Health Promotion Effectiveness:

Methodologicallssues and Challenges in the

African Region
David Houeto and Liliane Luwaga

Summary
If there is one thing that constitutes a challenge to health promotion specialists,
it is how to demonstrate the effectiveness of the approach. The demonstration
of evidence is difficult because of the methods used for its evaluation. This
is more so in Africa where the concept has not been fully adopted. The
development of health promotion in Africa is in the early stages and we
recognize that talking about its effectiveness to generate this evidence might
be premature and a difficult exercise. But several attempts have been made to
generate this evidence as illustrated in this book. In this chapter, we discuss
the methodological steps necessary for the evaluation of health promotion
effectiveness on the continent.

1.0 Introduction
When considering health systems in many occidental countries, it is notable
that those which are successful are vigorously applying the health promotion
concept in their health systems (e.g. Canada, Australia, Northern Europe, etc).
AIthough health promotion effectiveness is quite evident in these countries,
assessing this evidence raises sorne methodological issues (Nutbeam, 2000).
In Africa, on the contrary, the health system is inundated with a myriad of
health challenges emanating from communicable non-communicable and
neglected tropical diseases. Therefore, the question is: Is it easy to talk about
effectiveness and more so its evidence in the African context? We shall see in
the following paragraphs what health promotion is about in the context of the
developed and developing world and what this implies in generating evidence
of its effectiveness. We shall begin by addressing what we mean by the concept
of evidence of effectiveness.
26 . H EA LT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE S

2.0 Definitions
Evidence: Something is evident when it is apparent, manifest, obvious, palpable,
clear and plain. In other words, evidence is about something that has occurred
with certainty or the product of an observation/experiment (Rootman, 200 1a).
For health promotion interventions, when it cornes to evidence, first it is the
evidence that characterizes the linkages between the determinants ofhealth and
health status. When planning health intervention, it is important to make the
evident link with ail the factors that underpin the health issue being addressed.
This step is very important in helping interventions achieve effective outcomes
or results. In our opinion, many health interventions primarily miss doing
this at the initial stage. This results in implementation of interventions in an
isolated way (without or with little multi-sectorality), and with the limited use
of approaches instead of a combination of approaches as the concept of health
promotion demands. Secondly, evidence is concerned with the effectiveness of
health promotion interventions, which is linked with the interventions' results
at different stages of implementation (McMurtry, 2002).
In the African region, there is a great need to generate health promotion
evidence in order to convince policymakers, health professionals, and other
stakeholders to shift from the traditional way of dealing with health issues.
There is evidence that health promotion has the capability to impact more on
health development, in other words, it is effective.
Effectiveness: Effectiveness refers to when an intervention has an effect
or is able to bring about the intended result(s). This is achieved through
understanding the nature of the intervention, the characteristics of the target
population and the social, political, and environmental context. These can be
examined by assessing whether the intended target population was reached; if
the activities occurred as planned; and if the theory and assumptions underlying
the interventions conformed to health promotion princip les and approaches
(McMurtry, 2002). What this implies is that the outcomeevaluations encompass
various levels of complex activities, such as assessing how participants in the
intervention are faring, or whether they are doing better than a "control"
group, or if the intervention actually caused the intended outcome. A range of
outcomes and evaluation designs can he used to answer these questions as we
shall see further in this chapter.
 HEA LT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE S· 27

While discussing the various components of successful health promotion

interventions, it is essential to remember that while health and social services
play an essential role in this domain; their work is most effective when
complemented by other sectors of the society. Examples include education,
recreation, environrnent, central and local government, commerce, industry,
and the voluntary sector. Furthermore, health promotion interventions are
effective when outcomes lead to positive changes and enhance the behaviour
of the target populations, including the skills and norms. These outcomes also
include community actions, organizational practices and public policies (Rees
et al., 2004).
Africa, as alluded to earlier, is facing a challenge of generating and
implementing "evidence-based health promotion." This challenge is reflected
in the following questions: Do actors/players in health promotion know what
evidence or effectiveness mean? Are they practicing health promotion to allow
the generation of evidence and effectiveness? Do they know how to assess the
interventions, how to use and share the findings appropriately?

3.0 Status of Health Promotion in Africa

Gnahoui-David, Houéto and Nyamwaya (2005) have illustrated that health
promotion approaches are used separately in the African region with an
emphasis on health education. Health education is mainly concerned with the
communication of information rather than fostering the motivation, skills
and confidence necessary for people to take action to improve health. They
also mention a lack of qualified human resources in health promotion on the
continent. Nyamwaya (2003) established that Africa is stilliagging behind in
the adoption of health promotion principles and approaches. However, there
is sorne progress in sorne Anglophone countries on the continent. The main
challenge remains limited documentation as experienced during the literature
search as part of developing this chapter. One could relate this to the poor
sharing or dissemination of information, which characterizes the continent
and especially the French-speaking part of the region. The report cited ab ove
indicated that in reality there is little appreciation of the concept in the region.
It is common to learn about country projects, however, on further scrutiny, the
28 . HEALTH PROMOTION EFFECTIVENESS· METHODOLOGICAL ISSUES

form of participation referred to often does not fit with what it is anticipated
in health promotion approaches.
The above observation is similar to the one made by Raeburn and Corbett
(2001) in an analysis of interventions claiming to have involved communities.
These authors could distinguish three types of participation. The first type
is community-based health promotion, the lowest level of community
participation. Here the action is 'done to' the community, with little attempt
to engage it other than to cooperate. This kind of participation does not work
mainly because the community members are not at the centre of the action. It
is the external actors who do everything on their behalf with just an attempt to
involve them. The second type is the community action, which is the middle
level of community participation. It involves at least four sub-categories eaeh
of which represents varying degrees of effort to have active community input
into the health promotion process, but where the agendas are still primarily
under the control of the professionals or researchers. This type should help
obtain sorne results, but as eommunity members are not the main actors,
there is a gap in terms of sustainability and equity, so that at the end of the
intervention, there is no possibility for the partner community to continue
the actions in order to control the health issue they (community and external
actors) were dealing with. The third type is the community development,
which is the highest level of eommunity participation where it distinguishes
three sub-categories, community-controlled (the balance of power is with the
community); community building (development of the quality oflife and liking
of the community); and development of community capacity and strengths
(empowerment). This is considered the best type of community participation.
It focuses on the development of the entire community instead of dealing with
specifie and isolated issues without putting this in the specifie comm unit y
context. It works because community members are the ones implementing
the activities with external actors performing an advisory role. Results from
this kind of participation are considered sustainable and equitable because
community members will have gained sorne expertise and will be dealing with
the specifie needs of their population. In essence these authors were dedaring
that 'Community Developrnent Health Promotion (CDHP) works, and works
splendidly. But we can only draw this conclusion if we widen the concept of
 H EA LT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE S· 29

what we customarily calI health promotion (Raeburn & Corbett, 2001). It can
be argued that the CDHP works because the intervention power is in the hands
of the partner community who understand the issues better than the external
experts.
Given the current drive towards generating evidence of effectiveness,
health promotion practitioners in the sub-Saharan African region should be
seeking to understand the health promotion approaches that would lead to the
desired outcomes. This implies that the current concern of the region should
be to strengthen the capacities in health promotion so that interventions can
take the necessary characteristics, as defined above, in order to allow for an
assessment of effectiveness.

4.0 Effectiveness of Health Promotion: The

Issues
After considerable debate at the globallevel, there seems to be sorne consensus
that effectiveness in health promotion, although complex given the multiplicity
of disciplines in the field, should be demonstrated. There is, however,
no consensus as to how effectiveness should he measured. Traditionally,
measurement of effectiveness in health promotion has focused primarily on
outcomes (Allison & Rootman, 1996). This emphasis on outcomes is derived
directiy from the biomedical model of health, in which cause and effect are
perceived in a linear relationship. This approach singles out the experimental
design, and especialIy the randomised controlled trial (RCT) approach as
the only rigorous method for obtaining valid and reliable data (Rosen et al.,
2006). Three major arguments can he advanced against the relevance of using
the experimental design to assess health promotion effectiveness (Allison &
Rootman, 1996; Jackson et al. 2001; Kemm, 2006):
(i) a simple cause and effect analysis is difficult in multi-faceted
interventions such as usually employed in health promotion - it is
not easy to tell which cause had which direct effect;
(ii) it is difficult to determine control groups in real, dynamic
communities; and
(iii) in health promotion, the process, i.e. the way the outcomes
 t
t

30 . HEALTH PROMOTION EFFECTIVENESS: METHODOLOGICAL ISSUES

are achieved, IS an important consideration of evidence of

effectiveness.

A comprehensive study of effectiveness in health promotion conducted by

Nutbeam (2000) makes a case for measures of process as well as outcomes. It
is argued that since there are multiple entry points, disciplines and players in
health promotion, there is need to consider at least four measures:
health and social outcomes (quality of life, equity, reduced
i'l morbidity, disability and avoidable mortality);
i!
modifiable determinants of health (healthy lifestyles, effective
health services, healthy environments);
health promotion outeomes (health literacy, social action and
influence and healthy public policy and organizations): and
health promotion actions (education, social mobilization, and
advocacy).

The model assumes a dynamic relationship between the different outcomes

and actions. It does not presuppose a static, linear relationship.lt is cognisant of
the fact that one action may be directed at various outcomes and one outcome
may require several actions (Nutbeam, 2000). While debate on the theoretical
bases for health promotion effectiveness and how the required evidence should
be obtained is ongoing, sorne important aspects have been settled. Firstly, it
is now accepted that integrated studies that consider diversity, local contexts
and multi-disciplinarity are required, instead of a one-shot research. Secondly,
surveillance systems in health should incorporate issues of public awareness
and expectations (key aspects of health promotion practice), in addition to
aetiology. Such a development would facilitate evaluation of the changes
resulting from health promotion and shift focus towards the population's
health away from the individual. Thirdly, factors such as poliey, resources,
community interests/participation and ideologies that feature prominently in
health promotion practice require assessment to determine their contribution
to health outcomes. It is also important to stress that measurement of such
factors is not easily quantifiable, necessitating acceptance of the use of anecdotal
and qualitative evidence that is difficult to document quantitatively (McQueen
& Anderson, 2001).
 H EA l T H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOLO G 1 CAL 1 S SUE S· 31

HeaIth promoters and researchers from the African region have entered
this debate recently, which partIy is a reflection of the formative stage of health
promotion on the continent, with the major thrust being on clarification of
concepts and defining the identity of its practitioners. A fairly recent article
indicates that lack of clearly defined indicators for assessing health promotion
programmes is a major challenge in the development of the field in the Region
(Nyamwaya, 2003). Limited resources within the health sector and emphasis on
curative services are other factors that explain the less than adequate attention
given to measuring health promotion effectiveness. To date, only the Republic
of South Africa, besides the WHO regionaI Office for Africa (WHO-AFRO),
has embarked on systematic efforts to address the issue through the health
promotion standards initiative (Nyamwaya, 2003).

5.0 Justification for assessing Health

Promotion Effectiveness
Globally, practitioners in different health fields are coming under increasing
pressure to base policies and actions on evidence. Referring specifically to health
promotion, the WHO HeaIth Assembly urged ail member states to adopt an
evidence-based approach to health promotion policy and practice, using the
full range of quantitative and qualitative methodologies (WHO, 2000). The
WHO-AFRO Regional Health Promotion Strategy underscores the inadequate
understanding of the effectiveness of health promotion by policy makers and
the general public (WHO-AFRO, 2001). The Strategy then calls on countries
and WHO to carry out periodic inter-country evaluation of the effectiveness
ofhealth promotion (WHO-AFRO, 2002).
A number of arguments in favour of using resources to demonstrate
heaIth promotion effectiveness can be advanced. Evidence in support of
heaIth promotion effectiveness can satisfy those involved in health reform that
wish to see proof of the contribution of health promotion to cost reduction.
Furthermore, it would respond to critics who are not convineed about the role
of health promotion interventions in health development (Rootman, 2001b).
Policy makers need to know that health promotion works and that it adds
value to public heaIth - this knowledge will enable them to defend investments
32 . H EA LTH PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE S

in health promotion. Practitioners are interested in documenting the unique

contribution of health promotion to health and general development to
vindicate their demand for more resources fonpromotion activities.
In the African region, most of the health interventions address disease
specifie related risks (disease prevention) and do not have adequate health
promotion characteristics. Thus, it is still difficult to speak about the evidence
ofhealth promotion effectiveness at this moment in Africa when there is limited
effectiveness, given the characteristics of the activities carried out. However, as
shown in part II of this book, evidence of effectiveness is emerging in sorne
countries in the region. It should, however, be noted that certain aspects of the
health promotion concept are well known and used, but attributing them to
health promotion per se is somehow difficult. This difficulty leads us to ask the
question on how we can obtain the effectiveness of health promotion and its
evidence in an African context.

6.0 How Do We Obtain Evidence of Health

Promotion Effectiveness?
The effectiveness ofhealth promotion is not in dispute but the question is how
to prove it. According to Rosen et al., (2006) only RCT studies are regarded as
the gold standard that can give the relation between cause and effect. But for
interventions known as complex (comprising several components), key as it
is the case in health promotion interventions, RCT is not often adequate to
establish the relations of cause and effect (Campbell et al., 2000; Campbell et al.,
2007; Blackwood,2006; Green & Tons, 1997;Spelleretal., 1997). Indeed.because
of their complexity, interventions in health promotion utilize several factors
to be able to explain the results (Syme, 2004). More particularly, community
interventions aiming at the transfer of power from health professionals to the
cornmunity, as it is the case in health promotion, require a certain implication
of the investigator with an aim of justifying this "catch of power" (Campbell
et al., 2000; Green & Tons, 1997; Kemm, 2006; Speller et al., 1997). It is thus
difficult, in a health promotion intervention, to keep a certain distance and
"neutrality" with respect to the study community in terms -of interaction and
influence of the results. The aim of an intervention of this kind is obviously
 HEALTH PROMOTION EFFECTIVENESS: METHODOLOGICAL ISSUES- 33

to cause at community level the catch of power through the behavior of the
investigator (Baker & Teaser-Polk, 1998; Wyss et al., 1998). EtiologicaHactors
in the complex helath promotion interventions, it is clear that ail important
place must be necessarily granted to the qualitative method (Campbell et al.,
2000; Kemm, 2006; Syme, 2004).
The problem that the evaluation of health promotion effectiveness poses
is often that the interventions do not always have the characteristics of health
promotion as shown by Thomas et al., (2003). That is whyat the beginning
of the health education and sensitization campaigns it is usually impossible
to convincingly explain the effectiveness of health promotion. Health
education by itself does not make it possible to try out the effectiveness of
health promotion. It misses the other pillars ofhealth promotion, for example,
the healthy public policy dimension which supposes the establishment of
legislations and regulations, in other words the conditions favorable to health,
without forgetting advocacy which is a component needed to achieve this.
It would be thus difficult to establish that the approaches and principles of
health promotion failed to impact at aIl on the partner populations (Hoffman
& Jackson, 2003). This is currently the situation in Africa where many of the'
interventions referred to as health promotion are far from being it, because
they do not have aIl the characteristics of health promotion. We are, therefore,
proposing in this chapter sorne steps that can be taken to get evidence of the
effectiveness of health promotion interventions within the region as outlined
below.
Approaches to improve practice in health promotion: Health promotion
actors/players need to ensure the quality of their interventions in order
to fit the criteria of the 'best practioes' which are recognized by several
authors (Reaburn & Corbett, 2001; Glasgow et al., 1999, Iané-Llopis &
Barry 2005; McMurtry, 2002; Rootman, 2001a). These include health
promotion theory, values, principles, goals, ethics, concepts, beliefs,
assumptions, and context (e.g. perceptions and representations of the
partner population).
Scientific rigour in health promotion intervention/research: This
refers to the process of systematically studying a phenomenon, using
an appropriate design and methods to address the problem, and often
 34 • HEAlTH PROMOTION EFFECTIVENESS: METHODDlOGICAl ISSUES

including the development and testing of theory (Allison & Rootman,

1996). In other words, interventions and research in health promotion
need to be theoretically grounded; have a sound interventionlresearch
design; and be ethically appropriate.
Evaluation ofhealth promotion interventions. There are sorne principles
.that must guide evaluation of health promotion interventions when it
cornes to prove their effectiveness. Before evaluating health promotion
interventions, it is important to know its meaning. According to health
promotion definition, health promotion interventions should be
empowering, participatory, holistic, intersectoral, equitable, sustainable
and multi-strategic (WHO, 1998). Evaluation, as defined by WHO
(1998), is "the systematic examination and assessment of the features of
1.
an initiative and its effects, in order to produce information that can be
used by those who have an interest in its improvement or effectiveness".
Based on the principles of health promotion, the evaluation principles
include: participation at each stage, in appropriate ways, of those who
have a legitimate interest in the initiative (policymakers, community
members and organizations, health and other professionals, and local
and national health agencies); use of multiple methods of information
gathering procedures according to the different disciplines involved
in health promotion; enhancement of the capacity of individuals,
communities, organizations and governments to address important
health promotion concerns (capacity building) and its appropriateness,
designed to aocommodate the complex nature of health promotion
interventions and their long-term impact (Jackson et al., 2001).

There is a need to mention here that health promotion initiatives do

not need to be evaluated necessarily by the RCT and quasi-experimental
trial {QET) procedures because of the complexity of such interventions
(Raeburn & Corbett, 2001). According to Freimuth (2001), Health promotion
interventions are not like pills - they are much more complex and indirect
in the way they work. Therefore, its evaiuation designs may be very different
allowing health promoters to track a social influence prooess and document
its effects on social and political institutions as well as on individuals. In the
 HEA LT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE s. 35

same way, the WHO working group on this topic (WHO, 1998) mentioned in
its conclusion that health promotion initiatives should be evaluated in terms
of their processes as weIl as their outcomes. For this working group, the use of
RCT to evaluate health promotion initiatives is in most cases inappropriate,
misleading and unnecessarily expenses. Therefore, there is a need to support
the use of multiple methods, conduct further research into the development
of appropriate approaches to evaluating health promotion initiatives, and to
ensure that a mixture of process and outcome information is used to evaluate
all health promotion initiatives.
Collating and sharing evidence of health promotion effectiveness: It
is time to appreciate the initiative of this book whkh targets Africa
in particular. According to the arguments that we have so far made,
this initiative will certainly contribute to exhibiting the principles of
good practice in health promotion in order to reinforce the need to
ensure, with reference to experience in its application in other areas, a
component in every intervention that deals with gathering the.evidence
of health promotion effectiveness and to disseminate it. This, in our
opinion, could constitute a tool for advocacy with the decision makers
in the different countries of the region. We, however, acknowledge that
there are many challenges of getting evidence of health promotion
effectiveness, as it is the case in other parts of the world.

In the African region, there are many opportunities to demonstrate that

health promotion is an effective approach. For example, in many countries
in the region, cholera outbreaks still oceur regularly. In order to manage
these outbreaks, it is dear that there is a need for multi-sectoral interventions
which deal with several aspects of the disease induding water management,
the environment, urbanization, economie development (e.g. unemployment),
political and administrative issues (law and regulation e.g, on housing),
water and sanitation among others, and communities. In fact, cholera is a
health issue but not an issue .for the health sector alone. Another example is
malaria, as shown in Chapter 10 of this book which is, th.e leading cause of
morbidity and mortality in many countries in sub-Saharan Africa. There are
many programmes and initiatives aiming at rolling back malaria. But none
 36 -HEALTH PROMOTION EFFECTIVENESS: METHODOLOGICAL ISSUES

of these actions address the determinants of malaria. Consequently, malaria

continues to be a major burden for Afi;~cadespite the considerable resources
available from governments and their development partners. Furthermore,
the achievement of MDGs that are related to the health sector (goals number
4,5 and 6) is another opportunity to demonstrate the effectiveness of health
, i
; ! promotion (UN 2000). These health objectives cannot be achieved by only
, 1
the ministries of health. Achievement of these health-related MDGs requires
multi-disciplinary, multi-factoral and multi-sectoral interventions to alleviate
poverty, reduce child and maternal mortality, and to reduce the prevalence of
infectious diseases such as malaria, HIV and tuberculosis (all these are strongly
related to poverty which characterizes most countries in the region).ln order
for the health sector to achieve its related MDG indicators, it must partner
with other non-health sectors to address the causes of the causes.
The examples cited above indicate that health interventions can contribute
effectively to disease control through the health promotion approach. In other
words, the focus must be on the development of communities with sorne
specifie tasks for health promotion practitioners (Raeburn & Corbett, 2001).
It is also imperative to build social capital in order to equip communities as
actors that can be used to develop themselves. This might not be easy, but it
cm be done, it has been done and there is evidence to prove that it is feasible
(Nutbeam, 2000).

7.0 Challenges of Getting Evidence

Health promotion is a complex field, therefore, its measurement cannot he
merely an evaluation similar to that of other public health fields. The focus
in health promotion is not only on individuals but also and more so on
communities; on combination of strategies rather than single interventions;
on involving community members in programme design, implementation
and evaluation; and the use of qualitative as weIl as quantitative approaches
to research and evaluation. The particular nature of health promotion creates
specifie challenges. These indude the participatory aspect of research and
community development, an emphasison values, a focus on populations
rather than individuals, the social and cultural structures, the use of multiple
 HEA LT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 0 0 LOG 1 CAL 1 S SUE S· 37

strategies, collaboration across sectors, pro cesses as well as outcomes, and

the complexity and long-term nature of health promotion interventions and
outcomesOacksonetal.,2001).AccordingtoKahan(2004),inmeasuringnealth
promotion effectiveness, one needs to look at unexpected as well as expected
outcomes. There is also a need to include in one's repertoire, untraditional
measurement tools such as stories and folklore, and to consider as acceptable
not just quantitative/experimental evidence but qualitative/non-experimental
evidence as well. This conforms to the observation by Iackson etai. {2001) that
it is particularly important in analysing health promotion interventions to pay
attention to the inclusion criteria, which needs to be broad. The process must
consider the quality of evidence criteria that includes more than quality of the
study design, the complex analysis and integration of research design process,
a quality assessment protocol that includes both quantitative and qualitative
studies, and a synthesis protocol for qualitative studies.
There are many other aspects for consideration when talking about
challenges of getting evidence in the African region. These are related to the
constraints of the project funding which is usually limited (resoueoes for
generating evidence): capacity to monitor and evaluate health promotion
interventions; documenting health promotion evidenœ; sharing evidence;
and translating evidence into action. Health professionals, at country level for
example, need to build projects on priority health problems, taking into account
the particular context and orientate activities to address the determinants of the
health problems for which they have better tools compared to other actors, They
should help partners to choose strategies that are relevant for their countries
to solve the priority problems identified. To do so, health professionals have to
master the health promotion concept and its application. As health promotion
is not a very well established concept in sorne African countires, there is a need
to build capacity, induding on its evaluation, in generating evidence and for
mobilizing resources to generate and showcase evidence. Health promotion is
wrongly equated to the use of posters in many countries in the region but, as
we noted earlier with the example of cholera outbreak, it involves investment
in skills, appropriate environment, legislations. laws, healthy public policies
(housing, water and sanitation), etc.
 38 • HEALTH PROMOTION EFFECTIVENESS: METHODOLOGICAL ISSUES

8.0 Conclusion and way forward

While opinions differ about the nature of evidence and the methods used
to generate it, there is growing recognition that both process and outcome
evaluations are necessaryin demonstratingthe effectiveness ofhealth promotion
interventions. Process evaluation is concemed with how the interventions are
organized, delivered and used (evidenœ of best practice). Effectiveness refers
to outcomes. To demonstrate the evidence-of health promotion effectiveness
cannot he similar to the other fields of public health hecause of the complexity
of the pro cesses. For example, the use of ReTs to evaluate health promotion
initiatives is, in most cases, inappropriate and misleading. Programmes in
health promotion need to be analyzed according to their primary approach.
These could range from empowerment and advocacy, policy and enforcement,
to strategies that create or nurture supportive environments.
The way to go, in the African region, when considering the evidence of
health promotion effectiveness is fust to strengthen the health promotion
status on the continent in order to change the traditional ways of planning
and implementing health interventions at alilevels. This can he reinforced by
providing the evidenœ ofhealth promotion practioes that demonstrate positive
1
1 j
outcomes, There is a need in the region to support further research in order to
develop appropriate approaches to evaluate health promotion initiatives.
It is notable that sorne evidence exists which policy makers can utilize to
advocate for health promotion in order to raise its visibility, mobilize resouroes,
develop infrastructure, and-build capadty in this field (as demonstrated in Part
II of this publication). When interventions are developed and implemented
according to the health promotion concept, policy makers should allocate
sufficient resources for the evaluation, which should adopt participatory
approaches and utilize multiple rnethods that provide information on both
the process and outcomes. & health promotion itselfleads to development, the
evidence of its effectiveness will reinforce the organizational deveiopment and
networking that are greatly needed in Afrka. These can he achieved through
the creation of national research institutes and health promotion foundations
to support health prornotionpractioe and the generation of sound evidence of
ils effectiveness.
 H EALT H PRO MOT ION E F FEe T 1 VEN E S S: MET H 0 DOL 0 G 1 CAL 1 S SUE s. 39

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