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The Victorian Health Promotion Foundation: An overview

Publication Date: 19 September 1998

1. Introduction

The Victorian Health Promotion Foundation was established in 1987 as an independent statutory body funded by a dedicated levy of 5% on sales of tobacco products. This is a significant but small amount in comparison to the social and economic cost of smoking and less than 1% of the total Victorian Health budget.. In the 1992/93 year budget a ceiling of $25 million was established by the Victorian Government.. Now the ceiling stands at $22 million.

Funding allocation is divided up into 10% administration, 20% minimum for research, 30% for sports and arts, and 40% for Community, Health and schools settings. Surplus funds are used for consulting, development and evaluation.

2. Organisational Function of the Foundation

The goal of VicHealth is to promote health for all Victorians. The approach adopted by VicHealth to achieve this is through changes in organisational systems and practice to create healthy, supportive environments. Funding is one of a number of ways in which this is achieved. Other important functions of the Foundation include the following.

2.1. Internal and External Research and Development:

In order to have a sound conceptual base, there must be a high-level research and development capacity established so the Foundation can develop the strategic direction, funding policy and evaluation systems necessary to meet its goal.

VicHealth invests time organisationally on creating, reviewing and planning new strategies and programs to ensure the Foundation is continuously learning. A good example of this is the Partnerships With Healthy Industry Program which was born out of informal discussion on the merit of taking an organisational approach to the workplace setting. This program is now over five years old and is demonstrating that such an approach is an effective means of promoting health in workplaces .

Significant emphasis is also placed on continued research and development in health promotion to ensure that research findings help to set the scene for the future of health promotion activities.

2.2. Strategic Planning:

The most significant outcome of research and development is the establishment of a strategic plan. This is really an on-going process and there should be an internal capacity to undertake strategic planning and policy development at all times.

2.3. Intersectorial Project and Program Development:

The strategic plan highlights the current and future health promotion gaps from which programs can be developed. Developing inter-sectorial projects and programs helps identify population groups not currently being addressed and provides the opportunity for representative working parties to design and develop appropriate health promotion programs.

2.4. Funding:

VicHealth is not a bank, rather it provides funding for the implementation of health promotion programs and research for population groups in specific key settings.

2.5. Implementation

VicHealth sees it as important to take on an active role in the implementation process by providing guidance, training and, especially where sizeable dollars are involved, sitting on management committees.

3. Vichealth ‘Health Status’ Model

The health status model used by VicHealth attempts to change the focus of health promotion to the health status of population groups. In this model, priorities in terms of health promotion programs, key settings and the best combination of methods are selected and measured against the changing health status of the population group. It is hoped that one outcome of this model will mean that health promotion funders and implementers are held accountable for contributing to the health status of population groups, including those most disadvantaged by structural, physical, social and psychological factors. An emphasis on risk factors as a starting point a) does not necessarily show any impact on those with disabilities or are disadvantaged, and b) may not identify the underlying causal factors associated with risk behaviours. Epidemiological baselines therefore need to be developed to measure the health status of people as well as providing population-wide information of risk factor changes.

The health status model proposed by VicHealth, therefore uses four principles for planning health promotion programs and demonstrates that a comprehensive approach to health promotion engages in interventions along all four dimensions of the model.

3.1. Population Groups.

Population groups should be the starting point for health promotion for two reasons. First, by organising the population across the life-cycle into groups from birth to death we can ensure that a developmental view of people at different stages of their lives becomes incorporated into the design of health promotion programs.

The lifecycle approach to population groups encompasses the notion of building on each phase of life rather than passing from one phase to another. Common to all stages of life are significant issues of mental health and the impact on physical and mental health of the perception of well being.

Second, a population groups approach considers groups with special needs and their risks at different stages of life. For instance, Koories with general low-health status are particularly at risk. Similarly some ethnic communities such as newly-arrived migrants, refugees, or victims of torture are at risk while other ethnic communities have a better health status than Anglo-Australians in areas such as food and nutrition and sudden infant death syndrome. People with disabilities have particular health risks because of structural and social factors relating to the handicapping aspects of their disability. There is also the issue of primary prevention of disability which brings issues of genetic screening, accident prevention and further discussion of use of folic acid and other primary prevention initiatives. Unemployed people and people with lower socio-economic status have a general lower health status and are at particular risk. Disadvantaged men and men at mid-life are also a particular at-risk group requiring specific health promotion attention. Women are at particular risk for gender-specific health issues at different stages of the lifecycle.

Use of the population groups as the starting point to health promotion rather than a risk factor or a disease approach will ensure that the multiplicity of factors contributing to the health status of the population group are considered. For instance, to fully address the issue of alcohol misuse amongst women means that consideration must be given to the contributing factors of the status of women, employment status, self-esteem and self-concept and biomedical factors. In this case, concentrating only on a single risk factor or disease in the design of the intervention will assuredly result in continuing failure to comprehensively address the health status of that population group, as well as the failure to address the particular risk factor.

3.2. Health Indicators: Health Promotion Programs

Matching the population group with relevant health promotion programs and the appropriate methodological approach for achieving the goals and targets of the program is seen as the second dimension.
The development of knowledge about the health status of population groups will necessarily draw on knowledge about individual risk factors and diseases. Attempts to relate this information back to particular population groups will show up vast gaps in information, in that while population-wide information may be known and gender and lower socio-economic risk factor information will be sometimes be known for some risk factors, knowledge across the life cycle and about many groups at risk will be generally unknown. Self-perception of the population group itself about the significance of different risk factors to their lives will not be known.

Further, the impact of change in one risk factor on another by particular population groups will in general not be known.

3.3. Key Settings: An Organisational Approach To Health Promotion

Identifying key settings for the intersectoral implementation of interventions for organisational change is the third dimension in the VicHealth model.

The model demonstrates that an organisational approach to health promotion will emphasise changes in organisational systems that enhance the chance of individuals becoming healthy. This stands in contrast to the more common process of targeting individuals to change their behaviour either in isolation or in settings. Therefore the health of organisations of all kinds: families, workplaces, sporting clubs, arts bodies, general practice, or hospitals is a key to sustainable health promotion. For instance, in the area of workplace health the aim becomes one of achieving organisational health by ensuring that health becomes of significance to the corporate strategy which in turn impacts on financial, environmental and individual systems. While occupational health and safety and health promotion programs in the workplace are part of organisational health, the task is the development of healthy systems to ensure that health becomes part of the culture rather than a legislative requirement or a health promotion add-on.

The health status model is intrinsically multisectoral because it relies on key settings also external to health. The use of organisations outside the health sector provides a positive bridge for health promotion across a variety of disciplines and encourages a much wider involvement in health promotion than has previously been the case. The ability to implement health promotion programs in various key settings enables precision in reaching the population and allows for modification of programs suitable to the perceived needs and demands of the groups.

3.4. Creating a Match

Matching the population group with relevant health promotion programs for funding and identifying the appropriate methodological approach for achieving the goals and targets of the program is a major challenge for the Foundation. VicHealth does this through a combination of research, social marketing, promoting structural change, evaluating the impact and outcome of programs and then communicating the results.

3.4.1. Research

Research which uses a range of disciplines, including clinical social, psychological and legal research informs health promotion practice, by providing a broad picture of health status. The increasing use of cost-benefit analyses and health economics enables judgements to be made on the most economic use of resources and ensures assessment techniques in the implementation of programs.

The identification of areas where epidemiological baselines need to be developed is important for the design and implementation of effective health promotion programs. The rapid growth of the health promotion field has meant that the research base is not as extensive as it might be. For instance, in Victoria, there are now new initiatives to develop baseline health-status measures in areas of child and maternal health, adolescent, mid-life women and older people. All of these baseline developments include social, psychological and risk factors in the baseline; in relationship. Risk factor and disease baseline data itself is still patchy, with gaps in areas such as muscular-skeletal disease and risk factors. There is also a need for a greater understanding and analysis of the health promotion processes as they contribute to outcomes.

3.4.2. Raising Awareness of Health Issues

Sponsorships developed with sports and arts organisations can promote health through the development and application of appropriate health messages to link with sports and arts. Health priorities for health and research programs can be reflected in sponsorships, target markets and in the health messages formulated to reflect these.

Sponsorships also provide opportunities for structural change, such as smoke-free venues, low or no alcohol events, and healthy food choices at sponsored events. Sponsorships can achieve the development of sun protection through building design and tree planting. Sponsorships can lead to a greater level of participation in sports and arts by people who would benefit from increased opportunities for exercise and participation, to raise their health status. In the sports area, women, particularly young women, and people with disabilities, have very low participation rates resulting in higher levels of illness in areas where lack of exercise is a risk factor for post menopausal heart disease and osteoporosis in women.

Sports and arts sponsorships can reach groups who would be impossible to reach in any other way, and would certainly not be reached if health promotion were concentrated within the parameters of public health, within the health sector. For instance, ethnic communities can be reached through ethno-specific arts events and through specific sports events. Isolated rural groups with low health status can be reached through specific rural sporting organisations and arts sponsorships.

The process of creating broad social support enables health issues to be placed in areas on local, public or special interest community agendas. This is the first stage in affecting any long - term positive health change within the community. Awareness raising through sponsorship is an important step as a precursor to organisational change in that it can create an environment which welcomes the change.

3.4.3. Structural change: Empowering, Advocacy and Organisational Change

The health status model is premised on structural change and community, stateside and national action relies on the building of bases to support structural changes. These structural changes in turn support health processes which develop supportive environments supportive of healthy behaviour, as well as sustaining the initial changes.

Community level and self help activity can lead to local communities and self help groups acquiring skills and training for further broad-based change. Communities can gain competence in measurement of need, establishing priorities and implementing health promotion programs.

Legislative change, fiscal policy development and regulatory development, all contribute to individual and organisational health.

3.4.4. Assessing the outcome of health promotion programs

The success of health promotion initiatives is measured through rigorous and comprehensive evaluation. This measures health outcomes against intended effects. The results of such evaluations should inform the design and implementation of future health promotion initiatives to ensure their sustainability and guarantee their ability to be replicated elsewhere.

The assessment of the impact on the aggregation of project and program evaluation on health status of population groups is, the final objective. However, a problem for health promotion evaluation, as opposed to health service evaluation, is the longer time periods over which effects occur. This means that months or years may elapse before the outcomes of a program are fully realised.

3.4.5. Communication of Results

The communication of outcomes from health promotion projects is integral to the development of the health promotion movement both in Victoria and nationally.

The ability to inform the development of similar projects and to use current information to upgrade or refine initiatives, ensures that the lessons learned in undertaking health promotion programs have immediate and practical application.

3.5. Evaluation

Evaluation is essential throughout the health promotion program in order to make adjustments as required, communicate failures and successes to the wider community and for replicability where appropriate. The challenge for VicHealth is to determine the parameters of evaluation and the relevant baselines. For example, when evaluating the effectiveness of a sports program it may be important to assess the non-participation of specific population groups and identification of the barriers and enablers to participation and the adoption of health-enhancing behaviours.

There is still much to be done in the area of evaluation to ensure not only the project objectives are being met but the project highlights future strategies to adequately address equity issues and sustainablity.

4. Conclusion

The development of strategic plans for health promotion needs to result in changed health status for people. Single risk factor changes can mask or not take into account other health risks or their underlying cause for people at different stages of their life or at risk population groups. The development of health promotion programs based on plans that measure health status of population groups would ensure that programs are judged on the capacity to change the health status of people. While the change in risk factor baselines and disease prevalence is continually significant, the impact of such change on particular population groups is of more significance if health status is of concern. A number of risk factors interrelate with underlying causes and these causes need to be considered rather than diseases. This change in emphasis will lead to decision making about the best combination of methods as these methods will impact on the health status of the population group. A settings approach to health promotion shifts the emphasis away from expectations of changing the behaviour of individuals in isolation or as a captive audience to an emphasis on organisational change to enable behaviour change.

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