Advances in health promotion in Asia-Pacific: promoting health through hospitals

Abstract

Since 1990, the WHO Health Promoting Hospital (HPH) movement has tried to facilitate and support hospitals to assume a core responsibility in health promotion. The Taiwan HPH Network was established in December 2006, and became the largest HPH network in the world in 2013. Compared to Europe where the HPH has been more established, the pace of HPH development has been much more rapid. This rapid development provides an inspiring example for research and health promotion practice. Systematic data and empirical information have been collected about HPH in Taiwan, allowing for research to be published about the achievements of the HPH movement. This paper provides an overview of the existing literature on current progress of the HPH project according to the four main perspectives of the WHO-HPH movement: promoting the health of patients, promoting the health of staff, changing the organization to a health-promoting setting, and promoting the health of the community in the catchment area of the hospital. The assessment can serve as a stepping stone in understanding current HPH development in Taiwan and as a reference for future research.

Keywords

health-promoting hospitals network health care

Introduction

A series of ‘setting-based’ health promotion strategies, initiated by the World Health Organization (WHO) Ottawa Charter for Health Promotion in the mid-1980s, have become major pillars of health promotion reform worldwide (1). Of all settings, hospitals have received particular attention as health-focused institutions with strong influences on the health and wellbeing of their clients and workforce. ‘Reorientation of health services’ is identified as one of the priority action areas of the Ottawa Charter (1,2). In the past 30 years, several influential reports, including the Ljubljana Charter on Reforming Health Care, the Budapest Declaration on Health Promotion Hospitals, the Vienna Recommendations on Health Promoting Hospitals, the Bangkok Charter, and the Standards for Health Promotion in Hospitals, provided a framework and facilitated the development of the Health Promoting Hospitals (HPH) concept (3 –5). The ongoing discussions have urged hospitals to move beyond their traditional responsibilities for providing clinical and curative services, and shift service priorities and resources to include health promotion practices (6).

In addition to these conceptual developments, the WHO Regional Office for Europe initiated a pilot project in 1993 to test the HPH concept. The European Pilot Hospital Project, which lasted from 1993 to 1997, involved 20 partner hospitals from 11 European countries and marked the developmental phase of the HPH movement (2,7). Following this pilot developmental phase, the networks of hospitals and health care institutions have been consolidated and the HPH movement has expanded across different regions of the world. As of March 2015, there are more than 40 national and regional networks including more than 900 hospitals all over the world (8).

Alongside the development in the HPH concept and the expansion in number of networks around the world, many studies have tried to provide an empirical basis or evidence to the HPH movement. HPH research encompasses several domains. The evaluation studies focus on organizational development and aim to test feasibility, plausibility and acceptability in hospital organizations (5,6,9). Some studies assess capacity building and organizational changes (4,6,10). Other studies have gone further to identify specific barriers and enablers to adopting or implementing health-promoting hospitals. Evidence accumulated from several European countries suggests that HPH is ‘a plausible, acceptable, and feasible development’ for a variety of hospitals and health care systems in Europe (2). Several studies have also reflected positive impacts of HPH on capacity building and organizational changes in terms of health-promoting atmosphere or health-promoting practices in hospitals (9,11). However, many other studies suggest the opposite (4,5,12). The results are mixed and there are considerable doubts about the impacts of HPH. The lack of high-level evidence about the impacts of HPH on health promotion in hospitals deters the further progress of the HPH movement (4). More importantly, a more recent focus of organizational research on HPH is focusing more extensively on the role of health professionals in health promotion and on clinical health promotion including patient-oriented interventions (6).

According to the Vienna Recommendations, health-promoting hospitals comprise the four perspectives of patients, health care staff, the organization, and environments and communities. However, very little literature has systematically assessed the impacts of HPH using these four perspectives (3,4). Furthermore, previous literature is mostly focused on the HPH programs in Europe, United States, Canada, and Australia (4 –6,9). Only very limited evidence is available for other parts of the world including the Asia-Pacific region. As health promotion practice is not purely biological or clinically based, patient preferences, social values, medical culture, and health care systems matter significantly. The findings from Australia, European or North American countries may not be generalizable to health care systems in the Asian countries.

Taiwan established the first formal HPH network in Asia in December 2006. Although the development of the HPH framework has been much slower than in Europe, the Taiwan Health Promoting Hospitals Network has grown rapidly in the number of HPH member hospitals and health services, and has become one of the largest HPH networks in the world. Currently, Taiwan has more than 150 member hospitals and health services. The rapid expansion of the Taiwan HPH Network can be attributed to the resources and support received from the Taiwanese health authorities. The contribution of researchers and leaders from the HPH Secretariat and Taiwan Society of Health Promoting Hospitals, and the established concrete developmental strategies based on the WHO-HPH practices may have also reduced the barriers in becoming a certified HPH (13). The initiation and development of the Taiwan HPH network may serve as an inspiring example to the global health promotion movement. More uniquely, along with the development of the Taiwan HPH movement, systematic data and empirical information have been collected (14,15). These data support policymaking in health promotion activities in hospitals, and respond to the strong demand for a greater evidence base for HPH development.

In this review, we present the development of the Taiwan HPH network and examine the progress of HPH development in Taiwan in the four major perspectives: promoting the health of patients, promoting the health of staff, changing the organization to a health-promoting setting, and promoting the health of the community.

Methods

The data used in this study were obtained from a systematic search of the health-related databases Web of Science, PUBMED, and CINAHL using the terms ‘health promoting hospital*,’ ‘health promoting health services*’ and ‘Taiwan’. Articles were eliminated if they did not involve research or evaluation, and were not conducted in the context of or related to the performance of HPH in Taiwan. Of the 11 articles identified, seven met the criteria. All seven articles were published between 2009 and 2014. In order to supplement the data, reference lists from these articles were also reviewed and the internet was used to locate gray literature such as conference proceedings/presentations, and international and local organizational reports and presentations with a main focus on studying the progress or effect of this initiative.

The Matrix Method was used to organize and analyze the published studies (4,16). The main purpose of our review was to better understand what the HPH network in Taiwan has achieved with respect to the four perspectives. More specifically, a Review Matrix was developed to identify: the type and quality of studies conducted; key aspects or themes of the studies in relation to the four perspectives of HPH (promoting the health of patients, promoting the health of staff, changing the organization to a health-promoting setting, and promoting the health of the community); the changes or the influences recorded, and what remains to be done with respect to the four perspectives.

Results

Most of the studies analyzed used surveys and in-depth interviews for main data collection (Table 1). Only a few used archival data for analysis. The design of most evaluations was either a case study or cross-sectional. No systematic reviews or randomized controlled studies have been published. According to the hierarchy of evidence rules, no high-level research (i.e. level 1a, 1b or 2a) on HPH in Taiwan has been conducted. However, the data, when grouped and analyzed, still provided useful insights into the development and achievement of the HPH movement in Taiwan.

Table 1.

Characteristics of included published studies.

Reference	Study type/sample	Key themes studied	Results
Lin et al. (2009)	Case study: in-depth interview, archival data, staff survey, one HPH site	Enablers and barriers to HPH development	Barriers: limited understanding of the HPH concept; insufficient funding; and shortages in time, personnel, and professional skills in health promotion.
Lin et al. (2011)	Survey: 162 hospitals; response rate: 34.2%; self-assessment tool	Organizational changes	The higher the organizational HP status, the better the self-evaluated organizational and administrative effectiveness of HP.
Lee et al. (2012)	Survey: 52 HPH co-ordinators	Organizational changes	Seven dimensions were assessed: mission and strategy, leadership, organization culture, structure, system, management practices, and staff participation. HPH co-ordinators perceived a positive impact of HPH on hospitals’ organizational capacity and agreed that hospitals achieved an organizational change
Lee et al. (2013)	Case study: triangulation of various sources; qualitative data were analyzed by thematic analysis	Organizational changes/enablers and barriers to HPH development	Barriers: transactional barriers (i.e. insufficient support from external environments, leadership with limited authority, a preference for ideals over professionalism) than transformational barriers (i.e. insufficient system support, ineffective management practices, and inadequate staff participation).
			A positive impact on organizational change: more leadership support, a fine-tuned HP mission and strategy, pro-HP habits of physical activities, a supportive intramural structure, an HP-inclusive system, improved management practices and increased staff participation.
Lee et al. (2014)	Survey: 52 HPH co-ordinators	Organizational changes	Developments of workplace health promotion were assessed. Among HPH co-ordinators, 96% perceived a change in realigning strategies, 71% in more resources, 85% engaged in increased staff participation, and 66% in staff-oriented health services.
Lee et al. (2014)	Survey: 52 HPH co-ordinators	Enablers and barriers to HPH development	Five top barriers: inadequate national health insurance coverage of HP, staff detachment, incoherence of government policies, weak inter-sectoral link and resistance to change.
			Five top facilitators: leadership support, HP-inclusive hospital development mission and goals, government funding, founding of HP-related committee, resources, and health policies.
			Higher organizational capacity building was positively associated with number of facilitators, but negatively associated with number of barriers
Chiou et al. (2014)	Survey: 100 HPH and non-HPHs; 73,391 full-time staff (response rate: 74.3%)	Promoting the health of staff	Staff of HPHs had significantly more days exceeding 30-minutes physical activity than those of non-HPH hospitals; no significant difference was observed for 5 portions of fruits/vegetables a day or stress adaptation between staff of HPHs and non-HPHs.

Five themes were identified in the analyzed data. The themes identified were:

Health of patients

Health of staff

Organizational changes of HPH

Health of communities

Enablers and barriers to the implementation of HPH in Taiwan

Other than the last theme, all themes were closely tied with the four major perspectives of HPH. All themes are discussed below with reference to the relevant studies.

Promoting the health of patients

According to the Vienna Recommendations, health promoting activities shall incorporate the patient perspective. Ideally, health promotion activities need to be oriented towards increasing the competence and the capacity of individuals (3). Of the eight articles included for analysis, none specifically investigated the impacts of HPH on the competence and the capacity of patients in improving their health or health behaviors. But many hospitals in Taiwan, particularly the HPHs, actively participated in many important health promotion activities such as smoking cessation, obesity reduction, breastfeeding promotion, quality improvement in diabetes care, chronic kidney diseases and cancer, cancer screening, and age-friendly health care (17,18). Taiwan’s Health Promotion Administration has tried to compare hospital performance in quality of diabetes care between 112 HPHs and 75 non-HPHs in 2012 using the data from the national health insurance program (15). The results indicated that HPHs had a significantly better quality performance in several process indicators (i.e. regular AIC testing, eye examination, fasting lipid profile and microalbuminuria test). HPHs were also significantly more likely to participate in the diabetes pay-for-performance program. The difference in quality performance between HPHs and non-HPHs was most apparent among community hospitals. Overall, although many health promoting activities have been conducted in HPH in Taiwan targeting individual patients, the evidence in demonstrating the influence of HPH on increasing the competence and the capacity of individuals is still lacking.

Promoting the health of staff

As hospital staffs are a major stakeholder in the HPH movement, promoting the health of staff is fundamental to the concept of HPH. However, previous literature either in Taiwan or in other countries has mostly assessed the attitude or resistance of staff to implementing the HPH initiative, or specific health promotion activities in hospitals for staff. Very few have evaluated whether HPH did lead to better health of their staff. The unique data collection efforts and research findings in Taiwan may help to contribute to the knowledge gap. In 2011, Taiwan’s Health Promotion Administration conducted a nationwide hospital survey, Survey of Physical and Mental Health and Safety Needs in Health Care Full-Time Staff in Taiwan (15). All members of the Taiwan HPH project (66 HPHs) were invited to participate and 55 HPHs responded and agreed. By hospital accreditation level, a random sample of non-HPH hospitals was selected as a comparison group. Of the 61 selected non-HPH hospitals, 45 agreed to participate. As a result, a total of 100 hospitals agreed to participate in this survey. Of 98,817 questionnaires distributed to full-time staff in these 100 hospitals, 70,622 (71.5%) validated questionnaires were returned (15). Chiou et al. reported that staff of HPHs had significantly more days exceeding 30-minutes physical activity than those of non-HPH hospitals. But no significant difference was observed for five portions of fruits/vegetables a day or stress adaptation (14). Furthermore, Wei et al. found that although nurses working in HPHs did not have a lower risk of workplace violence, those working in an outstanding HPH had a significantly lower risk of workplace violence (19). Future research may help to explore the role of staff participation in reducing workplace violence by examining the potential correlation between HPH hospitals with greater staff participation in decision-making.

Changing organizations to a health-promoting setting

One cross-sectional survey of 162 hospitals in Taiwan in 2006 assessed the relationship between each hospital’s organizational health status and organizational effectiveness in implementing health promotion. The organizational health status was measured in terms of policy and leadership, physical environment, healthy culture and health resource and activity using the Organizational Health of Hospital Assessment Scale. The organizational effectiveness of health promotion in this study was defined as the hospital’s capacity to implement health promotion initiatives and achieve outcomes efficiently and effectively. Both administration and program effectiveness of hospitals in their health promotion activities were measured. The results indicated that hospitals with a higher overall score on the Organizational Health of Hospital Assessment Scale were significantly associated with better organizational effectiveness in health promotion, which lends support to the concept of HPH (20). Several other studies tried to assess potential organizational changes following the HPH initiative in Taiwan (21 –23). Both the findings from a survey of 52 HPHs in Taiwan and the report of a case study suggested that HPH led to a positive impact on hospitals in Taiwan regarding organizational changes in capacity building for HPH. Specific positive changes observed included both transformational and transactional organizational capacity for health promotion such as leadership, organizational culture, and mission and strategies (21,23). In addition, the HPH initiative also contributed positively to capacity building of workplace health promotion strategies among hospitals in Taiwan. Of hospital co-ordinators, 96% perceived a positive change in realigning strategies, and 71% perceived more resources. More importantly, 85% of the HPH hospitals engaged in increased staff participation and 66% in staff-oriented health services (22). This positive impact on organizational capacities may have strengthened the legitimacy and desirability of HP in the missions of hospitals and improved the effectiveness and efficiency of HP activities, but this was not reported (21).

Promoting the health of communities

Hospitals are affecting the health of their communities primarily by influencing the health of their patients and the health of their staff. But hospitals can also influence the health balance of the population and environment in their neighborhood. More specifically, the Vienna Recommendations for Health Promoting Hospitals emphasize the role and function of HPHs in promoting community health beyond the hospital settings. HPHs are encouraged to form close links with other levels of health care systems and the community, build alliances with professionals outside the hospital setting, and enhance hospital communication and co-operation with social and health services in the surrounding community (5,8). Although no specific published or unpublished research in Taiwan has systematically evaluated the effects of the HPH initiative on the health of communities, many HPH hospitals in Taiwan have been involved in the Environmentally Friendly Hospital project to promote health care without harm to the environment. According to the statistics of Taiwan’s Health Promotion Administration, a higher proportion of HPHs (94.9%) participated in the Environmentally Friendly Hospital project than non-HPHs (11.3%). For example, many hospitals collaborated with community leaders, environmental professionals, and engineers in improving energy efficiency, improving the public transportation system, reducing waste in water resources, and increasing recycling of resources.

Enablers and barriers to HPH implementation

Three studies assessed the barriers and facilitators to implementing HPH in Taiwan (13,21,24). Lin et al. used the data from in-depth interviews, hospital archival data, and a staff survey to analyze the organizational diagnosis phase of the case hospital and to identify problems encountered during health promotion practices. They found that although the case hospital passed the basic requirements for HPH, the general problems of limited understanding of the HPH concept, insufficient funding, and shortages in time, personnel, and professional skills in health promotion constituted major problems during the process of implementing HPH in Chinese hospitals (13). Lee et al. reported another case study of one member hospital of the HPH initiative in Taiwan. They found that the progress in health promotion was hindered by more transactional barriers (i.e. insufficient support from external environments, leadership with limited authority, a preference of ideals over professionalism) rather than transformational barriers (i.e. insufficient system support, ineffective management practices, and inadequate staff participation) (21). Another survey of 52 HPHs in Taiwan confirmed the presence of similar enablers and barriers to HPH. The commonly cited enablers were leadership support, HP-inclusive hospital development mission and goals, government funding, establishment of an HP-related committee, resources and health policies. The most commonly reported barriers were inadequate national health insurance coverage of HP, lack of strong staff involvement, incoherent government policies, weak integration across different sectors, and resistance to change (24). Improved organizational capacity building was associated with fewer barriers and more enablers.

Discussion

Previous literature reported on the progress and performance of HPH based on the research conducted mainly in Europe (4,6,9). Health Promoting Hospitals is a concept and an initiative that was first developed and implemented in Europe. Later the HPH initiative was promoted by the WHO and has been expanded to countries around the globe. Compared to the long history of HPH development and research in Europe, the development and research in Taiwan or the Asia-Pacific is relatively late, but developing fast. This literature review aimed to extend the HPH research scope to the Asia-Pacific by specifically assessing the progress of hospitals within the Taiwanese HPH Network, the first HPH network in Asia and the largest HPH network in the world. This review also identified research that has been conducted on the performance of HPH in relation to the four major perspectives identified by the Vienna Recommendations: promoting the health of patients, health care staff and communities, and changing the organization to a health-promoting setting in Taiwan.

According to our search, although there is literature that reports on the progress and the performance evaluation of HPH in Taiwan, the articles are mostly limited to the identification of enablers and barriers to implementation of the Taiwanese HPH project, and descriptions of organizational changes led by the HPH initiative. Many enablers and barriers facing Taiwanese HPHs are similar to those facing European HPHs. One barrier unique to Taiwan is inadequate national health insurance coverage of health promotion. Therefore, understanding potential enablers and barriers can not only help hospitals to adopt the HPH strategy, but also allow policymakers or health promotion advocates to find resources to help hospitals overcome these barriers and to facilitate the expansion of the Taiwanese HPH Network. The HPH network not only helps to connect individual hospitals and provide updated WHO materials to hospitals; it can also serve to enhance hospital communications to other social and health services in Taiwan and act as a strong advocate for health promotion in hospitals. The positive organizational changes observed in some hospitals following the HPH initiative in Taiwan lend support to the concept of HPH. More specifically, these observations all pointed out that the government has played a significant role in the rapid development of the Taiwanese HPH Network (13,21,24). The Health Promotion Administration of Taiwan has strongly advocated for value-added health care, helped remove barriers and has facilitated the process by increasing funding for preventive services, launching pay-for-performance mechanisms, providing project-based grants for HPH-related initiatives and engaging other key partners such as local public health departments, academia and hospital associations (25). However, despite these positive findings, the level of this descriptive evidence was low as these studies were mainly based on either a case study or a cross-sectional survey of only HPH co-ordinators. These studies suffer serious methodological limitations including single time point observation, the lack of a good comparison group, and poor generalizability.

In comparison to the number of evaluations conducted on organizational changes, even less published literature is available to provide strong evidence for the impact of the HPH project on the health of patients, health care staff, and communities. Although the systematic data collection efforts of Taiwan’s Health Promotion Administration about health care staff and quality of care allow these evaluations to have better study designs with a comparison group, there is still much room for improvement in terms of level of evidence. The ongoing global WHO-HPH Recognition Project has adopted a randomized controlled design as the way to provide high-level evidence for the effects of HPH on the health of patients and health care staff. The findings of this randomized controlled trial may substantially fulfill the demands for convincing evidence and strengthen the evidence base for HPH development. Since 21 of the 40 participating hospitals in this global WHO-HPH Recognition Project are located in Taiwan, the findings may provide particularly useful references for future HPH development in Taiwan.

A few limitations of this study may be noted. First, this literature review was restricted to studies published in English and accessible via the listed databases and gray literature published on the internet or government reports. Only a low number of studies met the inclusion criteria and were discussed in this review. More importantly, more research with a stronger evaluation design may help to improve the quality of evidence on the progress and development of the HPH project in Taiwan. Second, the quality of these studies and the level of evidence provided were only briefly examined as the focus was on the type and content of the studies. Third, the aim of this study was to introduce the progress and development of the HPH project in Taiwan. Only limited comparison is made between HPH development in Taiwan and other parts of the world. Future research may help to contribute in this regard.

The development of research in Europe may help to provide a constructive comparison. Since the 1970s, HPH research in Europe has moved forward from the early stages of concept development, to a phase of model or pilot project evaluation studies with a strong focus on organizational development, then to further refinement of HPH orientation as a quality movement, and recently to the role of health professions in health promotion and in clinical health promotion including patient-oriented interventions (6). The research design has started to include more quasi-experimental design or randomized controlled trails, instead of case studies as in the earlier research. In comparison, HPH research in Taiwan started in the early 2000s and included mainly evaluation studies of model or pilot interventions with organizational development and implementation challenges. The existing HPH literature in other domains such as HPH concept development or refinement, or the role of health professions in health promotion in Taiwan is less discussed. However, strong governmental support for, and the expansion of, the international HPH network offers more opportunities to expand research domains and establish international research collaboration between Taiwan and Europe. It helps to increase not only the quantity, but also the quality of HPH research in Taiwan.

Conclusion

The Taiwan HPH Network was established in December 2006, and became the largest HPH network in the world in 2013. Compared to Europe where the HPH was more established, the pace of HPH development has been much more rapid. This rapid development provides an inspiring example for research and health promotion practice and it is evident that the rapid expansion of the HPH project in Taiwan was not possible without strong government support and commitment. However, in terms of research development in Taiwan, the findings are relatively limited in research scope compared to the quantity and quality of evidence available in Europe. Nonetheless, there is an increasing amount of ongoing HPH research in Taiwan and there are exciting findings about the positive impacts of HPH on the health of patients, staffs, and organizational changes towards health promotion. This study provides an overview of the existing literature on current progress of the HPH project according to four major perspectives (i.e. patients, staff, organization, and communities) specified by the Vienna Recommendations for Health Promoting Hospitals, and specifies gaps in the literature. The assessment can serve as a stepping stone in understanding current HPH development in Taiwan and as a reference for future research. More high-quality research with rigorous design in Taiwan and other countries is fundamental to the functioning, legitimacy, and effectiveness of the global HPH movement.

Footnotes

Conflict of interest

The authors declare that there is no conflict of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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