Theory-informed health promotion: seeing the bigger picture by looking at the details

Contemporary health promotion is based on evidence and well grounded in relevant theory. This view, which has always been embraced and promoted by this journal, has become widely accepted by academic training institutions and decision makers, and increasingly also by practitioners. At the same time, however, health promotion continues to struggle with its evidence base and its theoretical foundations—perhaps even more so nowadays than at the time when the Ottawa Charter laid the foundations for the field.

Health promotion's ambivalent relationship with evidence is understandable, considering the continuing ambiguity as to what can be considered ‘evidence’. Much of the effort to strengthen the evidence base of health promotion has been inspired by the evidence-based medicine (EBM) movement, where ‘evidence’ typically stands for empirical data supporting either the scale or cause of a health problem or the causal relations between interventions and outcomes, and the randomized controlled trial is used as the ‘golden’—but often unachievable—quality standard for evidence. Policy makers, health managers and researchers have attempted to apply EBM to health promotion, but those attempts were doomed to fail. Since health promotion involves complex, integrated processes across different sectors within the community, the concepts and methods of EBM cannot be simply transferred to health promotion. Yet although it is increasingly accepted that health promotion needs other types of evidence (Learmonth and Mackie, 2000; McQueen and Anderson, 2001) and although concepts of scientific evidence suitable for health promotion have been proposed (Rychetnik and Wise, 2004; Aro et al., 2005; Armstrong et al., 2007), the EBM movement continues to dominate much of the discourse on health promotion effectiveness. The perverse consequence of this is that the inability of health promotion to provide evidence of effectiveness using the established methodology of EBM may well have weakened its position within health policy, as policy-makers tend to take the incorrect but often-held view, that a lack of evidence of effectiveness equals evidence of no effect (Speller et al., 2005). As long as the debate on what counts as good evidence continues, health promotion's relationship with evidence is bound to remain an uncomfortable one.

From evidence-based to theory-informed health promotion

If evidence-based health promotion is a worthy goal to strive for yet difficult to achieve in the short term, theory could offer a valuable alternative. After all, theories are essentially coherent sets of propositions that present a systematic view of phenomena by specifying relations among variables (Kerlinger, 1986). These relations have been tested in a number of concrete situations, which gives the theory its capacity to explain and predict phenomena. It seems only logical to draw upon this ‘condensed knowledge’ to guide decision-making in health promotion where sufficient evidence is not available. In fact, as pointed out by Green (Green, 2000), theory is also useful if evidence is available. The accumulated empirical evidence about effectiveness may indeed be of limited use for practitioners when it is not accompanied by theoretical principles to inform their wider application. Without these guiding principles, health promoters risk ‘being submerged in a postmodern morass of empirical evidence which on its own can do little to guide practice’ (p. 125).

Admittedly, health promotion practitioners and researchers sometimes seem to prefer drowning in a morass of fragmented and often contradictory evidence to embracing theory as a way out. Theory is often cast aside as being too abstract and too far removed from the real practice of health promotion. Yet it is possible to use a broader conceptualization of theory which does not offer universal explanations or predictions, but rather enhances the understanding of complex situations—much in the way Lewin (1951) intended by saying that there is ‘nothing more practical than a good theory’. If conceptualized in this way, theory-informed health promotion is not just a proxy for evidence-based health promotion, but also an equally important pillar of a movement towards achieving more effectiveness.

The value of theory to enhance effectiveness is nicely illustrated by the notion of theory-based evaluation (TBE), as defined by Birckmayer and Weiss (2000). TBE is essentially concerned with ‘opening the black box’ of evaluation and explaining how and why programs achieve, or fail to achieve, results. It requires the surfacing of the assumptions on which programs are based in considerable detail, linking what the program does (activities), the expected effects and what happens next to the expected or intended outcomes. The main benefit of this approach is that the evaluation will show which chains of assumption, as based on the theory, are supported by the data, and which assumptions break down. It also advances the development of knowledge, in the sense that better knowledge of the mechanisms of change will not only benefit the specific program, but may be generalized to other interventions.

However, despite its uncontestable value, the theoretical basis for health promotion receives remarkably little attention. This not only holds true for the effectiveness debate, where theory is seldom considered a key issue and, for instance, only marginally addressed in systematic reviews (Green, 2000), but also in the wider health promotion literature. As a case in point, of all the articles published in this journal in its 27 years of existence, only 27 explicitly mention a theory in their title, and 103 in the abstract. Similar results are seen for other journals in the field. The conclusion that health promotion research is still predominantly an a-theoretical enterprise thus seems not too far-fetched.

As for the place of theory as a basis for practice, the situation may even be worse. An Australian study revealed that even the ‘standard’ theories and models taught in health education courses and included in the leading textbooks are used by no more than 50% of practitioners (Jones and Donovan, 2004). Moreover, when theories are used and reported, in two-thirds of the cases they are concerned with a limited number of, predominantly, behavioural theories, notably the Health Belief Model, Social Change Theory, Self-Efficacy theory, the Theory of Reasoned Action and Theory of Planned Behaviour, community organization, Stages of Change theory, social marketing and social support/social network theory (Glanz et al., 2008). While health promotion covers a much broader terrain than behavioural science, other types of theories are even less often used. Breton and De Leeuw (2011), for example, looked at the application of policy theory in health promotion research, and found that out of the 119 articles they reviewed only 39 applied a theoretical framework, of which 21 referred to a theoretical framework from political science.

Finally, apart from the question as to which theories are being used, one should also raise questions about how these theories are used. An often-heard criticism is that researchers do not measure or analyse theoretical constructs correctly, or that they pick and choose variables from different theories in a way that makes it difficult to ascertain the role of theory in intervention development and evaluation (Glanz et al., 2008). So, the way health promotion researchers and practitioners use theory, test theory and apply theories in interventions leaves much room for improvement.

Mapping out theories in health promotion

The less-than-optimal theoretical grounding of health promotion research and practice is all the more surprising when considering the panoply of theories and models from diverse disciplines that health promotion can draw from. As stated before, health promotion covers a very broad terrain, which ranges from individual health behaviour theories and communication theory to change theories at individual, organizational and community level, community development theories and policy theory. Or could it be that this ‘affluence’ of theories is more the cause of the problem than the solution? Being confronted with the burden of choosing from such an array of theories, without any guidance on how and when to use them, may be just as discouraging as having to deal with too much unorganized empirical evidence. What is needed then is a map that helps health promotion researchers and practitioners ‘see the bigger picture’ and offers an orientation to select and use theory appropriately.

Such a map can come in two formats. The first one provides a birds’ eye perspective in the form of an overarching theoretical paradigm that encompasses the principal values of health promotion and its foundations for practice. The second one is a detailed roadmap, offering a compendium of relevant theories with indications on when and how to use them appropriately.

Both formats have already been developed and made available. An example of the first kind is Antonovsky's salutogenesis paradigm which, starting from the idea that focusing on peoples’ resources and capacities is more effective to create health than the classic focus on risks, ill health, and disease, developed the key elements of orientation towards problem solving and the capacity to use the available resources. Over the years, salutogenesis has become an established concept in health promotion, and both Antonovsky (1996) himself and others (e.g. Lindström and Eriksson, 2005) have argued that this concept could create a solid theoretical framework for health promotion. From a different perspective, McQueen et al. (2007) contend that the challenges of promoting health cannot be adequately addressed without considering the major societal shifts that have occurred in the latter half of the 20th century, and propose that the theoretical foundation for contemporary health promotion research and practice is to be found in a revised social theory which incorporates the concept of modernity. Their framework highlights seven key characteristics of modern health promotion that relate to this changing social context: the interplay of actor and structure, the dynamics of complexity and causality, the interface of inclusion and exclusion, the role of uncertainty and risk, the importance of learning and communication in a knowledge society, the task of framing interventions within new governance principles and the challenge of acting locally in a global world.

As for the ‘roadmap’ type of guidance, a number of compendia of relevant theories for health promotion have been published over the years. Each one follows its own principle to map out relevant theory. For instance, the monograph Theory in a Nutshell (Nutbeam et al., 2010) distinguishes between theories on the individual, community and organization level, explaining their significance, practical application and impact. Theory at a Glance (Glanz and Rimer, 2005), on the other hand, distinguishes more explicitly between explanatory and change theory. The Intervention Mapping approach (Bartholomew et al., 2001) explicitly aims to guide the user to relevant theoretical concepts, depending on the different stages of health promotion program design. But whatever their mapping principle, all of these guides aim to facilitate the selection of relevant existing theories and support their use to underpin programme development and implementation, with a view to enhance effectiveness.

Documenting the use of theory in research and practice

Which of the two perspectives—the bird's eye or the roadmap—is most conducive to strengthening the effectiveness of health promotion practice is an irrelevant question. In principle, both are essential and work in complementary ways to guide research and practice, much in the same way as a GPS uses both satellite images and detailed instructions to guide a driver to his destination. Broad theories of health promotion can help identify the challenges of promoting health and to point out the general direction in which the field should progress, whereas more detailed roadmaps can be used to guide the planning, implementation and evaluation of specific programs, making use of the best available ‘condensed’ knowledge. They provide the details that will help create the bigger picture.

However, while theories extract their explanatory and predictive power from the fact that they generalize across specific situation and contexts, which makes them very useful to guide decision-making, their application to a specific program or research question always requires the reverse process of contextualizing. While good practice is grounded in theory, good theory should be informed by practice (Glanz et al., 2008). Programs that make explicit use of theory to ground the decisions taken can inform the modification or refinement of theories. These decisions should not only be concerned with the individual, organizational, community level or social determinants of health as identified in explanatory theories, but also with the conditions and processes under which they impact on health. More and better use of change theories, and notably also of implementation theories, could shed light on these processes. But using theory is not enough: for the advancement of practice, and of theory itself, it is essential that this process is also well documented. Only published evidence about the use of theory to guide practice will strengthen the knowledge base for health promotion and, over time, result in the convergence of theory, research and practice.

Several papers in this issue of Health Promotion International provide good examples of the way this development can take shape, by explicating the theoretical foundations or models underpinning the actions they describe. Two papers take the ‘birds’ eye’ perspective, and use broader theoretical paradigms to guide their study: Togari et al. (2012) look at the association between children's and mothers, sense of coherence (SOC), thus contributing to the corroboration of Antonovsky's conceptual paradigm, while Inauen, Jenny and Bauer (2012) draw on the general perspectives of workplace health promotion to perform an organizational analysis in the workplace. Two other papers are more concerned with the application of theory in the implementation of a program. Carlfjord et al. (2012) apply the RE-AIM framework to evaluate outcome in terms of reach, effectiveness, adoption and implementation of a lifestyle program in primary care, and Baker et al. (2012) use a theoretical framework for assessing applicability and transferability of evidence to inform decision making within a public health case study of aboriginal Torres Strait islanders. I hope these examples will encourage others to follow suit, and to find many more papers of theory-informed research in future issues of the journal.

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