PubMed1997
Health promotion and health education have often been limited to evaluation of the effectiveness of actions and programmes. However, since 1996 with the Third European Conference on Health Promotion and Education Effectiveness, many researchers have become interested in "quality assessment" and new ways of thinking have emerged. Quality assurance is a concept and activity developed in industry with the objective of increasing production efficiency. There are two distinct approaches: External Standard Inspection (ESI) and Continuous Quality Improvement (CQI). ESI involves establishing criteria of quality, evaluating them and improving whatever needs improvement. CQI views the activity or service as a process and includes the quality assessment as part of the process. This article attempts to answer the questions of whether these methods are sufficient and suitable for operationalising the concepts of evaluation, effectiveness and quality in health promotion and education, whether it is necessary to complement them with other methods, and whether the ESI approach is appropriate. The first section of the article explains that health promotion is based on various paradigms from epidemiology to psychology and anthropology. Many authors warn against the exclusive use of public health disciplines for understanding, implementing and evaluating health promotion. The author argues that in practice, health promotion: -integrates preventive actions with those aiming to maintain and improve health, a characteristic which widens the actions of health promotion from those of classic public health which include essentially an epidemiological or "risk" focus; -aims to replace vertical approaches to prevention with a global approach based on educational sciences; -involves a community approach which includes the individual in a "central position of power" as much in the definition of needs as in the evaluation of services; -includes the participation and socio-political actions which necessitate the use of varied and specific instruments for action and evaluation. With the choice of health promotion ideology, there exist corresponding theories, concepts of quality, and therefore methods and techniques that differ from those used until now. The educational sciences have led to a widening of the definition of process to include both "throughput and input", which has meant that the methods of needs analysis, objective and priority setting and project development in health promotion have become objects of quality assessment. Also, the modes of action and interaction among actors are included, which has led to evaluation of ethical and ideological aspects of projects. The second section of the article discusses quality assessment versus evaluation of effectiveness. Different paradigms of evaluation such as the public health approach based on the measurement of (epidemiological) effectiveness, social marketing and communication, and the anthropological approach are briefly discussed, pointing out that there are many approaches which can both complement and contradict one another. The author explains the difference between impact (the intermediate effects, direct or indirect, planned or not planned, changes in practical or theoretical knowledge, perceptions, and attitudes) and results (final effects of mid to long term changes such as changes in morbidity, mortality, or access to services or cost of health care). He argues that by being too concerned with results of programmes, we have often ignored the issue of impact. Also, by limiting ourselves to evaluating effectiveness (i.e. that the expected effects were obtained), we ignore other possible unexpected, unplanned and positive and negative secondary effects. There are therefore many reasons to: -evaluate all possible effects rather than only those lined to objectives; -evaluate the entire process rather than only the resources, procedures and costs; -evaluate the impact rather than results; -evalu