How widespread are the use of frameworks and theories in applied health promotion research in rural and remote places? A review of programs targeted at cardiometabolic risk factors

Introduction: In Australia, modifiable cardiometabolic risk factors are in excess in rural and remote communities. High-quality community-level health promotion is paramount for the management of population health risk in such settings, especially in the context of reduced access to healthcare services. Two indicators of quality of health promotion programs are the use of formal frameworks and the adoption of socio-behavioural theories upon which to base intervention strategies. This study examined the extent to which these two quality elements were reported in health promotion programs designed to reduce cardiometabolic disease (CMD) risk in rural and remote settings. Methods: PubMed, ScienceDirect, Cochrane Library and EBSCOHost were searched using search strings linking health promotion programs, the geographic setting and CMD and risk factors. A title/abstract eligibility screen was conducted prior to full-text assessment. Articles had to report on the planning, implementation or evaluation of intervention strategies to be eligible. Articles were ineligible if they reported clinical drug trials or behaviour prescription efficacy trials. Results: Of eligible programs (n=62) from 66 articles, 37% (n=22) reported using a framework and 35% (n=22) reported the use of theories. While 16% (n=10) reported using both, 48% (n=30) reported neither.


A B S T R A C T
Introduction: In Australia, modifiable cardiometabolic risk factors are in excess in rural and remote communities. High-quality community-level health promotion is paramount for the management of population health risk in such settings, especially in the context of reduced access to healthcare services. Two indicators of quality of health promotion programs are the use of formal frameworks and the adoption of socio-behavioural theories upon which to base intervention strategies. This study examined the extent to which these two quality elements were reported in health promotion programs designed to reduce cardiometabolic disease (CMD) risk in rural and remote settings. Methods: PubMed, ScienceDirect, Cochrane Library and EBSCOHost were searched using search strings linking health promotion programs, the geographic setting and CMD and risk factors. A title/abstract eligibility screen was conducted prior to full-text assessment. Articles had to report on the planning, implementation or evaluation of intervention strategies to be eligible. Articles were ineligible if they reported clinical drug trials or behaviour prescription efficacy trials. Results: Of eligible programs (n=62) from 66 articles, 37% (n=22) reported using a framework and 35% (n=22) reported the use of theories. While 16% (n=10) reported using both, 48% (n=30) reported neither.

Introduction
In Australia, cardiometabolic risk factors (CMRs) and cardiometabolic diseases (CMDs) are in excess in rural and remote communities, which can be disadvantaged by reduced access to primary and secondary health services 1 and other conditions of 'place' that drive the expression of risk factors in individuals, termed 'environmental risk conditions' 2,3 . Together, the poorer access to health services and the population risk conferred by factors that are not amenable to change by 'treating the individual' using traditional health services makes high-quality community health promotion paramount for the management of population health risk in these settings.
The most prevalent CMD, type 2 diabetes mellitus, and its common causal risk factor abdominal obesity are endemic in the developed world and rising to epidemic levels across the developing world. Current evidence suggests that abdominal obesity constitutes the major clinical risk factor for the development of CMDs, with population attributable risks of 47% (for type 2 diabetes) and 13% (for cardiovascular disease) in Australia 4 .
Producing positive behavioural change to reduce this major causal risk factor requires targeting health behaviour at multiple levels, such as individual, organisational and community (as well as political). Thus, health promotion programs built upon a solid understanding of health behaviours and the socio-environmental contexts in which they occur have been found to be the most successful 5 .
The quality of applied health promotion research and practice varies, and the failure of low-quality programs has been associated with four major factors: (1) poorly specified or poorly rationalised intervention strategies 6 ; (2) atheoretical approaches or theory failure 5 ; (3) implementation failure 6 ; and (4) weak evaluation 7 .
The impact of these factors may be minimised by the use of comprehensive frameworks, which enables strategic planning and implementation of interventions, which can be further improved through evaluation. The content and structure of these frameworks are largely based on the guiding principles in which initiatives should be empowering, participatory, holistic, intersectoral, equitable, sustainable, and multistrategy -features that have evolved throughout the modern history of health promotion 8 . Furthermore, a sound theoretical basis underpinning the design of intervention strategies has been shown to increase the ultimate likelihood of success of health promotion programs, with increasing evidence suggesting larger effects with the use of multiple theories 5 .
This study aims to examine the extent to which health promotion programs focusing on modifying CMR or CMD in rural and remote settings report the use of health promotion planning, implementation and evaluation frameworks and pertinent socio-behavioural theories.

Methods
A search of the literature indexed in PubMed, ScienceDirect, the Cochrane Library and EBSCOHost was performed, backwards from December 2013 with no limit for maximal comprehensiveness. The search was limited to English language. The search strategy, as follows, was developed in order to achieve the stated research objective.
First, search terms for frameworks or theories were not specifically included as this would bias the results towards papers that report such use. Rather, health promotion programs were first searched for using the following terms: '(community intervention OR complex intervention OR community-based participatory research OR health promotion program)'.
Second, for CMR-and CMD-focused health promotion programs, behavioural and environmental intervention strategies are critical, so to reduce the possibility of missing pertinent studies in the above search, a search line was also included based on behavioural and environmental interventions using the following terms: '(behavioral risk factor* OR lifestyle OR environment*)'.
Third, a geographical setting focus was taken on rural and remote populations. Definitions of rural, remote and regional differ from country to country so all three terms were included: '(rural OR regional OR remote)'. Other terms such as 'agricultural populations', 'isolated populations'; 'indigenous populations' could also have been included; however, the latter two are not necessarily confined to rural and remote geographies.
Last, health promotion programs that target the prevention and management of CMD and reduction of CMR in the population were focused on. Common terms in this literature include obesity, metabolic syndrome, type 2 diabetes and cardiovascular diseases so the following search terms were included: '(obesity OR type 2 diabetes OR metabolic syndrome OR cardiometabolic risk OR cardiovascular disease risk)'. All studies identified by the search were assessed for relevance on the basis of a screen of the title and abstract, and, further to the search criteria, articles were eligible for inclusion if they reported on the planning and/or implementation and/or evaluation of intervention strategies. Exclusion criteria were also applied and included: (1) the study does not report on planning, implementation or evaluation of an intervention; (2) clinical drug trials such as these are not within the scope of community health promotion; (3) behaviour prescription efficacy trials such as these are not within the scope of the application of health promotion strategies in real-world contexts; (4) reports only on the development of a framework or theory (rather than on its application in context) and (5) not in a rural, regional or remote setting.
The full text of the selected articles was then accessed and reassessed for final inclusion, with additional relevant articles being selected using the reference lists of the included articles. A flowchart of the study selection is presented in Figure 1. Data extraction was then performed using a standardised form, which was piloted on the first ten articles and then adjusted accordingly. Data were collected on the study aim and conclusion; sample size and participant criteria; study design/methods; comparison/control groups; planning, implementation and evaluation framework used; theoretical constructs integrated; and process, impact and outcome evaluation. These data are synthesised in Table 1 (supplementary). A second author, who was blinded to the results of the first author, assessed approximately 15% of articles identified from abstracts and performed inclusion/exclusion screening and data extraction as aforementioned. This was in order to validate the results of the first author, and due to the high consistency during the literature screening and data extraction process, examining the remaining 85% of articles was unnecessary. Figure 1 represents the results of the database search, the application of inclusion and exclusion criteria, and additional inclusions based on reference list searches. A total of 1150 unique articles were identified by the initial search, and of these, 88 articles were eligible for study inclusion after applying the exclusion criteria based on title and abstract alone. Except for eight articles, the full text was retrieved and following further assessment, a total of 66 articles were included in Table 1, with 62 different programs being reported. Of the 62 programs summarised (Table 1), 23 used a planning, implementation and evaluation framework (37%). The frequency of the reported frameworks is shown in Table 2, with the community based participatory research and social ecological model being the most frequently reported, respectively. Of the 62 programs, 22 explicitly reported the adoption of appropriate whole theories or theoretical constructs (35%). The frequency of reported theories is shown in Table 3, with social cognitive theory and its predecessor social learning theory being the most frequently reported, followed by the transtheoretical model. In total, 32 programs (52%) reported using one or other of a framework (for planning, implementation and evaluation) or pertinent theories to underpin intervention strategies. Within these, ten programs (16%) reported use of both.

Results
The frequency of both reported framework and theory use varied to a small degree across different health promotion settings. Table 4 shows the frequency of reporting of both frameworks and theories across the settings of primary care, whole-of-community and community organisations (including schools and workplaces). The greater frequency of reported use of both frameworks and theories occurred in the community organisation settings.
Each program that had progressed to implementation as reported in the articles included an impact and outcome evaluation (n=52), and of these, nine explicitly reported an impact evaluation (17%), and 14 an outcome evaluation (27%). Twenty-four programs included a process evaluation (46%), 18 of which explicitly reported such (75%).          The frequency of both reported framework and theory use varied to a small degree across different health promotion settings. Table 4 shows the frequency of reporting of both frameworks and theories across the settings of primary care, whole-of-community and community organisations (including schools and workplaces). The greater frequency of reported use of both frameworks and theories occurred in the community organisation settings.
Each program that had progressed to implementation as reported in the articles included an impact and outcome evaluation (n=52), and of these, nine explicitly reported an impact evaluation (17%), and 14 an outcome evaluation (27%). Twenty-four programs included a process evaluation (46%), 18 of which explicitly reported such (75%).

Discussion
The most successful health promotion interventions are those designed with a structured framework for the ongoing development and maintenance of the program, and which enable continuous improvement through evaluation 75 . These frameworks embody the cardinal principles of health promotion, by increasing community capacity and empowering individuals, creating supportive environments, encouraging participation, taking a broad view of health and fostering intersectoral collaboration 8 . Furthermore, those designed with an explicit theoretical foundation are more effective at improving health behaviour 5 . Despite this, the development and implementation of health-promotion intervention strategies often proceeds without the use of these evidence-based approaches 76 .
This review has demonstrated, in the context of health promotion programs targeting the reduction of CMD risk in rural and remote populations, that 16% reported using both a standardised framework and pertinent theoretical constructs to underpin intervention strategy development and implementation. Moreover, 50% of programs did not incorporate either a framework or a theoretical foundation, strongly suggesting that the quality and rigour of applied health promotion programs targeting the reduction of CMD risk in rural and remote populations can be strengthened.
These findings tended to vary by the nature of the health promotion setting in rural and remote communities with community organisational interventions (including school and workplace-based programs) more frequently reporting the use of frameworks and theories when compared with 'wholeof-community' or primary care based programs.
In the 37% of programs that reported using a planning, implementation and evaluation framework, the most frequently used were community-based participatory research (CBPR) (26%) and social ecological model (SEM) (17%). However, there were ten alternative frameworks or models that were adopted and reported in this literature. CBPR is a transformative research model, which encourages community involvement and social action, facilitating healthoriented interactions and cohesiveness between academics, health professionals and the community. This enables interventions to be implemented across a larger population, and through integrating community theories into the research, this increases the likelihood of an intervention being long-lasting and successful 76 .
SEM was translated to a set of guidelines for community health promotion in 1996 77 . It positions behaviour as the outcome of interest, being determined by public policy, community factors, institutional factors, interpersonal processes and primary groups, and intrapersonal factors. This model targets both social environmental factors and the individual for health promotion, with interventions aimed at changing intrapersonal, interpersonal, institutional, community and global parameters 78 .
Both of these models have much in common with the precede-proceed model, which is perhaps the most comprehensive, integrated and well-known health promotion model, composed of formative phases (Precede: social, epidemiological, behavioural, environmental, educational and organisational diagnoses; resources and support appraisal), followed organically by implementation (representing the transition to Proceed) and evaluation of process (theory function), impact (on behavioural goals) and outcomes (on health and quality of life goals) 15,79 .
Of the adopted and explicitly reported theories in 35% of programs, social cognitive theory (SCT) and its predecessor social learning theory together accounted for close to half of all reported use across these health promotion programs (45%). However, more than a dozen other theories were adopted by the remainder of programs. SCT conceptualises human behaviour as the result of continuous reciprocal interaction between cognitive, behavioural and environmental factors; observation, imitation, and modelling of others' behaviours drives the individual's behaviour, which is subsequently either reinforced or deterred by reward or punishment, respectively. SCT describes four steps through which the individual must proceed: attention, retention, reproduction and motivation 80 .
The reasons for the choices of frameworks and theories adopted for these health promotion programs in these settings was in most cases not well articulated, although common to most frameworks was the principle that adopted theories should have meaning in the community setting and reflect the communities' understanding of CMD causation, prevention and management. This study has examined the extent of use, and has added to the literature knowledge about the frequency rank of framework and theory use for cardiometabolic health promotion in underserved rural and remote settings. However, future work should seek to better understand the reasons behind the adoption of specific frameworks and theories in health promotion programs across different community settings and target populations.
The possible impact of publication bias needs to be considered in the extrapolation of these findings beyond health promotion programs that are published in the academic literature. Many health promotion programs may have occurred in rural and remote settings that were never published and this review provides no knowledge of whether they were conducted under common frameworks or whether pertinent socio-behavioural theories were adopted in the development of intervention strategies. A limitation of this review is that a single author performed all the inclusion and exclusion criteria assessments and data extraction from full texts. Validation of inclusion/exclusion screening and data extraction was performed by a second author on approximately 15% of articles. Future research in this area could include investigating the interaction between the effectiveness and the quality of these programs in terms of their conceptual foundation.

Conclusions
Analysis of published literature indicates that 35% of health promotion programs targeting CMD risk in rural and remote settings reported using a planning, implementation and evaluation framework, and 35% reported a theoretical basis for intervention strategies. With approximately 20% overlap of programs reporting the use of both, this means half of the studies reviewed did not report using either a framework or theoretical basis for intervention. The most successful health promotion interventions are those that are based on these fundamental principles. Therefore, this review highlights the considerable remaining scope for improvement in the quality of conduct and reporting of health promotion programs targeting CMD risk in rural settings.
The combination of high prevalence of CMD and relatively poor access to primary healthcare services in rural and remote populations in Australia contributes to excess morbidity and mortality. In these settings, the use of best practice community health promotion programs is of increasing importance in order to optimise the ability of the discipline to achieve population health improvements in these disadvantaged populations.