SEE ALSO behaviour change; empowerment; evidence-based; needs assessment
The Theory of Change (ToC) is a method for participatory planning and evaluation that can be used to promote social change by defining long-term goals and then mapping backwards to identify necessary preconditions and interventions (Brest, 2010).
The Theory of Change is a means of getting from one point in an intervention to another by outlining the causal linkages in its short, intermediate and long-term outcomes. The identified changes are mapped as a pathway showing each outcome in a logical relationship to the others including the chronological flow of events. The links between outcomes are explained by statements of why one outcome is thought to be a prerequisite for another. The outcomes pathway can be shown diagrammatically using arrows that show the causal link. Early outcomes must be in place before intermediate outcomes, and intermediate outcomes must be in place for the next set of longer-term outcomes to be achieved. An outcomes pathway therefore represents the change logic accompanied by underlying assumptions for why specific connections exist between outcomes. Assumptions explain both the connections between early, intermediate and long-term outcomes and the expectations about how and why proposed interventions will bring them about. Assumptions can be evidence-based thus strengthening the case to be made about the plausibility and the likelihood that stated goals will be accomplished (Brest, 2010).
The ToC approach makes the distinction between desired and actual outcomes but requires stakeholders to model the desired outcomes before they decide on what types of intervention to implement. ToC differs from other methods of describing initiatives because it shows a causal pathway by specifying what is needed for goals to be achieved and requires an articulation of underlying assumptions which can be tested and measured. ToC also changes the way of thinking about initiatives from what you are doing to what you want to achieve (theoryofchange.org, 2014).
Project Superwomen started as a collaboration between a social service provider, a non-profit employment training centre and a domestic violence shelter in the United States. The purpose was to help female-abuse survivors to create long-term, liveable wage-employment opportunities. The project had two basic assumptions: (1) Non-traditional jobs, such as plumbing and carpentry, provide better wages and more opportunities; and (2) Women who have been through domestic abuse need more than job training to move to economic stability. In the first stage of the ToC participants set the long-term goals and then designed a simple map of the preconditions required to achieve them. This helped to visualize the goals as well as specify what was expected to change and for which outcomes they wanted to be held accountable. The long-term outcome was the employment of domestic violence survivors at a liveable wage. To achieve that goal, the participants identified the preconditions: survivors attain coping skills; survivors have marketable skills in non-traditional jobs; and appropriate workplace behaviour. After the first step the participants asked themselves what women would need if they were going to have long-term employment. Specifically, how would the project’s participants achieve the three identified preconditions (coping skills, marketable skills and appropriate workplace behaviour) to the outcomes? Any initiative is only as sound as its assumptions, in this case that jobs are available in non-traditional skills for women and are more likely to pay liveable wages and to provide better job security. These assumptions make explicit why the participants believe this project can work: there are jobs in non-traditional work and that those jobs can offer better financial and professional opportunities. ToC should be able to demonstrate progress on the achievement of outcomes through indicators that guide and facilitate measurement and make the outcomes understandable. The indicators of the ToC focuses on how to measure the implementation and effectiveness of the initiative. For example, outcome 1: Long-term employment at a liveable wage for domestic violence survivors. Indicator: Employment of women graduates. Threshold: Remain in job for at least six months and earn at least $12 per hour (theoryofchange.org, 2014).
A logic model approach differs from the ToC because it is an explanation of the process of producing a given outcome by outlining inputs and activities, the outputs they will produce and the connections between those outputs and the desired outcomes. The ToC is a strategic picture of the multiple interventions required to produce the early and intermediate outcomes that are preconditions of reaching a goal with given assumptions. The ToC summarizes work at a strategic level while a logic model would be used to illustrate the tactical, or programme-level, understanding of the change process (Brest, 2010).
Funders have become increasingly concerned about programme outcomes and accountability. This has led to the popularity of approaches, such as the ToC, that fundamentally allow different questions to be addressed and that make the programme more interesting as well as being a planning and evaluation tool. There are, however, many interpretations of the ToC and a widely accepted, standardized and evidence-based approach has not yet been developed.
KEY TEXTS
•Brest, P. (2010) ‘The Power of Theories of Change’, Stanford Social Innovation Review, 1 March (Spring)
•Funnell, S. and Rogers, P. (2011) Purposeful Program Theory: Effective Use of Theories of Change and Logic Models (San Francisco: Jossey Bass)
•Theory of Change (2014) Available at http://www.theoryofchange.org/what-is-theory-of-change. Accessed 25 March 2014
SEE ALSO addiction; advocacy; counter tactics; fear-based campaigns; lifestyle; non-communicable disease; risk factors; upstream and downstream; youth
Tobacco control attempts to restrict or prevent the use of tobacco products and includes price and tax increases, structural interventions such as tobacco-free environments, banning advertising and promotion, packaging and labelling and cessation initiatives (David et al., 2010).
Tobacco use is the single largest preventable cause of death in the world, causing 5.4 million deaths in 2005. Tobacco products contain nicotine which is addictive and are intended to be smoked, sucked, chewed or snuffed (Blas and Kurup, 2010). Establishing tobacco-free environments involves banning smoking in workplaces and public places and reducing the availability of tobacco by limiting the times and places where tobacco products can be used. It reduces exposure to second-hand smoke, reduces the acceptability of tobacco by changing social norms and influences accessibility through the requirement for government regulation to enact and enforce it. Banning advertising and sponsorship is designed primarily to reduce the acceptability of smoking and other tobacco use by changing social norms. Research has shown that the impact of health warning messages on tobacco packaging depended on the size and design of the content. Whereas obscure text-only warnings appear to have little impact, large warnings on the face of packages can increase health knowledge and perceptions of risk and can promote smoking cessation. Pictorial images plus health warnings that elicit strong emotional reactions are significantly more effective (Hammond, 2011). Countries vary greatly in the extent to which they have implemented comprehensive bans on tobacco advertising despite its effectiveness. Resistance to advertising bans from the tobacco industry can be through manipulating trade agreements over intellectual property rules or through promotion, product placement and glamorized depictions of smoking in the mass media.
The WHO Framework Convention on Tobacco Control was adopted by the World Health Assembly on 21 May 2003 and came into action on 27 February 2005. The WHO Framework Convention on Tobacco Control was developed in response to the tobacco epidemic and reaffirms the right of all people to the highest standard of health. Action on Smoking and Health (ASH) is an autonomous advocacy group that uses the principles of the Framework Convention on Tobacco Control in taking action against the risks associated with smoking. ASH does not blame smokers or condemn smoking but instead uses an evidence-based dual approach: information and networking and advocacy and campaigning. ASH has had some success, for example, in 2007 it won its campaign for a total ban of smoking in enclosed public places in England including in bars and private members clubs, cafés, restaurants and workplaces (Action on Smoking and Health, 2012).
Smoking cessation is the discontinuation of smoking including interventions directed at health care providers, medications including nicotine replacement therapy, counselling and web-based self-help programmes (Blas and Kurup, 2010). Despite their popularity smoking cessation interventions have received criticism for their small degree of success relative to the resources expended. For example, as many as 75% of ex-smokers report having quit without assistance and cessation without professional support or prescribed medication may be the most common method (Chapman and MacKenzie, 2010).
Tobacco use is closely associated with low socio-economic status and disproportionately affects males in both developed and developing countries. There is a clear relationship between cigarette price and consumption. Increasing the tax on tobacco is one of the most effective upstream interventions especially when tax revenue is used for cessation and other preventive programmes, as this serves as a redistributive function to increase access to health services (David et al., 2010). Tobacco corporations have far more influence than pressure groups or public health agencies and use a range of tactics designed to influence decision-makers, researchers, public opinion and policy analysis. In New Zealand, for example, the tobacco industry has been funding political parties for many years to gain influence over policymaking to control taxation on tobacco products and the banning of advertising (Hager, 2009).
Electronic cigarettes or e-cigarettes are electronic nicotine delivery systems using a battery-powered device to simulate smoking and releases a vapour that is designed to resemble tobacco smoke. E-cigarettes use a solution that contains a mixture of nicotine and a choice of flavourings to appeal to the smoker. New generations of e-cigarettes will become available that are able to deliver nicotine quicker and will more subtly resemble the act of smoking with, for example, lower levels of visible vapour. A series of surveys on e-cigarettes between 2010 and 2014 have shown that their use in the United Kingdom is continuing to rise but among young people it is negligible and growth remains at 0% for those who have never smoked. For current smokers the use of e-cigarettes has risen from 3% in 2010 to 11% in 2013, or from 700,000 to 2.1 million people. Ex-smokers reported using e-cigarettes to help them to quit and to prevent a relapse to tobacco use. The popularity of e-cigarettes has had a negative impact on other smoking cessation aids such as nicotine patches and tablets. The European e-cigarette market is now estimated to be worth up to $2.2 billion per year although this is a fraction of the tobacco industry which was worth about £15 billion in 2012. Whilst e-cigarettes may be able to provide a less-harmful alternative to cigarette smoking or to help smokers to reduce or quit smoking, concerns remain about safety, efficacy and the regulation of the sale of these products and their commercial marketing (Action on Smoking and Health, 2014).
The most notable successes of tobacco control interventions have been with the educated and economically advantaged in society – for example, between 1998 and 2004, there was a 9% decrease in smoking in the lowest quintile in Australia compared to a 35% decrease in the highest quintile (Baum 2007). It should be noted that considerable smoking-related disparities exist between socio-economic groups and while smoking cessation policies have succeeded in reducing overall tobacco use, they have not addressed socio-economic and ethnic disparities. More effort needs to be made to develop effective interventions that can reach people of low socio-economic status, adolescents and ethnic minorities.
KEY TEXTS
•Chapman, D. (2007) Public Advocacy and Tobacco Control: Making Smoking History (London: Wiley-Blackwell)
•David, A. et al. (2010) ‘Tobacco Use: Equity and Social Determinants’ in E. Blas and A. Kurup (eds), Equity, Social Determinants and Public Health Programmes (Geneva: World Health Organization), Chapter 11
•Hammond, D. (2011) ‘Health Warning Messages on Tobacco Products: A Review’, Tobacco Control, 20: pp. 327–337