Health Promotion International - recent issues

Adelaide revisited: from healthy public policy to Health in All Policies

Kickbusch, I., McCann, W., Sherbon, T. — 2008-02-13

Changes in smoking among restaurant and bar employees following Norway's comprehensive smoking ban

Braverman, M. T., Aaro, L. E., Hetland, J. — 2008-02-13

Norway implemented a nationwide ban on indoor smoking in June 2004. This study documents the smoking patterns of Norway's restaurant and bar workers before and after the ban, to determine changes in smoking prevalence and explore which individual and environmental characteristics were related to cessation. A national sample of food service workers was surveyed by telephone or Internet immediately before the ban and at 4 and 11 months post-implementation. Results showed that between baseline measurement and 4 months post-implementation, there were significant declines in prevalence of daily smoking (–3.6% points, p < 0.005), daily smoking at work (–6.2% points, p < 0.001), number of cigarettes smoked by continuing smokers (–1.55, p < 0.001) and number of cigarettes smoked at work by continuing smokers (–1.63, p < 0.001). No significant changes occurred in any of these variables between 4 and 11 months post-implementation. Logistic regression analysis revealed that only smokers' intentions at baseline to quit within 30 days predicted cessation at both follow-up time points. In addition, cessation at 4 months was predicted by lower daily cigarette consumption at baseline, whereas cessation at 11 months was predicted by baseline attitude toward ETS and exposure to ETS as measured at follow-up. In sum, Norway's smoking ban was accompanied by a reduction in smoking in the period immediately following the ban, and the reduction was maintained almost a year later. The finding that smoking cessation was consistently associated with smokers' intentions to quit within 30 days suggests that motivational and support programs could play a significant role in boosting cessation rates. It is recommended that targeted interventions be used to supplement the benefits of a comprehensive ban to achieve tobacco control objectives.

School children as health change agents in Magu, Tanzania: a feasibility study

Mwanga, J. R., Jensen, B. B., Magnussen, P., Aagaard-Hansen, J. — 2008-02-13

The feasibility of an action-oriented and participatory educational approach, where school children function as health change agents, in a rural community of (Magu district) Tanzania was explored. Observations, in-depth interviews and focus group discussions with pupils, teachers and parents were undertaken. Findings showed that study participants favoured an approach where school children played an active role as health change agents in a combined school and community health education project. This conclusion contradicts traditional views in many African cultures where power, status and wisdom are usually closely associated with old age. However, a number of barriers were found, including the curriculum, time constraints, class size, teaching materials and teachers' skills and working conditions. The idea that pupils act as health change agents in the community as part of an action-oriented and participatory health education approach in schools was supported. A list of factors to consider when planning an action-oriented health education project is provided and discussed.

People and money matter: investment lessons from the Ontario heart health program, Canada

Riley, B. L., Edwards, N. C., d'Avernas, J. R. — 2008-02-13

Resource allocation is a critical issue for public health decision-makers. Yet little is known about the level and type of resources needed to build capacity to plan and implement comprehensive programs. This paper examines the relationships between investments and changes in organizational capacity and program implementation in the first phase (1998–2003) of the Ontario Heart Health Program (OHHP)—a province-wide, comprehensive public health program that involved 40 community partnerships. The study represents a subset of findings from a provincial evaluation. Investments, organizational capacity of public health units and implementation of heart health activities were measured longitudinally. Investment information was gathered annually from the provincial government, local public health units and community partners using standard reports, and was available from 1998 to 2002. Organizational capacity and program implementation were measured using a written survey, completed by all health units at five measurement times from 1994 to 2002. Combining provincial and local sources, the average total investment by year five was $1.66 per capita. Organizational capacity of public health units and implementation of heart health activities increased both before and during the first 2 years of the OHHP, and then plateaued at a modest level for capacity and a low level for implementation after that. Amount of funding was positively associated with organizational capacity, yet this association was overpowered by the negative influence of turnover of a key staff position. Regression analysis indicated that staff turnover explained 23% of local variability in organizational capacity. Findings reinforce the need for adequate investment and retention of key staff positions in complex partnership programs. Better accounting of public health investments, including monetary and in-kind investments, is needed to inform decisions about the amount and duration of public health investments that will lead to effective program implementation.

Australian pension funds and tobacco investments: promoting ill health and out-of-step with their members

Walsh, R. A., Tzelepis, F., Stojanovski, E. — 2008-02-13

There has been no systematic examination of issues surrounding pension funds and their tobacco shareholdings. This paper describes two studies designed to document the tobacco investment policies and practices of pension funds, and to assess community and fund member attitudes to pension fund shareholdings in the tobacco industry. Chief executives (n = 282) of Australian pension funds were mailed questionnaires. Of 241 eligible funds, 107 (44.4%) returned questionnaires, representing about 61% of total Australian primary superannuation accounts. Twelve percent indicated that they did not currently hold tobacco investments, 30% held tobacco shares and 58% did not know or failed to answer. Overall, 6% of respondents said that they held no tobacco investments and would not consider future investments; 2% had formal policies precluding tobacco investments. Funds with 10 000 or more members were more likely (p = 0.0006) to report tobacco investments. External fund manager advice was the most important factor influencing the funds' position. In the second study, a one-third random sub-sample of consenting subjects from 12 000 households randomly selected from the New South Wales Electronic White Pages completed phone interviews. From 7141 eligible households, 3503 (49.1%) subjects consented. One-third (n = 1158) were asked the pension fund questions. Over three-quarters (77.4%) of all respondents disagreed that pension fund investments in tobacco were ethical. Approximately two-thirds (63.6%) of fund members (n = 852) agreed that their funds should not make tobacco investments. There were three statistically significant predictors of opposition to such investments: being female, more highly educated and non-smoking status. Nearly all pension funds treat tobacco investments like any other investment. In contrast, most of the public including fund members are strongly opposed to such investments. Suggestions for public health advocacy strategies to reduce the negative health promotion effects of pension funds in this area are outlined.

Understanding barriers and facilitators of fruit and vegetable consumption among a diverse multi-ethnic population in the USA

2008-02-13

A diet high in fruits and vegetables (F&V) has been associated with a decreased risk of certain cancers, reduced morbidity and mortality from heart disease, and enhanced weight management. Yet to date, most of the US population does not consume the recommended amount of F&V despite numerous interventions and government guidelines to promote consumption. Research has found various impediments to F&V consumption, such as high costs, an obesogenic environment and low socio-economic status. However, studies have not sufficiently focused on barriers and enablers to F&V intake among adult multi-ethnic populations. The present qualitative study examines 147 focus group participants' perceptions of impediments and enablers to F&V consumption. Twelve focus groups were conducted among African American, Hispanic and Caucasian men and women in North Carolina and Connecticut. Focus groups were audiotaped, transcribed verbatim and entered into QSR NVivo Software. Text data were systematically analyzed by investigators to identify recurrent themes both within and across groups and states. Focus group results indicate that most participants were aware of the health benefits associated with a diet rich in F&V. Yet many admitted not adhering to the Health and Human Service's recommendations. Individual impediments consisted of the high costs of F&V and a perceived lack of time. Early home food environment was perceived as affecting F&V consumption later in life. Other barriers reported were ethnic-specific. The African American participants reported limited access to fresh produce. This finding is consistent with numerous studies and must be addressed through health promotion intervention. Both the church and primary care clinics were described by African Americans as appropriate settings for health behavior interventions; these findings should be considered. Hispanic participants, mostly immigrants, cited inhibiting factors encountered in their adopted US environment. There is a need to improve the availability and access to fresh F&V commonly available in the home countries of Hispanic immigrants.

Using qualitative methodology to inform an Indigenous-owned oral health promotion initiative in Australia

Jamieson, L. M., Parker, E. J., Richards, L. — 2008-02-13

Indigenous Australians experience poor oral health. Oral health perceptions among a group of rural-dwelling Indigenous Australians were explored so that a culturally appropriate, community-owned oral health promotion initiative might be developed. Focus group methodology was used, with prompt questions including oral health knowledge, oral health's role in general health, how community oral health had changed in recent times, the causes of poor oral health and ways to prevent poor oral health at a community level. Some 34 participants took part; age range 21–72 years. A core category emerged from the data and was labelled ‘cultural adaptation’. Five sub-categories were also identified; ‘lifestyle changes’, ‘oral health behaviours’, ‘barriers to dental care’, ‘impact of poor oral health’ and ‘oral health literacy’. Participants felt that historical legacy impacted on the oral health of community members, through continued practices of being told what to do, where to live and what oral health services were available to them. Participants perceived they had little power over their oral health or oral health care decisions. Findings from the focus group discussions were used in the development of a context-specific, oral health promotion initiative, which involved construction of an audiovisual tool in Phase I and a series of interactive, context-specific seminars focused on key issues raised in the focus groups in Phase II. Oral health promotion initiatives among rural-dwelling Indigenous Australians may be more successful if perceptions of the anticipated audience are considered in the design stage of such strategies.

Promoting health in response to global tourism expansion in Cuba

Spiegel, J. M., Gonzalez, M., Cabrera, G. J., Catasus, S., Vidal, C., Yassi, A. — 2008-02-13

The ability of communities to respond to the pressures of globalization is an important determinant of community health. Tourism is a rapidly growing industry and there is an increasing concern about its health impact on local communities. Nonetheless, little research has been conducted to identify potential mitigating measures. We therefore took advantage of the ‘natural experiment’ provided by the expansion of tourism in Cuba, and conducted four focus groups and key informants interviews in each of two coastal communities. Participants expressed concerns about psycho-social impacts as well as occupational and environmental concerns, and both infectious and chronic diseases. A wide array of programs that had been developed to mitigate potential negative were described. Some of the programs were national in scope and others were locally developed. The programs particularly targeted youth as the most vulnerable population at risk of addictions and sexually transmitted infections. Occupational health concerns for workers in the tourism sector were also addressed, with many of the measures implemented protecting tourists as well. The health promotion and various other participatory action initiatives implemented showed a strong commitment to address the impacts of tourism and also contributed to building capacity in the two communities. Although longitudinal studies are needed to assess the sustainability of these programs and to evaluate their long-term impact in protecting health, other communities can learn from the initiatives taken.

Relations between Internet use, socio-economic status (SES), social support and subjective health

2008-02-13

This study aimed to explore relations between Internet use, socio-economic status (SES), social support and subjective health. Participants were from representative samples between 15 and 80 years of age from seven different European countries. Two different survey datasets were used: (i) eHealth trends (eHT; N = 7934) and (ii) the European social survey (ESS2; N = 11248). Internet users who had used the Internet for health purposes were compared with Internet users who had not used it for health purposes. Structural equation modelling was used to assess the relationships between SES, Internet use, social support and subjective health. Use of other media was compared to Internet use in relation to social support and subjective health. Internet use was found to be more closely related to social support and subjective health than use of other media. Internet use was also found to be a plausible mediator between SES and subjective health, especially through interacting with social support.

Setting an ethical agenda for health promotion

Mittelmark, M. B. — 2008-02-13

The Bangkok Charter for Health Promotion in a Globalized World has sparked lively dialogue. Welcomed by some as a Charter current to the times, there are others who see it as an unneeded and therefore unwelcome challenger to the Ottawa Charter for Health Promotion. Intended or not, the Bangkok Charter seems to signal a shift in discourse, from a social-ecological approach and an emphasis on individual and community capacity-building and empowerment, to an investment approach and an emphasis on globalization, macro-level factors and policy. Positively, the Bangkok Charter proclaims to build on Ottawa, and no one suggests it is meant to replace the Ottawa Charter outright. In concert with that, the dialogue today is not so much about the ascendancy of the one Charter over the other, but about the degree to which the Bangkok Charter remains true to the ethic of the Ottawa Charter. It is welcome that the Ottawa and Bangkok Charters are the subject of brisk dialogue about strategy and tactics in a rapidly changing world, and about the foundational values of health promotion. Regarding the latter, we have unfinished work in constructing an ethic for health promotion, and the present dialogue may inspire us to progress. Though we have the cornerstone of an ethic for health promotion, in the Ottawa Charter and in other principled documents that have followed, we have yet to build sufficiently on the cornerstone; an ethic for practice has yet to be codified, and the same is true for research. Health promotion journals, conferences and organizations can and should do more to facilitate dialogue on ethics in health promotion, and the Internet provides the means for all to participate actively.

Modelling the results of health promotion activities in Switzerland: development of the Swiss Model for Outcome Classification in Health Promotion and Prevention

2008-02-13

This paper describes the Model for Outcome Classification in Health Promotion and Prevention adopted by Health Promotion Switzerland (SMOC, Swiss Model for Outcome Classification) and the process of its development. The context and method of model development, and the aim and objectives of the model are outlined. Preliminary experience with application of the model in evaluation planning and situation analysis is reported. On the basis of an extensive literature search, the model is situated within the wider international context of similar efforts to meet the challenge of developing tools to assess systematically the activities of health promotion and prevention.

Shaping the future of health promotion: priorities for action

2008-02-13

The International Union for Health Promotion and Education, in collaboration with the Canadian Consortium for Health Promotion Research, and with support from the Public Health Agency of Canada, have formulated recommendations on priorities for action regarding the policies and system conditions necessary for sustainable and effective health promotion. The statement, launched in June in Vancouver at the IUHPE World Conference on Health Promotion and Health Education, and reproduced below, is the product of an international Project Advisory Group's reflections derived from a collection of commissioned field reports on renewing commitment to the path set out by the Ottawa Charter. The field reports themselves will be published in their entirety in a special issue of ‘Promotion & Education’, official journal of the International Union for Health Promotion and Education, in December 2007.

Health Promotion International

2008-02-13

The imperative of control

de Leeuw, E. — 2007-11-19

Time to give nutrition interventions a higher profile: cost-effectiveness of 10 nutrition interventions

Dalziel, K., Segal, L. — 2007-11-19

The aim of this study was to evaluate the economic performance of 10 nutrition interventions. The interventions included Mediterranean Diet, Intensive Lifestyle Change (nutrition and physical activity) to Prevent Diabetes, Reduced Fat Diet for persons with IGT, Nutritional Counselling in GP (GP, general practice/primary care), Nurse Counselling in GP, Oxcheck Nurse Health Checks in GP, Gutbusters Workplace (for men), Talking Computer, Multi Media 2 fruit 5 veg Campaign and the FFFF (Fighting Fit, Fighting Fat) Media Campaign. Markov models were constructed in order to estimate economic performance expressed as cost per QALY (quality adjusted life year) gained. Data from original clinical trial reports were used to populate the models, supplemented by the wider literature where required. Performance of the Mediterranean Diet and Intensive Lifestyle Change to Prevent Diabetes interventions could be estimated with most certainty and both were highly cost-effective interventions, at AU $1020 (US $760, £410) and AU $1880 (US $1410, £750) per QALY gained, respectively. The media campaign interventions appear highly cost-effective at AU $46 (US $34, £18) for ‘2 fruit 5 veg’ and AU $5600 (US $4200, £2200) per QALY gained for FFFF, but are associated with considerable uncertainty, and may be dominated under certain assumptions. Several interventions were cost-saving under plausible sets of assumptions, whereas a small number were potentially dominated. All interventions subject to economic evaluation appeared cost-effective relative to societal norms. Nutrition interventions can constitute a highly efficient component of a strategy to reduce the growing disease burden linked to over/poor nutrition. There is an urgent need for high-quality trial data from which economic performance of nutrition interventions can be modelled.

Food references and marketing to children in Australian magazines: a content analysis

Kelly, B., Chapman, K. — 2007-11-19

The aim of this study was to assess the content and extent of food references and marketing within popular children's magazines in Australia. Sixteen popular Australian children's magazines were selected, as determined by readership and circulation data. Back copies of each magazine were purchased for publications released between January and December 2006 (n = 76). Each magazine was assessed for food references on the basis of 23 food categories and 7 food-referencing types and as either branded or non-branded food references. There were a high number of overall food references within the children's magazines, with the majority of these being for unhealthy food products (63.7% unhealthy versus 36.3% healthy foods, p < 0.001). The food groups with the highest proportion of branded food references, and therefore paid marketing, were ice cream and iced confection (85.6% branded references), fast food restaurant meals (83.4%), high-sugar drinks (78.9%) and snack foods (73.4%). Of all magazines, those targeting males and children aged 7–12 years had the highest proportion of unhealthy food references (78.1 and 69.8% unhealthy food references, respectively). Food references within children's magazines are common and skewed towards unhealthy foods. Children's high magazine readership rates and a lack of advertising and product placement regulations for magazines in Australia make this media an attractive target for food marketers. The timely establishment of food marketing regulations within magazines are recommended to prevent further expansion of food marketing in this area.

Emergence Model of social and human capital and its application to the Healthy Municipalities project in Northeast Brazil

Yuasa, M., de Sa, R. F., Pincovsky, S., Shimanouchi, N. — 2007-11-19

We developed the Emergence Model and introduced the concept of social and human capital into designing and evaluating the Healthy Cities/Municipalities project to ensure health promotion infrastructure. This model hypothesizes that through the interaction and utilization of the other forms of capital, namely financial, physical and natural, the emergence of collective action takes place in the community or municipal setting. Subsequently, collective action may influence health and quality of life determinants. Once health and quality of life improvements are achieved, the enhancement of the social, human and other capital may be brought about through positive feedback, and successive collective action is thereby facilitated. According to the model, practitioners and policy makers of the Healthy Cities/Municipalities project should primarily strengthen social and human capital.

The model is currently applied to designing the Healthy Municipalities project implemented in rural areas of Northeast Brazil, where infrastructure and a supportive environment to facilitate collective action for control over health and health determinant have been considerably frail due to geographical, historical, social and cultural reasons. Various interventions have been conducted in the scope of the project to enhance social and human capital on three levels, namely the state, municipality and community. Through the capacity development of health promoters, obliging volunteers and so on, the project attempts to create the social mechanism that enables people to build healthy public policies through inter- and trans-sectoral collaboration as well as to address and resolve day-to-day issues using their potentialities.

The development of measures of community capacity for community-based funding programs in Canada

2007-11-19

Improving community capacity for influencing actions on the determinants of health is an immediate outcome of many Public Health Agency of Canada-funding community-based programs. Despite the importance of this outcome, it has been difficult to measure and describe the contribution of funding programs to improving community capacity. This paper reports on a study conducted to develop and establish the psychometric properties of scales that measure community capacity to address health issues in the context of federally funded community-based programs. A literature review and national think tank with 21 experts informed the development of the first draft of the scales that outlined nine key domains of community capacity. Two focus groups with community practitioners provided information on the face and content validity and general usability of this draft instrument. The revised instrument was sent for pilot testing to 114 community organizations. Qualitative and quantitative analyses were performed to assess the validity, reliability and usability of the instrument. Twenty-nine organizations returned a completed instrument (25% response rate). Principal Component Analysis confirmed scale unidimensionality for eight multi-item scales: all of the component loadings were considered good with all scales loading between 0.60 and 0.92. Scale internal consistency was also considered high with alphas between 0.72 and 0.86 for six of these eight scales. Spearman's correlations were significant for the remaining two multi-item scales (composed of two items each), indicating that the two items for each scale were significantly correlated to each other. One scale could not be analyzed quantitatively, as it contained only a single item. Triangulation of qualitative and quantitative results found consistency in interpretations of scale response sets. Feedback on the instrument indicated interest in using it for project planning and evaluation. Psychometric analyses and triangulation provided evidence of the construct validity and reliability of the instrument. The final instrument covers 9 domains and has a total of 26 items, each with a four-point rating scale and a section for qualitative contextual comments. The instrument provides quantitative and qualitative information on community capacity within the context and scope of community-based funding programs.

Window of opportunity for intersectoral health policy in Sweden open, half-open or half-shut?

Mannheimer, L. N., Lehto, J., Ostlin, P. — 2007-11-19

‘Health in All Policies’ (HiAP) is defined as a ‘horizontal, complementary policy-related strategy with a high potential for contributing to population health’. To ensure that health impacts are highlighted across sectors, the support of actors in different sectors, not just the health sector, is needed. Public health, here defined as a universally important but a low prioritized politics area, needs to involve high politics areas to fulfil the HiAP strategy. This study aimed to analyse the agenda setting, formulation, initiation and implementation of the intersectoral public health policy and one tool of HiAP, health impact assessment (HIA), at the national and local level (exemplified by Stockholm County) in Sweden. A literature search was carried out of scientific and grey literature on intersectoral health policy and HIA in Sweden. The study was a policy analysis, using a content analysis method, and the theoretical framework of Kingdon where the results were examined through problem identification (why a window of opportunity opens for an intersectoral health policy and HIA), the factors and impact of politics (support for the formulation and implementation of policy) and policy (how best to solve the problem). The results showed that actors perceived the problems (the rationale) differently depending on their agenda and interest. Politicians and experts had a high impact on the formulation of the policy, agreeing on the policy goals. However, there was little focus on implementation plans implying that the political actors were not in agreement, and the experts sometimes showing conflicting evidence-based opinions on how to best ensure the policy. Without this in place, it is difficult to involve high politics areas, and vice versa, without the involvement of high politics, it is difficult to achieve the policy. However, this is a long-term process, where small steps need to be taken, leaving the policy window half-shut.

The status of health-promoting schools in Hong Kong and implications for further development

Lee, A., St Leger, L., Cheng, F. F. K., Hong Kong Healthy Schools Team — 2007-11-19

An evaluation framework, called the Hong Kong Healthy Schools Award, has been developed to enable comprehensive collection and analysis of data reflecting the status of health-promoting schools (HPS) in Hong Kong. The key findings revealed a high prevalence of emotional problems, unhealthy eating habits, physical inactivity and risk-taking behaviours, leading to both intentional and unintentional injuries among students with higher prevalence among secondary school students. The results indicated a substantial lack of health policies in schools; it also indicated health services in schools not readily accessible to students and staff, and insufficient staff training in health promotion and education. However, most schools have made initiatives in environmental protection, established safety guidelines and strategies for managing students with emotional problems. The success of HPS depends largely on teachers' understanding of its building blocks. Evidence from the comprehensive mapping of the status of HPS in Hong Kong and from student surveys does show encouraging outcomes as well as identifying priority issues to be addressed in the next 5 years.

Health-promoting hospitals in Estonia: what are they doing differently?

Polluste, K., Alop, J., Groene, O., Harm, T., Merisalu, E., Suurorg, L. — 2007-11-19

The health-promoting hospitals (HPH) movement in Estonia was initiated in 1999. This study aimed to compare the implementation of health-promoting and quality-related activities in HPH and those which have not joined the HPH network (non-HPH). In the beginning of 2005, a postal survey was conducted among the top managers of 54 Estonian hospitals. The questionnaire was based on the WHO standards for HPH and on the set of the national quality assurance (QA) requirements for health services. The study demonstrated some significant differences in the uptake of health promotion and QA activities between HPH and non-HPH. For example, regular patient satisfaction studies were conducted in 83% of HPH and 46% of non-HPH (P < 0.03) and 65% of HPH and 46% of non-HPH cooperated with various patient organizations (P < 0.03). Systems for reporting and analysis of complications were implemented in 71% of HPH and 33% of non-HPH (P < 0.03); also, the implementation of various guidelines was more developed in HPH. All HPH have carried out a risk analysis on the workplace and staff job satisfaction studies were conducted in 89% of HPH and 41% non-HPH (P < 0.05). This study indicates that the concepts of HPH and QA are closely related. Making progress in health promotion is accompanied with QA and vice versa. Implementation of health-promoting activities in hospitals will promote the well-being and health of patients and hospital staff, and creates a supportive environment to provide safe and high-quality health services.

Twenty years since Ottawa and Epp: researchers' reflections on challenges, gains and future prospects for reducing health inequities in Canada

Collins, P. A., Hayes, M. V. — 2007-11-19

November 2006 marked the 20-year anniversary of the Ottawa Charter for Health Promotion and Canada's Epp Report. Encapsulating the tenets of health promotion (HP), these publications articulated a vision for reducing health inequities, and described a policy framework for achieving this vision, respectively. These documents also triggered the launch of the population health (PH) field, focused on elucidating the empirical relationships between socioeconomic gradients and population health inequities. Over two decades, a rich HP/PH theoretical and evidentiary base on socioeconomic gradients in health has established. Yet, despite valuable contributions from Canadian researchers, insufficient headway has been made in this country to achieve the Charter's vision.

There are numerous challenges to reducing population health inequities in Canada. Informational challenges include complexity of HP/PH evidence, and inadequate knowledge translation beyond traditional targets. Institutional challenges include the relative immunity of the healthcare sector to funding reductions, and the organization of policy responsibilities into silos. Concerns from non-healthcare sectors of ‘health imperialism’, and inter-governmental tensions are interest-related challenges, while ideological challenges include lack of media discourse on health inequities and a strong neo-liberal political climate.

Gains have been made in Canada towards reducing health inequities. The HP/PH discourses are firmly entrenched in academic and policy spheres across the country, while several inter-sectoral policy initiatives are currently underway. HP/PH researchers could be more proactive in the knowledge-translation sphere by engaging other researchers outside of medicine and health, non-healthcare policy-makers, and the general public, vis-à-vis the media, on the health inequities knowledge base. Ultimately, significant and sustained progress will only be made if researchers and other champions recognize the inherently political aspect of their work and understand how to overcome ideologically driven resistance.

Educating for a healthy, sustainable world: an argument for integrating Health Promoting Schools and Sustainable Schools

Davis, J. M., Cooke, S. M. — 2007-11-19

Al Gore's movie An Inconvenient Truth and the British government's Stern Review of the economics of climate change have provided heightened awareness of how humans are over-stretching the Earth's life support systems. The health of human populations and the health of global ecosystems are inextricably linked and the need for fundamental changes in how we live is becoming impossible to ignore. While not the complete answer, education must be a part of imagining and transforming our patterns of living. Learning embedded in educational systems derived from worldviews that replicate unhealthy and unsustainable lifestyles and environments is not a part of the solution but a significant part of the problem. In Australia, two internationally implemented whole-school reform movements, health promoting schools (HPS) and sustainable schools (SS)—seek to provide ways of operationalizing transformative educational processes. Both movements aim to build resilience and optimism, use action-oriented teaching and learning approaches, and have a focus on the future. While these two approaches to educational and social change have much in common, currently there is virtually no conversation between their proponents and advocates. This paper makes a case for HPS and SS to work together—both theoretically and practically—with the ultimate goal being the emergence of schools that are both green and healthy. Such integration would make an important educational contribution to the creation of a healthy, sustainable world.

Declarations, Charters and Statements Their role in health promotion

St Leger, L. — 2007-08-29

Managerial attitudes on the development of health promoting hospitals in Beijing

Guo, X. H., Tian, X. Y., Pan, Y. S., Yang, X. H., Wu, S. Y., Wang, W., Lin, V. — 2007-08-29

In 2002, the Beijing Committee for Disease Prevention launched guidelines based on the Ottawa Charter for Health Promotion on health promoting hospitals (HPHs). HPH pilot projects were then initiated, on a voluntary basis, in 44 Beijing hospitals. Evaluations have been undertaken to assess the impacts of the pilot project. This article outlines this HPH project, its development and evaluation and reports on the attitudes and contribution of hospital management as determined by questionnaires and interviews from 281 managerial employees from 106 Beijing hospitals (93 from pilot hospitals and 188 from control). The results of the evaluation indicate that long-term health promotion planning and health promotion specialized funds have been better established in pilot hospitals than in the control group and also that the concept of HPH is better understood by managerial staff in pilot hospitals than by those in control hospitals. The main perceived barriers faced in the development of HPH are shortages of funds, personnel, time management and professional skills. To further develop HPHs in China, effort needs to be made to ensure that hospital leaders and management are considered first. If managerial staff have an appropriate understanding of the concept and principles of HPH, then it is more likely that health promotion activities can be introduced into the daily workings of hospitals, and the necessary funds, personnel and training on health promotion skills be provided.

A decrease in both mild and severe bicycle-related head injuries in helmet wearing ages trend analyses in Sweden

Berg, P., Westerling, R. — 2007-08-29

Several international studies point at the efficacy of bicycle helmets in reducing head injuries. In Sweden, observational studies show that from 1988 to 1996 helmet use increased in all categories of cyclists. The objectives of this study were to analyse the trends of bicycle-related head injuries based on their main diagnosis and external cause of injury by different age groups. Our study area was the whole population of Sweden from 1987 to 1996. Outcome evaluation was based on data from the Swedish National Hospital Discharge Register concerning all bicycle-related injuries from 1987 to 1996, which presented 49 758 reported in-patient care. The trends in incidence rates (IRs) were studied with regression analyses. The results show that children under 15 years had the highest IRs. For these children, the IR decreased by 46%. The head injuries in children decreased both in collisions with motor vehicles and in other accidents. Similarly, the IR of concussion and skull fracture decreased. For non-head injuries, there were no significant changes for children. On the other hand, the incidence of both head and other injuries for adults aged 16–50 years increased. Ages above that showed no significant changes. Our conclusions are that the decrease in IR for bicycle-related head injuries refers to children in ages for whom bicycle helmet use during the period increased. This could not be explained by any general decrease in bicycle-related accidents or by any changes in the distribution of injuries after collision with motor vehicles. The increasing helmet use among younger schoolchildren probably contributed to the decrease in head injuries.

HIV prevention in sub-Saharan Africa: a multilevel analysis of message frames and their social determinants

Beaudoin, C. E. — 2007-08-29

In light of the great threat that HIV/AIDS poses in sub-Saharan Africa, the current study assesses HIV/AIDS posters from this region with specific reference to health message frames, including HIV sources, consequences, self-efficacy, preventive means, and barriers and benefits to employing such means of prevention. There is a two-step methodology. First, the content of HIV/AIDS posters from 15 sub-Saharan African countries was coded for the six health message frames. Second, relationships between the health message frames and four social determinants (HIV rate, HIV awareness, condom use and uncertainty avoidance (UAI)) were assessed with hierarchical linear modeling (HLM). Analysis indicates that self-efficacy is the most common frame, but that almost one-quarter of the posters has none of the six health message frames. HLM indicates some favorable findings, including that health message frames are used most often in countries with the most troubling levels of HIV awareness and condom use. Less favorably, health message frames are used least common in countries that have high levels of UAI and high HIV rates. Improvements for related media practices and policy are articulated.

Determinants of smoking among adolescents in the Southern Cape-Karoo region, South Africa

Panday, S., Reddy, S. P., Ruiter, R. A. C., Bergstrom, E., de Vries, H. — 2007-08-29

Tobacco control programmes in multi-ethnic societies must take into account ethnic differences in the determinants of smoking. The I-Change Model, an extension of the Theory of Planned Behaviour, was used to investigate the factors related to smoking among a sample of 3378 Black African, Coloured and White, monthly and non-monthly smokers in the Southern Cape-Karoo Region, South Africa. Across the ethnic groups, non-monthly smokers reported a more positive attitude towards non-smoking, social influences that were more supportive of non-smoking, higher self-efficacy in stressful, routine and social situations, greater intention not to smoke in the next year and lower levels of depressive mood and risk behaviour. Regression analyses suggested that the weight of these determinants may differ in predicting monthly smoking among the ethnic groups. Black African students may benefit from the development of attitudinal cognitions and coping skills to counter peer influence. Coloured students also require skills to resist peer influence. White students require coping skills in stressful and social situations. Although there are more common than unique determinants of smoking among South African adolescents, further research is needed to understand the influence of differing social, economic and cultural contexts on smoking onset.

Fresh Kids: the efficacy of a Health Promoting Schools approach to increasing consumption of fruit and water in Australia

Laurence, S., Peterken, R., Burns, C. — 2007-08-29

The Fresh Kids programme utilized the Health Promoting Schools (HPSs) framework to design a whole-of-school, multifaceted intervention targeting specific behaviours to promote healthy eating and reduce the risk factors associated with childhood obesity. The aim of the programme was to evaluate the effectiveness of the HPS framework to increase fruit and water consumption among primary school-aged children over a 2-year period. The study design was an interrupted time series. Four primary schools in the inner west of Melbourne, Australia, participated in the programme intervention. Baseline data were collected using a lunch box audit to assess the frequency of children with fresh fruit, water and sweet drinks, either brought from home or selected from canteen lunch orders. The lunch box audit was repeated periodically for up to 2 years following programme implementation to assess the sustainability of dietary changes. Across all participating schools, significant increases between 25 and 50% were observed in the proportion of children bringing fresh fruit. Similarly, all schools recorded increases between 15 and 60% in the proportion of students bringing filled water bottles to school and reductions between 8 and 38% in the proportion of children bringing sweet drinks. These significant changes in dietary patterns were sustained for up to 2 years following programme implementation. Targeting key nutrition behaviours and using the HPS framework is an effective and simple approach which could be readily implemented in similar childhood settings. Effective strategies include facilitating organizational change within the school; integrating curriculum activities; formalizing school policy and establishing project partnerships with local community nutrition and dietetic services.

Use of local area facilities for involvement in physical activity in Canada: insights for developing environmental and policy interventions

Riva, M., Gauvin, L., Richard, L. — 2007-08-29

Despite growing literature showing associations of availability and accessibility of facilities to greater levels of physical activity, considerably less is known about the actual extent of use of these facilities. The purpose of this study was to examine the individual (sex, age, education and extent of involvement in vigorous physical activity) and local area characteristics (socioeconomic status, locations and number of physical activity organizations per 1000 residents) associated with the use of local facilities for involvement in physical activity. A telephone survey was conducted with 3191 randomly selected adults in 22 non-contiguous areas across Canada. Use of local facilities for involvement in physical activity was examined among a subset of 1006 physically active adults. Data were analyzed using multilevel modeling. Findings revealed significant variation across areas in likelihood of use of local facilities among women but not men. Women in the 25–34 and 45–55 age categories were significantly more likely to use local facilities than women of 35–44 years of age. Women reporting greater levels of involvement in vigorous physical activity were more likely to use local area facilities. Higher area affluence and living in areas located in small urban towns were associated with greater use of local facilities among women only. None of the individual and local area characteristics was associated with the outcome among men. Understanding the processes associated with differential use of local area facilities for physical activity is essential for the implementation of effective environmental and policy interventions to increase physical activity in the population.

Dietary, physical activity and sedentary behaviour among Australian secondary students in 2005

Scully, M., Dixon, H., White, V., Beckmann, K. — 2007-08-29

The aim of this study was to provide a current assessment of Australian secondary students' self-reported dietary, physical activity and sedentary behaviour. This study also examined the relationship between television viewing and students' dietary behaviour. Data are from a cross-sectional survey of 18 486 secondary students in 2005 from all Australian states except Western Australia. Participants reported their usual daily consumption (number of serves) of vegetables and fruit; their weekly consumption of unhealthy/non-core foods including fast food meals, snack foods and high-energy drinks; their engagement in moderate-vigorous physical activity over the previous week; and hours spent using electronic media for entertainment and doing homework on school days. The study found that 20% of students were meeting the daily requirement of four serves of vegetables, whereas 39% were eating the recommended three daily serves of fruit. Consumption of unhealthy/non-core foods was high, with 46% of students having fast food meals at least twice a week, 51% eating snack foods four or more times per week and 44% having high-energy drinks four or more times per week. Fourteen per cent of students engaged in recommended levels of physical activity and 29% engaged in recommended levels of sedentary behaviour. Age and gender differences occurred for most measures, and there were some socio-economic status differences. Heavier television use was associated with lower consumption of fruit and higher consumption of unhealthy/non-core foods. On the basis of the results of this study, it appears that a significant proportion of Australian secondary students fall short of current, national dietary and physical activity recommendations for teenagers. Continual monitoring of these behaviours is essential to help inform research and policy and identify where future efforts should be directed.

Healthy Cities, local environmental action and climate change

Bentley, M. — 2007-08-29

This paper reports results of a study that explored the relationship between the local environmental actions of Healthy Cities programs and the adverse health impacts of climate change. The analysis is primarily based on a limited literature review of climate change and health, with particular attention to the relationships between Healthy Cities and climate change, and on documentary analysis of information from organization reports and website content associated with Healthy Cities programs in Europe and Australia. Four semi-structured interviews with key people in two Healthy Cities programs in Europe and Australia were conducted to provide information to supplement and complement the published information and to verify theme identification. The main findings of this study are that, although there is no explicit connection between the local activities of Healthy Cities programs and the potential (or actual) adverse health impacts of climate change, Healthy Cities programs are involved in many local environmental actions and some of these actions, for example, those relating to improving air quality and reducing pollution, are linked implicitly to the health impacts of climate change. Through their local relationships and their participation in regional networks, Healthy Cities are able to make connections between local environmental actions and the health impacts of climate change. Furthermore, expanding Healthy Cities to include eco-social sustainability as a central aim not only has the potential to strengthen the links between local environmental actions and climate change, but also presents a relevant health development setting for exploring the social and environmental sustainability of cities.

The nature of evidence resources and knowledge translation for health promotion practitioners

Armstrong, R., Waters, E., Crockett, B., Keleher, H. — 2007-08-29

Governments and other public health agencies have become increasingly interested in evidence-informed policy and practice. Translating research evidence into programmatic change has proved challenging and the evidence around how to effectively promote and facilitate this process is still relatively limited. This paper presents the findings from an evaluation of a series of evidence-based health promotion resources commissioned by the Victorian Department of Human Services. The evaluation used qualitative methods to explore how practitioners for whom the resources were intended, viewed and used them. Document and literature review and analysis, and a series of key informant interviews and focus groups were conducted. The findings clearly demonstrate that the resources are unlikely to act as agents for change unless they are linked to a knowledge management process that includes practitioner engagement. This paper also considers the potential role of knowledge brokers in helping to identify and translate evidence into practice.

Well-being and consumer culture: a different kind of public health problem?

Carlisle, S., Hanlon, P. — 2007-08-29

The concept of well-being is now of interest to many disciplines; as a consequence, it presents an increasingly complex and contested territory. We suggest that much current thinking about well-being can be summarized in terms of four main discourses: scientific, popular, critical and environmental. Exponents of the scientific discourse argue that subjective well-being is now static or declining in developed countries: a paradox for economists, as incomes have grown considerably. Psychological observations on the loss of subjective well-being have also entered popular awareness, in simplified form, and conceptions of well-being as happiness are now influencing contemporary political debate and policy-making. These views have not escaped criticism. Philosophers understand well-being as part of a flourishing human life, not just happiness. Some social theorists critique the export of specific cultural concepts of well-being as human universals. Others view well-being as a potentially divisive construct that may contribute to maintaining social inequalities. Environmentalists argue that socio-cultural patterns of over-consumption, within the neo-liberal economies of developed societies, present an impending ecological threat to individual, social and global well-being. As the four discourses carry different implications for action, we conclude by considering their varied utility and applicability for health promotion.