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April 2010, Volume 60, Issue 4

Original Article

Potential benefits and perceived need for health promoting hospitals in Pakistan: A healthcare Stakeholder’s perspective

Asif Raza Khowaja  ( Department of Community Health Sciences, Aga Khan University, Karachi )
Rozina Mistry  ( Aga Khan Health Services Pakistan, Aga Khan University, Karachi )
Ajmal Agha  ( Department of Community Health Sciences, The Aga Khan University Karachi )
Rozina Karmaliani  ( Aga Khan University School of Nursing, Aga Khan University, Karachi )


Objectives: To explore perceptions of healthcare stakeholders\' about health promoting hospitals, potential benefits and need in Pakistan.
Methodology: A qualitative exploratory study was conducted between July- August 2007. The data was collected through key-informant (KI) interviews and focus group discussions (FGD) with purposively selected hospital administrators, healthcare providers, health policy makers, and UN-donor agency representatives. The thematic analysis was done using QSR NVivo 2.0; and nodes representing themes were generated.
Results: The study participants perceived health promotion, a concept synonymous to health education. Those participants with public health background were better able to relate their perceptions to a more holistic view of health promotion; than those without public health background. Participants largely revealed HPH to benefit not only patients, but also community, hospital staff and hospitals at large. HPH transition was also perceived as \'opportunistic step\' for controlling triple burden of diseases, curtailing morbidity and mortality toll, and \'sole answer\' to promote population health, and wellbeing. Given the view, HPH was strongly recommended as "Need of the hour" for Pakistan.
Conclusion: The HPH settings would bring positive change in the healthcare delivery system, by empowering patients and local community. Technical trainings on health promotion for healthcare providers, constant policy dialogue, political will and support from community stakeholders will further strengthen the scope of health promoting hospitals in Pakistan (JPMA 60:274; 2010).


The word \'hospital\' in tradition brings a depressive picture to one\'s imagination of rows and columns of beds occupied by sick people waiting for treatment. In that context, hospitals were largely seen as "body repair" shops, where, the culture was dominated by curing disease or correcting deformity.1
Ideally, hospitals not only have impact on health of the population by means of treatment and rehabilitative services, but also on the local environment and economy in partnership with community.2 According to a global estimate, hospitals consume 40% to 70% of the national healthcare expenditure, constitute large number of healthcare taskforce, contribute major part in healthcare service delivery, therefore, potentially important for public health agenda.3 Today, World Health Organization(WHO) encourages hospitals to respond to the recent transition of thinking away from disease and illness oriented care towards more holistic healthcare, as Health Promoting Hospitals.4 WHO defined HPH that "Develops corporate identity, embraces aims of health promotion and demonstrates a healthy culture and structure within the hospital."5
Today HPH initiative has evolved as the eminent phenomenon in western part of the world, with 25 member states, 35 national or regional networks and more than 700 hospitals accredited internationally.6 In contrast, this phenomenon is rarely evident in the developing world, and remains an unexplored part in healthcare delivery system.7
In Pakistan, health promotion strategies in general are seen as an important element of social determinants of health; and to improve population health indicators. The particular emphasis to promote mental health, and social well being of an individual and communities is being encouraged.8,9 These strenuous efforts by the government have placed health promotion higher on the personal and public agenda.10 However, the inter-sectoral approach and coordinated efforts of the hospitals in relation to health promotion and disease preventions are unexplored, which further indicates paucity of information to potential benefits and perceived need for HPH in Pakistan.
This study was thus performed to explore perceptions of healthcare stakeholders\' about HPH and about potential benefits and need for HPH in Pakistan.


The qualitative exploratory study was conducted between July - August 2007.   This study design helped in understanding the subjectivity of the research topic being explored, and triangulated information to generate hypothesis for further studies.11 The literature review was done using key words on health promotion; and health promoting hospitals in the context of developing and developed world.
The study settings included; a private and public teaching hospital (Aga Khan University, and Jinnah Postgraduate Medical College Hospitals) at Karachi, selective health departments in government of Sindh (Planning and Development, Public Health, and Board of Governors of Public Hospitals), one section (Inspector General Public Hospitals) in MoH, two UN agencies "UNFPA" and "WHO"; and one donor agency "USAID" regional offices based at Karachi.
The study population was; the hospital administrators (Medical and Nursing Directors), healthcare providers (Doctors and Nurses), health decision or policy makers, and selective regional heads of UN and donor agencies. The eligibility criteria for these participants were: Professional relevancy, at least one year of job experience, and willingness to talk about health promotion at hospital. In order to explore general perceptions of healthcare stakeholders, these participants were invited from multiple settings.
The data was collected using key informant interviews with 11 participants and two focus group discussion (6 participants in each).  The participants were purposively selected, and information saturation was reached. The KI interview and FGD guides were developed in the light of literature search, and were pre-tested on the sub-set of target population, to evaluate questions\' appropriateness, comprehension, and duration. Assuming HPH as relatively new terminology, investigator also used few probes such as "health", "health promotion" and "health promotion in hospital", where needed.
The thematic content analysis was done, using qualitative data analysis software NVivo 2.0. The individual responses were coded on free nodes, which were further organized into parent (tree), child and sibling nodes, to drive themes and sub-themes.12 Later on, emerging themes and sub-themes were interpreted and assertions were made. Additionally, findings from FGDs helped to triangulate the obtained information from KI interview.
This study did not involve any physical or emotional harm to participants. The participation was made on voluntary basis, for which a written consent was obtained from all participants. The confidentiality was ensured by coding individual responses on unique participant identification codes. This study received ethical approval from Ethical Review Committee, Aga Khan University, Karachi.


The group of key informants included health decision or policy makers, whereas, all FGD participants were healthcare providers. The participants\' perceptions were categorized into following themes and sub-themes.
1. Health, Health Promotion and Health Promoting Hospital
2. Benefits of HPH
   a. Benefits to patients
   b. Benefits to community
   c. Benefits to hospital staff
   d. Benefits to hospitals
3. Need for HPH
Health, Health Promotion and Health Promoting Hospital:
Participants in KI interview and FGD perceived health as an \'ideal state\', which could be sustained through health promotion. The health promotion in hospitals in particular, was perceived as \'ring in a chain" integral component, which aims to promote population health. Model-1

presents perceptions on interconnected concept on health promotion.
Though participants perceived health promotion as an integral approach to achieve and sustain good health, however, it was largely reported synonymous to "health education\'. Those participants with public health background were better able to relate their perceptions to a more holistic view of health promotion than those without public health background. The participants (nurses and doctors) in a FGD revealed "Health promotion is to provide patients with charge-free admission, and medicine at the hospital."[FGD.#-02]. Similarly, there was generic understanding among KIs (those without public health background), who also perceived hospitals as \'centers for curing diseases and ailments\', and health promotion as, "untraditional activity for hospitals"[Participants K.I, P-04, passage 2 of 12, section 1.6 Para 62].
In contrast, KI (those with Public Health background) largely perceived health promotion as \'integral component of service delivery\' at the hospital and highlighted need for collaboration with the social sector to promote population health. This finding was further triangulated with another FGD conducted at the private hospital, where some of the participants (doctors and nurses) had taken public health short-courses, and they were able to relate health promotion for patients and community as, \'holistic approach\' of the service delivery at hospital.[FGD.#-01]
Potential benefits of HPH:
The KI were spontaneous in revealing benefits of HPH, however, frequent probes were used to direct FGD participants. The participants both in KI and FGD perceived HPH to greatly benefit patients, community, hospital\'s staff, and hospitals at large. These benefits were reported to be \'not mutually exclusive\'. The Model-2 presents perceived benefits of HPH.

Benefits to patients:
Health promotion at hospital was perceived to cater patients\' actual as well as potential health needs in the short and long-run. The common perceptions among KI & FGD participants were categorized into following sub-themes:
u Healthy stay at hospital: Participants previewed "Clean hospital environment, proper sanitation system and other environmental standards will help in providing a comfortable stay for patients at the hospital"[Participants K.I, P-04, passage 1 of 2, section 1..3.4 Para 32].  The FGD participants also reported that implementation of patients\' safety standards at the hospital shall prevent patients from hospital acquired infections and reduce number of accidental injuries.
u Knowledge is power: It was largely perceived that increase in knowledge among people about disease prevention would reduce risk of inflicting communicable/non-communicable diseases; avoid complications and promote healthy lifestyle. In addition, patients were also perceived as \'change catalyst\', who will disseminate information to others in family, friends and community [FGD.#-01].
u Decreased economic burden: The participants perceived "HPH as art state of the art facilities integrated under one-roof, will save patients\' cost and time" [Participants K.I, H-01, passage 2 of 2, section 1.5.1 Para 45]. The FGD participant revealed, "When patients will get coordinated services at the hospitals, it will shorten length of stay at the hospital"[FGD.#-02]. In this way, it would greatly contribute to quality of life, decreasing disability adjusted life years and save opportunity cost.
Benefits to community:
The participants in both KI and FGD perceived Health promoting hospital was perceived to benefit community directly and indirectly. The perceived direct benefits were mainly related to outreach services to the community, whereas, indirect benefits were to be reflected through population health gain and improving health indicators. The common perceptions among KI and FGD participants were categorized into following sub-themes:
u Care at the door step: The FGD participants perceived that community based services would narrow-down service gap between hospital and vulnerable people at community, "Community people will benefit from the locally provided services at schools, workplaces, and community settings"[FGD #-01].
u Capacity building: The participants in KI & FGD perceived community based health education and promotion programmes to create mass awareness about preventable public health problems, facilitate learning of emergency life saving skills, and develop local capacity building at community. The FGD participant narrated, "The community members could form disease specific interest groups, so that, others could learn from the experiences of their own people, in their own language"[FGD.#-01].
u Decreased morbidity and mortality toll: The participants viewed HPH to lead health conscious society, and make healthy Pakistan, "Health promotion per se, results in  decreased morbidity and mortality indicators, which ultimately shall help the country to attain Millennium Development Goals (MDGs)" [Participants K.I, P-01 passage 1 of 1, section 1.5.1 Para 75].
Benefits to hospital staff:
The healthcare providers perceived HPH settings directly proportional to achieve job satisfaction, motivation to work, and healthy task force at the hospital. The common perceptions among KI and FGD participants were categorized into following sub-themes:
u Healthier the workplace, happier the workforce: Participants in FGD narrated, "If the environment is hygienic and basic facilities are available, then staff will work comfortably"[FGD.#-02].  A KI narrated, "When staff gets facilities, healthy environment and updated knowledge, this builds their confidence and leads to an increased work satisfaction. This results in reduced staff absenteeism, reduced work related stress level, and sincere work." [Participants K.I, H-04 passage 3 of 5, section 1.5.2 Para 43].
u Professional growth: The FGD participants perceived "Working at state of the art hospital like HPH; staff will learn a lot, which will enhance their professional growth and maximize output"[FGD.#-01]. Similarly, there were generic perceptions among KI about knowledge of health promotion crucial to increase staffs\' expertise.
u Improved professional image among public: The KI, particularly nurses perceived HPH as improving their professional image in the public. "If nurses work on health promotion related activities for patients, attendants, and the community at large, then definitely, it will help to improve the professional image of nurses to a greater extent in our country." [Participants K.I, H-04 passage 5 of 5, section 1.9.9 Para 124].
Benefits to hospitals:
Though participants perceived HPH equally beneficial to public and private hospitals, however, the common perception related to public and private hospital are categorized separately.
Benefits to Public hospitals:
u Meeting goal of existence: The participants largely perceived that, transition to health promoting hospital would enable public hospitals to achieve objective of their existence, and improved reputation and quality standards among the local public. According to a KI, "The biggest benefit for the public hospital would be to achieve good population health, that is the purpose of our existence"[Participants K.I, P-02 passage 1 of 1, section 1.4 Para 54].
Benefits to Private hospitals:
u Reputation and financial gains: The KIs particularly the policy/decision makers symbolized HPH to a marketing strategy to make business and improve quality standards in the health care delivery. A KI stated, "If you have more patient volume at the hospital, you will have more revenues, which is important for sustainability"[Participants K.I, H-02 passage 2 of 3, section 1.5.4 Para 49].   In addition, an FGD participant revealed, "The hospital\'s reputation will rise in the community; it will get recognition nationally and internationally"[FGD.#-01].
Perceived need for HPH:
In view of the reported potential benefits, the participants recommended HPH as \'need of the hour\' for Pakistan. An FGD participant revealed, "We as a developing country, have limited resources, low literacy, poor vital health indicators, public health problems (communicable and non-communicable diseases) and yet more epidemics are emerging"[FGD #-01]. In addition, a KI revealed, "This is the time to do something extraordinary or something untraditional". [Participants K.I, D-02 passage 3 of 6, section 1.8 Para 61]. Though transition from curative to preventive and health promotion at hospital was perceived by some of the participants as \'untraditional\', many other participants (those with public health background) termed as "sole answer" to control morbidity and mortality toll from preventable diseases and assist Pakistan to attain Millennium Development Goal (MDGs). Moreover, this strategy was also perceived as \'cost effective\' approach that would yield \'positive return on investment\', promote \'healthy public policy\', and create friendly \'ethos\' for disease prevention. [Participants K.I, P-05 passage 8 of 10, section 2.2 Para 43].


Health promotion in hospital has its roots back to Ottawa Charter, the first ever international conference on health promotion held in 1986.13 The Ottawa charter defined health promotion as the process of enabling people to increase control over their health and its determinants, and thereby improve their health. Though the initial emphasis was upon creating healthy communities, schools and workplaces, however, a number of other settings, such as health promoting universities, health promoting prisons and health promoting hospitals were later evolved as part of the holistic approach to promote health and well being.14-16 The basic premise of a HPH was to apply the strategies of the Ottawa Charter for health promotion, and setting approach to reorient the organizations to become more health promoting.13
After the Ottawa Charter, a number of influential conventions and international conferences have been organized; Bangkok Charter being the recent move towards institutionalizing HPH in the globalized world. This charter was based on the fact that, the world context of health promotion has drastically changed since the 1986, and the factors affecting this change are increase in inequalities within and between the countries; new models of consumer society, communication, and marketing; and world environmental changes and urbanization.17
Given the globalized context and increasing trend of HPH accreditation worldwide, this study underscored the importance of health promoting hospitals, perceived benefits and local need for such initiative in Pakistan. The themes that emerged from this study highlighted health promotion as integral part of service delivery at the hospital, however, dominantly central to health education only. Although health education and health promotion are two distinctive approaches not interdependent, many nurses get confused and used them interchangeably.1 The HPH in this study was perceived as an untraditional responsibility for hospitals, which in the other way reflects WHO\'s efforts to mobilize hospitals to think and act beyond its traditional boundary as curative agent.18 There was obvious difference of perceptions among participants with and without public health background. Those with academic and professional exposure to public health could define health in a more holistic manner, and well comprehended preventive role of hospitals. This was an interesting finding, but could not be validated with any literature; except triangulated with FGD in the same study. The review of investigator\'s reflective diary revealed better understanding of health promotion among nurses, as compared to doctors in a FGD conducted at a private hospital. Since nurses are actively involved in patient history, direct care, and patients\' recovery plan, their general awareness to health promotion is central.19 Though comparing knowledge or attitude among study participants was not the study objective, this finding prompted as to how different nurses\' academic and professional grooming is at the private versus public hospital.
The benefits of HPH were perceived in a broader perspective to bring about a healthy change among patients at the hospital; and a positive impact towards healthy communities. The patient education incorporating self-management and empowerment remains a cost-effective strategy.20 Besides, HPH settings were perceived to create happier and healthier working environment for staff, as an important strategy to recruit and retain trained manpower. A research study in a local context reported, nurses\' satisfaction and longer job retention with the conducive working environment, performance based incentives, recreational activities, and empowerment.21 Interestingly, HPH was symbolized as an appealing phenomenon for both public and private health sector in Pakistan. Owning international accreditation would be an opportunity to grow business, and improve quality standards of care simultaneously. A research study reported that, hospitals involved in health promotion activities, turn to be cost-effective, and have competitive strategy to meet organizational legitimacy.22
In view of current health scenario and emerging public health problems, HPH trend was largely backed by majority of the study participants. The public health challenges of 21st century; such as cancer, road traffic accidents, and coronary heart diseases, health promotion at hospitals remains a significant need worldwide.23 The participants\' perceptions to why we need HPH in Pakistan are no more different from the experiences of European countries, which resulted in the transition from curative to preventive aspects of healthcare delivery, and led to the inception of HPH.2 Therefore, reorienting hospital services to incorporate health promotion would be one of the important strategies to achieve Millennium Development Goals (MDGs).24
This research study was first of its kind to explore international popular notion on health promoting hospitals, its potential benefits and need in our local context. The scope of this study was limited to healthcare stakeholders only; however, the investigator recognized the perspective of the community and social sector equally important for advocating demand for health promotion at hospitals. This study made a ground for future studies that shall explore community and other social sector perspectives on HPH, conduct policy analysis (hospitals\', provincial and national health policies), and propose tangible framework for establishing HPH in Pakistan.
This study concluded that HPH settings in Pakistan are the need of the hour; and reflect potential benefits to patients, hospital staff, and communities at large. The readiness for transition from curative to preventive aspects particularly owning the role of hospitals in health promotion and disease prevention is evident; the importance to encourage inter-sectoral collaboration; patients\' and community empowerment is well recognized. However, there should be a deeper review of, as to, how the HPH initiative can be taken in the current situation. In order to further strengthen the scope of health promotion in hospitals, healthcare providers should be given technical trainings on disease prevention and health promotion, policy dialogue be ignited to shift funding focus from curative to preventive strategies, and above all the political will and support from community leaders.


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