Improving the capacity of local health promotion systems in addressing the social determinants of health: a realistic evaluation of a program in the making in Brittany (France)
Abstract
Background
Tackling health inequalities calls for comprehensive programmes intervening in the complex system of a community. Evaluation needs to incorporate multiple perspectives from different sources (individual, sub-group, organisation levels) and account for the culture, and relationships within the local system. However, little is known of the means by which contextual factors and the perspective of the participants play an active role in shaping the intervention. Sound theoretical understanding could potentially illuminates the mechanisms operating in the black box of the intervention.
Objective: To explore how a complex health promotion intervention, aiming to better integrate social and structural factors in decision- and policy-making, was designed and piloted.
Methods
A health promotion programme known as “Ensemble, la santé pour tous en Pays de Redon” (Together, health for all in Redon, Brittany, France) was analysed. The programme begun in 2011 in a sanitary deprived area of Brittany (Pop. 95 000) and targets a group of local stakeholders in order to facilitate the development of a strategy to reduce health inequalities. Pawson & Tilley’s realistic evaluation approach was applied with a focus on the steering committee. Data from documents, participant observation, field notes, and semi-structured interviews were collected since the launch of the programme.
Findings
The steering committee uses public consultation and group discussions to foster actions on the social and structural determinants of health in the territory: housing, employment, income, education, etc. The mechanism of acculturation of the local stakeholders to health promotion was designed to inhibit mechanisms that generate health inequalities. Concurrently the empowerment of the local health promotion system was sought and is credited for the development of a local policy health plan (‘Contrat Local de Santé’) featuring health promotion principles.
Conclusion
It is known that the involvement and mobilization of key actors are necessary to the development and effective implementation of health promotion programmes. Evaluative research highlights how to conduct community interventions and why great care is to be given to the context, in the tailoring of health promotion programmes.
Key messages
Interventions constructed with the communities and key stakeholders contribute in the sustainability, transferability and acceptability of innovative health programs.
This study highlights piloting strategies of complex interventions in health promotion, where public consultation is an active ingredient, contributing to its effectiveness.