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Modelling the results of health promotion activities
in Switzerland: development of the Swiss Model
for Outcome Classification in Health Promotion
and Prevention
BRENDA SPENCER
1*
, URSEL BROESSKAMP-STONE
2
,
BRIGITTE RUCKSTUHL
2
,GU
¨
NTER ACKERMANN
2
, ADRIAN SPOERRI
3
and BERNHARD CLOETTA
3
1
Institute of Social and Preventive Medicine (IUMSP), University of Lausanne, 17, rue du Bugnon,
CH-1005 Lausanne, Switzerland,
2
Health Promotion Switzerland, Bern and
3
Department of Social and
Preventive Medicine (ISPM), University of Bern
*Corresponding author. E-mail: Brenda.Spencer@chuv.ch
SUMMARY
This paper describes the Model for Outcome
Classification in Health Promotion and Prevention
adopted by Health Promotion Switzerland (SMOC, Swiss
Model for Outcome Classification) and the process of its
development. The context and method of model develop-
ment, and the aim and objectives of the model are out-
lined. Preliminary experience with application of the
model in evaluation planning and situation analysis is
reported. On the basis of an extensive literature search,
the model is situated within the wider international
context of similar efforts to meet the challenge of develop-
ing tools to assess systematically the activities of health
promotion and prevention.
Key words: health outcome model; evaluation; health promotion; measurement
INTRODUCTION
Clearly, the need for an evaluation tool that
takes account of the complexity and long-term
nature of health-promotion activity, while ren-
dering such activity accountable in an evidence-
based world, is widely felt. The ‘evidence
debate’ (McQueen, 2001, 2003) has given rise to
a rich literature. Authors have challenged the
extension into public health and political
decision-making of the hierarchy of quality
established in clinical evidence-based medicine
(Rychetnik et al., 2002b; O’Neill, 2003;
Goldenberg, 2006; Irwig et al., 2006; Kemm,
2006; Lambert et al., 2006), this being of limited
relevance to the complex social situations at
issue in health promotion (Tones, 2000). The
complexity of evaluation in health promotion is
widely acknowledged and has received consider-
able attention (Green and Lewis, 1986; Tones
et al., 1991; Hepworth, 1997; Macdonald, 1997;
Speller and Learmonth, 1997; Ziglio, 1997;
Nutbeam, 1998; Briss et al., 2000; Learmonth
and Mackie, 2000; Raphael, 2000; Rychetnik
et al., 2002a; Dooris, 2005). A noteworthy con-
tribution to clarifying the issues involved has
been made by the WHO European Working
Group on Health Promotion Evaluation
Health Promotion International, Vol. 23 No. 1 # 2007 The Author(s).
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/2.0/uk/)
which permits unrestricted non-commerical use, distribution, and reproduction in any medium,
provided the original work is properly cited.
doi:10.1093/heapro/dam038
Advance Access published 10 December 2007
86
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(Rootman et al., 2001) and by the International
Union for Health Promotion and Education
(European Commission, 1999; IUHPE, 2004,
2005). Aside from international collaborations,
a number of countries and geographic regions
have invested considerable effort in establishing
working frameworks to standardise and improve
evaluation (King, 1996; Glasgow and Vogt,
1999; Reed et al., 2000; Watson and Wimbush,
2000; Kahan and Goodstadt, 2001; Thurston
et al., 2003; Saan and de Haes, 2005).
This paper documents attempts in Switzerland
over the past 4 years to develop a tool intended to
facilitate, improve and render more coherent the
evaluation and planning of projects in health
promotion: the Swiss Model for Outcome
Classification in Health Promotion and
Prevention (hereafter referred to as SMOC or
Swiss Outcome Model) (Cloetta et al., 2004, 2005)
(http://www.promotionsante.ch/en/knowhow/tools/
model.asp). In so doing, the tool is situated within
the broader epistemological context.
CONTEXT AND MANDATE FOR MODEL
DEVELOPMENT IN SWITZERLAND
Any evaluation tool destined for use at the
national level in Switzerland must be under-
stood within the context of the country’s federal
system (Knoepfel and Bussmann, 1998), which
generates considerable heterogeneity and diver-
sity despite the low population size (7.5
million). Citizens enjoy direct democratic rights;
political and administrative responsibilities are
shared between the Confederation and the 26
cantons (equivalent to a state in the USA,
Australia or Germany). Taxation, education
and health, for example, come under cantonal
authority. There are four national languages
(German, French, Italian and Romansch).
Health costs are managed through a system of
92 health insurance companies (Liste des
assureurs-maladie admis. Bundesamt fu
¨
r
Gesundheit. 25.01.2007, http://www.bag.admin.
ch/themen/krankenversicherung/00261/index.
html?lang=fr).
Health Promotion Switzerland is a foun-
dation, financed via a levy of 2.40 CHF (¼ 1.5E)
per health-insured person, and established by
the Swiss cantons and health insurance compa-
nies to initiate, coordinate and evaluate policies
to promote health—Art. 19/20, Federal Health
Insurance Act (Die Bundesversammlung der
Schweizerischen Eidgenossenschaft, 2006).
Improving evaluation and quality assurance at
all levels is a major priority.
The Swiss Model for Outcome Classification
is the result of several years of collaboration
between Health Promotion Switzerland and the
Institutes for Social and Preventive Medicine in
Bern and Lausanne. From the outset, the model
was intended:
† to be applied globally, i.e. used whatever the
particular approach and content of a health
promotion/disease prevention project,
† to supply a ‘common language’ to improve
communication between stakeholders,
† to give an overview of the activities of funded
projects, since each could be ‘plotted’ in the
different categories and sub-categories and
† to assist project leaders and evaluators in for-
mulating and assessing clear objectives and
outcome indicators.
STRUCTURE AND DESCRIPTION
OF THE MODEL
As illustrated in Figure 1, the model presents as
16 categories structured over four levels moving
from left (A) to right (D):
(A) health-promotion measures,
(B) factors influencing health determinants,
(C) heath determinants and
(D) health status of the population.
Both levels (A) and (B) are additionally struc-
tured according to four focal domains in health
promotion: infrastructures and services for
health promotion and prevention; formal organ-
isations, structures and networks (such as politi-
cal, legal and administrative systems and
commercial organisations); informal structures,
such as associations and groups in the commu-
nity; and individuals. The model essentially
embraces all concepts of the Ottawa Charter
(http://www.euro.who.int/AboutWHO/Policy/
20010827), but these are not necessarily struc-
tured in the same manner.
Level (A) is classified into four main
approaches.
(A1) development of health-promoting services,
(A2) advocacy; networking organisations,
(A3) social mobilisation and
(A4) development of individual skills.
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Health-promotion measures A1 to A4 are
intended to have results situated at level B,
these being, the establishment of:
(B1) health-promoting services and provisions,
(B2) health-promoting public policy and organ-
isational practice,
(B3) health-promoting social potential and
commitment and
(B4) individual health-related life skills.
These results, B1–B4, are, in turn, destined to
have an impact on the determinants of health
(C), classified in the model into three separate
categories:
(C1) health-promoting physical environment,
(C2) health-promoting social environment and
(C3) health-promoting individual resources and
behavioural patterns.
Finally, these determinants of health, C1–C3,
exert a positive influence on health (D), as
expressed in increased healthy life expectancy
and increased quality of life, or in lower rates of
morbidity or of premature mortality.
The above explanation being somewhat sim-
plified for the purposes of clarity, it is empha-
sised that although the model implicitly implies
a chain of effects, actions at level A being
intended to have an impact at level B, B on C,
and ultimately C on D, no absolute linear
understanding of causality is intended here. The
hypothesised chain of multiple effects is essen-
tially horizontal, but may include vertical move-
ments, particularly at level B. For this reason,
no arrows are depicted in the model: it is
acknowledged that pathways to the achievement
of health are multiple and rarely linear, and
therefore cannot be pre-ordained. When the
model is applied, the project or programme
designers define the movement of arrows
according to available data combined with their
conception of intended effects.
Each category of results at levels B and C has a
set of pre-defined sub-categories, as indicted in
Figure 1. Hence, the existence of a health-
promoting service (cf. category B1) is not a result
in itself unless it can be shown that (1) potential
users are aware of its existence, (2) it is accessible
to the intended target groups, (3) the service is
made use of and the users satisfied, (4) it is sus-
tainable and (5) the quality of service provision is
to a high standard. The purpose of developing
sub-categories was to provide a means of facilitat-
ing the formulation of indicators.
Obviously, no one project or programme
aims to act on all factors that determine health.
The SMOC aims to help programme and
project designers in determining their own
Fig. 1: Overview of the Swiss Model for Outcome Classification in Health Promotion and Prevention
(SMOC).
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particular objectives and the measures they
adopt to achieving these. Since the model is
intended as comprehensive, even when focuss-
ing on only one given project, the complexity of
health determinants remains acknowledged
through the continuing graphic presence of the
categories that are not selected.
Concepts central to health promotion such as
empowerment (Hubley, 2002; Wallenstein,
2006), participation (Bracht and Tsouros, 1990),
health literacy (Nutbeam, 2000; Kickbusch, 2002)
and lifestyle (Abel, 1999) do not appear explicitly
within categories in this model since they are
cross-sectional in nature and cannot be assigned
unambiguously to any one outcome category of
the model. For example, empowerment and par-
ticipation may designate not only the outcome of
an intervention, but also a guiding principle in
the conception of an intervention. In this sense,
they may be included as the measures in A or
as outcomes in B. Similarly, health literacy
may be attributed to B4 or B3, and lifestyle to
C2 and C3.
SMOC DEVELOPMENT PROCESS
Model development first began towards the end
of 2002. Originally inspired by the work
of Nutbeam (2000), the model retains his
four-level concept of movement from activity to
outcome. In Nutbeam’s model, these are pre-
sented vertically, and are specified as: health
and social outcomes, intermediate health out-
comes (modifiable determinants of health),
health-promotion outcomes (intervention
impact measures), health-promotion actions.
The SMOC continues to adopt the system of
classifying results into different pre-defined cat-
egories (Figure 1), but differs in a number of
ways: the titles and content of the categories
have been changed, and new ones have been
added (e.g. the inclusion of an approach related
to health-promoting services); each category is
sub-divided into, and therefore specified
through, a small number of sub-categories; the
four levels are presented horizontally, moving
from actions, on the left, to final outcomes, on
the right. Additionally, a detailed guide-to-use
accompanies the model, providing specific
examples of the way in which indicators may be
formulated from each of the sub-categories. In
this way, the model becomes a tool.
Figure 2 charts SMOC development through
three main phases: model construction, feasi-
bility testing and dissemination. The method of
model construction was essentially reiterative:
categories were proposed, and subjected to con-
sideration on the grounds of theoretical coher-
ence and pertinence. The latter was assessed on
Fig. 2: Calendar of the SMOC development process.
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the basis of the collective experience of the
authors and by applying the model to a series
of existing projects. Originally devised in
German, its subsequent translation into French,
English and Italian led to modification for the
purposes of conceptual harmonisation over all
languages. Translation served to highlight con-
ceptual ambiguity and increased the precision
of the tool.
The first version was applied in around 20
different health-promotion projects and pro-
grammes and in training workshops for health-
promotion professionals. Feedback data on ease
and appropriateness of use of the model
resulted in the production of a revised second
edition published on the Foundation’s Web site
a year later. As illustrated in Figure 2, the
SMOC was initially intended for project evalu-
ation, but the possibility for wider use became
progressively apparent once the model was
applied to concrete examples. For example, one
important feedback from the feasibility testing
was that the tool proved useful for situation
analysis and planning prior to project develop-
ment. These functions were then incorporated
into the basic concept. Similarly, it became
apparent that it could be used not only for indi-
vidual projects, but also in the case of pro-
grammes combining a number of projects (Bury
et al., 2005) and even in the development of
health-promotion or -prevention strategies at
cantonal or national level (Spencer et al., 2006).
The model is not designed to be used by a
project manager or evaluator alone, but is
intended for collective use, such as by the entire
project team or by key team members together
with evaluators. Moreover, the collective deter-
mination of a project’s model of effects (also
described variously in evaluation as theory of
action or programme logic) is itself a key part
of the process. The exercise of confronting
opinions and understandings renders explicit
assumptions remaining hitherto implicit. This
provides clarification for both individual
members and the team collectively and facili-
tates the production of transparent objectives.
The dissemination phase began towards July
2005. To some extent, dissemination began
beforehand, notably through availability on
Health Promotion Switzerland’s Web site and
through the Swiss Health Promotion National
Conference in January 2005 (Ackermann and
Spencer, 2005). The dissemination phase is,
however, characterised by wider use and by
institutionalisation of the SMOC, thanks to its
integration in further education and training
curricula in the field of health promotion and
public health throughout Switzerland. In
Switzerland, the SMOC is included in Masters
programmes (MPH, MAS) in six different uni-
versities. Additionally, the model is now an inte-
gral part of the Health Promotion Switzerland
funding process and is linked with the organis-
ation’s quality assurance tool Quint-essenz
(http://www.quint-essenz.ch/fr/). Table 1 pre-
sents some of the first applications of the model
illustrating the level of use (project, programme
or strategy), purpose and location. First
intended for internal project evaluation, it
became apparent that, in certain circumstances,
the SMOC could also prove useful for external
evaluations. One such example is its use as part
of the evaluation of the programme ‘Suisse
Balance’, designed to promote healthy body-
weight through the promotion of healthy eating
and physical activity (Bury et a l., 2005).
Application of the SMOC may be illustrated
by the development of the strategies on alcohol
and tobacco in the canton of Geneva,
implemented by the Department of the
Economy and Health. In each case, authors of
the model worked with the principal stake-
holders (Health Authority, the NGO mandated
for prevention of harm related to alcohol and to
tobacco, respectively) to (1) conduct a situation
analysis of alcohol- or tobacco-related problems
in the canton; (2) specify the revised cantonal
strategy and, in consequence, the major goals
for the next mandate; (3) develop a theory of
action in which current and planned activities
were discussed in relation to the major goals
and the hypothesised means (levels B and C) to
achieving them; (4) establish the programme of
activities for the coming years, the priorities in
relation to each goal over the coming year and
the indicators by which their achievement was
to be assessed. Negotiation took place in work-
shops in which activities, and results at levels B,
C and D, were written and physically arranged
on a poster-size version of the model. The
process was reiterative and continued until satis-
faction of all stakeholders was achieved. The
exercise brought about considerable clarification
of implicit values and motivation and was per-
ceived as highly useful and effective by the sta-
keholders involved. The next stage will be
evaluation of the two programmes using the
defined indicators.
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POSITIONING OF THE SMOC
IN RELATION TO OTHER MODELS
It was considered important to situate the Swiss
Model for Outcome Classification in relation to
similar attempts elsewhere to develop a systema-
tic approach to the evaluation of health-
promotion activities. The SMOC has links with
many different forms of scientific enquiry; the
models and tools identified from a systematic lit-
erature search each shared some, but not all, of
the characteristics of the SMOC and fell into two
main fields: health and evaluation. Those in use
having particular links with the SMOC are out-
lined below and further examples are referenced.
Models from the health field
A significant starting point in modelling the
determinants of health is seen as the Lalonde
report (Lalonde, 1974). Since then, various
models have been developed to improve the
practice of public health and health promotion,
some aiming to be comprehensive and others
more focussed on specific aspects.
As described above, the model bearing most
similarity to the SMOC is that of Nutbeam,
which first inspired the work in Switzerland.
Nutbeam’s model has been developed further
and applied for the evaluation of health-
promotion activities in Scotland by the Health
Education Board (HEBS) (Watson and
Wimbush, 2000). As with SMOC, the model
was found to be an important tool for engaging
stakeholders in the evaluation planning process
and for building consensus about outcomes.
The Netherlands Institute for Health
Promotion and Disease Prevention (NIGZ) has
developed a Health Promotion Framework,
which, in common with the SMOC, has four
Table 1: Initial applications of the SMOC
Title Organisation
responsible
Level Themes Purpose
Early detection of depression
and suicidal behaviour in
young people in the canton
of Bern
Cantonal Public
Health Authority,
Bern
Project Early diagnosis of
depression and suicidal
behaviour
Project and
intervention
planning
Bunt kickt gut – Swiss
intercultural street football
league
Infoklick Project Integration of migrants Design for
Autoevaluation
Midnight Basketball Midnight Projekte
Schweiz
Project Integration of young
people
External
outcome-focussed
evaluation
Suisse Balance (Healthy
eating and physical activity
promotion programme)
Health Promotion
Switzerland and
Federal Office of
Public Health
Nationwide
programme
Healthy bodyweight Design for external
Evaluation
Health Promotion in
pre-school age, City of
Bern
Public Health, Social,
Youth and School
Services in the
Canton of Bern
Municipal
strategy
Health Promotion in
pre-school age,
Intersectoral
collaboration
Development of a
common strategic
orientation
Development of a cantonal
strategy on alcohol,
tobacco, physical activity/
healthy eating in the
canton of Geneva
Cantonal Public
Health Authority,
Geneva
Cantonal
strategy
Alcohol, tobacco, physical
activity and healthy
eating
Setting of objectives
and indicators
National strategy for healthy
bodyweight
Health Promotion
Switzerland
Nationwide
strategy
Healthy bodyweight Situation analysis and
strategic planning
Afrimedia—HIV/AIDS
prevention for sub-Saharan
migrants
Swiss AIDS
Foundation
Nationwide
project
HIV/AIDS prevention Situation analysis and
intervention
planning
Development of a cantonal
strategy for health
promotion and prevention
Cantonal Department
of Health and
Finance, Glarus
Cantonal
strategy
Harmonisation of vertical
programmes towards a
common health
promotion strategy
Situation analysis and
priority setting
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main levels entitled ‘interventions—intervention
results—determinants—health’. However, the
specific elements or ‘boxes’ at each level differ
from those of the SMOC. The Netherlands
model also includes a pre-intervention level
designated ‘Organise’, covering seven different
kinds of resources required in order that inter-
ventions may take place, such as ‘Manpower
Competence, Methods/Materials ...’. The fra-
mework is completed by a surrounding circle,
representing different elements of societal
context (demography, politics, ...) (Saan and de
Haes, 2005; Saan and de Haes, 2006). As Health
Promotion Switzerland, the NIGZ also has a
complementary quality assurance tool available
to practitioners, the ‘Preffi’. Originally designed
to orientate research in health promotion, the
NIGZ model has a more theoretical emphasis
and different objectives than the SMOC. Under
development for over 10 years, it is also more
elaborate. Despite differences, when presented
together at an international workshop held in
2006 (Saan and de Haes, 2006; Spencer et al.,
2006), common factors regarding the utility of the
models were identified: to clarify objectives and
demonstrate to decision-makers how results may
be expressed other than in epidemiological data.
The European Community Health Promotion
Indicator Development (EUHPID) Project is of
key relevance to the SMOC in that it has pro-
duced a theoretically based model of health
development (Bauer et al., 2003, 2006).
Essentially, EUPHID proposes three main
classes of public health outcome indicators:
indicators of health (corresponding to level D
in the SMOC); indicators of individual determi-
nants of health (corresponding to SMOC cat-
egory C2); and environmental determinants of
health (separated in the SMOC into C1-physical
environment and C2-social environment). The
EUHPID model notably insists on the import-
ance of indicators maintaining a balance
between the pathogenic and the salutogenic
perspectives on health. This balance was also a
guiding principle in the SMOC construction, as
is apparent in the nomenclature of the sub-
categories. EUHPID acknowledges the need for
specific classes of process indicators to be devel-
oped, reflecting the strategies used to influence
ongoing health development. The EUPHID
model and the SMOC therefore prove comp-
lementary. The former proposes specific indi-
cators for the SMOC levels C and D; the latter,
in levels A and B, proposes an approach for
deconstruction of the process of moving from
intervention to impact on health determinants.
It should not be forgotten that considerable
work has been conducted over many years in
health education to develop a systematic
approach to intervention planning and evalu-
ation, as testified by manuals such as that of
Green and Lewis 1986. One of the most exten-
sively used tools is the PRECEDE model,
which stipulates the predisposing, reinforcing
and enabling factors necessary for behavioural
change towards health. Subsequently named the
PRECEDE-PROCEED model, it has been
extended to include wider issues such as the
environment and policy and organisational
factors necessary for change (Green and
Kreuter, 2004). Direct comparison with the
SMOC would be difficult, since PRECEDE-
PROCEED is more complex and ambitious in
its scope: the PRECEDE phase covers five
types of diagnosis (situation analysis), and the
PROCEED phase covers implementation and
three types of evaluation. Specific mention is,
however, made here in view of its importance in
the field: developed over the past 40 years, it is
widely taught and documented to have been
applied in around a thousand studies (http://
www.lgreen.net/precede.htm).
Table 2 summarises models and tools identi-
fied as having a similar purpose and approach
as the SMOC. The table includes both those
discussed above and additional models, destined
variously for programme planning, evaluation
and promotion of best practices. Of less direct
relevance to the SMOC, they are not further
developed here, but are included for reference
and in testimony to the myriad of attempts to
improve the state of the art in the field. It is
impossible to establish a taxonomy, distinguish-
ing between models on specific criteria, since
they overlap considerably. For example, choice
of the term ‘conceptual model’ or ‘tool’ reflects
a difference in emphasis, but no clear distinc-
tion between the two may be drawn. The
‘purpose’ indicated in the table is drawn from
the authors’ own descriptions.
Social psychology is present in health pro-
motion in relation to mechanisms associated
with salutogenesis, providing theoretical bases
for interventions related to health and beha-
viour so that they might be effective, such as
the transtheoretical model (Prochaska and
Velicer, 1997), or the theory of planned beha-
viour (Armitage and Conner, 2001) and offering
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insight regarding various aetiological psycho-
logical components of ill-health or good health,
e.g. locus of control (Lefcourt, 1982), learned
helplessness (Peterson et al., 1995), sense of
coherence (Antonovsky, 1996), self-efficacy
(Bandura, 1977) and empowerment (Yeo, 1993;
Wallenstein, 2006). Any one or more of these
different theories may be incorporated into the
SMOC, as and when appropriate, depending on
the mechanisms of action postulated by those
devising the projects or programmes.
Model construction as practiced in evaluation
The evaluation of activities in relation to project
and programme objectives is a key concern in
evaluation. A completely separate tradition
from public health, the field of evaluation has
developed entirely different understandings of
what constitutes evidence and the methods gen-
erally used to obtain it. Successive schools have
refined different theoretical concepts and
related techniques (Patton, 1997; Pawson and
Tilley, 1997). This tradition emphasises that
evaluation must be tailored to the specific
context and resources, and that it should be par-
ticipative, taking into account the perspectives
of the different stakeholders. Furthermore,
understanding of process is considered as
important as the assessment of outcome; the
former allowing us to distinguish inadequacies
in programme content from those in programme
implementation (Springett et al., 1995).
Evaluation in this sense is most known in the
public sector with regard to social policy analy-
sis, and the epistemological complexity of this
field and its potential contribution is relatively
little known to health practitioners. However,
health promotion and other fields, such as
health policy, are increasingly incorporating the
paradigm and methodology of evaluation into
their methodological toolbox (Lincoln, 1992;
Thompson, 1992; Springett et al., 1995).
The definition of a succession of objectives,
each defined by a number of indicators, and
leading towards an ultimate goal, is a character-
istic of many tools used in evaluation. The field
of evaluation boasts a rich methodology for the
analysis of process, impact and outcome in
complex situations. One technique that has simi-
larities with the SMOC is that offered by logic
models (CDC Evaluation Working Group, 2006)
(http://www.uwex.edu/ces/lmcourse/Resources/
ContentPages/bibliography2.htm). Part of a
wider approach in evaluation known as ‘theory-
based evaluation’ (Chen, 1994), a logic model
‘provides a graphic depiction of the relationship
between the main strategies of a program and
Table 2: Overview of relevant models and tools applied in health promotion
Title Description of purpose Reference
publication
EUPHID Health Development Model for the
classification of public health indicators (European
Community Health Promotion Indicator
Development Model)
European set of pathogenic and salutogenic
indicators for monitoring health-promotion
interventions; common frame of reference
Bauer et al.,
2006
Outcome model for health promotion (Nutbeam) Common framework for evaluating health
promotion; outcome hierarchy
Nutbeam, 2000
Health Promotion Framework/Knowledge
management cycle (NIGZ)
Common frame of reference on knowledge
required to optimise effectiveness; focus
research, guideline for intervention planning
Saan and de
Haes, 2006
PRECEDE-PROCEED Health-promotion planning and evaluation
(diagnosis, implementation, evaluation)
Green and
Kreuter, 2004
Interactive Domain Model (IDM) Framework designed to assist practitioners in
taking a Best Practices approach to health
promotion
Kahan and
Goodstadt,
2005
RE-AIM Framework Evaluation of public health impact (reach,
efficacy, adoption, implementation,
maintenance) of programmes
Glasgow and
Vogt, 1999
Project Description Framework Framework to assess the effectiveness of health
promotion
Thurston et al.,
2003
Results Mapping Programme evaluation tool Reed et al., 2000
Outcomes Hierarchy for Health Promotion
(Australia)
Framework/outcomes hierarchy; tool for policy,
planning and evaluation
King, 1996
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associated goals, objectives, population(s) of
interest, indicators and resources’ (Hyndman
et al., 2001). Its purpose is ‘to communicate the
underlying “theory” or set of assumptions or
hypotheses that program proponents have about
why the program will work’ (Funnell, 1997, 2000;
Schmitz, 1999). Their application now extends
into the field of public health (Letts and Dunal,
1995; Center for Disease Control, 1999;
Hyndman et al., 2001; Ministry of Health, 2006).
An important and key difference between this
type of modelling and that of the SMOC is that
in logic models the theory is separately con-
structed for each program (the theory of
the program), whereas programs to which the
SMOC is applied, by definition, all adopt the
theoretical underpinning of health promotion
(program constructed on the basis of an
acknowledged theory).
DISCUSSION
There are many types and different understand-
ings of what constitutes a ‘model’ (Earp and
Ennett, 1991). One such is the Swiss Model for
Outcome Classification in Health Promotion
and Prevention, which has both its strengths
and weaknesses in the compromises made in
order that it might exist. The first challenge is to
balance validity and ease of use: highly elabo-
rate models more validly represent the complex-
ity of causality in health and disease, but prove
difficult to put into operation. Models are by
definition reductionist in nature and this may
cause frustration. A higher degree of complexity
is possible if the model remains conceptual;
greater simplification is required when destined
as a tool for the planning or evaluation of a
specific project or programme. In considering
the inclusion of any additional element, the cor-
responding costs in terms of user-friendliness
must be borne in mind. It has been observed
that the SMOC is easily adopted when intro-
duced to potential users in a workshop. Its
feasibility of application on a wide scale in a
non-interactive setting is not yet known.
Impressions thus far are that ease of use
depends largely on the user’s level of familiarity
with the concepts involved and the techniques
of theoretical modelling.
Since the SMOC is designed for use not only
in health promotion, but also in disease preven-
tion, it may be used whether the perspective
adopted is biomedical, lifestyle or socio-
environmental (Raphael, 2000). Although
increasing the potential for use, this openness
regarding ideological positions leads to a certain
theoretical ambiguity that could prove proble-
matic to some. Similarly, the fact that use has
been extended from evaluation to planning and
to situation analysis limits the further refinement
of the SMOC in any one of these directions. In
the same way, the extension of use from project
to programme to strategy, which emerged directly
from application in the field, may at same point
raise theoretical or methodological problems.
No model is ideal or equally useful whatever
the purpose. Ultimately, however, the question to
be addressed is to what extent does the Swiss
Outcome Model fulfil its mandate. Evidence indi-
cates that it is in the process of so doing, with
feedback indicting that SMOC can serve as a
‘common language’ among stakeholders and as a
tool to improve accountability to funding
agencies and the general public. As yet, the
potential extent of dissemination is unclear, but
certain indicators of institutionalisation and sus-
tainability (Shediac-Rizkallah and Bone, 1998)
such as uptake by external organisations and
authorities and integration into postgraduate
teaching courses, are apparent. Finally, it would
appear that the SMOC has potential as a comp-
lementary tool with regard to theoretical work on
indicator development in the European region.
ACKNOWLEDGEMENTS
We are grateful to Barbara So-Barazetti and
IUMSP/BDFM documentation staff for their
contribution to the literature search and to
Myriam Maeder for layout assistance. Funding
to pay the Open Access publication charges for
this article was provided by Health Promotion
Switzerland.
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