Health Promotion International - recent issues

Busy times for health promotion: capacity building in action

McQueen, D. — Fri, 13 Nov 2009 06:38:18 PST

Evaluation findings on community participation in the California Healthy Cities and Communities program

Kegler, M. C., Painter, J. E., Twiss, J. M., Aronson, R., Norton, B. L. — Fri, 13 Nov 2009 06:38:18 PST

As part of an evaluation of the California Healthy Cities and Communities (CHCC) program, we evaluated resident involvement, broad representation and civic engagement beyond the local CHCC initiative. The evaluation design was a case study of 20 participating communities with cross-case analysis. Data collection methods included: coalition member surveys at two points in time, semi-structured interviews with key informants, focus groups with coalition members and document review. Participating communities were diverse in terms of population density, geography and socio-demographic characteristics. Over a 3-year period, grantees developed a broad-based coalition of residents and community sectors, produced a shared vision, conducted an asset-based community assessment, identified a priority community improvement focus, developed an action plan, implemented the plan and evaluated their efforts. Local residents were engaged through coalition membership, assessment activities and implementation activities. Ten of the 20 coalitions had memberships comprised of mainly local residents in the planning phase, with 5 maintaining a high level of resident involvement in governance during the implementation phase. Ninety percent of the coalitions had six or more community sectors represented (e.g. education, faith). The majority of coalitions described at least one example of increased input into local government decision-making and at least one instance in which a resident became more actively involved in the life of their community. Findings suggest that the Healthy Cities and Communities model can be successful in facilitating community participation.

Creating community action plans for obesity prevention using the ANGELO (Analysis Grid for Elements Linked to Obesity) Framework

Fri, 13 Nov 2009 06:38:18 PST

Community-based interventions are an important component of obesity prevention efforts. The literature provides little guidance on priority-setting for obesity prevention in communities, especially for socially and culturally diverse populations. This paper reports on the process of developing prioritized, community-participatory action plans for obesity prevention projects in children and adolescents using the ANGELO (Analysis Grid for Elements Linked to Obesity) Framework. We combined stakeholder engagement processes, the ANGELO Framework (scans for environmental barriers, targeted behaviours, gaps in skills and knowledge) and workshops with key stakeholders to create action plans for six diverse obesity prevention projects in Australia (n = 3), New Zealand, Fiji and Tonga from 2002 to 2005. Some sites included sociocultural contextual analyses in the environmental scans. Target groups were under-5-year-olds (Australia), 4–12-year-olds (Australia) and 13–18-year-olds (all four countries). Over 120 potential behavioural, knowledge, skill and environmental elements were identified for prioritization leading into each 2-day workshop. Many elements were common across the diverse cultural communities; however, several unique sociocultural elements emerged in some cultural groups which informed their action plans. Youth were actively engaged in adolescent projects, allowing their needs to be incorporated into the action plans initiating the process of ownership. A common structure for the action plan promoted efficiencies in the process while allowing for community creativity and innovation. The ANGELO is a flexible and efficient way of achieving an agreed plan for obesity prevention with diverse communities. It is responsive to community needs, combines local and international knowledge and creates stakeholder ownership of the action plan.

Implementing a standardized community-based cardiovascular risk assessment program in 20 Ontario communities

Fri, 13 Nov 2009 06:38:18 PST

The aim of the study is to describe the implementation of the Cardiovascular Health Awareness Program (CHAP) in 20 mid-sized communities across Ontario, Canada, and identify key factors in the successful multi-site delivery of a collaborative cardiovascular risk assessment and management program. Lead organizations were identified and contracted following a request for proposals. An Implementation Guide detailed steps in community mobilization and delivery of volunteer-led pharmacy-based cardiovascular risk assessment sessions. Process data were collected through final reports; a debriefing meeting; and interviews with program staff. All 20 communities successfully implemented CHAP. Overall, 99% (338/341) of family physicians agreed to receive assessment results and 89% (129/145) of pharmacies held sessions. Five hundred and seventy-seven volunteers conducted 27 358 risk assessments for 15 889 unique participants. Essential program components were consistently included, however, variations in materials, processes and support occurred. Factors in program success included: local expertise, centralized support, identification and engagement of local physician and pharmacist opinion leaders and a balance of standardization and flexibility. Monitoring delivery of a multi-community cardiovascular risk assessment program yielded key factors in program success to inform development of a sustainable and transferable model.

Cardiovascular disease risk factors and women prisoners in the UK: the impact of imprisonment

Plugge, E. H., Foster, C. E., Yudkin, P. L., Douglas, N. — Fri, 13 Nov 2009 06:38:18 PST

Cardiovascular disease (CVD) is a leading cause of death throughout the world. In high income countries, the greatest burden of disease is seen in those from lower socio-economic groups. It is therefore likely that CVD is an important issue for prisoners in the UK, the majority of whom were either unemployed or in non-skilled employment prior to imprisonment. However, there is little research examining this issue. The aim of this study was to examine the prevalence of five modifiable cardiovascular risk factors (smoking, physical activity, diet, body mass index and hypertension) in women prisoners on entry to prison and then 1 month after imprisonment. This was a prospective longitudinal study involving 505 women prisoners in England. Participants completed a questionnaire containing questions about health-related behaviours within 72 h of entering prison. The researchers measured their blood pressure, height and weight. They followed up all participants who were still imprisoned 1 month later and invited them to participate again. The results showed that women prisoners were at high risk of CVD in the future; 85% smoked cigarettes, 87% were insufficiently active to benefit their health, 86% did not eat at least five portions of fruit and vegetables each day and 30% were overweight or obese. After 1 month, there were few improvements in risk factors. This may in part reflect the fact that, unlike prisons in other high income countries, there are currently no systematic approaches which address these health issues within UK women's prisons.

Impact of front-of-pack 'traffic-light' nutrition labelling on consumer food purchases in the UK

Sacks, G., Rayner, M., Swinburn, B. — Fri, 13 Nov 2009 06:38:18 PST

Front-of-pack ‘traffic-light’ nutrition labelling has been widely proposed as a tool to improve public health nutrition. This study examined changes to consumer food purchases after the introduction of traffic-light labels with the aim of assessing the impact of the labels on the ‘healthiness’ of foods purchased. The study examined sales data from a major UK retailer in 2007. We analysed products in two categories (‘ready meals’ and sandwiches), investigating the percentage change in sales 4 weeks before and after traffic-light labels were introduced, and taking into account seasonality, product promotions and product life-cycle. We investigated whether changes in sales were related to the healthiness of products. All products that were not new and not on promotion immediately before or after the introduction of traffic-light labels were selected for the analysis (n = 6 for ready meals and n = 12 for sandwiches). For the selected ready-meals, sales increased (by 2.4% of category sales) in the 4 weeks after the introduction of traffic-light labels, whereas sales of the selected sandwiches did not change significantly. Critically, there was no association between changes in product sales and the healthiness of the products. This short-term study based on a small number of ready meals and sandwiches found that the introduction of a system of four traffic-light labels had no discernable effect on the relative healthiness of consumer purchases. Further research on the influence of nutrition signposting will be needed before this labelling format can be considered a promising public health intervention.

Building capacity in local government for integrated planning to increase physical activity: evaluation of the VicHealth MetroACTIVE program

Thomas, M. M., Hodge, W., Smith, B. J. — Fri, 13 Nov 2009 06:38:18 PST

Integrated planning is a holistic approach to addressing the needs of local communities built on partnerships between those responsible for development, environmental quality and service provision. This study investigated the extent and key influences on the use of integrated planning to promote physical activity among six metropolitan councils in Melbourne Australia, which took part in the MetroACTIVE Project funded by the Victorian Health Promotion Foundation from 2005 to 2007. The evaluation entailed interviews conducted at the mid-term (N = 67) and completion (N = 50) of the project, and the review of relevant documents. Respondents included elected councillors, chief executive officers, officers from different council divisions and the project staff employed in each council. Three councils showed evidence of integrated planning for physical activity, whereas the remainder focused on the delivery of community participation programs. Leadership from senior management and an organizational culture that supported collaboration across council departments were prerequisites for integrated planning. Employment of a dedicated project officer with skills for engaging management and building partnerships within the organization was important. Barriers to integrated planning were a complex organization structure, high demands on the council due to a growing residential population and a poor climate among staff. Overall, integrated planning was found to be a viable approach for developing a coordinated approach to this issue involving the range of council services and functions. Ongoing strategies are needed to facilitate senior management commitment and organizational capacity for integrated planning, with leadership provided by departments responsible for infrastructure or corporate planning.

Social capital does matter for adolescent health: evidence from the English HBSC study

Morgan, A., Haglund, B. J. A. — Fri, 13 Nov 2009 06:38:18 PST

Social capital has grown out of the recognition that health-related behaviours are shaped and constrained by a range of social and community contexts and that the ways in which an individual relates to social networks and communities has important effects on their health and well-being. Given the strong and complex inequalities that exist in adolescent health at both the national and international levels, social capital, acting a protective factor (or asset), may help reduce poor outcomes. The aim of this study was to measure and assess the relative importance of a range of social indicators representing the different domains of social capital on the health, wellbeing and health-related behaviours of young people. The study population was a random sample of 6425 school children aged 11–15 years old in 80 schools in England. Data were collected by a standardized questionnaire under supervised conditions in the classroom developed as part of the WHO Health Behaviour in School Aged Children (HBSC) study. This study has shown that social capital matters for young people's health, statistically significant relationships were found between the range of social capital indicators and the health and health-related outcomes selected for study. For example, young people with a low sense of family belonging and low involvement in the neighbourhood were almost twice as likely to report poor health (OR = 1.87 and 1.96, respectively). Low involvement in the neighbourhood was also highly associated with low consumption of fruit (OR = 2.48) and vegetables (OR = 2.62). Overall, however the strength of associations found varied across health behaviours and indicators of social capital and this requires further examination.

Alcohol use and related harms in school students in the USA and Australia

Fri, 13 Nov 2009 06:38:19 PST

Recognizing there have been few methodologically rigorous cross-national studies of youth alcohol and drug behaviour, state student samples were compared in Australia and the USA. Sampling methods were matched to recruit two independent, state-representative, cross-sectional samples of students in Grades 5, 7 and 9 in Washington State, USA, (n = 2866) and Victoria, Australia (n = 2864) in 2002. Of Washington students in Grade 5 (age 11), 10.3% (95% CI 7.2–14.7) of boys and 5.2% (95% CI 3.4–7.9) of girls reported alcohol use in the past year. Prevalence rates were markedly higher in Victoria (34.2%, 95% CI 28.8–40.1 boys; 21.0%, 95% CI 17.1–25.5 girls). Relative to Washington, the students in Victoria demonstrated a two to three times increased likelihood of reporting substance use (either alcohol, tobacco or illicit drug use), and by Grade 9, experiences of loss-of-control of alcohol use, binge drinking (frequent episodes of five or more alcoholic drinks), and injuries related to alcohol were two to four times higher. The high rates of early age alcohol use in Victoria were associated with frequent, heavy and harmful alcohol use and higher overall exposure to alcohol or other drug use. These findings reveal considerable variation in international rates of both adolescent alcohol misuse and co-occurring drug use and suggest the need for cross-national research to identify policies and practices that contribute to the lower rate of adolescent alcohol and drug use observed in the USA in this study.

Health impact assessment of quality wine production in Hungary

Adam, B., Molnar, A., Bardos, H., Adany, R. — Fri, 13 Nov 2009 06:38:19 PST

Alcohol-related health outcomes show strikingly high incidence in Hungary. The effects of alcohol consumption are influenced not only by the quantity, but also the quality of drinks; therefore, wine production can have an important effect on public health outcomes. Nevertheless, the Hungarian wine sector faces several vital problems and challenges influenced by the country's accession to the European Union and by the need for restructuring. A comprehensive health impact assessment (HIA) based on the evaluation of the Hungarian legislation related to the wine sector has been carried out, aiming to assess the impact of the production of quality wine versus that of table wine, using a range of public health and epidemiological research methods and data as well as HIA guidelines. The study finds that the toxic effects of alcohol can be reduced with an increased supply of quality wine and with decreased overall consumption due to higher cost, although this might drive some people to seek illegal sources. Quality wine production allows for improved use of land, creates employment opportunities and increases the incomes of producers and local communities; however, capital-scarce producers unable to manage restructuring may lose their source of subsistence. The supply of quality wine can promote social relations, contribute to a healthy lifestyle and reduce criminality related to alcohol's influence and adulteration. In general, the production and supply of quality wine can have an overall positive impact on health. Nevertheless, because of the several possible negative effects expected without purposeful restructuring, recommendations for the maximization of favourable outcomes and suggestions for monitoring the success of the analysis have been provided.

Ways of healthy aging: a case study of elderly people in a Northern Thai village

Fri, 13 Nov 2009 06:38:19 PST

This ethnographic study was conducted to explore ways of healthy aging and the influence of culture on health-related behaviors in a rural community in Northern Thailand. In-depth interviews, focus group discussions, participant observations and field notes were used to understand the lives of seven healthy Thai older adults aged 75 years and over. Data were collected from March 2007 to February 2008, with ongoing ethnographic analysis involving coding, identifying patterns, generalizing and making reflective notes to elucidate the cultural patterns of behavior. All informants perceived health as interrelated with their life styles, which was, in turn, closely related to their cultural roots, suggesting that culture influences the health of all members of smaller, closely knit communities, including the elderly, by integrating physical, social and spiritual health for older adults and their families.

Disseminating best-evidence health-care to Indigenous health-care settings and programs in Australia: identifying the gaps

Clifford, A., Jackson Pulver, L., Richmond, R., Shakeshaft, A., Ivers, R. — Fri, 13 Nov 2009 06:38:19 PST

Indigenous Australians experience a disproportionately greater burden of harm from smoking, poor nutrition, alcohol misuse and physical inactivity (SNAP risk factors) than the general Australian population. A critical step in further improving efforts to reduce this harm is to review existing efforts aimed at increasing the uptake of evidence-based interventions in Indigenous-specific health-care settings and programs. This study systematically identifies and reviews published Indigenous-specific dissemination studies targeting SNAP interventions. An electronic search of eight databases and a manual search of reference lists of previous literature reviews were undertaken. Eleven dissemination studies were identified for review: six for nutrition and physical activity as a component of diabetes care, three for alcohol and two for smoking. The majority of studies employed continuing medical education (n = 9 studies), suggesting that improving health-care providers’ knowledge and skills is a focus of current efforts to disseminate best-evidence SNAP interventions in Indigenous health-care settings. Only two studies evaluated reminder systems, despite their widespread use in Indigenous-specific health-care services, and only one study employed academic detailing, despite its cost-effectiveness at modifying health-care provider behavior. There is a clear need for more Indigenous-specific dissemination research targeting the uptake of secondary prevention and to establish reliable and valid measures of Indigenous-specific health-care delivery, in order to determine which dissemination strategies are most likely to be effective in Indigenous health-care settings and programs.

Barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review

Korkiakangas, E. E., Alahuhta, M. A., Laitinen, J. H. — Fri, 13 Nov 2009 06:38:19 PST

The aim of this systematic review was to identify the reported barriers to regular exercise among adults either at high risk or already diagnosed with type 2 diabetes (T2D), because of the importance of exercise in the prevention of T2D. We searched the MEDLINE, Cinahl and PsycINFO databases. All potentially relevant articles were reviewed by two researchers, and 67 titles were found, of which 13 papers met inclusion criteria. Internal and external barriers to exercise were identified among adults either at high risk of T2D or already diagnosed. Internal barriers were factors which were influenced by the individual's own decision-making, and external barriers included factors which were outside of the individual's own control. It is important for counselling to identify the internal and external barriers to regular exercise. In this way, the content of counselling can be developed, and solutions to the barriers can be discussed and identified. Further research on the barriers to regular exercise is needed.

Social vaccines to resist and change unhealthy social and economic structures: a useful metaphor for health promotion

Baum, F., Narayan, R., Sanders, D., Patel, V., Quizhpe, A. — Fri, 13 Nov 2009 06:38:19 PST

The term ‘social vaccine’ is designed to encourage the biomedically orientated health sector to recognize the legitimacy of action on the distal social and economic determinants of health. It is proposed as a term to assist the health promotion movement in arguing for a social view of health which is so often counter to medical and popular conceptions of health. The idea of a social vaccine builds on a long tradition in social medicine as well as on a biomedical tradition of preventing illness through vaccines that protect against disease. Social vaccines would be promoted as a means to encourage popular mobilization and advocacy to change the social and economic structural conditions that render people and communities vulnerable to disease. They would facilitate social and political processes that develop popular and political will to protect and promote health through action (especially governments prepared to intervene and regulate to protect community health) on the social and economic determinants. Examples provided for the effects of social vaccines are: restoring land ownership to Indigenous peoples, regulating the advertising of harmful products and progressive taxation for universal social protection. Social vaccines require more research to improve understanding of social and political processes that are likely to improve health equity worldwide. The vaccine metaphor should be helpful in arguing for increased action on the social determinants of health.

An exploration of the theoretical concepts policy windows and policy entrepreneurs at the Swedish public health arena

Guldbrandsson, K., Fossum, B. — Fri, 13 Nov 2009 06:38:19 PST

In John Kingdon's Policy Streams Approach policy formation is described as the result of the flow of three ‘streams’, the problem stream, the policy stream and the politics stream. When these streams couple, a policy window opens which facilitate policy change. Actors who promote specific solutions are labelled policy entrepreneurs. The aim of this study was to test the applicability of the Policy Streams Approach by verifying whether the theoretical concepts ‘policy windows’ and ‘policy entrepreneurs’ could be discernable in nine specified cases. Content analyses of interviews and documents related to child health promoting measures in three Swedish municipalities were performed and nine case studies were written. The policy processes preceding the municipal measures and described in the case studies were scrutinized in order to find statements related to the concepts policy windows and policy entrepreneurs. All conditions required to open a policy window were reported to be present in eight of the nine case studies, as was the most important resource of a policy entrepreneur, sheer persistence. This study shows that empirical examples of policy windows and policy entrepreneurs could be identified in child health promoting measures in Swedish municipalities. If policy makers could learn to predict the opening of policy windows, the planning of public health measures might be more straightforward. This also applies to policy makers’ ability to detect actors possessing policy entrepreneur resources.

Corrigendum to 'Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey' [HEAPRO 24 (2009) 252-261]

Fri, 13 Nov 2009 06:38:19 PST

Health Promotion International: special supplement on European Healthy Cities

Tsouros, A., Green, G. — Fri, 13 Nov 2009 06:41:00 PST

City leadership for health and sustainable development: The World Health Organization European Healthy Cities Network

Tsouros, A. — Fri, 13 Nov 2009 06:41:01 PST

This paper provides an overview of European Healthy Cities Network (EHCN) organized by the WHO Regional Office Europe. The focus is on the third of five phases covering the period 1998–2002. Fifty-six cities were members of the WHO-EHCN and over 1000 European cities were members of national networks. Association with WHO has given municipalities legitimacy to move into a domain often associated with health service. Equity and community participation are core values. City mayors provide political leadership. Intersectoral cooperation underpins a Healthy Cities approach. The WHO Regional Office for Europe supports WHO-EHCN, providing guidance and technical leadership. Cities’ processes and structures are prerequisits for improvements in health and are central to the evaluation of Phase III of the WHO-EHCN.

Healthy Cities in a global and regional context

Lawrence, R. J., Fudge, C. — Fri, 13 Nov 2009 06:41:01 PST

Since the beginning of the WHO European Healthy Cities Network in 1987, the global and regional contexts for the promotion of health and well-being have changed in many ways. First, in 2000, the United Nations Millennium Goals explicitly and implicitly addressed health promotion and prevention at the global and regional levels. Second, the concern for sustainable development at the Rio Conference in 1992 was confirmed at the World Summit in Johannesburg in 2002. During the same period, in many regions including Europe, the redefinition of the roles and responsibilities of national, regional and local governments, reductions in budgets of public administrations, the privatization of community and health services, the instability of world trade, the financial system and employment, migration flows, relatively high levels of unemployment (especially among youth and young adults) have occurred in many countries in tandem with negative impacts on specific policies and programmes that are meant to promote health. Since 1990, the European Commission has been explicitly concerned about the promotion of health, environment and social policies by defining strategic agendas for the urban environment, sustainable development and governance. However, empirical studies during the 1990s show that urban areas have relatively high levels of tuberculosis, respiratory and cardiovascular diseases, cancer, adult obesity, malnutrition, tobacco smoking, poor mental health, alcohol consumption and drug abuse, sexually transmitted diseases (including AIDS), crime, homicide, violence and accidental injury and death. In addition, there is evidence that urban populations in many industrialized countries are confronted with acute new health problems stemming from exposure to persistent organic pollutants, toxic substances in building structures, radioactive waste and increasing rates of food poisoning. These threats to public health indicate an urgent need for new strategic policies and research agendas that address the complex interrelations between urban ecosystems, sustainable development, human health and well-being. The WHO Healthy Cities project is one important vector for achieving this objective at both global and regional levels.

Evidence for Healthy Cities: reflections on practice, method and theory

de Leeuw, E. — Fri, 13 Nov 2009 06:41:01 PST

The European Healthy Cities project can be characterized as a social movement that employs an extremely wide range of political, social and behavioural interventions for the development and sustenance of urban population health. At all of these levels, the movement is inspired by ideological, theoretical and evidence-based perspectives. The result of this stance is a dynamic, complex and diverse landscape of initiatives, plans, programmes and actions. In quantitative terms (the number of WHO designated cities and associated cities and communities through national networks), ‘Healthy Cities’ can be regarded as an extraordinary accomplishment and a credit for both WHO and cities in the movement. In qualitative terms, however, critics of the movement have maintained that little evidence on its success and effectiveness has been generated. This critique finds its foundations in the mere perceptions of evidence, the politics of science and urban governance, and perspectives on the preferred or professed utilities of evidence-based health notions. The article reviews the nature of evidence and its interface with politics and governance. Applying a conceptual framework combining insights from knowledge utilization theory, theoretical perspectives on (health) policy development, theory-based evaluations and planned intervention approaches, it demonstrates that, although the evidence is overwhelming, there are barriers to the implementation of such evidence that should be further addressed by ‘Healthy Cities’.

Partnership structures in the WHO European Healthy Cities project

Green, G., Price, C., Lipp, A., Priestley, R. — Fri, 13 Nov 2009 06:41:02 PST

The development of new partnership structures for public health is an important goal of the World Health Organization's Healthy Cities project which covers a network of European municipalities. A review was carried out of the partnership structures and key changes arising from the project, based on the responses of 44 cities to a structured questionnaire, interviews with 24 city representatives and publications from the project from 1988 to 2003. Cities reported elaborate partnership mechanisms usually combining formal and informal working methods. Differences between cities could partly be related to differences in the way that local government is organized within countries and partly differences in local choices and circumstances. A relationship between the effectiveness of partnership arrangements and delivery of key elements of the project was discernable. Most cities reported having changed their processes for decision-making and planning for health as a result of membership of the WHO European Healthy Cities Network. One of the most potent stimuli for these changes was the action to which a city had committed as part of its membership of the Network.

Community participation and empowerment in Healthy Cities

Heritage, Z., Dooris, M. — Fri, 13 Nov 2009 06:41:02 PST

Community participation and empowerment are core principles underpinning the Healthy Cities movement. By providing an overview of theory and presenting the relevant findings of evaluations, this article explores how cities in the WHO European Healthy Cities Network have integrated community participation and empowerment within their development. Reflecting the inclusion of public participation and empowerment within the designation criteria for project cities, the evaluation of Phase III in 2002 demonstrated that community participation continues to be a high priority in most project cities. One-third of cities regularly consulted with large parts of their populations and another third undertook occasional consultations. Nearly 80% of cities had mechanisms for community representatives to participate in decision-making; and more than two-thirds of cities had initiatives explicitly aimed at empowering local people. Subsequent research carried out during 2005 further highlighted the centrality of public participation to the Healthy Cities movement. It found that all project cities continued to support community involvement. Community participation is an essential part of the process of good local governance, and empowerment remains at the heart of effective health promotion. To be meaningful, these processes must be seen as fundamental values of Healthy Cities and so must be developed as an integral part of long-term strategic development.

The evolution of the WHO city health profiles: a content review

Webster, P., Lipp, A. — Fri, 13 Nov 2009 06:41:02 PST

The WHO European Healthy Cities project developed city health profiles (CHPs) to provide the evidence base for health planning. A CHP is a public health report that brings together key pieces of information on health and its determinants in the city and interprets and analyses the information. This CHP would then form the basis of a city health development plan that would set out strategies and programmes of intervention to improve the health of a city's population. A content review of the CHPs produced by the cities in the WHO European Healthy Cities Network in 1995 and repeated 10 years later, attempted to undertake a systematic and comprehensive content review of the CHPs. The results show that in both reviews, demographic information was covered comprehensively. The inadequate coverage of areas of health status and socio-economic conditions in the 1995 review was covered comprehensively in 2005. Coverage of lifestyles, infrastructures and public health policies and services had improved since the 1995 review. The findings indicate that profiles presenting information on health and its determinants provide an evidence-base to inform health planning for the city. However, problems were still encountered in undertaking appropriate analysis to identify inequalities within the city and make recommendations that could be translated into targets. Just as the cities have adapted and evolved throughout the WHO Healthy Cities project, so have CHPs. The range of health profiles produced by cities demonstrate how they have evolved from basic tools that started by collecting routinely available information on death and disease to sophisticated mechanisms that gather an array of relevant information from a wide variety of sources through a range of methods. Most cities have understood the concept of a CHP as an evidence-based tool to inform health policy and planning and to strengthen the public health agenda.

The introduction of health impact assessment in the WHO European Healthy Cities Network

Ison, E. — Fri, 13 Nov 2009 06:41:02 PST

The World Health Organization (WHO) has been a strong and persistent voice calling for the recognition of the role of health in development and of the impact of socio-economic development on health. Health impact assessment (HIA) is one mechanism that can be used to achieve this goal. The objective of this paper is to describe HIA practice in the WHO European Healthy Cities Network and present some of the initial learning from a collective approach to introducing this relatively new methodology into municipal business. One of the foundations for this was a European Union (EU)-funded project entitled Promoting and Supporting Integrated Approaches for Health and Sustainable Development at the Local Level across Europe (PHASE). For Phase IV of WHO European Healthy Cities, HIA was made one of four core themes, and a sub-network in HIA was set up to support the introduction and development of the methodology. The use of HIA by four cities in the Network—Belfast, Onex-Geneve, Helsingborg, Bologna—illustrates the challenges and successes experienced in the initial stages of Phase IV.

City health development planning

Green, G., Acres, J., Price, C., Tsouros, A. — Fri, 13 Nov 2009 06:41:02 PST

The objective of this evaluation was to review the evolution and process of city health development planning (CHDP) in municipalities participating in the Healthy Cities Network organized by the European Region of the World Health Organization. The concept of CHDP combines elements from three theoretical domains: (a) health development, (b) city governance and (c) urban planning. The setting was the 56 cities which participated in Phase III (1998–2002) of the Network. Evidence was gathered from documents either held in WHO archives or made available from Network cities and from interviews with city representatives. CHDPs were the centrepiece of Phase III, evolving from city health plans developed in Phase II. They are strategic documents giving direction to municipalities and partner agencies. Analysis revealed three types of CHDP, reflecting the realpolitik of each city. For many cities, the process of CHDP was as important as the plan itself.

Equity and social determinants of health at a city level

Ritsatakis, A. — Fri, 13 Nov 2009 06:41:03 PST

Equity in health has been the underlying value of the WHO Health for All policy for 30 years, distinguished from equality and difference in a commissioned series of theoretical reports in the early 1990s. This article examines how cities translated this principle into action. Using information designed to help evaluate Phase III (1998–2002) of the WHO European Healthy Cities Network, plus documentation from city programmes and websites, an attempt is made to assess how far stakeholders in cities understood the concept of equity in health, had the political will to tackle the issue and the types of action undertaken. Results show that cities focused mainly on support for vulnerable groups, and a wide range of actions were being implemented, including lifestyle-oriented methods or those to improve access to care. Few cities made the necessary shift towards more upstream policies to tackle determinants of health such as poverty, unemployment and housing. There was little experience of evaluating the impact of interventions to reduce the gaps. This is partly explained by a frequent lack of local level data reflecting inequalities in health. The article concludes that although half the cities in the Network needed stronger action to make equity in health an integral part of long-term planning, innovative experience was available to be shared by its members in Phase IV (2003–2008) of the Network.

Healthy urban planning in European cities

Barton, H., Grant, M., Mitcham, C., Tsourou, C. — Fri, 13 Nov 2009 06:41:03 PST

This article describes the WHO ‘healthy urban planning’ (HUP) initiative as it has developed through the laboratory of the Healthy Cities movement and evaluates the degree to which applicant cities successfully developed plans for HUP. The paper provides a brief historical perspective on the relationship of health and planning and an overview of the ways in which urban spatial development affects health. It then turns to the WHO European Healthy Cities Network (WHO-EHCN) and explains the evolution of the HUP programme through Phase III (1998–2002) of the Healthy Cities Project, showing how the programme has grown from experimental beginnings to being ‘mainstreamed’ in Phase IV (2003–2008). Each city wishing to join the WHO-EHCN in this latter phase produced a programme for further development of HUP, and these were assessed by the Bristol Collaborating Centre. The paper presents the overall results, concluding that a significant progress has been made and the most advanced cities have much to offer municipalities everywhere in the best practice for integrating health into urban planning.

National networks of Healthy Cities in Europe

Janss Lafond, L., Heritage, Z. — Fri, 13 Nov 2009 06:41:03 PST

National networks of Healthy Cities emerged in the late 1980s as a spontaneous reaction to a great demand by cities to participate in the Healthy Cities movement. Today, they engage at least 1300 cities in the European region and form the backbone of the Healthy Cities movement. This article provides an analysis of the results of the regular surveys of national networks that have been carried out principally since 1997. The main functions and achievements of national networks are presented alongside some of their most pressing challenges. Although networks have differing priorities and organizational characteristics, they do share common goals and strategic directions based on the Healthy Cities model (see other articles in this special edition of HPI). Therefore, it has been possible to identify a set of organizational and strategic factors that contribute to the success of networks. These factors form the basis of a set of accreditation criteria for national networks and provide guidance for the establishment of new national networks. Although national networks have made substantial achievements, they continue to face a number of dilemmas that are discussed in the article. Problems a national network must deal with include how to obtain sustainable funding, how to raise the standard of work in cities without creating exclusive participation criteria and how to balance the need to provide direct support to cities with its role as a national player. These dilemmas are similar to other public sector networks. During the last 15 years, the pooling of practical expertise in urban health has made Healthy Cities networks an important resource for national as well as local governments. Not only do they provide valuable support to their members but they often advise ministries and other national institutions on effective models to promote sustainable urban health development.

Acting on the social determinants of health: health promotion needs to get more political

Sparks, M. — Thu, 06 Aug 2009 09:01:41 PDT

Meeting the challenges of the Ottawa Charter: comparing South African responses to AIDS and tobacco control

Taylor, M., Meyer-Weitz, A., Jinabhai, C.C., Sathiparsad, R. — Thu, 06 Aug 2009 09:01:41 PDT

The paper compares the response of the South African Government to HIV and AIDS with the government's policy development concerning the use of tobacco. The high burden of disease from HIV and AIDS in South Africa and the morbidity and mortality from the use of tobacco are outlined. Using the framework of the Ottawa Charter for Health Promotion, the paper reviews and critiques the Government's different stance to building public policy, creating supportive environments, engaging community participation, developing personal skills and re-orienting the health services, for HIV/AIDS and tobacco. The result of these policy choices is described. The lack of adequate implementation of the key elements of the Ottawa Charter has resulted in high morbidity and mortality due to the spread of HIV infection in South Africa. This has also influenced the resurgence of tuberculosis, and the accompanying MDR and XDR TB epidemics. The high prevalence of HIV infection has also meant that the health system is unable to cope with the large numbers of patients requiring anti-retroviral treatment, and the early morbidity and mortality of young economically active people has had devastating social consequences, resulting in the large numbers of orphans. In contrast, South Africa is a signatory to the World Health Organizations' Framework Convention on Tobacco Control, and has successfully implemented many of the policies.

Implementation of a campus-wide Irish hospital smoking ban in 2009: prevalence and attitudinal trends among staff and patients in lead up

Thu, 06 Aug 2009 09:01:41 PDT

We report the evidence base that supported the decision to implement the first campus-wide hospital smoking ban in the Republic of Ireland with effect from 1 January 2009. Three separate data sources are utilized; surveillance data collected from patients and staff in 8 surveys between 1997 and 2006, a 1-week observational study to assess smoker behaviour in designated smoking shelters and an attitudinal interview with 28 smoker patients and 30 staff on the implications of the 2004 indoors workplace smoking ban, conducted in 2005. The main outcome measures were trends in prevalence of smoking over time according to age, sex and occupational groups and attitudes to the 2004 ban and a projected outright campus ban. Smoking rates among patients remained steady, 24.2% in 1997/98 and 22.7% in 2006. Staff smoking rates declined from 27.4% to 17.8%, with a strong occupational gradient. Observational evidence suggested a majority of those using smoking shelters in 2005 were women and health-care workers rather than patients. Attitudes of patients and staff were positive towards the 2004 ban, but with some ambivalence on the effectiveness of current arrangements. Staff particularly were concerned with patient safety issues associated with smoking outdoors. The 2004 ban was supported by 87.6% of patients and 81.3% of staff in 2006 and a majority of 58.6% of patients and 52.4% of staff agreed with an outright campus ban being implemented. These findings were persuasive in instigating a process in 2007/08 to go totally smoke-free by 2009, the stages for which are discussed.

Promoting employee wellbeing: the relevance of work characteristics and organizational justice

Lawson, K. J., Noblet, A. J., Rodwell, J. J. — Thu, 06 Aug 2009 09:01:41 PDT

Research focusing on the relationship between organizational justice and health suggests that perceptions of fairness can make significant contributions to employee wellbeing. However, studies examining the justice–health relationship are only just emerging and there are several areas where further research is required, in particular, the uniqueness of the contributions made by justice and the extent to which the health effects can be explained by linear, non-linear and/or interaction models. The primary aim of the current study was to determine the main, curvilinear and interaction effects of work characteristics and organizational justice perceptions on employee wellbeing (as measured by psychological health and job satisfaction). Work characteristics were measured using the demand–control–support (DCS) model (Karasek and Theorell, 1990) and Colquitt's (2001) four justice dimensions (distributive, procedural, interpersonal and informational) assessed organizational justice (Colquitt, 2001). Hierarchical regression analyses found that in relation to psychological health, perceptions of justice added little to the explanatory power of the DCS model. In contrast, organizational justice did account for unique variance in job satisfaction, the second measure of employee wellbeing. The results supported linear relationships between the psychosocial working conditions and the outcome measures. A significant two-way interaction effect (control x support at work) was found for the psychological health outcome and the procedural justice by distributive justice interaction was significant for the job satisfaction outcome. Notably, the findings indicate that in addition to traditional job stressors, health promotion strategies should also address organizational justice.

Micro grants as a stimulus for community action in residential health programmes: a case study

Schmidt, M., Plochg, T., Harting, J., Klazinga, N.S., Stronks, K. — Thu, 06 Aug 2009 09:01:42 PDT

This paper aimed to explore the contribution of a micro grant financing scheme to community action in terms of residential health-promoting initiatives, interorganizational collaboration and public participation. The scheme was two-fold, consisting of (i) micro grants of 500–3500 Euros, which were easily obtainable by local organizations and (ii) neighbourhood health panels of community and health workers, functioning as a distributing mechanism. Data were collected using three methods: (i) observations of the neighbourhood-based health panels, (ii) in-depth interviews with policy-makers and professionals and (iii) analyses of documents and reports. This study demonstrated the three-fold role of micro grants as a vehicle to enable community action at an organizational level in terms of increased network activities between the local organizations, to set an agenda for the ‘health topic’ in non-traditional health agencies and to enable a number of health-promoting initiatives. Although these initiatives were attended by small groups of residents normally considered hard to reach, the actual public participation was limited. In their role as a distributing mechanism, the health panels were vital with regard to the achieved impact on the community action. However, certain limitations were also seen, which were related to the governance of the panels. This case study provides evidence to suggest that micro grants have the potential to stimulate community action at an organizational and a residential level, but with the prerequisite that grants be accompanied by increased investments in infrastructure.

Assessment of organizational readiness for health promotion policy implementation: test of a theoretical model

Rutten, A., Roger, U., Abu-Omar, K., Frahsa, A. — Thu, 06 Aug 2009 09:01:42 PDT

Models explaining the engagement of organizations in different policy sectors in health promotion policy implementation often utilize retrospective data. The current study attempted to model determinants of organizational readiness (goals, resources, obligation, opportunities) in supporting health policy implementation prospectively. Twenty qualitative interviews with representatives of organizations from different policy sectors, levels of government and organizational legal entities were conducted at the beginning of a project for the promotion of physical activity among women in difficult life situations. Organizational support in developing, implementing and disseminating the project was documented over 36 months. Results indicated that in most organizations, determinants were not favorable for health promotion policy action for physical activity among women in difficult life situations. Six organizations did not report any favorable determinant, and two organizations reported four. The other 12 organizations reported positive results for some of the determinants. Project work received support from 6 out of the 20 organizations. A case study of three organizations indicated that engagement or disengagement of organizations in health promotion policy actions might be partly explained by the theoretical model. The prospective assessment of organizational readiness in implementing health promotion policy is highly relevant for health promotion. Considering the proposed theoretical framework may aid in advancing our understanding of factors that are related to organizational engagement in health promotion actions.

Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey

Thu, 06 Aug 2009 09:01:42 PDT

The objective of this paper is to measure health literacy in a representative sample of the Australian general population using three health literacy tools; to consider the congruency of results; and to determine whether these assessments were associated with socio-demographic characteristics. Face-to-face interviews were conducted in a stratified random sample of the adult Victorian population identified from the 2004 Australian Government Electoral Roll. Participants were invited to participate by mail and follow-up telephone call. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA) and Newest Vital Sign (NVS). Of 1680 people invited to participate, 89 (5.3%) were ineligible, 750 (44.6%) were not contactable by phone, 531 (32%) refused and 310 (response rate 310/1591, 19.5%) agreed to participate. Compared with the general population, participants were slightly older, better educated and had a higher annual income. The proportion of participants with less than adequate health literacy levels varied: 26.0% (80/308) for the NVS, 10.6% (51 33/310) for the REALM and 6.8% (21/309) for the TOFHLA. A varying but significant proportion of the general population was found to have limited health literacy. The health literacy measures we used, while moderately correlated, appear to measure different but related constructs and use different cut offs to indicate poor health literacy.

The evolution of a UK regional tobacco control office in its early years: social contexts and policy dynamics

Thu, 06 Aug 2009 09:01:42 PDT

The Smoke Free North East Office (SFNEO) is the first dedicated tobacco control office in the UK coordinating a regional tobacco control network, Smoke Free North East (SFNE). On the basis of ethnographic research conducted between 2006 and 2008, this article examines the context for SFNEO's emergence at this time and in this region of England, and the main policy and practice challenges it has faced in its early years. SFNE formed in a favourable political and cultural climate, although regional champions were crucial in setting it up. It has worked well in branding itself and in taking advantage of the opportunity to lobby in support of comprehensive smoke-free legislation, although the success of the legislation presents a risk that people will regard SFNE's work as finished. There is a need for independent sustainable funding, strong partnership working and the ‘bringing together’ of existing organizations under its leadership for an organization such as SFNE to succeed. SFNE offers a model that is transferable to other places as well as to other public health concerns such as alcohol, and has been taken up by public health planners and policy makers with alacrity. This indicates a general perception that SFNE plays an effective role in public health delivery.

The attitudes of patients and staff towards aspects of health promotion interventions in mental health services in Sweden

Svedberg, P., Hansson, L., Svensson, B. — Thu, 06 Aug 2009 09:01:42 PDT

The present study investigates attitudes towards aspects of health promotion in mental health services, as rated by patients and staff. The aim of the study was to investigate similarities and differences in attitudes towards health promotion interventions among patients and staff in mental health services, using a newly developed questionnaire, the Health Promotion Intervention Questionnaire (HPIQ). The study has a cross-sectional design and a sample of 141 patients and 140 staff were recruited to the study. The response rate was 59% for the patients and 50% for the staff. The participants were asked to rate the attitudes of the 19 items included in the HPIQ. The result showed that patients and staff in some cases share similar attitudes regarding aspects of health promotion intervention. According to both groups, empowerment is the most important intervention in health promotion. Significant differences between the ratings of patients and staff appeared regarding all subscales of HPIQ. Patients rated alliance and educational support significantly higher than staff and staff-rated empowerment and practical support significantly higher than patients. Based on these findings, it is of importance to meet patients' desire for information and knowledge in an interactive manner with an empowerment approach to promote health in mental health services.

A conceptual framework for understanding and improving adolescents' exposure to Internet-delivered interventions

Crutzen, R., de Nooijer, J., Brouwer, W., Oenema, A., Brug, J., de Vries, N. K. — Thu, 06 Aug 2009 09:01:42 PDT

Although exposure is crucial to improve the public health impact of Internet-delivered interventions, it appears that in practice exposure to such interventions is low. Therefore, a conceptual framework, which incorporates elements of user experience of websites, is applied to Internet-delivered health behaviour change interventions aimed at adolescents and results from previous explorative research are incorporated. This framework, described from the point of view of an intervention's development team, can be used in practice to optimize user experience and therewith improving exposure rates to Internet-delivered interventions and increasing the number of revisiting users.

Health literacy revisited: what do we mean and why does it matter?

Peerson, A., Saunders, M. — Thu, 06 Aug 2009 09:01:42 PDT

‘Health literacy’ refers to accessing, understanding and using information to make health decisions. However, despite its introduction into the World Health Organization's Health Promotion Glossary, the term remains a confusing concept. We consider various definitions and measurements of health literacy in the international and Australian literature, and discuss the distinction between the broader concept of ‘health literacy’ (applicable to everyday life) and ‘medical literacy’ (related to individuals as patients within health care settings). We highlight the importance of health literacy in relation to the health promotion and preventive health agenda. Because health literacy involves knowledge, motivation and activation, it is a complex thing to measure and to influence. The development of health literacy policies will be facilitated by better evidence on the extent, patterns and impact of low health literacy, and what might be involved in improving it. However, the current lack of consensus of definitions and measurement of health literacy will first need to be overcome.