This article examines the state of the art in health promotion indicator development over the past few years and presents five conclusions from this review, The authors put forward proposals for the development of health promotion indicators based on the question, "What research in health promotion will lead to appropriate indicators?”. The authors illustrate some areas of concern both for researchers and policymakers and suggest a number of indicators, appropriate to each of these groups, for important dimensions of health, health-related processes and health resources. The dialogue between health researchers and health decision-makers is growing and links are being made; it is important to continue this proces

MCQUEEN, DAVID

NOACK, HORST

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HEALTH PROMOTION© Oxford University Press 1988Vol. 3, No. 1Printed in Great BritainTowards health promotion indicatorsHORST NOACKDepartment of Social and Preventive Medicine, University of Berne, SwitzerlandDAVID MCQUEENResearch Unit in Health and Behavioural Change, University of Edinburgh, United KingdomSUMMARY77iis article examines the state of the art in healthpromotion indicator development over the past fewyears and presents five conclusions from this review.The authors put forward proposals for the develop-ment of health promotion indicators based on thequestion, "What research in health promotion willlead to appropriate indicators?". The authors illustratesome areas of concern both for researchers and policy-makers and suggest a number of indicators, appro-priate to each of these groups, for importantdimensions of health, health-related processes andhealth resources. The dialogue between healthresearchers and health decision-makers is growing andlinks are being made; it is important to continue thisprocess.INTRODUCTIONHealth promotion has been defined as theprocess of enabling people to increase controlover and to improve their health. Healthpromotion means action that aims at making theconditions of health more favourable throughadvocacy. Health promotion aims at reducingdifferences in health among population groupsand ensuring equal opportunities and resourcesto enable people to realize most fully their healthpotential. Health promotion demands co-ordinated action by government and by thehealth, economic and social sectors, by non-governmental and community organizations andby the media, to mediate between differinginterests in society for the pursuit of health.Further, health promotion calls for concertedaction and strategies to build healthy publicpolicy; to create supportive environments; tostrengthen community action directed towardshealth; to develop personal skills; and to reorienthealth services (Ottawa Charter for HealthPromotion, 1986).Although health promotion comprises familiarnotions and principles, the concept as a whole isnovel and highly challenging. And so is theconcept of health promotion indicators. Thespecific request for health promotion indicatorscame from interested parties such as the RegionalOffice for Europe of the World Health Organ-ization (WHO), largely reflecting interestsprincipally expressed by policy-makers ingovernment. There is not much evidence thatsuch indicators were of primary concern toworkers or researchers concerned with healthpromotion. The request for such indicatorsseems logical, for valid and reliable informationcan be a highly valuable tool both for bureau-cratic planners and for the policy-makers andpractitioners committed to advocating healthpromotion, enabling people to protect andimprove their health, and to mediating betweenconflicting interests related to health.At the start the task of identifying anddeveloping indicators of health promotionseemed relatively straightforward. Questionswere posed. What indicators exist that can be7374 H. NOACK AND D. McQUEENused now? What indicators exist that can bemodified to be suitable for health promotion?What indicators need to be developed? Asdiscussions progressed, it became obvious thatnot only were there no simple answers to thesequestions, but that there were many morequestions than originally envisaged.THE STATE OF THE ARTA review of the efforts of the past few years leadsto several conclusions about the state of the art inthe development of health promotion indicators.To begin with, because research, as well asprogrammes, specifically directed towards healthpromotion hardly exists, it was just not possibleto discuss health promotion indicators in anyproper context. It seems that the identificationand development of health promotion indicatorswas often seen largely as a technical issue thatcould be approached pragmatically simply byapplying the familiar principles and methods ofmeasurement to a new class of phenomena.Second, the link or, rather, the interfacebetween concepts of health and the concepts ofill health or disease have received little attention.Should good health and ill health be taken asmore or less distinct phenomena caused bydifferent conditions or factors, as the early workof Bradburn (J969) and more recent research byHeady et al. (1984) seem to suggest? This would,of course, imply distinct concepts of health pro-motion on the one hand and of the preventionand treatment of disease on the other, and there-fore different sets of indicators. If this were thecase another question would arise. Would thisperspective be compatible with a holistic conceptof health and a holistic concept of healthpromotion (Noack, 1987)?Third, previous efforts have paid littleattention to the question of who will use healthpromotion indicators and for what purpose. Itseems that people often silently assumed thateventually a universal set of indicators would beavailable to fulfil all possible health informationneeds. Quite obviously, the kind and number ofmeasurements needed in a research projectexamining, for example, the influence of socialsupport and lifestyle factors on wellbeing wouldbe quite different from the information selectedby policy-makers or health planners to decide ona particular community health programme foradolescents. In this latter situation the publicmay wish to know what scientific evidence wasused to make specific decisions and why.Fourth, there does not seem to be consensusbetween experts on what kind of informationabout health promotion would be most appro-priate for a particular purpose. Because theconcept of health promotion largely reflectsdynamic phenomena, how can we measure theprocess involved? There is, of course, a myriadof relevant health-related processes, such as, forexample, health behaviour, patterns of socialinteraction, and communication. In general,these processes are difficult to categorize and tomeasure, and their relationship with health willfrequently be debatable. One might ask whetherit would be easier and more efficient to developmeasures of health resources. Again, manyvariables could be chosen on the basis of their(frequently undefined) link with health. Whynot, then, use measurements of certain dimen-sions of health (such as perceived wellbeing,assessed health-related quality of life, or theability to fulfil important social roles) as indirecthealth promotion indicators or as outcomemeasures? This tends to be the approach taken inthe evaluation of medical treatment and careprogrammes for various groups of chronically illpeople (Katz, 1987; Lohr & Ware, 1987).Finally, because health promotion researchand programmes are emerging fields of activities,yet another question has rarely been addressed.What information on health promotion isneeded? It seems to be a common belief, at leastamong members of the health promotioncommunity, that, in order to introduce healthypublic policy and to monitor the impact of healthpromotion programmes, a whole new generationof quantitative indicators will be needed. Thisbelief can be challenged. First, in most in-dustrialized countries a vast amount ofinformation on numerous health-related factorsis routinely collected but not used because, sofar, health has not been a major public concern.Second, it seems that most decisions in healthpolicy and planning are based on qualitativeinformation, including interpretations of researchresults and practical experience. Thus, the needfor health promotion indicators must be discussedin the wider context of the health informationsystem that a society is willing to build andmaintain.In view of these issues it seems unlikely thatmuch additional progress will be made byTOWARDS HEALTH PROMOTION INDICATORS 75more meetings of experts called to discuss theproblems of health promotion indicators. Asprevious efforts suggest, the use of expert panelsor Delphi techniques will yield little that is new oruseful. The problem is not the generation of evermore candidates for health promotion indicators.Instead, emerging concepts and principles ofhealth promotion, whether stemming fromWHO documents such as the Ottawa Charter orother sources, need to be integrated fully intohealth promotion research. Until health pro-motion research has such a basis, it is unlikelythat any set of valid and reliable indicatorsspecific to health promotion will be forthcoming.Further, without a solid health promotionresearch framework, there will be no base onwhich to develop and test promising indicatorcandidates. Finally, in the saga of indicatordevelopment the cart has often been put beforethe horse, with the concern for providingindicators that are simple and immediatelyavailable for the so-called end users, usuallypolicy-makers. This has led to a sense of urgencyin indicator development that simply cannot beassuaged by researchers faced with limitedresources and time.indicators but determining the research inhealth promotion that will lead to appropriateindicators. One key element in any suggestedresearch would be a concept of decision-linkedresearch, as it is sometimes called. This isresearch linked to a dialogue with policy-makers(and/or health promotion practitioners) and tonew areas for policy decisions. The major dif-ficulty with the term is that it puts heavyemphasis on the interests and needs of the enduser and tends to underplay the role andindependence of the researcher. Thus we prefer anotion of integrated health policy and research,in which responsibility is shared equally betweenthe researcher and end user. Essentially, a formof unprejudiced dialogue should take placebetween all interested parties; further, it shouldbe motivated by collaboration that involves linksbetween research and policy at three levels. Table1 presents the framework for integrated healthpolicy and research. It illustrates some areas ofconcern for both researchers and policy-makers.Researchers and policy-makers will bring issuesconcerning them to dialogues on health, health-related processes and health resources.SOME MODEST PROPOSALSAs indicated above, the sound development ofhealth promotion indicators is inevitably tied togood health promotion research. The task is nolonger defining appropriate health promotionDIALOGUEDialogue on healthTwo sets of questions about levels of health canbe developed: one set for researchers and aparallel set for policy-makers. Researchers mayTable 1: Framework for integrated health policy and researchTopics Research issues Policy issuesHealthProcessesResourcesConcepts and dimensionsof good and ill healthof population subgroupsBehaviour and actions ofinstitutions and individualsaccounting for positive andnegative healthIndividual, organizationaland societal resources(including knowledge, skills,social networks, socialrelations and social support)accounting for positive andnegative healthHealth targets related tohealth needs of populationsubgroupsCommitment of organizations,institutions and individualsto action and behaviourrelated to positive healthMaintenance and creation ofsocietal, organizational andindividual health resources(including health informationsystems) and reduction ofrisks to health76 H. NOACK AND D. McQUEENhave many questions about the meaning andnature of health; in particular, it is interesting toobserve differences in these meanings in variouspopulation subgroups. For example, how arehealth problems and needs perceived by differentgroups? Policy-makers' questions may centrearound the health targets for subgroups in thepopulation. How do the targets set by the policy-makers relate to needs? The overall question iswhether the questions asked by both parties inthe dialogue converge. The answer might wellinfluence the type of health promotion indicatorsfound acceptable by both groups.For example, the researchers might see in-dicators that allow the description of differencesamong social groups with regard to wellbeing andhealth outlook (Ware, 1987):• self-rating of health at present;• personal evaluation of physical condition;• feelings of anxiety, nervousness, tenseness,depression, moodiness, downheartedness;• frequency and intensity of general positiveaffect; and• expectations about health in the future.Policy-makers, on the other hand, may seeindicators that allow the formulation of targetsfor health planning and social policy (Ware,1987):• limitations in performance of self-care, inmobility and physical activities;• ability to perform everyday activities;• confinement to bed due to health problems;• freedom of limitations in performance ofusual role activities (work, housework,school work) due to poor health; and• ratings of the intensity, duration, andfrequency of pain as well as limitations inusual activities due to pain.Dialogue on health-related processesMany research questions centre around thegeneral question of determining the specificindividual and social processes that account forpositive and negative health. For example,researchers may wish to know more about howthe actions and behaviour of institutions,organizations and individuals account forchanges in positive and negative health. Theymay be interested in:• activities in organizational development andtraining of staff in order to reorient healthpolicy towards health promotion;• the support of public health policy byprimary care physicians and specialists;• the frequency of communications abouthealth-enhancing behaviour between peoplein the workplace or students at school;• the number of people involved in com-munity activities related to health pro-motion {Consultation on Health PromotionIndicators, 1987); and• balance between behaviour related topositive and negative health in differentsubgroups of the population.Health policy-makers will probably ask aboutthe pragmatic commitments institutions have tosupport these processes for positive health. Theymay prefer to discuss the following issues:• the assessment of known and/or possible(positive and negative) effects of all areas ofpublic policy (such as agriculture, transport,housing, and sports (Consultation onHealth Promotion Indicators, 1987));• the existence of interdepartmental healthplanning at different levels of government(Consultation on Health PromotionIndicators, 1987);• the proportion of people in differentsociodemographic groups who reduce orcease smoking or have never smoked (Con-sultation on Health Promotion Indicators,1987);• the proportion of people in different socio-demographic groups who have changed to ahealthier diet;• self-reported awareness and practice of safesex (Consultation on Health PromotionIndicators, 1987); and• the proportion of people who practise self-care in the case of such minor health prob-lems as colds, headaches, and back pain.Dialogue on health resourcesAbout resources, the researchers will look for theindividual and societal resources (or healthpotentials) accounting for positive health andhealth-related processes. Examples of indicatorsthat they may suggest are (Consultation onHealth Promotion Indicators, 1987):TOWARDS HEALTH PROMOTION INDICATORS 77• the existence of means of assessing theimpact of public policy on health status;• the level of knowledge of policy-makersabout health issues;• measures of inequity in income and wealthdistribution;• the existence of private and professional net-works that enhance personal functioningand coping; and• the level of public knowledge about environ-mental and behavioural health resources.Policy-makers, on the other hand, will beinterested in the commitments needed to improveand maintain positive health resources and toreduce health risks. They may see the followingas indicators of health resources (Consultationon Health Promotion Indicators, 1987):• the existence of consultative bodies (such asforums and councils) for and channels ofcommunication of community health needsand demands;• the existence of systematic programmes forthe dissemination of relevant, accurate andclear information on health matters inschools;• the existence and enforcement of trafficsafety regulations, including those on theuse of seat belts in cars and helmets bymotorcycle riders;• the existence and enforcement of safetyregulations in the workplace; and• the availability of networks that provideboth satisfying social contact and help whenneeded.cedure to identify available data or methods fordata collection or, if data are lacking, to develop,test and apply new methods of collection. Severalarticles in this issue of Health promotion pointout a number of powerful and readily availablemethods of providing useful information onhealth and health promotion indicators. It wouldbe naive, however, to think that the developingdialogue between researchers and policy-makersis free of conflict and simply a good thing.Researchers have traditions. Some of them, suchas their professional independence, are com-promised in such a dialogue. Policy-makers mustallocate resources under pressure from vestedinterests. Some vested interests may clash signi-ficantly with the beliefs and values of researchers.If these conflicts can be overcome, the dialoguewill lead ultimately to what may be labelled ahealthy research policy.It would be premature to end on an optimisticnote at this stage in the development of a healthyresearch policy. Some very clear and presentdangers in the current environment threatenfurther work. Resources for both research andpolicy development in many countries arediminishing, owing to both economic andpolitical pressure. In many countries, universitiesand traditional research environments are underconsiderable pressure to reduce budgets andstaff. At the same time, funding groups increas-ingly demand total accountability and moreresults with fewer resources. This allowsresearchers very little freedom. Other facts mustalso be faced: health promotion indicators willnot be developed for free, and this topic mustcompete with others that are better developedand more coherent.CONCLUSIONThe evidence accumulated from all the efforts toidentify health promotion indicators shows thatthe dialogue between health researchers andhealth decision-makers is growing and that linksare being made. It must be emphasized that thisdialogue should continue and be fostered. Ulti-mately it will lead to a set of reasonable healthpromotion indicators. Until this process is morefully developed (which will require a couple ofyears), the identity of the most appropriateindicators will be unclear.Once a consensus has been reached in thisdialogue it is a relatively straightforward pro-REFERENCESBradburn, N. M. (1969). The structure of psychological well-being. Chicago, Aldine.Consultation on Health Promotion Indicators (1987).Edinburgh, Research Unit in Health and BehaviouralChange, University of Edinburgh (unpublished docu-ment).Heady, B. et al. (1984). Well-being and ill-being: differentdimensions? Social indicators research, 14: 115-139.Katz, S., ed. (1987). The Portugal Conference: measuringquality of life and functional status in clinical practiceand epidemiological research. Journal of chronic diseases,40(6).Lohr, K. N. & Ware, J. E., Jr., ed. (1987). Proceedings ofthe Advances in Health Assessment Conference. Journalof chronic diseases, 40 (Suppl. No. I).78 H. NOACK AND D. McQUEENNoack, H. (1987). Concepts of health and health promotion. Ware, J. E., Jr. (1987). Standards for validating healthIn: Abelin, T. et al., ed. Measurement in health pro- measures: definition and content. Journal of chronicmotion and protection. Copenhagen, WHO Regional diseases, 40(6): 473-480.Office for Europe, pp. 5-28.Ottawa Charter for Health Promotion (1986). Health pro-motion, 1(4): iii-v.

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