Evaluation in health promotion
Ev
Evalua
aluattion
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healthh
promotion
omotion
pr
inciples and
Principles
es
perspectives
WHO Regional Publications
European Series, No. 92
Evaluation in health promotion
Principles and perspectives
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Evaluation in health promotion
Principles and perspectives
Edited by:
Irving Rootman, Michael Goodstadt,
Brian Hyndman, David V. McQueen,
Louise Potvin, Jane Springett
and Erio Ziglio
Health
Canada
Santé
Canada
WHO Regional Publications, European Series, No. 92
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Specific studies and technical and other terms
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Contents
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Part 1. Introduction and framework
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Part 5. Synthesis and conclusion
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Part 1
Introduction and framework
Introduction to the book
Irving Rootman
WHO European Working Group on Health Promotion
Evaluation
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1
A framework for
health promotion evaluation
Irving Rootman, Michael Goodstadt,
Louise Potvin and Jane Springett
3 " $
" What is health promotion?
" ! B
!"! 9 " 3 ! 3 Recent origins
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A 3053 ? ! / ,6 8-" ,E1A ?-< !" Definitions
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$ !" & Table 1.1. Definitions of health promotion
Source and date
Definition (emphasis added)
Lalonde, 1974 (3)
A strategy “aimed at informing, influencing and assisting both individuals
and organizations so that they will accept more responsibility and be
more active in matters affecting mental and physical health”
US Department of
Health, Education, and
Welfare, 1979 (19)
“A combination of health education and related organizational, political
and economic programs designed to support changes in behavior and in
the environment that will improve health”
Green, 1980 (20)
“Any combination of health education and related organizational, political and economic interventions designed to facilitate behavioral and
environmental changes that will improve health”
Green & Iverson, 1982
(21)
“Any combination of health education and related organizational, economic, and environmental supports for behavior conducive to health”
Perry & Jessor, 1985 (22) “The implementation of efforts to foster improved health and well-being in
all four domains of health [physical, social, psychological and personal]”
Nutbeam, 1985 (23)
“The process of enabling people to increase control over the determinants
of health and thereby improve their health”
WHO, 1984 (24), 1986
(4) and Epp, 1986 (25)
“The process of enabling people to increase control over, and to improve,
their health”
Goodstadt et al., 1987
(26)
“The maintenance and enhancement of existing levels of health through
the implementation of effective programs, services, and policies”
Kar, 1989 (27)
“The advancement of wellbeing and the avoidance of health risks by
achieving optimal levels of the behavioral, societal, environmental and
biomedical determinants of health”
O’Donnell, 1989 (28)
“The science and art of helping people choose their lifestyles to move
toward a state of optimal health”
Labonté & Little, 1992
(29)
“Any activity or program designed to improve social and environmental
living conditions such that people’s experience of well-being is increased”
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Table 1.2. Definitions of health promotion deconstructed
Source and date
Activities
(programmes, policies, etc.)
Winslow, 1920 (2)
“Organized community effort for the education of the individual in personal
health, and the development of the social
machinery”
Processes
(underlying mechanisms)
Sigerist, 1946 (1)
Objectives
(instrumental outcomes)
Goals
(ultimate outcomes)
“... to ensure everyone a
standard of living”
“... the maintenance or
improvement of health”
“Health is promoted”
“... by providing a decent
standard of living, good labor
conditions, education, physical
culture, means of rest and recreation”
Lalonde, 1974 (3)
“... informing, influencing and assisting “... so that they [individuals
both individuals and organizations”
and organizations] will accept
more responsibility and be
more active in matters affecting mental and physical
health”
US Department of Health,
Education, and Welfare,
1979 (19)
“A combination of health education and
related organizational, political and economic programs”
“… that will improve health”
“… designed to support
changes in behavior and in the
environment”
Green, 1980 (20)
“Any combination of health education
and related organizational, political and
economic interventions”
“... that will improve health”
“... designed to facilitate
behavioral and environmental
changes”
66
Green & Iverson, 1982 (21) “Any combination of health education
and related organizational, political and
economic supports”
“… for behavior”
“… conducive to health”
6E
Source and date
Activities
(programmes, policies, etc.)
Perry & Jessor, 1985 (22)
“The implementation of efforts”
Processes
(underlying mechanisms)
Objectives
(instrumental outcomes)
Goals
(ultimate outcomes)
“... to foster improved health
and well-being in all four
domains of health [physical,
social, psychological and personal]”
Nutbeam, 1985 (23)
“The process of enabling peo- “… over the determinants of “... and thereby improve their
ple to increase control”
health”
health”
WHO, 1984 (24), 1986 (4)
Epp, 1986 (25)
“The process of enabling people to increase control over
[their health]”
Goodstadt et al., 1987 (26) “… through the implementation of
effective programs, services, and policies”
Kar, 1989 (27)
“… and thereby to improve
their health”
“The maintenance and
enhancement of existing levels
of health”
“The advancement of wellbe“… and the avoidance of
health risks by achieving opti- ing”
mal levels of the behavioral,
societal, environmental, and
biomedical determinants of
health”
O’Donnell, 1989 (28)
“The science and art of helping people
choose their lifestyles”
“... to move toward a state of
optimal health”
Green & Kreuter, 1991 (7)
“The combination of educational and
environmental supports for actions and
conditions of living”
... conducive to health”
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Meaning and practice of evaluation in health promotion
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Perspectives
Introduction
Louise Potvin
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Beyond process and outcome
evaluation: a comprehensive
approach for evaluating health
promotion programmes
Louise Potvin, Slim Haddad and Katherine L. Frohlich
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issues and debates
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4
Participatory approaches to
evaluation in health promotion
Jane Springett
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Table 4.1. Characteristics of positivism and hermeneutics
Positivism
Hermeneutics
Objective observation
Critical subjectivity
Explanation and prediction
Understanding and finding meaning
Search for general knowledge and
standardization
View of every situation as unique
View of social organization as combinations Stress on richness, variety and depth
of similar things
Surface view
Hypothesis testing through formal definition Dialectical cycle to gain knowledge
of ideas and measurement
Mechanistic, with a focus on an object that Dialogue and subjective participation (understanding
has no voice and is submissive
is not real unless it is mutual)
Aim: the power to control the collection of
facts
Aim: enlightenment, edification, enrichment, personal
growth
Emphasis on quantity
Emphasis on quality
Source: adapted from Dahlbom & Mathiassen (4).
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conceptualization
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Table 4.2. Differences between the natural and social sciences in
approach to and methods of programme evaluation
Question
Natural sciences
Who performs evaluation? External experts
Social sciences
Community, project staff facilitator
What is examined?
Indicators of success identified by
Predetermined indicators of
success, principally cost and health participants, which may include
health outcomes and gains
outcomes/gains
How?
Focus on objectivity, distancing
evaluators from other participants;
uniform, complex procedures;
delayed, limited distribution of
results
When?
Usually at programme completion; Merging of monitoring and evalusometimes also mid-term
ation; hence frequent small-scale
evaluation
Why?
To ensure accountability, usually
summative, to determine whether
funding continues
Self-evaluation, simple methods
adapted to local culture; open,
immediate sharing of results
through local involvement in evaluation processes
To empower local people to initiate,
take and control corrective action
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Table 4.3. The advantages and disadvantages
of external and internal evaluators
External evaluators
Internal evaluators
Can take a fresh look at the programme
Know the programme well
Are not personally involved
Find it harder to be objective
Are not part of the programme’s normal power
structure
Are part of the programme’s normal power structure
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prestige from evaluations
May be motivated by hopes of personal gain
Are trained in evaluation methods, may have
experience with other evaluations, are regarded
as experts by programme participants
May not be trained in evaluation methods, have
little or no more training than others in the programme
Are outsiders who may not understand programmes or the people involved
Are familiar with and understand programmes
and can interpret personal behaviour and attitudes
Source: Fuerstein (29).
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ED
5
Transformative alliance
between qualitative and
quantitative approaches in
health promotion research
Sylvie Gendron
Introduction
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6
Evaluation of quality-of-life
initiatives in health promotion
Dennis Raphael
Overview
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inequality
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( ( $ ) ( @ 6 = #
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= ) 1 @ K 0 Developmental disabilities
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7
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and measurement
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to health promotion
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8 V ' + B 8 V ! 2 + 8 V0 Table 6.1. Lindström’s model for the quality of life of children
in Nordic countries
Spheres
Global
External
Dimensions
1. Macro environment
2. Culture
3. Human rights
4. Welfare policies
1. Work
2. Income
Interpersonal
Personal
Examples
Physical environment
Responsiveness to the United Nations
Convention on the Rights of the Child
Welfare distribution
Parental education and satisfaction
with employment
Income distribution
3. Housing
1. Family structure and function
Quality of and satisfaction with housing
Satisfaction with family, lack of
negative events
2. Intimate friends
3. Extended social networks
Support from friends, neighbours and
society
1. Physical
2. Mental
3. Spiritual
Growth, activity
Self-esteem and mood
Meaning of life
Source: Lindström (66).
7
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8 V0 ) ! * *
! & # " ! 0
( Centre for Health Promotion approach
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Table 6.2. The Centre for Health Promotion’s domains of quality of life
Domains
Subdomains
Contents
Being
Physical
Physical health, mobility, nutrition, exercise, fitness and
appearance
Psychological
Independence, autonomy, self-acceptance and freedom
from stress
Spiritual
Personal values and standards and spiritual beliefs
Physical
Physical aspects of the immediate environment
Social
Relationships with family, friends and acquaintances
Community
Availability of societal resources and services
Practical
Home, school and work activities
Leisure
Indoor and outdoor activities, recreational resources
Growth
Learning things, improving skills and relationships,
adapting to life
Belonging
Becoming
& ! ! ; !! !" & Key issues
! ) H ! * ! # & 0 H # ! & ) The community quality-of-life project: understanding communities
through a health promotion approach
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7
Economic evaluation
of health promotion
Christine Godfrey
Introduction
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9 # ; 5 ) ( & 0 ) 6 ) ! ! ( # ! * 4
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Cost-minimization analysis
D%
+ # & + * Table 7.1. Different types of full economic evaluation
Type of study
Treatment of alternatives
Measurement/
Valuation of costs
in alternatives
Identification of
consequences
Measurement/
Valuation of
consequences
Cost-minimization
analysis
Monetary terms
Identical in all relevant
respects
None
Cost–effectiveness
analysis
Monetary terms
Natural units (life years
Single effect of interest,
gained, numbers stopping
common to both
alternatives, but achieved to smoking, etc.)
different degrees
Cost–utility analysis
Monetary terms
Single or multiple effects, Healthy years or
not necessarily common to (more often) QALYs
both alternatives
Cost–benefit analysis Monetary terms
Single or multiple effects, Monetary terms
not necessarily common to
both alternatives
Source: adapted from Drummond et al. (1).
) ( # ) & ) & ) ! 9 ) ; & + 3 ! ) & # Cost–effectiveness analysis
3 ! ) 9 ; 9 ; ? + ! ) D7
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& 3 !
! 6 @ 3 1 @ ! # 9! <%; ! # ) & DS ! DD
B H
# 7
Table 7.2. An example of cost–benefit analysis:
legislation for bicycle helmets in Israel
Benefits and costs
Values (US $)
Benefits
Value of lives saved
8 939 979
Reduced health care costs
17 412 622
Reduced long-term care costs
25 263 243
Reduced need for special education
1 527 131
Productivity gain from reduced disabilities
7 545 779
60 688 754
Costs
Health education programme and helmets
Total social benefits
(20 143 984)
40 544 770
Source: adapted from Ginsberg & Silverberg (17).
! 3 ) 1 @ ! # ! #
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# 6 # @ ' # # ! $ 3 ! D2
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? ! & & & # # 27
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health promotion
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' =
" &
) & ) " 2D
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" ) & # 5 ) ? 3 ! 3 & 3 3 " # * " + " * ( ) ) # Are economic evaluations ethical?
! $ 22
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6 # - 8: & - 8: - 8: + ) & Does health promotion save money?
? + & 2<
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8
Health promotion: towards
a quality assurance framework
Richard Parish
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" ) %
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The Ottawa Charter for Health Promotion:
the starting point for quality
! ? ' $ H / ='? . ? " ! <2
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Stages of the quality assurance cycle
$ ) = # ) ) Identifying key areas
! #
, # '&CI &6 1 ) 9 ; , & 9 ; $ # & = # # 9 ; 6 3 3
( ) ) & ? )
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- <<
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Setting standards
# 9 # 4<S ; ? ( Specifying measurement criteria
! Constructing an audit tool
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* # * ) Comparing practice with standards
= ) 9 ;
( # )
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Fig. 8.1. The starting point for quality in health promotion planning
Clarify the health promotion
issue or problem
Agree the target groups
Formulate precise programme
objectives: usually educational,
behavioural, environmental or
organizational
Quantify desired outcome
within given period of time
(target setting)
Rewiew possible
methodological approaches
Take account of the nature
of the issues, level of
intervention required and
time limits
Take account of existing
knowledge, attitudes,
behaviour, environmental
factors and organizational
systems
Have due regard of
approximate costs, time limits
and social, economic and
environmental constraints
Consult
stakeholders
Agree intervention approach
Determine precise resources
required
Acquire funding and other
resources
Determine immediate target
groups, significant mediators
and support systems
Determine skills deficit and
training required
Allocate tasks
Pilot-test progamme where
unproven methods are proposed
Execute programme
Evaluate programme
>%
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necessary
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Investigating policy
networks for health:
theory and method in a larger
organizational perspective
Evelyne de Leeuw 22
Introduction
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Fig. 9.1. Study of the national debate on health policy
in the Netherlands, 1980s
Research questions
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analysis
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interviews
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of the policy
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analysis
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Introduction
Michael Goodstadt
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Louise Potvin and Lucie Richard
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11
Evaluating community initiatives
for health and development
Stephen B. Fawcett, Adrienne Paine-Andrews,
Vincent T. Francisco, Jerry Schultz, Kimber P. Richter,
Jannette Berkley-Patton, Jacqueline L. Fisher,
Rhonda K. Lewis, Christine M. Lopez, Stergios Russos,
Ella L. Williams, Kari J. Harris and Paul Evensen 3 3
Introduction
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Fig. 11.1. The community initiative as a catalyst for change
Dissemination
More distal
outcomes
Community
adaptation,
institutionalization
and capacity
Collaborative
planning
Community
implementation,
action and
change
Source: adapted from Fawcett et al. (26).
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Fig. 11.2. Logic model for the documentation and evaluation system of the University of Kansas
Work Group on Health Promotion and Community Development
Phases of
community
initiatives
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evaluation
activities
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initiative
products
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concerns
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data on
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implementation of key
components
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adaptation,
institutionalization
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adaptation
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community
capacity
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outcomes
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outcome
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and its
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concerns
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strategies and tactics
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action and change
Adaptation
and
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community
initiative
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capacity to
intervene
Greater
ability to
evaluate
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measurable
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understanding of
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' ( H 7 @ 7 % Fig. 11.3. Community changes (intermediate outcomes) from work to prevent
adolescent pregnancy in Geary County, Kansas, 1993–1996
120
Change
in director
110
100
Cumulative numbers of changes
90
80
Outreach
worker
hired
70
60
Staff on
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New
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12
Evaluating health promotion
in schools: reflections
Sarah Stewart-Brown44
: : Schools as a setting for health promotion
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13
Evaluating health promotion
programmes in the workplace
Lindsey Dugdill and Jane Springett
Introduction
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Table 13.1. Participatory evaluation of a health promotion programme: main actions, associated actions and comments
Main actions
Associated actions
Step 1. Clarify the aims Get the participants on board.
Set up an evaluation group.
and objectives of the
proposed programme. Determine what the real health problem is.
Establish baseline information.
Comments
The importance of spending time on this groundwork cannot be overemphasized. Involvement of the right people will ensure commitment
to the use of the information generated and a good response to any
questionnaires. The evaluation group (at least three people) should
reflect the range of interests. Proper clarification makes the evaluation straightforward.
Step 2. Design the
framework for evaluation and what questions to ask.
Decide the purpose of the evaluation and who will use the information.
Decide what questions are useful to ask in relation to achieving aims
and objectives.
Decide from whom to collect information.
Decide whether process as well as outcome information is needed.
Take this action before deciding what measures to use. If the objectives have been stated clearly, this should be relatively easy. Be clear
about the aims of the evaluation; this affects what questions are
asked. The main aim is to see whether the activities in the programme resulted in achieving the stated objectives. Try to look at
process as well as outcome.
Step 3. Design the
framework for evaluation and decide how
to measure change.
Decide what to measure and which methods to use.
Decide on sample size and target population.
Decide when to collect the information.
Good measurement depends on being clear about the issues. Methods should be appropriate to the questions and need not be numerical. Be realistic and honest about limitations of time and money.
Step 4. Collect the data. Make sure data collection is unobtrusive and does not add to partici- There will be problems of confidentiality and bias. Bias is most common in self-reported behaviour. Problems are smaller if all stakeholdpants’ workload or, if it does, they can see the value of doing it.
ers have been involved. Participation is a key.
Make sure participants are still on board.
Keep participants informed by regular feedback.
Remember that data are not information.
Main actions
Associated actions
Interpret data in association with the evaluation group, comparing
Step 5. Evaluate the
results to determine the what actually happened with what was expected.
effectiveness of the pro- Remember that numbers are only indicators of what the world is like.
gramme.
Step 6. Make recommendations.
Comments
Data are not information until they have been interpreted. This is best
done as a collaborative process, so the participants understand how
the results were obtained. Remember the value of so-called soft
information, and that some health changes take time to be revealed.
If the participants have been involved in the process, they will already
Clarify what is useful.
be committed to acting on the findings and be receptive to results
Cover practical changes for immediate implementation.
Include the costs and benefits of not implementing as well as implementing the recommendations. Challenge existing beliefs.
Look for longer-term changes that may not yet be visible.
Source: Workplace Task Force report. London, Department of Health, 1993.
: # % * # 2 H
Q 1Q Principles for the evaluation of health promotion
in the workplace
8 # Starting the formative evaluation process with health needs assessment
* ! .
: 0
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$ * , # & 7 : : @ * =
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I , = : ) : "
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2 I Producing useful information
" . G * ' ( $
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> " : ' ( $ &
% > -
Evaluation practice as a process in the workplace
$ # # # 2 " > : : : : @ " I 8 " " # Recommendations for improving evaluation practice
in the workplace
Integration of evaluation with other workplace activity
2 E ' ( E # --
" 7 # Choice of methodology
I " 0 2 " H " , % ' (G % " # Bridging multiple sites
$ # # 0 I " Relevant evaluation indicators
: . : " 0 # # % I ' ( #
' (: " Crossing interfaces
8 & 0 -4
Conclusion
: " @
# @ References
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14
Evaluation in urban settings:
the challenge of Healthy Cities
Lisa Curtice, Jane Springett and Aine Kennedy
Introduction
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for evaluation
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$ " 3 " " . B C . ) $ 3 # @ : " " " ! 3 The nature of the policy-making process
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* % ' ( ' ($ . * 0 $ 0 # 0 , 0 * " 0 !I$ !I$ ' 0 ( ' ( , , : , I ! 3 3 Consensus and controversies in evaluation
! 3 @ . -14
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! 3 & & # ' ( " ' # " ( ! 3 : ! 3 ! 3 FI 3 . ! 3 $ " Principles and values
! 3 & * -15
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5 0 6 < J , ! 1? = A : = : F$ 4 @!)! 3 0 I " $ 9 0 3 ; > & G 0 % ! * 11 0 $ H ! ; 0 I Evaluating Healthy Cities initiatives at the community level: Drumchapel
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Overview
! 3 ! 3 ) @!) 0 " I 3 > & % @ " ; Guideline and recommendations
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--4
Part 4
Policies and systems
Introduction
David V. McQueen and Jane Springett
! "" " "
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15
Evaluating healthy public policies
in community and regional contexts
Alfred Rütten
Key issues in evaluating healthy public policies
- " ("
/ 4 770+ " # " " . 4 , B
7 , B
' " " B
& , B
5 ' " B
Defining healthy public policies
( " ) ' % # # " * . # . " #" # " C " &4
( " ) + 8 + " D E
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! ( " ) ) - " >++ % 8 " 2 " " ( " 3 , # " " &7
Making a strategy for healthy public policies work
D E " # = " 8 " " " ! ' 8 " " ! * ,'( ( - Defining impact
! F " G " / ) 770F " G 2 " ( ( " ( ( " ) , &
" .
" Measuring impact
* (" " /) &0# " Options for responding to the evaluation issues: example
" # ,'( * , + / 8 + + 3 0
* * Policy environment
, + ( * 3 " " =
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Evaluating healthy public policies at the local level
# * ,'( * , + + % : ? ( * Health promotion issues
! 8454/ 40 ,'( * , + = Fig. 15.1. Key elements of an implementation structure
for healthy public policies at the local level
Levels
Outcomes
3
Health promotion agendas and issue networks
Healthy public policies
Investments for
health promotion
6
Cooperative planning
2
Outcomes
defined by the
cooperative planning
group and by the
planning method
5
Health lifestyles of
the local population
Social, economic,
physical environments
Active lifestyles and
community participation
Social networks
Health-enhancing
infrastructures
7
Local policies
Local politics
Local policy arenas
Principles
Creating health
Community engagement
Building alliances
Securing investments
1
4
+ 8
. : # + % : * " 2 &
+ " , * " / 0 " # + % : * " / 0 " 8 " + . ( * " " F Implementation process
! "8454/ 70 # + % : * = / 0
" " " # Policy-making level
! " " " " ! "8454/ 0 : , B " B ,
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, " F * 8 " Population level
(
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+ % : * " 2 /8454 &0
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! / 0 * " /8454 50(
" / 0 " / 0 ! " " " " ( " /
0 " / " 0 / 0
Evaluation design
* " 8 454 # /8 4570 &;
" Fig. 15.2. Design for an evaluation of healthy public policies at the local level
Implementation
process
Cooperative planning
Evaluation process
Internal evaluation
External evaluation
Analysis of key elements,
structures and actors on
the policy-making and
population levels
Selecting the
planning group members
Evaluating group
dynamics
Feedback to
the planning group
Brainstorming
Defining guidelines
and concrete goals
Setting priorities
Defining measures
Assessing evaluability
Inplementing measures
Evaluating
measures/outcomes
Evaluating
outcomes of
group dynamics
Evaluating
external outcomes
# ( "
2 " / . 0 " ( # " " / 0 # " 8 * " F / " 0 " 5@
/84570! " ) " " " " # " 8 Use of quantitative data
8 " : # + % : * ) + " I # " " " *
,'( * " ! *
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/ 0 ! " " > 3 Evaluating healthy public policies outside the local level
" " ,'( * , + " 54
* , + " Implementation process
# " . ! , + " 8 % + + ) " ,'( * " . F /8 450 " + / J0 " Fig. 15.3. Current policy implementation structure
Cabinet
State level
Ministries
Regional administration
Regional level
Communities
Issues
Local level
! 845 " " K " "
# 57
,'( * " " * /845&0
! " " " ! > 3 # * ! 3 Fig. 15.4. Desired implementation structure for healthy public policies
Cabinet
Audit Group
State level
Regional administration
Umbrella Group
Regional level
Communities
Cooperative planning
group
Local level
Ministries
( /" 0 " * + 2 2 " " " > 3 5
8 ! 3 + ) * " C " . " "# " , ,'( * > ) ) ' % " ,'( * * " * " " Evaluation design
* " " * " > 3 Phase 1. Case–consultancy approach
> 3 " K " # # " >
3 " * ,'(
! "8455 * > 3 ,'( * ,'( " " " 8 * > 3 " * " , * " ! " "" 5&
Fig. 15.5. Intersectoral evaluation and learning process:
case–consultancy approach
Generic
problems
Umbrella Group
projects (and
specific issues)
Evaluation process
to bring expertise
(action learning)
Experience and
expertise
Local experience
and expertise
Project
case
WHO expertise,
case work and
networks
Outcomes
Problem solution (direct
result on case and
indirect results on other
projects)
Use of knowledge/expertise
The most powerful learning
Facilitation of joint work
Encouragement of
integrated strategy
!D E 2 >
3 " " " # " " " 2 "
# " - " " " Phase 2. Measuring the impact of alliance building
- C" " " " # * * 55
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, * ) ,'( *
. 8 D E > 3 " * , + 8 D
E 3 ( . " " > 3 8 > 3 " " 4 * " * + " !" * . " > 3 " " Audit of health impact of state public policies
> 3 " " 8 + + ! /845&0% ,'( * ! " " /) 60,'( ( - " =' + - ,'( 5
% % " , + ! " " " 8
C3( 2 > 3 # * + Conclusion: towards a framework for evaluating
healthy public policy
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16
Evaluation of health promotion
policies: tracking a moving target
Nancy Milio
Introduction
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Public policy: purpose and environment
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Policy environment
Fig. 16.1. Health organizations and policy-making
Policy impacts
Goods and services: jobs, housing, food, education, environment
Economy
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Table 16.1. Strategies for disease prevention and health promotion
Intervention strategy
Focus
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Homes and communities
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17
Evaluation of countrywide
health promotion policies:
the Canadian experience
Reg Warren, Irving Rootman and Rick Wilson
Introduction
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