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The Use of Theory in Heart Health Promotion: What it can (and cannot) tell us

Contents of OHPE Bulletin 372.1, The Use of Theory in Heart Health Promotion: What it can (and cannot) tell us

I Introduction
II Story
III Discussion
IV Conclusion

-- Introduction and Conclusion by Lisa Mitchell, Heart Health Resource Centre (HHRC)
-- the Story, by affiliates of the HHRC and program practitioners, and Discussion, by Jennifer Poole (health promotion consultant and PhD candidate in the Social Science and Health Program, Department of Public Health Sciences, University of Toronto), are excerpted from The Use of Theory in Heart Health Promotion: What it can (and cannot tell us), an HHRC resource by Jennifer Poole. For more information on this resource, please see section IV.

If you have a resource or point of view to add to this article, let us know by writing to More information on our Letters to the Editor column can be found in our submission guidelines (

I Introduction

In The Use of Theory in Heart Health Promotion: What it can (and cannot tell us), Jennifer Poole notes, "The word 'theory' generates a fair amount of response. It can make some queasy and some curious, some calm and some confused. Often, it generates a feeling of vague, creeping anxiety. It is a word that we hear regularly in health promotion work, tied up with best practices and improved outcomes. It is something that we think that we should know. Yet, theory does not have to be daunting. It can be made accessible and understandable and ultimately improve the work we undertake as health promotion practitioners." (Poole, 2003)

With this thinking, the Heart Health Resource Centre (HHRC) is making available this review of six heart health stories about different kinds of initiatives in a variety of settings. Stories were crafted by a team of professionals affiliated with the HHRC as well as by practitioners involved in the work described. Jennifer discusses the stories and analyzes which theory is exemplified, the pros and cons of that theory and what other theories are evident. Also included in The Use of Theory is a chart that summarizes the theories used as well as some of the other popular theories in health promotion today.

According to Jennifer, "the resource will not provide you with an extensive analysis of each and every theory in health promotion. Rather the resource aims to offer the reader a critical perspective on health promotion theories and how they may or may not be helpful in designing and implementing effective heart health programming." (Poole, 2003).

Below, we provide an excerpt with an example story and discussion. For information on obtaining the complete resource, please see the Conclusion below.

II Story

Speaking Up, Speaking Out--Saving Community Environmental Supports by Cutting Our Teeth on Community Advocacy

Thunder Bay citizens are passionate about moving their community forward and are not afraid of challenges. In fact, they have a local community development plan entitled "Fast Forward," which started as part of the Ontario Healthy Communities Coalition. Within "Fast Forward" there is a "Quality of Life Committee." While this committee sees the development of community trails, air quality and recycling as prime objectives, the community members really adopted the Quality of Life mantra when advocating against certain city budget cuts they saw as detrimental.

In the fall of 2001, the City of Thunder Bay announced $850,000 in budget cuts to the City's Recreation Department. The cuts included closing three city pools, outdoor rinks, a neighbourhood children's program, the Chippewa Park wildlife zoo and the Thunder Bay Conservatory (an indoor greenhouse) and reducing support for community centre councils.

Many groups and individuals spoke out against the cuts, citing the Quality of Life vision as rationale. Anne Ostrom, the Heart Health Coordinator of Take Heart Thunder Bay, explains that the Healthy Communities perspective means that Thunder Bay is focused on quality of life issues that provide supportive environments to sustain healthy communities.

Anne states that "Part of Take Heart ThunderBay and other groups success in advocacy has been, in part, because we tied our issue to the Fast Forward Quality of Life objectives. Fast Forward had the support of city councilors."

A. Reaction Action

Community reaction was swift and negative. Like other community groups, Take Heart Thunder Bay was dismayed by City Council's decision. At the next meeting of the Take Heart Thunder Bay Steering Committee, they discussed the issue. The community seemed most alarmed about the closure of the Chippewa Park Zoo and the Thunder Bay Conservatory. But for Take Heart Thunder Bay, it was the reduction of pools and outdoor rinks, the elimination of a neighbourhood children's free drop-in program (many sites) and the cut to a city-wide Recreation Supervisor position that caused the greatest concern. These programs provided local, inexpensive or free, accessible recreation services to neighbourhoods across the city. Take Heart Thunder Bay strongly believed that access to community environmental supports created healthy physical activity opportunities, enhanced the quality of life for the community and buttressed other heart health initiatives in the community.

B. A New Role

Take Heart Thunder Bay sprung into action - but not without some concern. They had not been in an advocacy role before - how could they do this - and would they be effective? Undeterred, Take Heart Thunder Bay's coordinator, Anne Ostrom, turned to the Thunder Bay Health Unit for advice. The Health Promotion Planner for Tobacco, Simon Hoad, had been working on healthy public policy with respect to smoke-free public places for several years. Hoad gave Ostrom some specific and well timed advice:
* Keep communication to City Council very brief - a one page policy statement is the most information you can get across;
* Make three key points supported by two statistics each, no more; and
* Know your councilors, who supports the issue and why - keep them up-to-date with any information that can help them make logical, informed arguments on your behalf.

In addition to Hoad's advice, Ostrom had another "ace" in the hole - Ostrom was very familiar with her community, knew the Recreation Division staff well and could get information about the issue quickly and easily. "I kept my ear to the ground, I knew who to talk to, and this helped me to understand both sides of the issue, and where the Coalition needed to push hardest."

C. The Heart of the Matter

Mobilizing quickly, the Take Heart Thunder Bay Coalition developed a position paper on the issue for City Councilors. They made a presentation at a community forum to discuss the cuts and wrote a Letter to the Editor of the local newspaper. With each opportunity, the Coalition stuck to the same key message:
* Children and youth involved in positive recreation opportunities build self esteem, social connections and leadership skills - improving the odds that they will stay out of trouble and away from drugs and alcohol.
* Cuts to physical activity programming and infrastructure that supports active lifestyles increases the strain on already stressed health care services.
* The City will jeopardize the community's ability to develop innovative, grassroots programs and community centre services if Recreation Supervisor positions are eliminated.

D. Endgame

In the end, Take Heart's advocacy efforts, and that of the community of Thunder Bay, had an impact. The City rescinded all proposed cuts to recreation programs in the community, and key environmental supports that build heart healthy lifestyles, were saved. Ostrom knows that the coalition cannot take credit for saving the Recreation Programs on their own, but she adds, "We were among the only people speaking up for the neighbourhood recreation programs and outdoor rinks. These were the services we needed to save in order to keep accessible environmental supports available to our whole community."

E. Collective Success

In addition to saving important community services that help create a healthy community in Thunder Bay, advocating to save valuable community recreation programs proved to the Coalition that not only could they act as one cohesive group but that they could also be successful at it. The coalition began thinking more as a collective than as single organization or as individuals. "It's been a subtle shift," says Anne "now I see more of the members wanting to take an advocacy role on issues like our smoke-free bylaw."

The collective's success has been translated into a new initiative planned for 2003-2004. The Coalition plans a new program called the "Take Heart Network." In this initiative, the coalition will help to inspire individuals within a specific channel or community to make a difference for healthy lifestyles wherever they can - whether it be at work, within the school setting, or in the community. "There are people out there who have a role to play in promoting healthy lifestyles, and we want to support them in playing it," explains Anne. "We've shown what speaking up can do; now we want to inspire other people to be healthy lifestyle leaders wherever they can."

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III Discussion

A. Speaking Up (and Out) in Thunder Bay: What Theory does the Story Exemplify and

What we see here is a fitting example of the Ecological Model of Health Behaviour (Glanz et al, 2002).

With a focus on the individual, group and environment, this model was developed (and then added to) by such theorists as Skinner, Laurin, Barker and Bronfenbrenner working through the 1950s, 60s and 70s. Buoyed by the Healthy Community concept, it has also enjoyed a certain visibility in recent years. It assumes that to understand health behaviour, we must focus on people's transactions with their physical and social surroundings or "environment." It also has a number of central principles.

First, it assumes that health is influenced by issues at multiple levels (individual, organization, group and environment). Second, it assumes that many different kinds of environmental influences affect health behaviour including our food, the buildings we live in and how our community is designed. It argues that behaviour-specific goals are helpful in health promotion work, but multilevel interventions may be most effective. By multilevel, it argues that if the goal is to get people walking more, we may need to hand out pamphlets but we also need to build sidewalks, hold workshops, establish walking clubs, re-zone land into parks and improve cross walks! Clearly, these kinds of interventions need multisectoral groups to keep them going, and they also demand different forms of evaluation (outcome as well as process). However, political dynamics/battles/agendas can limit ecological interventions, so they to need to analyzed as part of the environment and addressed accordingly.

Looking at the success story in Thunder Bay, it is possible to see how the group took an ecological approach to the political dynamics they felt not only affected them but the healthy community environment they had helped to create. First, they assumed that cuts would impact the community at multiple levels. Kids' self-esteem and leadership skills would be affected (individual and groups), hospitals and other health services would be affected by having to shoulder the burden (organizations), grassroots programs and services would be affected (groups, community) and the cuts could lead to higher rates of drug and alcohol use. Secondly, the advocacy team was multisectoral including the local health unit and those adept in public policy and communication. Third, they planned a multileveled intervention including a position paper to council, presentations at community forums and letters to the editor of the local newspaper. Cuts now rescinded (Hurrah!), they have also planned to work at multiple levels in the future, including interventions that target individuals, workplaces, schools and the community in general.

B. Pros and Cons

The Ecological Model can do much for health promoters. It has proven especially useful when working on widespread issues in a community such as obesity and smoking in public places (Glanz et al 2002). The emphasis on multiple factors at different levels builds on the social determinants of health and makes visible some of the structural issues that impact health such as power/race/class(es). Given this, it is perhaps the most effective model for in-depth analysis and sustainable change, enabling us to see around, underneath and outside our usual problem definitions. It dovetails nicely with other approaches such as community capacity building and the model's focus on getting multisectoral groups involved may ultimately enhance the funding, resources and sustainability of a program.

Yet, in reality, we all know multisectoral collaboration is often difficult to create. There may be issues around process and negotiation of goals and these challenges may not be workable in the tighter time-lines we often face. The emphasis on multiple forms of evaluation may also conflict with the trend towards tight, more quantitative measures of health promotion outcomes. For those folks without the flexibility of Take Heart Thunder Bay, the emphasis on political agendas may also place organizations in advocacy roles not in keeping with their funder or agency's agenda. It may, and often does, "produce some anxious moments" as we veer outside our comfort zones. Similarly, the analysis of environmental influences impacting health behaviour may uncover issues outside the supposed "scope" of program (think Erin Brockovich). Decisions around what to focus on and how to go about such wide-reaching "environmental" change may ultimately prove destructive for coalitions not ready or without the capacity to take on such challenges.

C. What Other Theories are Evident in the Story?

As mentioned, the ecological model dovetails nicely with community capacity building. In the story, we can also identify threads of other approaches namely Diffusion of Innovations (Anne's ace in the hole was her insider knowledge of the Recreation Department) and social marketing (Anne consulted with Simon Hoad at the Thunder Bay Health Unit for an audience analysis and advice on how to tailor her message to this particular segment of the audience (i.e., the city council). She learned council would be more willing to spend time on her ideas if it was written with what Simon perceived as their needs (for brevity, clarity and impact) in mind. She also used various kinds of media to get her message across including print, presentations and letters to the newspaper).

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IV Conclusion

If this story exhibiting theory in action has whet your appetite for more, there are five more community stories highlighting theories you can draw on as you plan your interventions:
* Etobicoke/York: Network Analysis
* Hastings-Prince Edward Counties: Diffusion of Innovations
* Chatham-Kent: Community Capacity Building
* Wellington-Dufferin: Diffusion of Innovations
* Northumberland, Haliburton and the City of Kawartha Lakes: Community Capacity Building

The HHRC hopes that this resource will serve as a practical tool: use it as food for thought as you aim to select the appropriate theory or theories that will help guide, ground and explain the important work you do in heart health or health promotion in general.

HHRC encourages you to download the resource off of their website. The Use of Theory in Heart Health Promotion: What it can (and cannot) tell us is available at as a PDF file.

If you have any questions about this resource, please contact Lisa Mitchell at

And for those Ontario heart health practitioners seeking additional support in program planning, you can get in touch with HHRC staff to explore using their consultation program. Call 1 (800) 267-6817 and speak with program coordinators Karima Kassam (x236) or Lisa Mitchell (x242).

V References

Glanz, K., Rimer, B.K. and Lewis, F.M. (Eds.) (2002). Health Behaviour and Health Education: Theory, Research and Practice. 3rd Edition. San Francisco: Jossey Bass.

Poole, J. (2003). The Use of Theory in Heart Health Promotion: What it can (and cannot) tell us. Toronto: Heart Health Resource Centre.