Challenges of studying complex community health promotion programmes : Experiences from Stockholm diabetes prevention programme

Sammanfattning: The main objective of this thesis focused on how to capture the complexity in the implementation of a community health promotion programme. The thesis is based on experiences of Stockholm diabetes prevention programme (SDPP), which was implemented in 1995-2004 in three municipalities, and include documentation within the programme, annual local governmental reports, local news cuttings, questionnaires and group discussions with the local steering committees members. The material have been analysed by qualitative and quantitative content analysis. In study I , the planning model developed for SDPP was applied to study the programme development. It identified that the programme had been implemented mainly as planned. Physical activity was the risk factor that had become the major focus of intervention. Tobacco consumptions had been added as a fourth risk factor. In study II, the participatory spidergram methodology was applied to assess the extent and development of local intersectoral participation. Wide local intersectoral participation was achieved in planning and implementing activities whereas participation in allocating local resources, leadership and network were more restricted. Communication and shared responsibility appeared critical in influencing the development and perception of participation. In study III, a matrix with WHO s Health For All-targets was developed to identify health promotion activities within the local governments. Each target area was valued in relation to whether intersectoral collaboration and policy or monitoring systems had been established. It was found that almost all the target areas had been addressed, although main focus was given to environmental issues, unemployment, social care and welfare.Health promotion activities were often presented as environmental strategies. The social welfare administration and board for environment and health protection were most frequently involved in health promotion efforts. Policies or monitoring systems were developed within equality, alcohol and drugs, welfare, disability, and environmental and local Agenda 21 plans. In study IV, media monitoring and media analysis was applied to analyse the frequency, characteristics and content of newspaper coverage related to physical activity. Physical activity was reported both as a positive feature in the municipalities and an issue that created debate about priorities and resources. The public, local organisations and the authorities were involved in the debates. Health aspects were used as an argument when discussing the availability of activities, facilities and recreation areas. With the applied study design it was not possible to evaluate if the programme had had any impact on the health related content in the articles except for articles directly linked to the programme. In conclusion , the applied analytical tools enabled to study the implementation processes and analyse various actors roles or potentials in the implementation. A thorough documentation and monitoring of programme operations was found essential to capture the many activities and actors involved during such a long-term programme. The contributions of the analytical tools are that they have included several dimensions and data sources in the analysis. These methods would probably be more useful in formative evaluations to enable to adjust program operations during the implementation and to seize an important learning opportunity.