Health Promotion International, Vol. 18, No. 2, 107-113,
June 2003
© Oxford University Press 2003
Beijing health promoting universities: practice and evaluation
Beijing Center for Disease Prevention and Control, 1Beijing Municipal Health Bureau, 2Beijing Municipal Education Committee and 3UNICEF Beijing, Beijing, People’s Republic of China
Address for correspondence: Tian Xiangyang, Health Education Institute, Beijing Center for Disease Prevention and Control, No. 16, Hepingli Zhongjie, Beijing 100013, China E-mail: hpoff{at}sohu.com
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SUMMARY |
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 TOP SUMMARY INTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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The aims of this study were to create a health promoting university within the framework of the Ottawa Charter for Health Promotion. Strategies included reforming and issuing healthy policies, creating a healthy physical and social environment, developing personal health skills, reorienting the health services, and implementing intervention activities. To evaluate the study, 180 students and 120 teaching/administrative staff were sampled for an in-depth interview with open-ended questions administered 1 year after the launch of the project. To assess health knowledge and behavior, 2500 students were sampled to answer a questionnaire, both prior to and following project implementation. With respect to policies, environment and health services, 166 students and 117 teaching and administrative staff participated in the in-depth interview. Approximately three-quarters (75.90%) of university students considered that the physical environment of the campus had improved significantly and 83.73% reported they had a good social environment. All university administration departments made commitments to health promotion. Consultations on mental health, smoking cessation and STD/AIDS prevention were provided all year round. Health education was included in a curriculum as a selective course with 1–2 credits. Almost two-thirds (60.66%) of teaching/administrative staff reported that they had had a yearly physical examination. In the final stages of the research, significantly more college students reported improved mental health (38.25% compared with 17.93% at baseline) (p < 0.01) and more were knowledgeable about transmission of STDs/AIDS (57.00/35.50% compared with 51.66/28.20% at baseline, respectively) (p < 0.01). Significantly less regular smokers were found (45% compared with 15.81% at baseline) (p < 0.01). However, there was a significant increase in high-fat food intake (44.81% compared with 49.50%) (p < 0.01) and pre-marital sex (5.11% compared with 14.00%), and a significant decrease in physical exercise participation (29.41% compared with 23.50%) (p < 0.01). As a health promotion setting, the university community can benefit greatly from implementing health promotion campaigns based on the principles of the Ottawa Charter.
Key words: evaluation; health promotion; university
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INTRODUCTION |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Health promotion is the process of enabling people to increase control over and improve their health (Ottawa Charter for Health Promotion, 1986
) by identifying and realizing aspirations, satisfying needs, and changing or coping with the environment. Successful health promotion requires the coordinated action of the whole community, not only of the health sectors. It has been reported that university-based health promotion can:
... potentially enhance the contribution of universities to improving the health of populations and to adding value in the following ways: 1) by protecting the health and promoting the well-being of students, staff and the wider community through their policies and practices, 2) by increasingly relating health promotion to teaching and research, and 3) by developing health promotion alliances and outreach into the community (Tsouros et al., 1998
University is a setting in which knowledge and skills should be taught, and a safe, healthy and supportive social as well as physical environment should be created (DeRoos, 1977). Moreover, the university has a responsibility to work towards emphasizing and increasing the students’ capacity to gain control over and improve their health, and to reorient the focus of health services from merely addressing illness to prioritizing illness prevention and health promotion.
In China, 10% of rural and 60% of urban adolescents and youths live and study at university for 4–5 years. It is a significant time in their lives, as it is a transition period from adolescence to adult youth, when many behavioral patterns and lifestyles are formed with lifelong implications. Studies have shown that adjustable unhealthy behaviors exist among college students (Svenson et al., 1997). Furthermore, several other studies have indicated that there is a strong need for health education/promotion in the university setting (Emmons et al., 1998; Stock et al., 2001), and university-based health promotion programs could change student knowledge, behaviors and lifestyles substantially (Svenson et al., 1997; Emmons et al., 1998; Sun et al., 1999; Walsh et al., 1999).
The Health Promoting Universities project was implemented from August 1997 to December 2000 as a joint collaboration of Beijing Municipal Health Bureau, Beijing Municipal Education Committee and Beijing Municipal Health Education Institute, with the support of the World Health Organization (WHO). The project covered six universities in the Beijing area with >100 000 students.
Objectives
The objectives of the study were:
- to create health promoting universities within the framework of the Ottawa Charter for Health Promotion;
- to improve the supportive environment for health in the university community; and
- to empower the university community members to improve and sustain their health and the health of others.
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METHODS AND STRATEGIES |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Framework for a Health Promoting University
- Adopting or reforming university policies with the aim of making them supportive of the health of both students and teaching/administration staff. The policies should encompass measures to create a supportive healthy environment, and to promote a healthy diet, smoking control, first-aid, physical examinations, STD/AIDS prevention, mental health consultation, etc.
- Creation of a health-supporting physical and social environment, including promotion of safety, sanitary facilities, green areas, healthy study and living facilities, a trusting and interpersonal caring atmosphere, and appropriate help for the handicapped and those with lower economic status.
- Development of personal skills with respect to health, including self-help, first-aid, coping with peer group pressure, sexual relationships, etc., through group training, peer group education, enrollment in health education courses and so forth.
- Provision of health services, i.e. universities providing regular consultation on mental health, smoking cessation, STD/AIDS prevention, healthy diet, etc.
- Students were encouraged to take part in community activities to improve their adaptability.
For intervention activities, see Table 1.
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Evaluation
Policies, environment and the provision of health services
Before the start of the project, major administrators of the six project universities were consulted to study health policies, the environment and the provision of health services. When the project finished in 2000, 166 college students (30 students from each university) and 117 subject teaching and administrative staff (20 respondents from each university) were interviewed individually using a pre-constructed questionnaire containing questions about policy implementation, the creation of environments and health services to evaluate the impact of the project.
Health knowledge and behaviors
Since the departments of each university are composed of similarly sized classes (~50 students), all classes were coded as a basic sampling cluster. Five-hundred college students were randomly sampled from each of the five larger universities, and 250 were chosen from the smaller one using a stratified clustered sampling strategy [nine classes (sampling units) with ~50 students each] at the points of pre- and post-project implementation. Each student was interviewed using a pre-constructed questionnaire [reliability (test, re-test) = 0.86, validity = 0.88]. More than 80% of students completed the questionnaire both at baseline and during final research (n = 2360 and 2347, respectively). The interviewers were pre-trained in personal communication with college students. Confidentiality and the purposes of the research were emphasized to each selected student.
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RESULTS |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Healthy policies
Major administrators of the five project universities were consulted on the subject, and they indicated that no systemic health promoting policies had been launched before. Several workshops were conducted with the participation of administrators from municipal education departments, health sectors, health promotion professionals and university administrators/teaching staff. This resulted in the adoption of a series of policies:
- policies on organization, implementation and coordination of the project;
- policies on enforcement and supervision of the health policies;
- policies on the building of a safe and healthy physical and social environment;
- policies on the provision of necessary health services that are easily accessible for everybody; and
- policies on the control of behavioral risk factors and the development of personal health skills.
One year after the policies were adopted, most of them were being implemented. Individual in-depth interviews indicated that 51.2% of the students knew that their university was working towards becoming a health promoting setting, and 31.33% of students knew that the university administration departments had made commitments to promote health. Policies on control of risk factors were implemented and a large proportion of students had received health education on smoking control (54.22%), physical exercise (58.53%), a healthy diet (53.61%), STD/AIDS (64.46%), safe sex (37.95%) and healthy lifestyles (53.01%). Exactly one-third of teaching/administrative staff reported participating in intrauniversity routine conferences on health promotion, which were held periodically during the implementation of the project.
Physical environment
The sports and public facilities of the participating universities improved greatly. However, the opening times and services provided do not yet fully meet the needs of the members of the community. More than three-quarters (75.90%) of the students reported a greatly enhanced campus environment since the launch of the health-promoting university project, but only 45.78% were satisfied with the sports facilities.
Social environment
Most students (83.73%) acknowledged that there were good interpersonal relations, equity, and a trusting, respectful atmosphere at the university, and 81.93% of students had taken part in community activities. Almost all (90.96%) considered that the minorities, i.e. those with different cultures and religious backgrounds, were respected appropriately.
Resources for health promotion
Funds were appropriated for health promotion in the yearly budget of the universities to guarantee the smooth running of intervention activities.
Health services
Consultation on mental health, smoking cessation and STD/AIDS prevention were provided all year long. Forty-two percent of students had a mental health consultation last year. Health education was included in the curriculum as a selective course worth 1–2 credits, in which 65.66% of students wished to enroll. All students received the necessary inoculations.
More than 10% of university hospital staff took responsibility for healthcare, health education and health promotion, 60.66% of teaching/ administrative staff reported having a yearly physical examination, and 63.25% noted that the university hospital checked the blood pressure of most patients.
Health knowledge and behavior
The numbers of students completing the questionnaire at baseline and during final research were 2360 and 2347, respectively, and no significant differences in the social characteristics of both groups was noted (see Table 2). A significant decrease was seen during final research compared with baseline in: (i) the number of students trying to smoke [tried to smoke at least once in the past month: 17.25 and 39.78%, respectively (p < 0.01)]; (ii) the regular smoking rate [smoked at least 100 cigarettes in the past 6 months and smoked each week: 15.81 and 4.50%, respectively (p < 0.01)]; and (iii) the high-fat food intake habit [eat oil-fried foods/fatty meat at least five times a week in the past 6 months: 44.81 and 37.00%, respectively (p < 0.01)]. A significant increase was noted in self-reported good mental health [with no or little depression, anxiety, nervousness, sadness, etc. in the past month: 17.93% at baseline compared with 38.25% (p < 0.01)] and knowledge on STD/AIDS transmission [correctly answered questions about the major transmission routes of STD/AIDS viruses: 28.20/ 35.50% compared with 51.66/57.00%, respectively (p < 0.01)].
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Despite the improvements noted above, there was a significant decrease in physical exercise participation [29.41% at baseline compared with 23.50% (p < 0.01)], a significantly greater intake of high-salt foods (eat extremely salty food at least five times per week in the past 6 months: 44.81% at baseline compared with 49.50% (p < 0.01)] and an increase in pre-marital sex [had sexual intercourse at least once in the past month: 5.11% compared with 14.00% (p < 0.01)] (see Table 3
).
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DISCUSSION |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Although the Health Promoting Universities project is a relatively new concept, both worldwide and in China, and there is little experience and no blueprint for reference (Dowding and Thompson, 1998
), the Beijing Health Promoting Universities project has highlighted a new approach for developing health promoting settings. It appears that the key points for project success and sustainability are: (i) the launch of healthy policies; (ii) the training of teaching staff (Blair et al., 1984); (iii) curricular health education; and (iv) setting up health education as an elective course. The launch of healthy policies was the most important component of the project, and as such required the coordinated efforts of all stakeholders. Representatives from university teaching and administrative staff, students, university hospitals, local health bureau, education committees and health educators/professionals were consulted and a conference was developed to discuss the launch of the project. The approach of cross-sectoral participation and the intensive involvement of the local education administration department ensured the support of both academic and government authorities.
An important observation is that there are strong similarities between higher education institutions in China: most of the universities are public- or government-supported, with similar regular and intra-university administration systems, and most university students have experienced a similar primary/middle school education. It is therefore predicted that the health promotion activities could be similarly effective at other Chinese universities. Health promotion campaigns are thus strongly recommended for universities in other Chinese cities.
Chinese universities differ per se from those in the western higher education system. The university is a functional community, comprising a student dormitory, a dining room, sports facilities, recreational venues, classrooms and a library, and most of the students stay, study and live at the university for 4–5 years continuously. In such a self-functional university community, students are affected deeply by university policies and their physical and social environments (Baumgarten, 2001). Considering all the above, the project adopted an environment change strategy rather than the traditional health education methods, with the main focus being placed on individual health knowledge, attitude, belief and practice. Following project implementation, evaluation revealed that most students (75.90%) thought their campus environment had improved significantly since the project was implemented. Most policies were practiced and the emphasis in the university hospital health services shifted from a doctor/patient-centered curative model to a wider approach stressing health promotion and protection. The percentage of students trying to smoke decreased, while the proportion with good reported mental/emotional health and who were knowledgeable about the channels of transmission of STD/AIDS increased significantly.
A significant decrease was found in the participation in physical exercise, however. This is probably related to the change in season; the final questionnaire research was conducted in winter while the baseline research was in autumn. In addition, significantly more pre-marital sex was reported by the students, which was probably due to previous lack of reporting as the subject was traditionally considered a taboo before the launch of the project. Having received more sex health education, students were likely to have reported pre-marital sex more openly. The reported increase in high-salt food intake may be associated with a rising awareness of salty food types, resulting from education surrounding salt and hypertension. The causes of the three above-mentioned trends require further study before they can be understood fully.
The effect of health promotion intervention on students’ health knowledge and behavior should be treated cautiously. When the final research was conducted in 2000, the intervention cohort had changed because the students who were surveyed in 1997 had graduated and left the university. The new students who were sampled to participate in the final research may have had a comparatively better health knowledge and behavior background resulting from better middle school health education than the students sampled for baseline research. To confirm the real effect of the health promotion intervention, a grade-based follow-up and a retrospective study should be conducted.
The smooth implementation of the project depended largely on cooperation between the Beijing Health Bureau and the Education Committee, and on securing the support of the latter in the early stages of project implementation. In China there is usually a strong relationship between health and education departments and university hospitals, which jointly provide disease prevention and health care information for students and teaching staff. During project implementation it was found that the motivation of Education Committee officers and the mobilization of university administration staff were crucial for the project’s success. Prior to contacting the university administration departments, workshops were held for officers from educational authorities and health departments. The university administrators were then more amenable, knowing that the project had already received firm support from the Education Committee.
Intensified training was the second important strategy for reaching university administrators and teaching staff. In fact, before the training, most university staff did not know much about health promotion and their main idea concerning health was that when they fell sick they should see a doctor at the university hospital. The project experience is thus that if university staff are trained in both health skills and health promotion, they become more willing to participate in and contribute to the project.
Overall, although a significant change was observed both in the environment and in health knowledge and behavior as a result of implementing the Beijing Health Promoting Universities project, further studies should be conducted to confirm the real effect since no control groups were used in this research.
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CONCLUSIONS |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Through implementation of the Health Promoting Universities project, health services were re-oriented to health promotion and improving health knowledge/behavior among college students.
As an intervention setting, the university community can benefit greatly from implementing health promotion campaigns based on the principles of the Ottawa Charter for Health Promotion.
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ACKNOWLEDGEMENTS |
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The Beijing Health Promoting Universities project is a collaborative campaign with WHO, and is supported financially by WHO China.
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REFERENCES |
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TOPSUMMARYINTRODUCTIONMETHODS AND STRATEGIESRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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