Oral presentation for Canada Global Health Conference

1. Cross-Culture Research for Developing
Chinese version of the WHO Self-Assessment
Tool for Health Promotion in Hospital
Fengqiong Zhou
Department of Health Management
Canadian Conference on Global Health 2010
(formerly Canadian Conference on International Health)
GLOBAL HEALTH: A HUMANITARIAN CRISIS?
Sunday, October 31st to Wednesday November 3rd, 2010,Oattwa

2. OUTLINE
 1. Object
 2. Context
 3. Methodology
 4. Result
 5. Result explanation and discuss
 6. Conclusion

3. Objective -1
Develop a Chinese version of WHO Self-
Assessment Tool for Health Promotion in Hospital
(WHOSATHPH) through cross-culture research
method.


4. Objective -2
 Discuss the strategies of developing health
promotion in hospital(HPH) in
undeveloped regions;
 Explore the role of value and culture of
HPH on performance effect of health care
system.

5. Context
 Why develop HPH?
 Hospitals play a central role in the health care system;
Hospital cost $
>= 60% of total health
expenditure
Hospital expenditures
are the main part of total health
investment in most countries;

6.  Hospitals produce a great
deal of waste materials;
 Hospitals can become
Potentially hazardous
workplaces.

7. Hospitals are high “people volume” institutions
and are the distribution centers of health and
disease knowledge.

8. Why develop WHOSATHPH ?
 WHOHPH theory and principles offset
the defects of the current hospital
service evaluation standard system.

9. Traditional Hospital Service Evaluation System
 International Organization for Standardization
(ISO),
 Total Quality Management (TQM),
 Principles of European Foundation for Quality
Management (EFQM) .
 The Joint Commission on Accreditation of Health
Care Organizations (JCAHO),
 Joint Commission International (JCI)

10. Traditional Values and Strategies for Hospital Management
Quality
Control In hospital
Disease
Treatment
Health
Expert
Pharmacy
Medical
Science
Technology

11. The defects of Traditional Hospital Service Model
Health Expert

12. American people assess their health care system
U.S. is...
Better Worse Same DK/Ref
Canada 40% 30% 4% 26%
France 31% 14% 3% 53%
Great Britain 37% 17% 6% 40%
Source: Debating Health: Election 2008, Harvard School of Public
Health/Harris Interactive. March 5-8, 2008
http://www.hsph.harvard.edu/news/press-releases/2008-releases/republicans-
democrats-disagree-us-health-care-system.html.

13. WHO HPH Conception and Principle

14. Theory and Principles of HPH
Source from: Groene Oliver, 2006

15. New functions and roles for HPH
Lifestyle
intervention
Nutrition, In and outside
water, air, Hospital
exercise
Patient &
Health
People’s
Pharmacy
Education HEALTH
Medias and
propaganda Social Science Medical science
Foster Health and technology
Values and
Culture

16. Main values and principles of WHO HPH development
HEALTH

17. Health Investment and Health Promotion
Total expenditure on health Life Expectancy at Birth
per capita (Intl $, 2006)
80
6714
The United
States
China 75 75
72
342
The United States China Female Male

18. The resources for HPH development between
China and USA
145
The United States(2000)
China(2005)
94
In Unite States, the cost of medical service
is 5.9% of total family expenditure
26
14
10 9
Physicians Nursing and Other health
density midwifery service
personnel providers
In China, the cost of medical service is
density density
12.5% of total family expenditure
per 10000 population ( data resource : WHO)

19. The challenges and questions for HPH
development
 The effectiveness and strategies for HPH
development;
 The management and performance of HPH in
health care system;
 The Relationship between Health Promotion and
economic development, burden or motivation?

21. The Challenges for China HPH Development
The changes for Chinese health professionals to develop HPH are
very big.
Serve 1.3billion population who live in the polluted environment.
China’s health service resources are scarce. Even so, the limited
Health resource distribution is extremely unbalance and unfair.
•

22. Because of the serious defect of health policy and political policy
and institution, serious insufficient financial investment on health
care system, China health professionals have to gain money from
patients’ pocket directly.
Patient can not get equal access health service.

23. China’s health service resources are scarce.
Even so, the limited Health resource distribution is
extremely unbalance and unfair. Patient can not get
equal access health service.
China Hospital VIP Ward

24. Sanitarium for General hospital
Senior Officers for Public

25. Nursing Hospitals and wards for
Officers


26. China General Hospital and ward


27. China Doctors’ Work Environment
Health workers generally have to face various huge work
stress and work in unsafe work environment.

28. China Doctor Moral Models: China government requirements
to health workers,
only contribute their life and talent without asking for any remuneration
= be a happy slavery

29. One Chinese Hospital’s doctors and Nurse have to
take on Helmet when they work.

30.  Developing a Chinese version WHOASHPH
and test its reliability for further international
comparison research and help China hospital
leaders practice and follow complete HPH
principle;
 Give a primary description of China HPH
developing level;
 Found the further research for HPH theory
developing and practices.

31. A falling leaf can indicate that
autumn’s coming……

32. Methodology

33. Cross-culture research Reliability
process Test
Translated the Spot field
source Back investigation
Pilot
instrument from translated
English into
test
it into (Non-probability
Chinese English sampling )

34. Cross-culture research process:
 Translated the source instrument from English into
Chinese;
 Pilot test: Investigated 8 Chinese health specialists in
Montré al;
 Back translated it into English;
 Two health specialists and the author of WHO self-
assessment tool for HPH (Prof. Oliver Groë ne)
commented the language equivalence of the back
translation version.


35. WHOSATHPH (Groene Oliver, 2006)

36. WHOSATHPH (Groene Oliver,2006)

37. Standard1 Management policy

38. Semantic Equivalence Research
Chinese version and English version
针对问题 to item 针对词语 to word and phrase
用自己的 对条目作用意义的评
你认为这个问题问
话复述 对选择答案 对某个特定术语和词组的认识 价comment the value
的是什么what do
标准 repeat 的解释 understanding to a term and 每个词语的理解 understanding to words to this item
you think about
stand 维度 条目 by own`s explanation phrase
this question
ard doma item words
in code
符合
准确 不清楚n 不符合 准确 不理解的词 有价值 不清楚do
错误w 能 不能n 逻辑 不清楚no 不合适的词 建议用词sugge 没有n
corre o illogi corre 错误wrong can`t valuab n`t
rong yes o logic clear not proper sted word o
ct clear cal ct understand le know
al
1.1
1.2
1
1.3
1.4
一 2.1
2 2.2
2.3
3.1
3
3.2

39. Spot field investigation
(Non-probability sampling )
 22 Hospitals were sampled from three different
“GRADS” Chinese Hospitals from 5 June to 30
August 2008;
 40 hospital leaders, 3 health management
researchers, and 1 government officer were
interviewed or investigated;
 The Sampling cities chosen were from the different
economic development levels in China developed
East region (Shanghai), middle developed region
(Hefei), and undeveloped West-South region
(Kunming);

40. The Geography of the Sample Hospitals

41. Sick-
The name of Shanghai Sample Hospitals Grade
beds

42. Kunming Sample Hospitals Grade Sick-beds
The First Affiliated Hospital of Kunming Medical University 1500
3
The Second Affiliated Hospital of Kunming Medical University 1200
Wu Hua People Hospital 2 160
Wu Hua Fengning Community Hospital 22
1
Wu Hua Community Health Service Center 0
Anhui Sample Hospitals Grade Sick-beds
The First Affiliated Hospital of Anhui Medical University 1890
Hefei Second Civic People Hospital 550
3
Hefei First Civic People Hospital 1600
Anhui Provincial Hospital 1400
Hefei Second Civic People Hospital 2 321
Shushan Administration Division San Li An Community Health Service Center 48
1
Shushan District community Health Service Center 50
Shushan Jingang Town Community Health Service Center 50

43. China Best Teaching Hospitals

44. Shanghai Community Hospital

45. 9 hospitals, 15 hospital leaders were from Shanghai;
8 hospitals, 10 hospital leaders were from Hefei;
 4 hospitals, 15 hospital leaders were from Kunming.
All the respondents voluntarily completed the
questionnaire survey independently; Repeated
questionnaire survey was also completed voluntarily after
3-7 days .

46. The HPH activities Record in Kunming First Affiliated Hospital

47. Results

48. The Reliability of Chinese version WHOSATHPH
Language equivalence test
Backward translation English version compared with the original
English version;
completely the same
WHO Self assessment tool for HPH
WHO Self assessment tool for HPH 1.2
The hospital arranges the resources for the
implementation of health promotion
Objective: Objective • 1.2.1
• The hospital makes a special budget
1. to describe the framework • To describe the framework for the and materials to ensure the
of health promotion, to organization’s activities implementation of health promotion
concerning health promotion as services.(evidence: check the budget
integrate health promotion and personnel resources)
an integral part of the • 1.2.2
as a part into the quality organization’s quality • All clinical departments can provide the
management system in management system. operational guidelines or pathways with
regard to health promotion.(evidence:
hospital. check guidelines)
• 1.2.3
1. completely the same • The easy recognized structures and
thing facilities (including resources, spaces,
2.almost the same equipments) for health promotion have
been built up by the hospital.
3. Some
• (evidence: special elevator for patients.)
4. almost not
5. completely different
9
6
48

49. Only one word was marked as having a different meaning between
the back translation version and the original version by all of 40
items ( the word in Chinese version --- back-translation -- the original
version is : 满足 – Satisfy -- Match).

50. The reliability of Chinese version
WHOSAHPH
The general Cronbach's alpha of the Chinese version
WHOSATHPH was 0.938.
For each domains:
management and policy was 0.793;
patients assessment was 0.819;
patient information and prevention was 0.807;
healthy workplace was 0.785;
continuity and cooperation was 0.755.
The results showed that the Chinese version WHOSATHPH has high
internal consistency and good language equivalence.
But it still needs further large sample size research for the further
validity test.

51. Self assessment of HPH development score mean
by China hospital leaders (ANOVA, SPSS.16)
Grade I Grade II Grade III Officer TOTAL
and
Mean SD Mean SD Mean SD Mean SD
other
Number 11 9 21 2 41
Total means 144.82 48.2 158.67 32.1 154.19 33.6 148 152.7 37.1
management 28.45 8.1 29.44 8.6 27.67 7.9 28 27.6 7.97
policy
patient
22.6 8.8 23.8 6.2 24.1 6.6 38 23.6 7.0
assessment
patient
information and 19.45 9.7 21.33 5.8 21.57 5.7 16 20.35 6.9
intervention
Develop healthy
32 13.6 36.89 7.7 35.43 8.7 36 34.8 10.0
workplace
continuity and
26.18 11.8 30.22 6.1 28.43 7.4 30 28.22 8.4
cooperation

52. China HPH development level
Total Grade1 Grade2 Grade3
sha Ku Kun
shangha Kunmi ngh Hefe Kunmi shang Hef nmi shan Hef min
i Hefei ng ai i ng hai ei ng ghai ei g
N 12 10 13 3 3 2 3 2 3 6 5 8
Total HPH mean 145 132. 156. 165 148. 170.
score 136.83 148.2 168.8 .3 3 168.5 143.33 5 .3 129.3 2 1
management
policy 22.67 29.4 33.92 25 29.7 34.5 23.33 29 36 21.17 29.4 33
38.
patient assessment 34.33 26.2 45.23 33 21.7 47 38 28 40 30.5 26.2 46.8
patient information 20.
and intervention 18.83 23.8 23.31 67 18.7 24.5 18.33 26 22 18.17 23.8 23.5
developa healthy 32. 39.
workplace 33.42 37.2 38 33 33.7 38 33.33 37.5 33 34 37.2 37.5
continuity and
cooperation 27.58 31.6 28.31 29 28.7 24.5 30.33 36 28 25.58 31.6 29.4

53. Self assessment of HPH development score mean
by China hospital leaders

54. The mean Score of Self-assessment HPH by
China Hospital leaders
Cities :
Shanghai HPH (N=15): 142.1 + 26.4
Hefei HPH (N=10): 162.3 + 40.0
Kunming HPH (N=15): 160.6 + 42.6

55. Different Grades Hospitals:
Grade III (N=21) Mean + SD: 154.19 + 7.3
Grade II (N=9) Mean + SD: 158.67 + 10.7
Grade I (N=11) Mean + SD: 144.82 + 14.54
The results indicated that Chinese hospital leaders
self-assessed a high HPH development level. China
Hospitals HP level didn’t present general statistic
significant difference in hospital size and in regions
with different levels of economic development.

56. Discussion

57. China HPH development feature
Groene Oliver found that Europe bigger hospitals
may have better possibilities to implement health
promotion standards than smaller ones in
European HPH development research. But in this
study, China’s HPH development level didn’t
show that HP level is related to hospital size or
economic development levels.
However, further large sample size research is
needed for more general results and conclusion
about China HPH development situation.

58. TCM and HPH
 HP has always been China’s basic rule and
policy with respect to health development
because of HP value in TCM.
 To handle the pressures resulting from the
shortage of the health investment, China
Health Ministry has to depend on TCM to
provide accessible,
affordable, safe and
effective health services.

59. China Health Promotion Philosophy
A great doctor must concentrate and
aspirate his profession without any
selfish desire and lust when he treats
disease. He ought to have great
philanthropy and compassion
to people, and swears to rescue
Patient’s sufferings.
— Dr. Simiao Sun (541-682)

60. Golden Rules for Health Promotion
Dr. Simiao Sun ( 581-682)
 To promote health, people should keep good life
style and life habits.
 People should self perfect his personal quality,
don't touch the deleterious things. As long as
people self health promotion of his body and
spirit, he will not attach any disease neither his
body nor his mind. There is not any source to
produce disaster. It is the Golden Rule for health
promotion.

61. Golden Rules for Health Promotion
 People, who well know the strategy of health
promotion, focus on the prevention of disease. This
is the Golden Rule of health promotion.
 Therefore, when people practice the activities of
health promotion, he not only focuses on medicine
and nutrition, but also stressed on his behaviours.
 Only when people have perfected his behaviours, he
could have long well healthy life even without
medicine.
 Without quality healthy behaviours, people could
not have long quality life; even he has the best
medicine.

62. Long Health Life/ China HP culture and practice
China Famous TCM doctors all have a health long life. In the history, sixty
TCM famous doctors lived over 70 years old, most of them lived over 80
years old, a few of them even lived over 100 years old.
A famous TCM doctor who is 94 A 90 years old Chinese lady who has
excellent health body with natural black
years old, he daily works time
hair. She started to practise healthy daily
is 10 hours. food style 60 years ago when she was
sick. Since she ate healthy food daily, she
never gets sick and always keeps health.

63. TCM integrates health philosophy, health value
and culture concerns into the social sciences
that advocates the disease prevention rather
than treatment, treats ailments in a timely way
before it becomes serious, stresses that
disease treatment should combine mental and
physical elements, emphasizes the harmony
between mind and body, man and society, as
well as man and nature. all of which match the
core principles of WHO HPH.

64. China HPH Developing Principles and
Strategies
Emphasize the patients-center;
public benefits,
disease prevention,
(ex. Regular and free or cheap public
disease screening)
Primary healthcare service first.
Focus on school health education
and healthy lifestyle education.


65.  Depend on the regular evaluation and inspection of
medial service quality and security;
 Emphasize health professional ethics;
 Stress on the adaptive healthcare service
development that matching the national/regional
economic developing conditions.

66. Various evaluation and Competition

67. Shanghai HPH Practices Effect
In 2007, Shanghai health
expenditure per capital ranged
from $90 to $540, life expectancy
was 78.37/83.29( M/F) years,
infant mortality was 3/1000,
Maternal Mortality was
6.68/100000 given birth.
(Data source: Shanghai Health Ministry,
2008 Statistic Report).

68.  Focus on HPH efficiency and close
cooperation.
 Stress on interactivity between patients,
the public, and health professional
workers.
 Focus on the exchange
of successful world
experiences regarding
New theory, technology,
and management.

69. China The USA
Undeveloped country, Gross Developed Country
national income per capita Gross national income per
(PPP international $): 4,660 capita (PPP international
1.3billion population, $): 44,070
Polluted environment, 0.3billion population
Healthy environment

70. China HPH Developing Conditions
Chinese doctor’s office U.S doctor’s office
Chinese hospital crowded and noisy The US hospital register center
waiting hall

71. One China best HPH teaching Hospital ICU ward The US. hospital ICU ward

72. China National Health Education Activities and
Far-ranging National HP Movement
Stress is put on the professional ethics and a spirit of
dedication. Emphasize the public, universal, and benevolent
value of health service and National HP movement.

73. USA Hospital Service Model is disease treatment
model but not health promotion model

74. Lessons learnt from the US failing in HPH practices
The health care system relies heavily on private and not-for-profit
health insurance which drives the health care system in a
marketing business direction.
Over stress the money value and business
marketing role of the health service system;
It ignores the public benefit value and public
participation of health service.

76. Lessons learnt from the US failing in HPH practices
Over depend on advanced medical professional
services;
Ignores the national Pubic HP;
Ignores the important role of the entire society’s
(public) participation in the health promotion
movement;
Ignores fostering a healthy lifestyle and culture
development.

77. Conclusions

78. •The Chinese version WHOSATHPH has a high internal consistency
and good language equivalence.
Reliability
•HPH development level may not be related directly to advanced and
expensive medical equipment, the environment conditions and health
expenditure's.
•The hospital size might be not related to the HPH developing level.
Value of HPH
Development
• Developing country ( or an economically undeveloped region) can
develop high effective performance of HPH through national public
Strategy of participation movement.
HPH • Fostering a national HP value and culture is more effective and
important than unique money investment for HPH developing.

79. Issues and suggestions for
HPH Development

80. Synthesize Prevention and Treatment, National deversified health
Primary and Advanced Medical Service. promotion campaign and
government financial support
Stress on healthy lifestyle
education since
childhood

81. Acknowledgement
 University of Montreal
 Department of Administration of Health
(Farand Lambert, Régie Blais, et al)
 Direction of International Relation( Yves Guay)
 Fudan University (Fu Hua, Zhou Lei, et al)
 Anhui Medical University ( Ma Ying, et al)
 Kunming Medical University( Wan Chonghua, et al)
 Montreal University Women Club.
Professor: Oliver Groëne and Jiqian Fang

82. China research cooperation partners for this research
Professor Fu Hua
(First Line, middle)
and his graduated
students (Shanghai)
Dr. Ma Ying`s
students
Prof. Wan Chonghua (Hefei)
(Kunming)

83. The First Affiliated Hospital of Sun Yat-sen University
(Guangzhou)
The hospital where I had worked for seven years. Today, it has 2228 hospital
beds, has the most advanced medical equipment, is one largest hospital in