enablers and barriers identified critical parts of the system to target change processes; however, the interdependency between these enablers and barriers was not identified in this literature review. Taking a systems approach to better understand the interdependent relationships between management support, leadership, external specialist assistance, skilled staff, partnership work, resource allocation and competing work priorities may help to better understand how organisational capacity for health promotion can be increased within health service organisations. This is particularly important within Aboriginal and Torres Strait Islander communities where problems are complex and there is strong interconnectedness between the health service and the community.

The literature review identified consistent themes in the enablers and barriers for organisations to increase their health promotion capacity. For health services to deliver both treatment and health promotion functions to the communities they service, organisational systems need to support managers and practitioners, ensuring there is a skilled health promotion workforce with opportunities to work in partnership. The challenge of competing work priorities will remain. However health promotion needs to be recognised as a priority and embedded into organisational roles and responsibilities. A supportive policy environment that identifies health promotion as a core part of business will reinforce this within the organisation.

With limited information on how health promotion capacity has been increased in Aboriginal health organisations, the relevance of these findings for ACCHS is not clear. Further research into how ACCHS deliver health promotion, and the identification of enablers that assist practice in that setting, will address this knowledge gap.